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Road Traffic Crashes in the Arab World:From Evidence to Public Policy and Action

Wesley M. Rohrer, Khaled Al-Surimi, and Carroline P. Lobo

ContentsRoad Traffic Crashes: A Growing Challenge but Preventable Threat to Public Healthin the Eastern Mediterranean Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Global Policy Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Economic Impact of RTCs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Policy Development and Action Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Safe Road Users (Pillar 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Post-crash Response (Pillar 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10RTC Fatalities in the Eastern Mediterranean Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Vehicle Design and Safety Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Road Safety Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Safer Roads and Mobility (Pillar 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Road Safety in the Gulf Cooperation Council (GCC) Nations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26National Case Studies of Road Safety Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

National Road Safety Case Study 1: Egypt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26National Road Safety Case Study 2: Qatar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27National Road Safety Case Study 3: Oman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28National Road Safety Case Study 4: Saudi Arabia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

W. M. Rohrer (*) · C. P. LoboDepartment of Health Policy and Management, University of Pittsburgh, Graduate School of PublicHealth, Pittsburgh, PA, USAe-mail: [email protected]; [email protected]

K. Al-SurimiKing Saud bin Abdulaziz University for Health Sciences (KSAU-HS), College of Public Health andHealth Informatics, Riyadh, Saudi Arabiae-mail: [email protected]

© Springer Nature Switzerland AG 2019I. Laher (ed.), Handbook of Healthcare in the Arab World,https://doi.org/10.1007/978-3-319-74365-3_104-1

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https://doi.org/10.1007/978-3-319-74365-3_104-1

AbstractRoad traffic crashes (RTCs) are one of the leading causes of death, posing a majorthreat to safety and well-being globally by exacting tremendous clinical, eco-nomic, and humanistic burden. This chapter aims to provide detailed insights intothe existing issues of road traffic safety. The chapter begins by explaining theimpact of RTCs on mortality and road safety emphasizing that RTCs are publichealth crises that need immediate attention. This is followed by a discussion of thepolicy frameworks designed by major organizations such as the World HealthOrganization, World Bank, and the United Nations to improve road traffic safetyaround the world. The chapter then delves into a discussion of RTC risk behaviorand legislation, economic impact of RTCs, strategies for enhancing traffic safety,legislation and enforcement, and advocacy efforts for safety education. Specialattention is given to seat belts and child restraint use, impaired driving due to druguse, distracted driving, and highway engineering and safety management. Thechapter provides a special focus on RTC prevention efforts and policies in thecountries of the Gulf Cooperation Council – Bahrain, Kuwait, Oman, Qatar,Saudi Arabia, and the UAE. The chapter concludes by discussing some of themajor policy targets (e.g., public safety awareness, driver education) which havebeen supported by existing research.

KeywordsRoad traffic crashes (RTC) · Road safety management · World HealthOrganization (WHO) · WHO Eastern Mediterranean Region · WHO Decade ofAction for Road Safety 2011–2020 · World Bank · Gulf Cooperation Council(GCC) [that includes Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and theUnited Arab Emirates (UAE)] · Seat belts · Child restraints · Distracted driving ·Drink driving · Global Road Safety Facility (GRSF) · Global New CarAssessment Programme (NCAP) · International Traffic Safety Data and AnalysisGroup (IRTAD) · US Department of Transportation (DOT) National HighwayTraffic Safety Administration (NHTSA)

Road Traffic Crashes: A Growing Challenge but PreventableThreat to Public Health in the Eastern Mediterranean Region

Preface

Several points of clarification about the authors’ approach to this chapter may beuseful to the reader. Although the focus, i.e., the effects of road traffic–related healthand safety incidents in the Arab World, may seem straightforward, various termshave been used in the literature to address this important domain of global health.The term “road traffic accidents (RTAs)” was used commonly in the earlier(pre-2010) literature, but this term has fallen out of favor with the growing recog-nition that road traffic–related deaths and injuries are preventable rather than being

2 W. M. Rohrer et al.

viewed as acts of God or random processes that are beyond our control. Alternativeterms used in the literature include road traffic incidents (RTIs) and road trafficcrashes (RTCs), and road safety has become the most commonly referenced termcovering the advocacy, policy initiatives, compliance, and action plans targeting theprevention of road traffic–related mortality, injury, disability, and the resultingeconomic and social costs. In this discussion, the author chooses to use road trafficcrashes (RTCs) as the generic term for these incidents and road safety as the blanketterm for preventative and remedial approaches.

Another important issue is the scope of this discussion in terms of nations andpeoples affected. Although the Arab World designation is broadly useful, the authorapplies theWHO category of the Eastern Mediterranean Region (EMR) that includes22 nations of the Middle East and North Africa as delimiting the focus of thispresentation. Consequently, the non-Arab peoples in this region, including the nationof Iran, will be included as well as comparisons with benchmark nations outside theEMR. Several tables based on the most current WHO data include a sample of15 nations within the EMR that reflect the range of national wealth, economicdevelopment, and diverse cultures within the region.

Finally, it should be noted that a substantial and expanding literature concerningroad safety and RTCs focused on this region is available, the breadth of which farexceeds the limits of an overview text. Furthermore, the WHO reports on road safetyin the Eastern Mediterranean Region (2010, 2013, and 2015) and the most currentGlobal Status Report on Road Safety 2018 are essential sources of epidemiologicaldata, legislation, and road safety initiatives and will be relied upon substantially fortrends and most current available data. The underreporting of RTCs and in somecases unavailability of reliable national data is a well-recognized constraint. Aselective sampling of more current literature will reflect the nature, scope, andchallenges of ongoing research in this area.

Although the author is using the five pillars model of the Decade of Action forRoad Safety 2011–2020 as a framework, road safety management, safer roads andmobility, safer vehicles, road user behavior and post-crash response – road userbehavior and to a lesser extent, road safety management – will be given mostconsideration.

Introduction

Deaths, serious injuries, and disability resulting from road traffic crashes (RTC) are amajor threat to global health and, specifically, for the population in the EasternMediterranean Region (EMR). Based on recent estimates (2018), RTCs cause inexcess of 1.35 million lives each year and as many as 50 million injuries globally.This prevalence results in RTCs being the 8th leading cause of death for all ages(refer to Table 1) and the 1st cause of death for children, adolescents, and youngadults in the 5- to 29-year age cohorts. As of 2018, deaths worldwide resulting fromRTCs exceed those from HIV/AIDS, tuberculosis, and diarrhea combined (WHOGlobal Status Report on Road Safety 2018). It is notable that more than 50% of

Road Traffic Crashes in the Arab World: From Evidence to Public Policy and. . . 3

RTC-related deaths occur among the most vulnerable road users including pedes-trians and those riding bicycles and motorcycles, and 93% of RTC fatalities occur inlow- and middle-income countries, far in excess of these nations’ share of registeredvehicles, i.e., about 60%. The fact that 73% of all RTC deaths annually are amongmales under the 25 years of age cohort is especially concerning for its implicationson family income potential and national productivity (WHO, Fact Sheet: Roadtraffic injuries, December 7 2018).

Although some progress has been made in many of the developed economiesbetween 2010 and 2016, e.g., the European Union, Norway, Australia, New Zealand,Canada, the UK, Ireland, and Korea, the USA has experienced an increase of 13.5%of RTC-related fatalities (International Transport Forum, Road Safety Annual Report2018). During this period RTC-related deaths decreased by 3.6% among the32 nations represented in the road safety database maintained by the InternationalTraffic Safety Data and Analysis Group (IRTAD). At the global level, theRTC-related mortality rate of about 18 deaths per 100,000 population represents arather flat trend line between 2000 and 2016.

Although the growth in motorized vehicles has steadily increased globally, thedeath rates per 100,000 vehicles have declined from 135 in 2000 to 64 in 2016.Although this 50% decrease shows progress at the global level, RTCs still represent amajor cause of death and serious injury unevenly distributed among regions andnations. This inequity is demonstrated by the fact that the risk of death is three timesgreater for people in low-income countries (LIC) compared to those in high-incomecountries (HIC), based on the World Bank classification. Furthermore, while only1% of motor vehicles are registered in low-income countries, these nations experi-ence 13% of RTC-related deaths globally. Within the LIC group, no nation showedprogress in the number of traffic deaths since 2013; 1 nation reported no change inRTC-related mortality; and 27 nations reported increased RTC mortality (GlobalStatus Report on Road Safety 2018).

Table 1 Road traffic crashes as cause of death

Rank

Cause

% of total deathsAll causes

1 Ischaemic heart disease 16.6

2 Stroke 10.2

3 Chronic obstructive pulmonary disease 5.4

4 Lower respiratory infections 5.2

5 Alzheimer’s disease and other dementias 3.5

6 Trachea, bronchus, lung cancers 3.0

7 Diabetes mellitus 2.8

8 Road traffic injuries 2.5

9 Diarrhoeal diseases 2.4

10 Tuberculosis 2.3

Global Health Estimates 2016: Deaths by Cause, Age, Sex, by Country and by Region, 2000–2016.Geneva, World Health Organization, 2018


The EMR presents special challenges to the implementation of road safetystrategies due to the disparities of wealth within and across these nations, culturalissues, the rapid growth of economic development, and the age distribution of thepopulation. Across the World Health Organization (WHO) regions comparing RTCdeaths per 100,000 population, the EMR showed a slight increase between 2013 and2016, from 17.9 to 18 per 100,000. This places the EMR 3rd behind Africa at 26.6and South- East Asia at 20.7 per 100,000 and just below the global average for 2016of 18.2 (refer to Table 2). It is notable that in the EMR, 45% of the deaths occur to themost vulnerable road users, pedestrians, motorcyclists, and bicyclists, with pedes-trians representing 28% of all RTC deaths in the region.

