evaluation of effectiveness of safety seatbelt legislation in the united arab emirates
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Accident Analysis and Prevention 36 (2004) 399404
Evaluation of effectiveness of safety seatbelt legislationin the United Arab Emirates
Mohammed El-Sadig a,, Mohammed Sarfraz Alam b, Anne O. Carter a, Khalid Fares b,Hashel Obaid Salem Al-Taneuiji b, Peter Romilly c, J. Nelson Norman a, Owen Lloyd a
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, UKReceived 4 December 2002; received in revised form 29 January 2003; accepted 30 January 2003
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 (JanuaryJune 1998) or the post-implementation period (FebruaryAugust 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 (2 = 77.68,P < 0.001). While the proportion of minor injuries increased from 42% (95% CI: 3648%) in the pre-implementation period to 77% (95%CI: 7183%) in the post-implementation period, the proportion of moderate to fatal injuries declined from 54% (95% CI: 4860%) 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: 5267%). 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
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: email@example.com, 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) 399404
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.
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 patients 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 patients 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-threateningsurvivable; 5: critical, survivableuncertain; 6: fatalunsurvivable) (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. The 2-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 Wilcoxons rank-sum (MannWhitney) test.
In the pre-implementation period (JanuaryJune 1998) asample of 247 cases was enrolled. Overall, 85% were male,most were aged 1944 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