Accident Analysis and Prevention 36 (2004) 399–404

Evaluation of effectiveness of safety seatbelt legislationin the United Arab Emirates

Mohammed El-Sadiga,∗, Mohammed Sarfraz Alamb, Anne O. Cartera, Khalid Faresb,Hashel Obaid Salem Al-Taneuijib, Peter Romillyc, J. Nelson Normana, Owen Lloyda

a Department of Community Medicine, Faculty of Medicine and Health Sciences, UAE University, P.O. Box 17666, Al-Ain, United Arab Emiratesb Al-Ain Hospital, Al-Ain Medical District, Ministry of Health of United Arab Emirates, P.O. Box 1006, Al-Ain, United Arab Emirates

c Division of Economics, School of Social and Health Sciences, University of Abertay Dundee, 158 Marketgait, Dundee DD1 1NJ, Scotland, UK

Received 4 December 2002; received in revised form 29 January 2003; accepted 30 January 2003

Abstract

Seatbelt legalisation was implemented in the United Arab Emirates (UAE) in January 1999. This provided the opportunity to evaluatethe effectiveness of the legislation in the Eastern District of Abu Dhabi Emirate in the UAE by establishing levels of injury severity frommotor vehicle crashes (MVC) before and after the legislation and the rate of compliance with the legislation. Data were obtained from amajor hospital in the Eastern District of Abu Dhabi Emirate, UAE. Subjects were a systematic sample of MVC victims who arrived aliveat hospital in either the pre-implementation period (January–June 1998) or the post-implementation period (February–August 2000). Themain measures of outcome were injury severity codes, numbers of hospital bed days and rates of admission and discharge at hospital. Theanalysis of injury severity from MVCs, from the pre- to the post-implementation period, revealed a significant declining trend (χ2 = 77.68,P < 0.001). While the proportion of minor injuries increased from 42% (95% CI: 36–48%) in the pre-implementation period to 77% (95%CI: 71–83%) in the post-implementation period, the proportion of ‘moderate to fatal injuries’ declined from 54% (95% CI: 48–60%) to17% (P = 0.001) and the median number of hospital bed days declined from 5 days (25%= 2; 75%= 8) to 3 days (25%= 1; 75%= 4)(P = 0.028). The rate of seatbelt compliance reported by occupants involved in MVCs in the post-implementation period was 59% (95%CI: 52–67%). The implementation of the seatbelt legislation in the Eastern District of Abu Dhabi Emirate was associated with statisticallysignificant reduction in morbidity in those arriving alive at hospital following MVC, including reduced severity of injury, admission rateto hospital and the duration of hospital stay. More active implementation of seatbelt law would most likely further reduce severity of MVCinjuries and fatalities in the Eastern District of Abu Dhabi Emirate, UAE.© 2003 Elsevier Ltd. All rights reserved.

Keywords: Seatbelts; MVC injuries; Injury severity; UAE; Traffic accidents

1. Introduction

Programmes for motor vehicle crash (MVC) and injuryprevention are growing in size and depth and involve agrowing number of agencies in most countries in the world.After World War II, the number of motor vehicles rose dra-matically, as consequently did the numbers and severity ofinjuries from MVC (Haight, 1994; El-Sadig et al., 2002).These increases, together with the increasing cost of medicalcare and rehabilitation of victims of those injuries, broughtthe realisation that more efforts should be made to preventinjuries (Haight, 1994; Miller et al., 1998). In particular,traumatologists combined efforts with safety engineers and

∗ Corresponding author. Tel.:+971-3-7039463; fax:+971-3-7672022.E-mail addresses: msadig@uaeu.ac.ae, Msadig40@hotmail.com(M. El-Sadig).

biomechanics specialists to target post-crash injury (i.e. sec-ondary) prevention in addition to crash (i.e. primary) preven-tion. That effort culminated in establishing the effectivenessof safety seatbelts, airbags, crash helmets and collapsiblesteering columns before the 1970s (NOMESCO, 1997).

Safety seatbelts are effective in reducing the risk of in-jury in motor vehicle crashes (Kaplan and Cowley, 1991;Viano, 1995; Rivara et al., 2000). Effectiveness is definedas the percentage reduction in injuries and deaths for peo-ple with the device compared to those without it when thecrash occurred. It is well established that safety seatbeltsand other restraints are very effective in reducing morbidityand mortality from MVCs in addition to medical treatmentcosts of victims (Nelson et al., 1993; Marine et al., 1994;Miller et al., 1998).