Road traffic mortality rates per 100,000 in the EMR range from 8.0 (Bahrain) to32.1 (Iran) with a median of 21.5 in Yemen. The high-income nations of the GulfCooperation Council (GCC) show RTC fatality rates as follows: Bahrain (8.0). UAE(10.9). Qatar (15.2). Kuwait (18.7). Oman (25.4). and the KSA (27.4) with the topthree exceeding the global mean of 18.2/100,000.

In characterizing the road traffic safety status of the Middle East and North Africa(MENA) region, Dahdah and Bose (2013) provide an apt summary of this publichealth challenge and contributing factors posed by RTCs in the EMR:

Table 2 Road traffic injury fatalities per 100,000 population, by World Health Organization’sregion, 2013 versus 2016

Source: Decade of action for road safety: Saving millions of lives, 2011–2010, page 4 (2011). WorldHealth Organization, Geneva, Switzerland


The poor road safety performance of Oman, Saudi Arabia. Iran, Libya and others in MENAis largely due to excessive speeding and lack of police enforcement, with ineffective penaltysystems; and rapid motorization growth and road building combined with poor road designand vehicle regulations. (p. 2)

Although some improvement has been seen since the WHO Global Status Report of2013 on which most of the published epidemiological literature in this area is based,the factors contributing to the unnecessary and preventable loss of lives, especiallyamong the young, serious injury and disability, and the resulting loss of nationalproductivity are still exacting a toll. These human and economic costs are likely tocontinue without a coordinated, multi-sector campaign endorsed by national andregional leadership with dedicated funding to insure sustainability.

Global Policy Context

The United Nations General Assembly adopted a resolution in 2010 proclaiming theperiod 2011–2020 as the Decade of Action for Road Safety and published a globalaction plan to reduce RTC mortality and injuries with a specific target of saving fivemillion lives worldwide. Implementation of the Global Plan depends upon nationscommitting to these broad goals and developing nation-specific action plans, mea-surable goals, regulatory apparatus, and dedicated funding. Beginning in 2015,global status reports were to be published to identify progress and areas in whichfurther action was required. The importance of road safety as a global health prioritywas demonstrated by the incorporation of road safety within the post-2015 GlobalAgenda and the Sustainable Development Goals. Specifically, under the umbrella ofSDG 3 (improving health), SDG 3.6 established a target of decreasing the number ofRTC-related global deaths and injuries by 50% by 2020. SDG 11 (sustainable cities)calls for insuring access to safe, affordable, and sustainable transport systemsaccessible to all, especially vulnerable users including children, the elderly, andpersons with disabilities by 2030.

Other advocacy groups, professional associations, and foundations havesupported the priority expressed in the SDG framework by calling for an extendedtime frame for achievement of a dramatic decrease in RTC fatalities beyond 2020and to include reduction in RTC-related injuries. The Towards Zero Foundation, acharity registered in the UK, is working internationally to reduce RTC fatalities andinjuries to zero by promoting road safety and sustainable mobility through its SafeSystem model. Its #50by30 campaign calls for extension of this goal of 50%reduction in RTC mortality and serious injury until 2030 as being more realistic(Towards Zero Foundation, 50by30: Halve road deaths & serious injuries by 2030:A new target for a decade of SDG action for road safety).

The foundation principle of the “safe system” approach adopted by the TowardsZero Foundation is expressed by the World Road Association (PIARC) as “an ethicalposition where it can never be acceptable that people are seriously injured or killedon the [roadway] network” (Road Safety Manual: A guide for practitioners, 2). This


approach entails that effective road safety systems must be established that recognizedriver, passenger, and pedestrian fallibility and vulnerability by insuring an inte-grated, multi-sector approach to the design, implementation, and management of asustainable road safety program, one that entails “layers of protection in the form ofsafe roads, vehicles, speeds [and] people around the fallible and vulnerable human[users] in order to prevent deaths and serious injuries” (www.towardszerofoundation.org/thesafesystem/#system).

Bloomberg Philanthropies, headquartered in the USA, is another influentialadvocacy forum to promote global road safety. This foundation has providedfunding to implement evidence-based interventions in a global network of urbanareas, to strengthen road safety legislation in five nations, and to initiate auto crashtesting. Bloomberg’s agenda emphasizes the need for effective legislation andenforcement of road safety measures, addressing the lack of safety vehicle designstandards and/or enforcement in many low- and middle-income nations. Anotherpriority is accorded the development and consumer use of an efficient, safe, moreaccessible, and sustainable urban mass transport, noting that the implementation ofan effective bus transit system can reduce RTCs and fatalities by 40–50% (www.bloomberg.org/program/public-heaIth/road-safety/#solution).

Economic Impact of RTCs

A literature review-based analysis of the economic impact of road traffic accidents(RTAs) by the Evidence on Demand Organization in collaboration with the UKDepartment for International Development concluded that “poor crash and injurydata collection in conjunction with inconsistencies in crash costing efforts acrosscountries mean that identifying the macro impacts of crashes with real precision isnot currently possible” (Fletcher 2014). Nonetheless the author also concludes thatRTA-related losses are considerable and certainly justify greater investment in roadsafety management initiatives than is currently obligated. Fletcher cites a study(Sivak and Schoettle 2013) of WHO Global Status Report data that road fatalitiesare related to national economic development in a nonlinear (U-shaped) curve inwhich fatalities are lowest for low-income and high-income nations relative tomiddle-income nations. This commonly reported pattern is presumably affected bythe increasing number of vehicles associated with economic growth, a developmentthat is eventually offset by the safety features of newer vehicles and greater invest-ment in roadway safety improvements. This author also believes that RTA economiccost estimates developed by iRAP (International Road Assessment Programme) andthe WHO in 2013 ranging from 2% to 5% of GDP are reasonable, especially for low-and middle-income nations (LMIC) that are likely at the high end of this range(Fletcher 2014).


http://www.towardszerofoundation.org/thesafesystem/#system

http://www.towardszerofoundation.org/thesafesystem/#system

http://www.bloomberg.org/program/public-heaIth/road-safety/#solution

http://www.bloomberg.org/program/public-heaIth/road-safety/#solution

Policy Development and Action Framework

“Road safety is no accident. It requires strong political will and concerted, sustainedefforts across a range of sectors.” This advocacy statement from theWorld Report onRoad Traffic Injury Prevention prepared by the World Health organization and theWorld Bank (WHOWorld report on road traffic injury prevention, 2004) provides anappropriate introduction to the efforts to address the public health implications ofRTCs at a global level. It is notable that the World Health Day in April 2004 was thefirst one devoted to assuring road safety as a response to the growing challenges toglobal health presented by RTCs. However, the recognition of the extent of theproblem of threats to road safety as a global challenge goes back to a WHO reportin 1962.

The Global Plan for the Decade of Action for Road Safety 2011–2020 (WHODecade of Action for Road Safety 2011–2020, Saving millions of lives 2011) wasdeveloped in response to the United Nation’s General Assembly Resolution 64/255and provides a blueprint for initiating and coordinating local, regional and nationalaction, broad goals, and performance targets for enhancing road safety within thedecade. Estimated targets for lives saved are shown in Fig. 1.

That RTC-related mortality and injury can be prevented through systematic,coordinated action is expressed in the Global Plan: “Experience suggests that anadequately funded lead agency and a national plan or strategy with measurabletargets are crucial components of a sustainable response to road safety” (WorldBank, Global Road Safety Facility Strategic Plan 2013-2020, p. 2). Indeed, thepreventative steps to reduce RTC-related deaths and injury are well recognizedand incorporated into the architecture of the Global Plan as an array of specific

2.0

1.8

1.6

1.4

1.2

Num

ber

of d

eath

s (m

illio

ns)

1.0

0.8

0.6

0.4

0.2

02011 2012 2013 2014 2015 2016

Year2017 2018

5 million lives saved

Projected increasewithout action

Projectedreduction ifaction taken

2019 2020

Fig. 1 Decade of Action for Road Safety 2011–2020: Saving millions of lives. (Source: Decade ofaction for road safety: Saving millions of lives, 2011–2010, page 5 (2011). World Health Organi-zation, Geneva, Switzerland)


activities and targets, comprising a “safe system” model organized around the fivestrategic “pillars” detailed below.

1. Road safety management• Encourage regional networks to develop national road safety strategies, action

plans, and measurable targets.• Ground all efforts in research-based evidence and best practices.

2. Safer roads and mobility• Improve road infrastructure, design, and management using safety-conscious

principles and practices.• Protect the safety of all users, including the most vulnerable.

3. Safer vehicles• Apply state-of-the-art engineering and information technology to enhance

passive and active safety mechanisms.• Provide incentives for development and consumer adoption of improved

vehicles.4. Safer road users

• Improve driver and passenger behaviors through driver education and the useof safety belt, child restraint, and helmets (bicycle and motor cycle users).

• Ensure consistent enforcement of traffic laws and penalties to discourageunsafe speed, drunk and distracted driving, and other risky behaviors.

5. Post-crash response• Increase responsiveness to RTA emergencies and transport to appropriate

trauma facilities.• Develop enhanced rehabilitation services and devices.

Essential to the achievement of these pillars and the associated targets specified inthis Global Plan for Road Safety are effective global coordination, advocacy andmonitoring, and improved data collection at local and national levels. WHO mon-itors progress toward achieving the goals and targets in the Global Plan by publish-ing status reports that highlight both progress made and gaps that require greaterattention and commitment of resources.

In parallel to the WHO Global Plan, the World Bank administers the Global RoadSafety Facility (GRSF), a global partnership program established in 2006 whosemission is to provide funding, encourage knowledge transfer, and provide technicalassistance to initiate and leverage road safety investments as countermeasures to theupward trends in RTC-related deaths and serious injuries, especially in LMIC. GRSFfunding has supported existing road safety management programs in 30 nationsacross World Bank regions with an associated investment in road safety of over $500million. The GRSF has adopted the second-generation or safe system approach thatrecognizes the need for coordinated efforts across public sectors, NGOs, andfor-profit entities (Global Road Safety Facility Strategic Plan 2013-2020, p. 1).GRSF programs are organized to support the five pillars of the Decade of ActionPlan for Road Safety 2011–2020.


Although the safe system approach calls for an integrated, multi-sector, andcomprehensive strategy that entails shifting some responsibility from road users toother stakeholders, this chapter will focus attention on safer road users (Pillar 4),including both driver, passenger, and pedestrian behavior as risk factors that have thegreatest immediate effect upon the likelihood of RTCs and Pillar 5 that addresses theactions of first responders and emergency/trauma care providers to mitigate theincidence of death and severity of injury.

Safe Road Users (Pillar 4)

The Global Plan summarizes the broad goals of the “safer road users” pillar as a setof activities to:

Develop comprehensive programmes to improve road user behavior [by insuring] sustainedor increased enforcement of laws and standards combined with public awareness/educationto increase seat-belt and helmet wearing rates, and to reduce drink-driving, speeding andother risk factors. (WHO Global Plan, p. 16)

Activity 1 urges increased public awareness of road safety risks and prevention bysocial marketing initiatives. Activity 2 calls for legislators and public officials to “setand seek compliance with speed limits and evidence-based standards and rules toreduce speed-related crashes and injuries.” Activities 3–6 use equivalent language toaddress drink-driving, motorcycle helmet use, seat belts and child restraints, andcommercial transport vehicle operation, respectively. Activity 8 recommends pro-motion of graduated driver licensing systems for novice drivers. All are actions thathave direct application to addressing the RTC challenge in the EMR.

Post-crash Response (Pillar 5)

The broad goal statement of the post-crash response pillar is to “increase respon-siveness to post-crash emergencies and improve the ability of health and othersystems to provide appropriate emergency treatment and longer term rehabilitationfor crash victims” (WHO Global Plan, 17). Specific activities identified includedeveloping prehospital and trauma care systems; implementation of a nationwideemergency reporting phone number; providing capacity for early rehabilitation andsupport services to those injured and bereaved; initiating appropriate road userinsurance plans; encouraging thorough RTC investigations and just settlements forvictims; and providing employer incentives to hire individuals with disabilities.Again, all these activities and initiatives are quite relevant to enhancing road safetyin the EMR.


RTC Fatalities in the Eastern Mediterranean Region

The incidence of death associated with RTCs in the EMR exhibits a wide rangeacross the nations of the region reflecting differences in economic development,infrastructure, urbanization, income level, demographics, cultural norms, regulation,and enforcement. Table 3 shows the range of RTC fatality rates for 15 of the EMRnations, a representative group that reflects the diversity of economic wealth anddevelopment and political and social stability across the region. RTC deaths per100,000 population range from 5.3 for the West Bank/Gaza to 28.8 for Saudi Arabia.The five nations in this region, not included in this table for which this data has beenreported, fall within this range. It should be noted that these rates are based on WHOestimates as of 2016 that attempt to correct for the bias of underreporting due tonon-integrated national data systems, unreliable data capture and reporting, andperhaps intentional underestimation by some enforcement personnel. By compari-son, the comparable data points for the UK/Northern Ireland and the USA are 3.1and 12.4 deaths per 100,000 population, respectively.

Unfortunately, little reliable data is available for reporting the incidence ofRTC-associated cases of permanent disability, a serious deficiency in understandingthe social and economic implications of RTCs. The rates of RTC-related permanentdisability that are reported range from 1.2% in the West Bank/Gaza to 9% in Qatar,and the reliability of these estimates is uncertain due to lack of standard definitionsand reporting methods (WHO Road Safety in the Eastern Mediterranean: Facts fromthe Global Status Report on Road Safety 2015, p. 21).

Figure 2 summarizes the status of best practice legislation within the EMR as of2013.

Although it is likely that subsequent progress has been made in legislation insome nations in the region, the pattern of strengths and deficiencies reflected in theFig. 2 is instructive. Limits on excess speed and constraints on drink-driving areshown to be areas of relative strength in best practice legislation with all reportingnations in the region having national speed limits and drink-driving prohibitions onthe books. However, it should be noted that irregular and uncertain enforcement thatis widely reported in the literature serves to erode the effectiveness of robustlegislation and the public’s confidence in responsible officials’ commitment toroad safety. At least 90% of the EMR nations have national laws requiring motor-cycle helmet and seat belt use but not for all passengers. Several studies in the regionhave reported low use of seat belts by drivers and passengers, especially thoseoccupying rear seats, in spite of a high level of awareness among those surveyedthat their use enhances safety. The lack of legislation requiring the use of childrestraints is especially troubling as the failure to properly secure infants and youngchildren is well reported in the research. The overall pattern is clear, unfortunately, asin each domain of safe driver behavior legislation, best practices across all regulatorycriteria fall below 30%.

Table 4 provides a more detailed summary of the status of best practice legislationrelevant to road safety for the sample of 15 nations within the EMR as of 2013(WHO, Road Safety in the Eastern Mediterranean Region: Facts from the Global


Table

3Roadtrafficfatalities,po

pulatio

n,andregistered

vehicles

forselected

EMRnatio

ns

Cou

ntry

Afghan

Egy

ptIran

Jordan

Kuw

ait

Lebanon

Morocco

Oman

Pakistan

Qatar

KSA

Som

alia

Sud

anUAE

WB/

Gaza

Pop

ulation

34.7

95.69

80.28

9.46

4.05

6.00

35.28

4.42

193.20

2.57

32.28

14.32

39.58

9.27

4.79

No.

ofregistered

vehicles

0.67

8.41

30.38

1.50

2.00

1.87

3.79

1.37

18.35

1.33

6.89

0.59

1.25

3.39

0.27

Reportedroad

trafficdeaths

1565

8,211

15,932

750

424

576

3,78

569

24,44

817

89,03

116

52,311

725

159

WHO

estimated

road

traffic

deaths

5,23

09,28

716

,426

2,30

671

51,09

06,91

771

327

,582

239

9,311

3,88

410

,178

1,67

825

2

WHO

estimated

rate

per

100,00

0pop

ulation

15.1

9.7

20.5

24.4

17.6

18.1

19.6

16.1

14.3

9.3

28.8

27.1

25.7

18.1

5.3

Sou

rce:World

Health

OrganizationGlobalStatusReporton

RoadSafety20

18adapted


Status Report on Road Safety 2013). Although it is likely that some legislativeinitiatives are being contemplated at the national and/or local level subsequently, thistable provides an interim report card of the legislative/regulatory framework affect-ing road traffic safety within the region.

According to this profile, most progress has been made in setting effective speedlimits and mandatory seat belt use. While national drink-driving laws are establishedacross the region, for 70% or more of these nations, the regulations do not satisfybest practice standards. Although this deficiency may be explained by the presump-tion that religious and cultural practice forbid or discourage any use of alcohol,actual patterns of drink-driving would vary across the region. Similarly, although90% or more of these countries have national legislation requiring the wearing ofmotorcycle helmets, under 30% have met all best practice standards for helmetdesign and use. The legislative posture for the use of mandatory child restraints isof special concern as less than 30% of the EMR have national legislation in place,though over two-thirds have laws prohibiting young children from traveling in thefront seat.