In the United Arab Emirates (UAE), seatbelt legislationwas implemented in January 1999 (El-Sadig, 2002). It

0001-4575/$ – see front matter © 2003 Elsevier Ltd. All rights reserved.doi:10.1016/S0001-4575(03)00033-2

400 M. El-Sadig et al. / Accident Analysis and Prevention 36 (2004) 399–404

required only front seat passengers to wear seatbelts. Theimplementation of the legislation provided the opportunityto evaluate the compliance of the population in the East-ern District of Abu Dhabi Emirate, UAE, with the law, toestablish levels of MVC injury severity and lengths of hos-pital stay before and after its implementation, and, therebyto determine the potential benefits of the safety seatbeltlegislation in the District.

2. Methods

Data on injury outcomes from review of medical recordsof individuals injured in MVCs and taken to Al-Ain Hospi-tal (before and after the implementation of the seatbelt leg-islation in the UAE) were abstracted. Al-Ain Hospital is oneof two major hospitals in the Eastern District of Abu DhabiEmirate, UAE. The hospital receives annually about 70% ofthe total of MVC casualties in the district (MoH, 1999).

The severity of injury was coded for all victims accordingto the AIS codes, using the AIS90 manual (AAAM, 1990).For the case series sample of MVC victims injured before thelegislation, the study recruited subjects from 18 January to30 June 1998 (the pre-implementation period). For the caseseries sample of victims injured after the enactment of seat-belt legislation, the study recruited subjects from 2 Februaryto 3 August 2000 (the post-implementation period).

For the pre- and post-implementation periods, the studyused data abstraction forms to collect data on MVC victimsbrought alive to Al-Ain Hospital in the UAE. The first formwas used to retrieve data for the ’pre-implementation’ pe-riod from patients’ medical records. Inclusion criteria wereall persons who presented alive to the Accident and Emer-gency Room (ER) of the hospital as a result of involvementin MVCs during the time periods specified. Using the ERregistry, which identifies MVC victims, every fifth patientbrought alive to the hospital was selected. Information onthe patient’s demographics was abstracted. Then a panel oforthopaedic and trauma surgeons and nurses retrieved rel-evant data on injury diagnoses and inpatient hospital treat-ment. The second form, which was composed of two parts,was used to collect data for the post-implementation period.Research assistants at the ER of Al-Ain Hospital completeddescriptive details for every fifth person meeting the inclu-sion criteria during the time period at the time of presen-tation to the ER. These details included the mechanism ofinjury, the seating position of the occupant and the use ofsafety belts. The data were gathered from various sources:the patient, his relatives or friends and the police. After that,the form was set aside until the patient was discharged fromthe ER or the hospital. Then, using the patient’s medicalrecord, orthopaedic and trauma surgeons completed its sec-ond part, containing details of injury diagnoses and inpatienthospital treatment.

In the absence of any routine injury coding system inthe UAE, the study used trauma and orthopaedic specialists

to estimate injury severity, from MVC patients’ recordsfor both data forms, using the Abbreviated Injury SeverityScale (AIS) (AAAM, 1990). This was done through con-verting injury diagnosis and text descriptions of injuriesinto AIS90 codes (AAAM, 1990). The AIS categoriseseach injury by body region (head or neck, chest, abdominalor pelvic contents, extremities or pelvic girdle and general)and by severity (0: no injury; 1: minor; 2: moderate; 3:serious, not life-threatening; 4: severe, life-threatening—survivable; 5: critical, survivable—uncertain; 6: fatal—unsurvivable) (Baker et al., 1974; Bull, 1978; Yates, 1990;Durbin et al., 2001). The AIS ranking order of severityis based on the criterion of ’threat to life’, determined byclinicians. Accordingly, all patients’ injuries in the pre- andpost-implementation periods were assigned AIS severitycodes. For multiple injuries, affecting more than one bodyregion, the codes were assigned on the basis of the injurywith the highest severity. The days of hospitalisation per pa-tient were calculated by counting the difference between thedate of admission and the date of discharge from hospital.