National speedlaw in place

100%

Speed

Road safety in the Eastern Mediterranean Region

Drink-driving

Motorcyclehelmet

Seatbelts

Childrestraint

90-99% 70-90% 50-70% 30-50% <30%

Speed limits onurban roads≤ 50 km/hour

Localauthoritieshave thepowerto modifynational speedlimits

Met all criteria

BAC limitfor generalpopulation≤ 0.05 g/dl

BAC limit foryoung/novicedrivers≤ 0.02 g/dl

Law applies toall road andengine types

Law requireshelmet tobe properlyfastened

Lawappliesto rear seatpassenger

Met allcriteria

Law restrictschildren undera certain ageheightfrom sitting infrontseat

Met all criteria

Met all criteria

Law requireshelmet to meeta national orinternationalstandardMet all criteria

Drink-drivinglaw is based onBAC

Law appliesto motorcycledrivers and adultpassengers

Law appliesto driversand frontseatpassengers

Law is basedon age-weightheight or acombination ofthese factors

National drink-drivinglaw in place

Nationalmotorcyclehelmet law inplace

Nationalseat belt lawin place

National childrestraint law inplace

Fig. 2 Status of best practice legislation within the EMR as of 2013. (Source: WHO. Road safety inthe Eastern Mediterranean Region: Facts from the Global Status Report on Road Safety 2015, 14)


Table

4Roadsafety

regu

latio

nandenforcem

entforselected

EMRnatio

ns

Cou

ntry

Afghan

Egy

ptIran

Jordan

Kuw

aitLebanon

Morocco

Oman

Pakistan

Qatar

KSA

Som

alia

Sud

anUAE

WB/

Gaza

Max

urban

speed

limit(km/h)

9060

6090

4550

60–

9010

080

4050

–50

Max

motorway

speedlim

it(km/h)

9010

012

012

080

100

120

–13

012

0Non

eNon

eNon

e–

110

Blood

alcohol

limita

––

–<0.08

–<0.05

<0.02

––

––

––

�0.01

–

Drink-drivinglaw

enforcem

entb

68

73

53

510

49

91

710

5

Motorcyclehelmet

law

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Motorcyclehelmet

enforcem

entb

–3

57

35

710

39

2–

310

5

National

Seatbelt

law

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Seatbeltlaw

enforcem

entb

–7

86

54

810

67

3–

510

6

Child

restraint

required

No

No

No

No

No

Yes

No

Yes

No

No

Yes

No

No

Yes

Yes

Child

restraint

enforcem

entb

––

––

–3

–7

––

1–

–7

3

National

lawmob

ileuse

driving

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Sou

rce:World

Health


RoadSafety20

18,adapted

a g/dl

bScale0–

10


However, even if all nations were to adopt best practice legislation for road safety,the effectiveness of the statutory framework depends primarily on the degree of roaduser compliance, enforcement, and effective sanctions. Without the latter compo-nents of road safety assurance, the legislation on the books becomes irrelevant inpractice which may further erode public trust in road safety promotion and preven-tion measures.

Excess Speed as a Risk FactorThe facts that RTC-related deaths and severe injuries are preventable and the severityof injuries can be lessened by modifiable behavior change are sobering but alsopromising. Excess speeding is a commonly recognized factor contributing to boththe risk of RTCs and the likelihood of death and the severity of injuries. For example,an increase of 1% in speed yields a 4% increase in fatalities, and the risk ofpedestrian deaths increases 4.5 times with an increase from 50 to 65 km/h, bothspeeds well below the posted limits on multiple lane highways in most of the world.The failure to use seat belts and child restraints in four-wheeled vehicles and helmetsby motorcyclists are of special concern as risk factors. With proper use of seat belts,drivers and front-seat passengers reduce their risk of fatal and serious injuries by ashigh as 50% and rear-seat passengers by 25%, while the proper use of child restraintsis estimated to reduce RTC fatalities among children by 60% (WHO, Fact Sheet:Road traffic injuries,7 December 2018).

Impaired Driving: Drug UseAWHO policy brief, Drug use and road safety (WHO 2016), grounded in empiricalevidence, contends that psychoactive drugs, both legal and illicit, affect neurologicfunctioning and motor responses in various ways that lead to impaired driving.Among the most common and risky manifestations of drug impairment are drows-iness, cognitive confusion, abnormal motor function, mood changes, errors in timeestimation, and imbalance. The report shows that of the 1.25 million RTA fatalities in2013, 15% were attributed to drunk driving and 3.2% were associated with drugimpairment. It is noted that prevalence of drug use among drivers in RTAs with fatalinjuries ranges from 8.8% to 33.5% globally with amphetamine use associated with50% of these deaths and cannabis about 20%. With the increasing stressors of dailylife in economically developing nations, and rising prevalence of mental healthissues, it is reasonable to expect that the prevalence of drug-impaired driving willalso follow. The impact on nations in the Eastern Mediterranean will be especiallydifficult to forecast and measure as cultural factors within Islamic societies are likelyto result in underreporting of drug-impaired driving.

Distracted DrivingDistracted driving is defined as the situation “when some kind of triggering eventexternal to the driver results in the driver shifting attention away from the drivingtask, e.g., a ringing mobile phone” (WHO/NHTSA Mobile Phone Use, 11). The riskis that in a distracted state, the driver’s attention on her/his primary activity, i.e., thecomplex set of tasks entailed in safe driving, is diverted by attention to a secondary


task, watching a highway billboard, tuning the car radio, drinking coffee, or sendinga text message on the cell phone. Such distraction, even for a few seconds induration, can result in various risky behaviors including ignoring traffic lights andsigns, overtaking and tailgating vehicles ahead, sudden braking, swerving intoanother lane, and failing to notice pedestrian crossings.

Although a wide array of distracting events are potential concerns, most attentionhas been focused on the use of mobile phones for voice and text communicationwhile driving. The proliferation of cell phone subscriptions globally, estimated to be4.6 billion in 2010, makes the use of mobiles while driving a major and growingconcern. This increase in cell phone use parallels the growth in automobile registra-tion and traffic globally, especially in the low- and middle-income developingnations. A study in 2009 concluded that distracted drivers are more likely thannon-distracted drivers by a factor of 4 to be involved in an RTC. Furthermore, driverswho text while driving are 20 times more likely to be involved in an RTC (VirginiaTech Transport Institute, July 27 2009, citing NHTSA, Distracted Driving GlobalFact Sheet). Research in this area is difficult since post-crash police reports areunlikely to capture whether cell phone use was a factor and self-reports of drivers arelikely to be influenced by liability and related concerns. Accordingly, the consensusamong researchers and policy advocates is that the use of cell phones while drivingas a contributing factor to RTCs is underreported. Although 32 nations implementedlegislation banning cell phone use while driving as of 2011, the extent of enforce-ment of these laws is difficult to assess (NHTSA, Traffic Safety Facts Research Note.Report No. DOT HS 812 381).

Studies in the USA, Canada, Europe, Australia, and New Zealand of distracteddriving as a contributing factor to RTCs range from 10% (New Zealand) to 37%(Spain). US studies reported that 1.4 million RTCs were associated with the driver’smobile phone conversations, while 200,000 RTCs were attributed to texting whiledriving (WHO/NHTSA, 14-15). Braitman and McCartt (2010) report that 66% ofyoung drivers in the USA use cell phones when driving. Caird et al. (2014) cite anNHTSA 2013 report that driver distraction while texting contributed to 10% ofdeaths and 17% of serious injuries in 2011.

Among all cell phone uses, Ranney et al. (2012) found that texting resulted in thehighest level among all sources of distraction. Hedlund (2006) reported that cellphone use was responsible for 15–25% of all RTCs. McEvoy et al. (2005) reportedthat prolonged use of cell phones while driving – 1 hour/day for 30 days – increasedlikelihood of accidents by 400–600%. Ritchell (2009) estimated that drivers’ send-ing/receiving text messages increased the likelihood of RTCs by a factor of 23.

In a study in Toronto, Canada, Redelmeir and Tibshirani (1997) wished todetermine whether the use of cell phone while driving increases the risk of RTC.The researchers analyzed cell phone records of 699 drivers involved in RTCs withsubstantial property damage but not personal injury over 14 months. The authorsfound that the risk of an RTC was four times greater when the driver was using a cellphone than when not being used and that cell phone use within 5 minutes of collisionincreased the risk by almost a factor of 5. The results also showed no significant


difference in likelihood of risk between handheld and hands-free use of the cellphone while driving.

Selected Recent Studies of Distracted Driving in the EMRBaig et al. (2018) studied the prevalence of and attitudes about mobile phone usewhile driving among 593 students at King Abdulaziz University in Jeddah using asurvey of behavior and attitudes about texting while driving. Of the completedsurveys, 90% reported texting while driving, and two-thirds reported texting veryor fairly often. While the majority of respondents considered the use of mobilephones while driving to be “unsafe, illegal, and dangerous,” they yet continued to doso. The authors’ recommendations included greater emphasis on distracted drivingas a road safety hazard in school curricula; increased public awareness through amedia campaign, including providing RTC injury and death rates to the public; andstrict implementation and enforcement of traffic violations against texting anddriving, with penalties including license suspension.

Arvin et al. (2017) investigated the frequency of cell phone use while driving onIran’s roads based on observational surveys of a random sampling of about 1,800drivers. Among the findings were that 10% of all drivers observed used cell phoneswhile driving; drivers aged 18–25 years were the highest group of users (14.2%); ahigher percentage of drivers traveling alone used cell phones than drivers accompa-nied by passengers; and the presence of children traveling lowered the rate ofdriver’s cell phone use by over 50%.