Overall, the following outcomes were measured identi-cally from both time periods: location as driver or non-driverin the vehicle, severity of injury using the AIS90 and thenumber of days of hospitalisation.

Data variables were coded and analysed, using the sta-tistical software package SPSS Version 10. Theχ2-test wasused to test the statistical significance of differences in cat-egorical variables between the two evaluation periods (P ≤0.05 was considered as the cut-off value for significance).The numbers of days spent in hospital were compared usingthe two-sample Wilcoxon’s rank-sum (Mann–Whitney) test.

3. Results

In the pre-implementation period (January–June 1998) asample of 247 cases was enrolled. Overall, 85% were male,most were aged 19–44 years while 20% were below 18 yearsand 14% above 45 years; over one quarter were UAE citizenswhile the others were expatriates (Table 1). Of all victims,36% were drivers, 22% were passengers while 42% were un-specified road-users. Forty-two percent sustained minor in-juries, 18% moderate injuries, 24% serious injuries and 8%severe injuries; 43% were admitted to the hospital (Table 2).Of those admitted to hospital, 89% were discharged withoutcomplications, and 11% were transferred to specialist hos-pitals for further treatment (Table 2); drivers spent a medianperiod of 5 hospital bed days (Table 3).

In the post-implementation period (February–August2002) a sample of 173 was enrolled. Overall, 82% weremale, over three quarters were aged 19–44 years while 16%were below 18 years and 8% above 45 years (Table 1).Thirty-one percent were UAE citizens while the others wereexpatriates (Table 1). Of the total victims, 29% were backseat passengers, 26% front seat passengers, 24% drivers and21% non-specified road-users; 59% were using seatbelts

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Table 1Socio-demographic factors of MVC casualties arriving alive at Al-Ain Hospital in Al-Ain, UAE, before and after the implementation of seatbelt legislation1998 and 2000

Characteristics Proportions in thepre-implementation (%)(N = 247) (95% CIa)

Proportions in thepost-implementation (%)(N = 173) (95% CIa)

P-valueb

Sex n.s.Male 84.6 (80.1–89.1) 82 (76.3–87.7)Female 14 (9.8–18.6) 18 (12.3–23.7)

Age (years) n.s.<18 20 (14.9–25.1) 16 (10.5–21.5)18–24 17 (12.2–21.8) 25 (18.5–31.5)25–34 27 (21.3–32.7) 31 (24.0–38.0)35–44 22 (16.7–27.3) 20 14.0–26.0)>44 14 (9.6–18.4) 8 (3.9–12.1)

Nationality n.s.UAE 28 (22.4–33.6) 31 (24.1–37.9)Other Arabs 29 (23.3–34.7) 24 (17.6–30.4)Asians and others 43 (35.8–49.2) 45 (37.6–52.4)

Road-user n.s.Driver 36 (27.9–44.1) 25 (18.3–31.7)Passenger 22 (15.0–29.0) 54 (46.3–61.7)Others 42 (33.7–50.3) 21 (14.7–27.3)

Seatbelt-useAll occupants – 59 (50.2–67.6)Drivers – 86 (74.1–97.3)Front seat passengers – 88 (77.3–97.7)Back seat passengers – 11 (2.0–20.0)Unknown – 60 (17.0–100)

a 95% confidence interval.b By χ2 two-tailed test.

Table 2Injury severity of MVC casualties arriving alive at Al-Ain Hospital, UAE, before and after implementation of seatbelt legislation 1998 and 2000

MVC injury severity Proportions in thepre-implementationperiod (%) (N = 247)(95% CIa)

Proportions in thepost-implementationperiod (%) (N = 173)(95% CIa)

P-valueb

Outcomes at ER n.s.Discharged from ER 57 (50.8–63.2) 64 (56.8–71.2)Admitted to hospital 42 (35.8–48.2) 35 (27.9–42.1)Dead 1 1

Outcomes at wards n.s.Discharged without complications 89 (85.0–93.0) 92 (88.0–96.0)Transferred to specialist care in another hospital 11 (7.0–15.0) 8 (4.0–12.0)

Injury severity (by AIS) <0.001None 3 (1.0–5.1) 6.1 (2.4–9.8) –Minor 42 (35.8–48.2) 77 (70.6–83.4) <0.001Moderate 18 (13.2–22.8) 7.3 (3.3–11.3) 0.007Serious 24 (18.6–29.4) 5.5 (2.0–9.0) <0.001Severe 8 (4.6–11.4) 1.8 (0.0–3.8) 0.006Critical 3 (1.0–5.1) 0 (0) 0.04Fatal 1 (0.0–2.3) 1.8 (0.0–3.8) –

a 95% confidence interval.b By χ2 two-tailed test.

402 M. El-Sadig et al. / Accident Analysis and Prevention 36 (2004) 399–404

Table 3Number of hospital bed days of MVC casualties arriving alive at Al-Ain Hospital, Al-Ain, UAE, before and after implementation of seatbelt legislation1998 and 2000

Descriptive statistics (percentiles) N Percentile

Minimum 25th 50th 75th Maximum

Number of hospital bed days per driver in the pre-implementation period 19 1 2 5 8 36Number of hospital bed days per driver in the post-implementation period 14 1 1 3 4 6

Mann–WhitneyU-testa N Mean rank Sum of ranks

Pre-implementation period 19 19.74 375Post-implementation period 14 13.29 186

a Exact significance (one-tailed test)P = 0.028.

at the time of the crash. Most (86%) of drivers and 88%of front seat passengers were using seatbelts while 11%only of back seat passengers were using them. Over threequarters sustained minor injuries, 7% moderate injuriesand 6% serious injuries; 35% were admitted to the hos-pital (Table 2). Among those admitted to hospital, driversspent a median period of 3 hospital bed days (25%= 1;75% = 4) (Table 3). Ninety-two percent of those admit-ted were discharged without obvious complications aftercompleting treatment, and 8% were transferred to specialistcare for further treatment for disability and neurologicalcomplications (Table 2).

The comparative analysis of the pre-/post-implementationperiods revealed statistically significant declines in injuryseverity from MVCs in the Eastern District of Abu DhabiEmirate, UAE (Table 2). In the assessment of the overalleffect of the legislation, when the proportion of the groupof casualties which sustained ‘moderate to fatal injury’ wascompared in the pre- and post-implementation periods, theproportion was 16% in the post-implementation period com-pared to 54% in the pre-implementation period (RR= 3.0).The individual comparison for each AIS injury category re-vealed similarly significant declines in injury severity (P <

0.001) in the post-implementation period (Table 2). Equallyimportantly, minor injuries increased from 42 to 77%, a pat-tern that complemented the downward trend of injury sever-ity in the Eastern District following the implementation ofthe seatbelt legislation.

The analysis of hospital admissions among drivers inthe pre- and post-implementation periods, using Wilcoxon’srank-sum (Mann–Whitney) test, showed a significant changein the duration of hospital stay between the two periods(Table 3): the median duration of hospital bed days declinedfrom 5 to 3. Drivers were the only passengers who could becompared between the two databases, as they were the onlyoccupants comparable in the databases.

4. Discussion

The results demonstrated that the risk of moderate tofatal injuries in those presenting alive at hospital, following

a MVC declined by three-fold after the implementationof the legislation. The number of hospital bed days forMVC casualty drivers also showed a significant reduction.The reduction in the rate of admission to hospital in thepost-implementation period, though not statistically signif-icant contributed to the declining trend of injury severity.These findings together suggest a decline in injury severityfrom MVC in the Eastern District of Abu Dhabi Emirate,following the implementation of the legislation. The find-ings are consistent with results obtained elsewhere. Forexample,Kaplan and Cowley (1991)in a study in the USshowed that seatbelts reduced the total number of injuriesby 34%, major injuries by 57%, minor injuries by 20%and deaths in the belted group to zero. The unbelted grouphad a mean AIS score twice as great as the belted groupand were hospitalised 1.6 times longer and at double thecost.Viano (1995)estimated the effectiveness of seatbeltsas reaching 42% in preventing fatalities, in addition to12% effectiveness provided by a driver side airbag. ButRivara et al. (2000), while showing similar consistent ratesin reducing fatalities found an associated increased risk ofserious injury to the chest and abdomen.