Eid and Abu-Zidan (2017) investigated contributory factors, severity, and out-comes of distraction-related RTC injuries in the UAE based on the RTC injuryregistry in two trauma center hospitals in 2006–2007. Of the 44 patients satisfyingstudy criteria, the two most common sources of distraction were mobile phone useand “deep thinking.” It is notable that of this sample only one-third of respondentswere wearing a seat belt. The greatest number of distracted driving RTCs occurredbetween 6:00 a.m. and 12 noon periods that include the employment rush hour andbeginning of the school day. Since the authors were not convinced that banning cellphone use would be effective due to lax enforcement, priority should be given topublic awareness campaigns and traffic safety education.

Bendak (2014) assessed the risk of texting while driving among male UAEdrivers aged 21–25 in which the subjects participated in driving simulation whilereading and responding to programmed changes in road conditions. The resultsshowed decreased driving performance while driving and texting as exemplifiedby increasing eye deviations, crashes, and lane and road boundary crossings. Theauthor attributed the pattern of simulated driving behavior to increased cognitiveload of texting resulting in decreased steering control.

Seat Belt Use and Child RestraintsThe WHO Global Status Report on Road Safety 2018 estimates that the proper useof seat belts reduces RTC fatalities among drivers and front-seat passengers by up to50% and the risk of death and serious injury to rear-seat passengers by 25%. Thereport notes that “mandatory seat belt legislation . . . is a cost-effective means of


reducing road traffic deaths and injuries, especially in rapidly motorizing low- andmiddle-income countries.” The report also notes that “increasing seat belt userequires multi-sectoral action beyond the setting of appropriate legislation” (p. 40).

Seat belt use and the associated legislation for mandatory use are included amongthe main challenges to road safety addressed in the Road Safety Annual Report 2018of the International Traffic Safety Data and Analysis Group (IRTAD). The IRTADprovides evidence-based advocacy and reporting of road safety based on its datacollection and analysis representing its 59 member nations. The report notes that “theuse of seat belts is regarded as one of the most effective measures to save lives andreduce the severity of crash injuries” (IRTAD Road Safety Annual Report 2017,p. 29).

Among the group of participating IRTAD nations that provided data for estimatedseat belt compliance in front seats (as of 2017), the only nation from the EMR,Morocco, reported a 60% compliance, placing it in the bottom tier of six nationsreporting less than 70% compliance. For the equivalent estimates of rear-seatpassenger use of seat belts, Morocco reported 25%, placing it among the ten nationswith compliance rates of 33% and below.

Consistent with the established global consensus among policy and technicalexperts that road traffic crashes and the resulting deaths and injuries are largelypreventable, the low rate of seat belt use is especially notable and deplorable in someregions, including the EMR. That most EMR nations have national seat belt laws inplace indicates that lax and erratic enforcement of noncompliance with seat belt useis the major challenge.

Failure to properly install and use seat belts and age-appropriate child restraints isa major risk factor for RTC-related death and injury. Although the effectiveness ofseat belts depends on characteristics of the crash and the age and seating of theoccupants, considerable evidence supports the efficacy of seat belts in reducing therisk of death and mitigating the severity of injury. As shown in Fig. 3, estimates oflives saved among drivers and passengers by the use of seat belts in the decade2000–2009 in the USA are impressive, ranging from over 12,000 to 16,000 per year(WHO Decade of Action for Road Safety 2011–2020, Saving millions of lives,p. 11).

The concerns expressed by nonusers about seat belt use resulting in death byentrapment or harm to pregnant women or the fetus are not supported by empiricalevidence (WHO &World Bank. World report on road traffic injury prevention 2004,p. 91) There is considerable variability in the use of both seat belts and childrestraints even when their use is legally sanctioned, and studies suggest that thereis greater use on high-speed highways than in congested urban roadways. Onefinding that appears to be common across regions and nations is that young maledrivers use seat belts less frequently than other drivers and are also more likely to beinvolved in RTC fatalities.

In an observational and survey study of a US national sample of drivers withunrestrained children in their vehicle (Raymond et al. 2017), findings include thefollowing:


• Unrestrained children were more likely to be front-seat passengers in the chargeof an unrestrained driver and traveling in a vehicle with four or more passengers.

• The most frequently reported justification for not using a child restraint was theshort length of the trip.

• Drivers of unrestrained children were more likely to have reported having nosources of information about the benefits and use of child restraints.

These findings should be relevant to other nation’s drivers, passengers, andpolicymakers, including those in the Eastern Mediterranean Region.

Selected Studies of Child Restraint and Seat Belt Use in the GulfCooperation Council (GCC) NationsThe behavior of drivers and passengers to use to use seat belts and parents or otheradult caregivers to secure children in age-appropriate child constraints is of specialimportance in road safety management as these protective devices are easily acces-sible and when used appropriately are proven to be effective in decreasing thelikelihood of fatalities and serious injuries to drivers and passengers involved infour-wheeled vehicle crashes. Certainly, the protection of vulnerable children fromavoidable threats to their health and safety would be regarded as a nearly universalpublic health priority. The findings of a subsample of 20 articles addressing seat beltand child restraint usage among the GCC nations within a broader systematic reviewof the RTC literature focused on the Eastern Mediterranean Region were notable inaddressing the use and nonuse of seat belts and child restraints as contributing factorsin the epidemiology and clinical outcomes of RTCs (Rohrer et al. 2017).

Among the most interesting results of the 13 studies that had an epidemiologicalfocus were the following:

Fig. 3 Lives saved by seat belts, USA, 2000–2009. (Source: Decade of action for road safety:Saving millions of lives, 2011–2010, page 11 (2011). World Health Organization, Geneva,Switzerland)


1. A majority of drivers and front-seat passengers in these nations fail to use seatbelts.

2. Child restraints are not routinely or properly used.3. Non-national expatriate drivers and passengers are more likely to use seat belts

and child restraints than nationals.4. Older drivers are more likely to use these safety devices than younger drivers.5. While there is wide acknowledgment of the benefits of using seat belts and child

restraints, this does not translate into high compliance.6. Although reported reasons for nonuse vary, “discomfort,” “forgetting,” and

“being dangerous” are among the factors often cited.

Seat Belt UseA retrospective case-control study in Qatar of about 5,300 patient records examinedthe relationship between seat belt use and fatalities and severe injuries in RTCs.Among the findings were that seat belt use in Qatar was relatively low as onlyone-third of the accident victims had worn seat belts, i.e., 34% of males and 32.6% offemales. Also, it was discovered that occupants in RTCs not using seat belts werealmost twice as likely to experience serious injury or death as belted victims. Theauthors concluded that “prehospital morbidity and mortality appears to be reducedsignificantly by the consistent use of seat-belts by the motoring population in Qatar”(Munk et al. 2008).

Bendak and Al Saleh (2013) conducted an observational study of seat belt use andfactors affecting compliance in the UAE. As of 1999 seat belt use for drivers andfront-seat passengers has been legislated. However, the study’s findings showed thatonly 61% of 5,600 drivers used seat belts and only 43.4% of 2,640 front-seatpassengers complied. On examination of demographic characteristics, findingsincluded that younger drivers reported less frequent use and were less aware of theimportance of SB use than older drivers and female drivers and were less likely tochange behavior after one booked offense. It was also shown that expatriate driversreported higher use of seat belts but also were less likely to be stopped by the policethan nationals. The authors concluded that the current enforcement level and sanc-tions were not effective deterrents for noncompliance with this essential road safetybehavior.

A study of 300 male college students in the health sciences in Saudi Arabia(Al-Khaldi 2006) found that 76% of the students surveyed reported a moderate tohigh knowledge of road safety regulations and 89% being convinced of the impor-tance of using seat belts. However, 30% of those surveyed reported “rarely/never”using seat belts when driving within the city and 24% while driving on nonurbanhighways, while the comparable figures for rarely/never using seat belts when ridingas a passenger were 33% and 29%, respectively. When asked to indicate theirreasons for not using seat belts, the most common response (36%) was “forgetful-ness” followed by restricted movement and anxiety.


Child RestraintsA study of the predictive power of a planned behavior construct compared the beliefsof a sample of 220 pregnant Saudi women about the use of infant restraints with anindependent observational sample of 150 women leaving the hospital, post-delivery.In spite of the fact that the planned behavior constructs predicted 38% of thewomen’s intentions to use child restraints when riding, a finding consistent with asimilar Iranian study (Tavafian et al. 2011), observation of the post-dischargemothers showed that none of these women placed their infants in car seats whenleaving the hospital, presumably holding them in their arms (Nelson et al. 2014).

Raman et al. 2013 conducted a survey study in Kuwait of parents of children18 years or younger concerning their driving habits, knowledge of child passengersafety and driving laws, and their use of child restraints. The authors noted thatalthough most nations in the Gulf Region have laws regarding seat belt use,estimates of compliance vary widely, e.g., 29% in the UAE, 50–65% in Kuwait,and over 90% in Oman, and that only 30% of nations in the WHO EasternMediterranean Region required all vehicle occupants to use seat belts. Legislationpassed in 1994 requires that all front-seat occupants must wear seat belts and thatchildren under 10 years old are not permitted to sit in front seats. Of the 552 parentssurveyed, 34% reported being involved in an RTAwhen accompanied by a child, andabout 37% of this group reported an injury to the child. Almost 75% of thosesurveyed indicated that they wore seat belts all or most of the time. However, over44% of parents reported allowing a child to sit in the front seat and, almost the sameproportion had held a child in her/his lap while driving. The reported knowledgeabout and use of age-appropriate child restraints varied widely by age of child withreported use ranging from only 14% by parents of 6-year-old children; 26% forinfants, and 52% for parents with 3-year-old children. It is notable that 25% of theparents agreed that in the absence of police presence, it wasn’t necessary to wear aseat belt; however over three-quarters of parent agreed that the government shouldpass more legislation to ensure child safety and that more public awareness aboutchild safety in vehicles was needed (Raman et al. 2013).

Given considerable evidence of studies across the globe that the use of seat beltsand child restraints reduces the likelihood of death and serious injury, the high ratesof RTC-related mortality, injury, and disability in this region as compared to theUSA, Canada, and Europe, the prevalence of nonuse of these safety measures withinthese affluent nations is disturbing. Of the sample of articles reviewed, five suggestthat ineffective enforcement of existing traffic laws is also a contributing factor tothis public health threat and eight made explicit recommendations for improvedlegislation, policing, and enforcement of traffic laws and/or more public safetyeducation. These findings reinforce an expert consensus that a coordinated, appro-priately funded, and sustainable road safety management program is both necessaryand achievable.


Helmet UseThe IRTAD also identifies helmet use as a major challenge since the riders ofmotorcyclists, mopeds, and bicycles are considered along with pedestrians to bethe most vulnerable road users. Although most of the IRTAD members (except theUSA) have national laws requiring helmet use on motor-driven two wheelers,compliance rates are variable assuming reliable estimates are even available.Morocco which has had a national law since 1976 reports 65% compliance fordrivers of such vehicles and 34% for passengers. Morocco, along with the majorityof IRTAD participating nations, has no national law requiring helmet use forbicyclists.

Of the 20 EMR nations providing data for the WHO Global Status Report onRoad Safety 2018, all but one, Afghanistan, have a national law requiring helmet useon motorized two-wheel vehicles. Only four of these nations, Cyprus, Lebanon,Saudi Arabia, and Tunisia, set age prohibitions on children as passengers. Of the18 nations providing ratings of enforcement, the mean rating on a scale of 0 to10 was 5 with 3 being the modal rating. Only four nations (Cyprus, Iran, Morocco,and Pakistan) reported estimated helmet wearing rates ranging from 10% in Pakistanto 98% for drivers and 92% passengers in Oman. The overall pattern of responsesreflects a policy recognition of the importance of helmet wearing but a weak level ofenforcement and deficiency of data capture.

Vehicle Design and Safety Devices

Vehicle design and safety device installation complements and encourages safedriving behavior. Global NCAP (New Car Assessment Programme) is a nonprofitUK advocacy organization whose mission is to support new automobile safetytechnologies in emerging markets by providing technical assistance and qualitystandards and a platform for sharing best practices and consumer information;supporting enhanced vehicle safety regulatory and assessment capacity in emergingmarkets; and promoting the use of safer vehicles and safety devices by fleetmanagers globally. Specifically, Global NCAP has developed vehicle assessmentsafety protocols for child occupants and other passengers (Global NCAP, Assess-ment Protocol: Child Occupant Protection 2017).

Road Safety Management

Pillar 1 of the Global Plan “encourages the creation of regional road safety instru-ments . . . multi-sectoral partnerships and designation of lead agencies with thecapacity to develop and lead the delivery of national road safety strategies, plansand targets.” In summary this pillar addresses the policy framework for the devel-opment, monitoring, and evaluation of effective road safety strategies and actionplans at the regional, national, and local levels. The design and maintenance of


relevant road safety data and ongoing research to support best practices to supportpolicy design and implementation are at the foundation of this policy pillar. Anoptimal cycle of action steps in an effective road safety management programincludes screening the road network for potential safety problems; diagnosing theproblems identified to determine root causes; determining effective problem resolu-tion; conducting a cost-benefit analysis of the policy/project options; assigningpriority to preferred projects; and conducting safety effectiveness appraisals (referto Fig. 4). Data relevant to key components of road safety management are shown inTable 5 for the 15 EMR nations included. It is notable that only 11 of the 15 nationshad developed a national road safety strategy as of 2013; 10 had a road safety agencyfunded to lead road safety efforts at the national level; only 7 had established specificRTC fatality reduction targets; and only Morocco, Oman, and the UAE had all 3 bestpractices of the institutional road safety framework at the national level.

Among this group of 15 EMR nations, 11 had achieved inspections and/or starratings of existing roadways; 11 had established at least some road design standardsfor cyclists and pedestrians; yet only 1, i.e., Egypt, had applied UNECE vehiclestandards. The lack of the latter is a cause for concern as failure to mandate safe autoand truck safety standards represents a risk factor that can only be effectivelyaddressed at the national level in partnership with public safety monitoring andenforcement at both national and local levels.

Instituting policies to develop and fund urban public (mass) transit has a range ofbenefits beyond the potential reduction in RTCs and the associated fatalities andinjuries due to reduced auto traffic. Greater access to and use of efficient urbantransit, especially employing electric-powered vehicles, can result in decreasedpollution, especially important in a region in which asthma and other respiratorydiseases are an increasing public health concern, and in the stress associated withtraffic congestion.

The indicators of best practice for post-crash response include the availability of anationwide emergency care phone number, a trauma registry at national or local

NetworkScreening

Diagnosis

CountermeasureSelection

EconomicAppraisal

ProjectPrioritization

SafetyEffectiveness

Evaluation

Fig. 4 Optimal roadwaysafety management processcycle. (Source: US DOT,Federal HighwayAdministration. Crashmodification factors inpractice: Quantifying safety inthe roadway safetymanagement process)


Table

5Roadsafety

managem

entforselected

EMRnatio

ns

Cou

ntry

Afghan

Egypt

Iran

Jordan

Kuw

aitLebanon

Morocco

Oman

Pakistan

Qatar

KSA

Som

alia

Sudan

UAE

WB-

Gaza

National

Road

Safety

No

Yes

Yes

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Leadag

ency

funded

–No

No

–Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Fatalityreduction

target

–2–5%

10%

––

–02

0%,

2020

;50%

,20

26

25%

–13

0by

2022

––

20%

3deaths/

100,00

0–

Designstan

dards

for

pedestrian/cyclist

safety

Som

eSom

eSom

eSom

eNo

Som

eNo

Full

Som

eFull

Som

eNo

Som

eSom

eNo

Inspection

s/star

ratingof

–Yes

Yes

Yes

––

Yes

Yes

Yes

Yes

Yes

–Yes

Yes

Yes

Policy&

Investment

inurban

public

tran

sport

Yes

Yes

Yes

Yes

No

No

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Vehiclestan

dards/

controls

No

Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

Traum

aregistry

Non

eNationalSub

-NNon

eNon

eNon

eNo

Som

efacilities

Sub

-NNationalSub

-NNon

eSub-N

Sub

-NNon

e

National

Emergency

CarePhon

eNumber

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Multip

leYes

Yes

Non

eMultip

leYes

Yes

Formal

certification

forpreho

spital

providers

No

Yes

Yes

Yes

Yes

No

No

Yes

No

Yes

Yes

No

No

Yes

No

Source:World

Health


RoadSafety2018,adapted


levels, and a formal certification process for first responders and other prehospitalemergency providers. It is encouraging that all nations in this sample except Somaliahave a nationwide emergency response number. However, only two nations, Egyptand Qatar, maintain a national trauma registry though six others have registries at thesubnational or local healthcare facility level. As of 2013 only 8 of the 15 hadestablished a formal certification program for prehospital responders. This patternis a major concern given the potential effects of prompt and well-trained respondersand best practice emergency care in preventing death and minimizing the effects oftraumatic injury associated with RTCs. Another factor relevant to assuring appro-priate and efficient post-crash emergency care is the availability of effective com-munication and coordination processes between first responders, emergency transitfor victims (road or flight), and hospital trauma care providers. Although notexplicitly addressed in Table 3, this component of the road safety framework iscrucial and deserves further study in the EMR context.

Safer Roads and Mobility (Pillar 2)

The goal of Pillar 2 (safer roads and mobility) of the Global Plan for road safetyframework is expressed as the need to “raise the inherent safety and protectivequality of road networks for the benefit of all road users, especially the mostvulnerable (e.g., pedestrians, bicyclists and motorcyclists)” (Global Plan, p. 13).

The following figure provides a useful framework for a strategic approach toimplement highway safety improvement programs that should have global applica-tion (USDOT Highway Safety Improvement Program Guide 2016). Highway net-work screening entails identification of locations in the highway network with ahistory of RTCs that would benefit from a safety improvement. Once a site has beenidentified, diagnosis requires study of causal factors resulting in RTCs and thephysical characteristics of the roadway and terrain that would constrain or facilitatesafety measures. Countermeasures are defined as highway improvement interven-tions designed to decrease the likelihood of subsequent RTCs at the site. Economicappraisal entails cost/benefit analysis as the basis for evaluating each potentialintervention and ranking priorities among alternative projects.