In the post-implementation period, 59% of casualties in-volved in crashes self-reported the use of seatbelt when thecrash occurred. Although such evidence might overestimatethe actual rate of seatbelt compliance in the Eastern Districtof Abu Dhabi Emirate, UAE—bearing in mind the finesimposed for violations—it suggests a notable improvementas opposed to the rates reported byBener et al. (1994),which described estimates of not over 11% for frequent useand 6% for non-frequent use before the implementation ofthe seatbelt legislation. The analysis of the association be-tween seating position and seatbelt-use revealed that 86%of drivers and 87% of front seat passengers reported usingseatbelts as required by the law. On the other hand, only11% of back seat passengers reported using seatbelts whenthe crash occurred (backseat passengers are not covered inthe current legislation). A more reliable estimate could havecome from a roadside observational study. Compared toother countries, similar rates of compliance following theimplementation of seatbelts have also been reported. Forexample, in the US,Marburger and Friedel (1987)estimated

M. El-Sadig et al. / Accident Analysis and Prevention 36 (2004) 399–404 403

the rate of compliance to be within the range of 60–90%,while Hauswald (1997)estimated the actual rate amongdrivers in the US to be 40%. However, these high rates ofcompliance for front seat passengers taken in conjunctionwith the overall reduction in injury severity for all passen-gers and the reduction in the number of hospital bed daysfor drivers, demonstrated in the post-implementation period,clearly suggest the effectiveness of the implementation ofthe seatbelt legislation in the Eastern District of Abu DhabiEmirate.

The descriptive analysis of the socio-demographic data inthe pre- and post-implementation periods revealed that thesex distribution of MVC casualties remained similar in bothperiods. Also, the proportionate distribution of casualties ac-cording to nationality did not differ in the two comparisonperiods. Asians maintained the highest proportions in bothevaluations, reflecting their high proportion in the District’spopulation (56%). UAE citizens constituted the second high-est proportion in both evaluations (28 and 31%, respectively)despite the fact that they represent approximately 20% ofthe total population. The high rate of involvement of UAEcitizens and the concentration of that on young age groups(19–44 years) is alarming and suggests that safety cam-paigns should be targeted at them (El-Sadig et al., 2002). Acomparison of the age distribution of casualties between theperiods showed that, in the post-implementation period, astatistically significantly higher proportion (29%) of MVCinjuries was in the age group 19–24 years compared to thepre-implementation period while the proportion for the agegroup >45 years declined significantly from 14 to 6%. Thisdeclining trend in the occurrence of MVC injury in the olderage cohort and the increasing trend within the younger agecohorts may suggest the presence of a greater tendency to-wards non-compliance with seatbelt legislation among theyounger age groups or a higher degree of risk-taking driv-ing. This dictates that specific prevention strategies shouldbe directed to these groups, such as driver training and ed-ucation, legislation and/or monitoring the implementationof existing laws, especially those planned to enhance thecompliance of the population with seatbelt law. The find-ings also supported the extension of seatbelt legislation toinclude the requirement that back seat passengers also useseatbelts.

4.1. Limitations

Several limitations should be considered when interpret-ing the results of this paper. The study is restricted to casesthat arrived alive at the ER department in the hospital. There-fore, an increase or decrease in the rates of those who diedprior to arriving at ER or who did not require any med-ical care could bias the results. The data were collectedretrospectively for the pre-implementation period. This re-sulted in failure to obtain important epidemiological infor-mation such as the use of restraints among vehicle occupants;as such information was missing for most of the sample

population. During the post-implementation period, the useof restraints was determined mainly through self-reporting,which could bias the results due to fear of legal liability. Inboth evaluations, some information relating to injury sever-ity was not available from medical charts, leading to thepossibility of underestimating injury severity for casualtiesin both databases. The periods through which the databaseswere collected were not identical and did not include thefull year. However, due to the rarity of metrological eventsin the UAE, there are no major variations in MVC incidenceand severity (El-Sadig et al., 2002) over time. Finally, onlydriver data was fully comparable between the two data col-lection periods.

Acknowledgements

The authors would like to extend their thanks to the staffin Al-Ain Hospital for their valuable assistance in producingthis paper. We also wish to extend special thanks to thestaff in the Community Medicine Department, Faculty ofMedicine and Health Sciences of the UAE University fortheir help in producing this paper. In particular, we thankDr. Peter Barss and Dr. Hafiz Ahmed for their comments onthe manuscript and Mr. S.V. Shinelal for his valuable helpin collecting the data.

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