To insure the effectiveness of each intervention and the overall efficacy of thesafety management process, systematic post-intervention evaluation is required todetermine the extent and nature of improvement, i.e., whether progress has beenmade in decreasing the frequency and severity of RTCs and the associated fatalitiesand serious injuries. This model provides a useful framework for strategic planningand evaluation of highway safety improvements applicable across national, regional,and local circumstances. However, the patterns of driver, passenger, and pedestrianbehavior and the sociocultural and economic characteristics affecting highway usemust be recognized as distinct, critical factors that must be considered in highwaysafety improvement and management.


Road Safety in the Gulf Cooperation Council (GCC) Nations

The GCC states, i.e., Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the UnitedArab Emirates (UAE), provide a somewhat unique perspective from which toaddress the public health and social and economic problems associated with RTCs.According to a consultant’s report on developing a road traffic strategy for Qatar,these characteristics include an “under-developed motorized culture,” a “relativelyunsophisticated integrated transportation system,” deficiencies in local traffic man-agement, and less than optimal governmental systems of vehicle registration anddriver licensing (Jamieson Foley & Associates 2008, p. 480). This report alsoindicated factors associated with the Islamic culture of the GCC that were relevantto the efficacy of road safety interventions. The fact that alcohol consumption isprohibited – even if not always faithfully practiced – mitigates one major risk factorthreatening road safety. However, a degree of cultural “fatalism” or reliance on“divine protection” manifest, for example, in avoiding the use of safety restraintson the basis that “divine will,” determines the outcomes of driver behavior, is anobstacle to this proven safety measures and may inadvertently promote recklessdriving (Jamieson Foley & Associates 2008, p. 481).

National Case Studies of Road Safety Strategies

The following four national case studies provide a more nuanced view of road safetychallenges and policy initiatives across a sample of EMR nations reflecting thediversity of socioeconomic, political, and cultural factors within the region.

National Road Safety Case Study 1: Egypt

Consistent with the WHO Global Plan, in 2011, Egypt, a middle-income nation,developed a strategic plan for road safety to acknowledge its past progress and framefuture actions to reduce RTCs, fatalities, and injury. The objectives of the planinclude developing model speed control and seat belt use programs; improvingroad traffic injury databases and injury surveillance; instituting social marketingcampaigns for road safety awareness; developing road safety expertise and roadsafety advocacy groups; and monitoring and assessing all road safety interventions(WHO, Egypt: A national decade of action for road safety 2011).

As background the report noted that RTCs accounted for almost 62% of deathsdue to injuries and 34% of nonfatal injuries. It is notable that the report estimates that70% of road traffic injuries occur among the most economically productive agegroups. This reflects a pattern both within the EMR and globally and represents aconsiderable component of the economic impact of RTCs. Based on WHO statistics,Egypt was among the three nations in the EMR with the lowest RTC mortality rate of12.8 per 100,000 (2103) yet reported 12,295 RTC fatalities of which 70% were maleand 30% female and 154,000 injuries in 2007. Based on 2013 statistics, almost halfof the fatalities were to drivers and passengers in four-wheeled vehicles, 29%


pedestrians, 7% bicycles and motorcycles, and 15% other road users (WHO GlobalStatus Report on Road Safety 2015). By 2013, road traffic fatalities had decreased to10,466, of which 83% were male and 17% female.

As of 2013, Egypt had enacted relevant road safety legislation affecting driverand passenger behavior, including:

• Urban speed limit of 60 km/h• Drink-driving legislation with random breath/alcohol testing• Motorcycle helmet law that applied to drivers and passengers• Seat belt law that applied only to drivers• Restrictions on children occupying front seats• Prohibition of handheld mobile phone use while driving

In spite of this legislative framework, it should be noted that the maximum urbanspeed limit exceeds the WHO standard of 50 km/h and that enforcement of the speedlimits, the drink-driving law, and the motorcycle helmet law was perceived to fall inthe range of 5 to 6 on a 10-point scale. Based on a 2011–2012 report, seat beltcompliance rates were low, i.e., drivers, 14–19%, and front-seat passengers, 3–4%.However, no data was available on the use or enforcement of child restraints.

Although a lead agency was established as a focus for road safety planning,neither the National Council for Road Safety nor the implementation of the nationalroad safety strategy was funded in Egypt’s national budget at the time of that report.

National Road Safety Case Study 2: Qatar

Qatar is a high-income GCC nation, producing the highest gross domestic product(GDP) per capita in the world, $124,927 US. Its economy is heavily dependent on itshuge natural gas reserves, supplemented by petroleum and tourism. Only about 10%of the population of 2.1 million are indigenous Emirati. Like other high-incomeGCC nations, Qatar has experienced very rapid economic growth during the past twodecades, resulting in rapid growth in urbanization and motor vehicle use. This wasassociated with a steady increase in road traffic fatalities from 2000 to a peak ofabout 260 per year in 2006.

The implementation of a national traffic safety campaign contributed to a dra-matic decline to about 200 in 2007 (Qatar National Road Safety Strategy2013–2022, p. 7). Of the 204 reported road traffic fatalities in 2012 (WHO GlobalStatus Report on Road Safety 2015), 90% were male occupants and 10% female.However, WHO estimates show 330 road fatalities, representing 15.2 deaths per100,000. Of the recorded road traffic deaths, 38% involved passengers of four-wheeled cars and light vehicles; 34%, drivers of these vehicles; and 28%, pedes-trians. For a comparable time period, RTC- related serious injuries increased fromabout 420 in 2000 to a peak of about 570 in 2008 with a decline and leveling offthrough 2010 (Qatar National Road Safety Strategy, p. 8).


Although national speed limit laws are established, the maximum urban speedlimit of 100 km/h is double that of the WHO recommended limit. Although nationaldrink- and drug-driving laws are also in place, random breath testing has not beenimplemented. Motorcycle helmet laws for both drivers and passengers, seat belt userequirement for drivers, restrictions for children sitting in the front seats, and pro-hibitions against cell phone use by drivers are established by statute. Enforcementfor compliance with the speed limits, drunk-driving, helmet use, and seat belt lawsare perceived to be relatively effective, with mean of 7.75 on a 10-point scale acrossthese categories. However, the lack of information on the rates of compliance withseat belt and child restraint begs the question of the efficacy of these regulations.

The Qatar road traffic strategy provides both a vision, safety improvement targets,and an action plan to reduce RTC fatalities and serious injuries to 130 and300, respectively, by 2022. This corresponds to reducing annual RTA fatalitiesfrom 14 to 6 per 100,000 and serious injuries from 33 to 15 per 100,000. It isnotable that the Qatari road traffic strategy is viewed as contributing to Qatar’snational vision by contributing to the four pillars of human, social, economic, andenvironmental development and the importance of traffic safety management to theoverall wealth, health, and well-being of the society.

National Road Safety Case Study 3: Oman

The Sultanate of Oman, a high-income member of the Gulf Cooperation Councilnations, presents an interesting case in microcosm for the Gulf Region as reflectingthe factors that contribute to RTCs as a major public health problem in this region.The rapid economic growth and urbanization of Oman following the discovery of oiland natural gas deposits in the 1960s included rapid development of its transporta-tion infrastructure. The 10 km of paved roads in Oman at this time of transition hadincreased to 25,000 km by 2009 (Islam and Hadhrami 2012) along with greater autoownership and roadway usage. During the period 2004–2013, RTC deaths per100,000 population peaked in 2008 at about 34, declining to about 25.4 per100,000 by 2013 (WHO national profile data, 2013). Of the RTC deaths in 2013,64% were drivers and passengers of automobiles and light trucks; pedestrians, 23%;occupants of heavy trucks and buses, 8%; and cyclists and motorcyclists, 5%.

A study of risky driving behavior of 1,003 university students and staff in Oman(Al-Reesi et al. 2013) provides useful insights into whether self-reported riskydriving behaviors are predictive of road crash outcomes. The subjects were askedto complete the widely used Manchester Driving Behavior Questionnaire (DBQ),reporting the frequency of 26 behaviors, demographic data, their involvement in oneor more RTCs, and whether their behavior caused the crash. The age range of thosesurveyed was 17–58 years, and the majority (69%) of those who participated weremales. Of those surveyed about 52% reported at least one driving violation in thepast year with excessive speed being the most common infraction, and 92% reportedthe use of cell phones while driving. A majority (60%) reported that they wereinvolved in at least one RTC, 57% of whom admitted to causing the crash. The DBQ


scores clustered around three factors: deliberate violations, errors, and mental lapses.The authors report that overall lapses and errors accounted for more risky drivingbehavior than deliberate violations. However, in comparison with DBQ results fromstudies in Qatar and UAE, Omani subjects’ mean scores on the item, “disregardspeed limits,” were considerably higher than the Qatari and Emirati respondents.Based on a review of similar DBQ studies internationally, the authors report thattheir sample exhibited relatively high levels of risky driving behavior and concludewith the recommendation that a driver safety strategy must integrate both drivereducation and consistent enforcement to produce sustainable change in road trafficsafety practices in Oman.

Oman has a fully funded, national road safety strategy overseen by the NationalCommittee for Road Safety. Consistent with the WHO Decade of Action for RoadSafety (2011–2020), Oman sets a goal of 25% reduction in RTA fatalities by the endof the decade. To further this goal by insuring safer roads and mobility for the mostvulnerable road users, the Omani road safety system includes audits for new roadconstruction and regular inspection of existing roads and policies to encourageinvestment in public transportation and promotion of walking and cycling and effortsto separate groups of road users to protect the most vulnerable.As of 2013 Oman hadpassed legislation to constrain risky road user behavior, including speed limit lawsbut no maximum roadway speed limits. A drink-driving law with random breathtesting is in place but without specification of blood alcohol limits. A nationalmotorcycle helmet law requires helmet use for both drivers and passengers. Seatbelt use for drivers and front- and rear-seat passengers is also required by nationallegislation as is the use of child restraints. Legislation also addresses drug-impairedand mobile phone use while driving. Surveys show high levels of confidence inenforcement of these laws, except for the use of child restraints.

Oman has focused attention on road safety by establishing a research program toinsure that evidence-based approaches to developing a sustainable road traffic safetymanagement system are utilized. The Omani Research Council in 2007 identifiedRTCs as among the five major societal challenges in the nation. An inter-sector,multidisciplinary steering committee was formed to implement the road safety pro-gram’s mission: “To reduce road traffic deaths and injuries by building knowledgeand capacity in road safety research methods and facilitating the development ofevidence-based road safety interventions” (The Research Council, Road safetyresearch program n.d.). The four main research themes established include crashanalysis, behavior and social issues, legal and compliance issues, and trauma careservices, consistent with the five pillars of the WHO Decade for Action framework.By championing and funding research in these areas, road safety advocates intend toprovide decision-makers relevant evidence to guide policy and system developmentin this key public health priority.


National Road Safety Case Study 4: Saudi Arabia

The Kingdom of Saudi Arabia presents an especially interesting case of the chal-lenges of effecting road safety management programs in a nation which has the 2ndhighest prevalence of RTCs in the Gulf Region, second only to Iran. Not only hasSaudi Arabia experienced dramatic increases in population, urbanization, and motor-ization in the past 30 years, it is currently undergoing a profound social andeconomic transformation initiative, Vision 2030, promoted by and under the direc-tion of Crown Prince Mohammed bin Salman (referred to as MBS throughout theRegion), heir-designate to rule the Kingdom well into the twenty-first century.Although this plan focuses on diversifying the economy away from oil extractionand export and toward knowledge-based industries, it has profound socioculturalimplications including increasing opportunities for women in employment andgreater participation in the public sphere, a notable example of which is looseningthe cultural prohibition on women to drive. Driving in urban SA is quite challengingdue to the volume of traffic until well after midnight; aggressive driving behaviors,especially among young males; erratic parking patterns; and a public perception ofloose and uneven enforcement of prevailing speed limits, use of seat belts and childrestraints, and other traffic regulations.

According to the WHO Global Status Report on Road Safety 2015, Saudi Arabiahad enacted relevant road safety legislation affecting driver and passenger behavior,including:

• National speed limit law with urban speed limit of 80 km/h• National drink-driving law but without random breath/alcohol testing• National motorcycle helmet law• National seat belt law but uneven enforcement applied to front- and rear-seat

occupants• National law on mobile phone use while driving that prohibits handheld mobile

phone use that also applies to hands-free phones

On the other hand, Saudi Arabia has not yet developed safety legislation requiringthe use of appropriate child restraints.

A systematic review of the literature on RTCs in Saudi Arabia (Ghaffer andAhmed 2015) noted that the fatality rate associated with RTCs in Saudi Arabia,29 per 100,000 population, was double the rate of Western affluent nations like theUSA. The authors concluded that excessive speed and reckless driving were thefactors most commonly associated with death and injury from RTCs. The authorsalso noted the tendency of young adult males, aged 20 to 30 years, to avoid wearingseat belts and a perceived increase in the incidence of children under the legal drivingage being behind the wheel. It is notable that all risk factors addressed in this revieware subject to prevention through behavior change and safety education strategies.

A study of RTCs in Saudi Arabia by Al-Naami et al. (2010) focuses on thedevelopment of a trauma system defined as “a preplanned, comprehensive andcoordinated regional injury response network,” in which the “essential components


include trauma prevention, prehospital care, hospital care, rehabilitation, systemadministration, trauma care education and training, trauma care evaluation andquality improvement” (Al-Naami et al. 2010, p. 50). The authors note that anestimated one-fifth of all Ministry of Health hospital beds are filled due to RTCsand that the annual economic costs of RTAs were at least $5.6 billion US annually,representing between 2.2% and 9% of GDP. The authors assert that these and relatedindicators of the impact of RTCs on Saudi Arabia mandate the development of aneffective trauma care system in addition to initiatives to promote driver educationand behavior change. While focusing on the need for a greatly enhanced trauma caresystem, the authors recognize the effects of driver behavior, vehicle maintenance androadway design, and repair issues as contributing factors to the RTC crisis in theKSA. The authors identify the use of cell phones while driving and the lowcompliance with the use of seat belts as behavioral risk factors. Poor tire mainte-nance and unsafe roads, especially outside urban areas, and the subsequent risk ofblowouts and RTCs are also considered “hot safety issues” in the Kingdom(Al-Naami et al. 2010, p. 51). The authors make a compelling case for a systemsapproach to the complexity of road safety management and the need to address bothbehavioral, engineering, technical, and sociocultural aspects of RTCs in developingeffective prevention and response strategies and processes.

A survey-based study of about 2,400 Saudi youth aged 15–24 years by Moradi-Lakeh et al. (2016) includes self-reported items addressing road behavior. Theauthors found a high prevalence of risky driving and travel behavior, indicatingthat about 75% of young drivers disregarded speed limits and are noncompliant withthe use of safety belts. Of this sample, 73.5% reported never using seat belts aspassengers whereas only 6.1% of US students sampled reported rarely or never usingseat belts when another person was driving (Kann et al. 2016).

A survey of self-reported road safety attitudes, traffic violations, involvement inRTCs, and risky driving behaviors of 287 Saudi males aged 18–24 years was used asthe basis for structural equation modeling of key variables (Mohamed and Bromfield2017). The findings identified three categories of driving behavior, two of which,aggressive driving and excessive speed driving, were influenced by drivers’ attitudestoward road safety and were associated with involvement in RTCs. Somewhatsurprisingly, attitudes regarding road safety had no effects on RTC involvement. Itis notable that this sample was skewed toward higher education and SES levels andexclusively males due to the prohibition on women driving in Saudi Arabia at thattime.

A study by Al-Shammari et al. (2009) analyzed the extent of and factors affectingpedestrian death and injury due to RTCs. Based on WHO data (2004), RTCsinvolving pedestrians accounted for one-third of all RTC-related fatalities andserious injuries worldwide. The authors report a study indicating that pedestriansrepresent at least 25% of RTC fatalities in Saudi Arabia (Al Ghamdi, 2002). Theauthors’ study examined pedestrian and driver characteristics, time of day andlocation of the RTCs, environmental conditions, accident site location, post-crashconsequences, and factors likely to have contributed to the RTCs. The authors’findings based on 460 crashes included the attribution of primary responsibility to


the pedestrians (46%) and to the drivers (42%). Inattention of drivers (42%) was theleading variable resulting in RTCs caused by drivers at 44% followed by excessivespeeding at 27%. Of crashes caused by pedestrians, 65% were due to inattention andby crossing roadways at locations other than crosswalks. A notable finding was thatdrivers younger than 30 years accounted for almost two-thirds of the RTCs involvingpedestrians, while 11% were drivers under the legal driving age of 18 years, a widelyrecognized problem in the KSA. The findings of the study have clear implications forroad safety and driver education, traffic law enforcement, and roadway engineering.

In summary this sample of studies reflects both the extent of the challenges posedby RTCs to the public health and economy of the KSA and the need for best practicelegislation to be reinforced by road safety education for drivers, passengers, andpedestrians and rigorous, consistent, and fair enforcement of traffic laws.

Conclusions

RTCs are a major threat to public health globally, especially in the WHO EasternMediterranean Region. RTCs are the 2nd leading cause of fatalities in the region andthe leading cause of death among adolescents and young adults. Consequently,death, serious injury, and disability that result from road crashes not only entailpersonal and family tragedy and hardship but also have immediate and long-termeconomic consequences for each nation. The estimated cost in terms of healthcareand rehabilitation, lost productivity, and social support services represents between2% and 5% of GDP globally. Given that most RTCs are preventable, these social andeconomic costs must be weighed against the investment necessary to develop moreeffective safety management systems. Strong evidence supports the conclusion thatimproved public safety awareness; driver education; better enforcement of existingtraffic laws, especially excessive speeding and compliance with seat belt and childrestraint use for all are essential components of an effective and sustainable roadsafety system.

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