Risk factors of deaths related to road traffic crashes in World Health Organization regions: A systematic review
Alireza Razzaghi1, Hamid Soori1, Amir Kavousi2, Alireza Abadi3, Ardeshir Khosravi4, Abbas Alipour5 1 Safety Promotion and Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2 Department of Epidemiology, Safety Promotion and Injury Prevention Research Center, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran 3 Department of Community Medicine, Faculty of Medicine; Department of health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran 4 Department of Statistics and Informatics, Iranian Ministry of Health and Medical Education, Tehran, Iran 5 Community Medicine Department, Medical Faculty, Mazandaran University of Medical Sciences, Sari, Iran
Date of Submission
Date of Acceptance
Date of Web Publication
Correspondence Address: Prof. Hamid Soori Safety Promotion and Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran Iran
Source of Support: None, Conflict of Interest: None
Background: Identification of risk factors involved in road traffic deaths (RTDs) could help policymakers and road traffic managers to adopt effective strategies and approaches for the prevention and control of these incidents, while the lack of accurate data on the risk factors of RTDs causes the problem to persist. This systematic review aimed at assessing the national studies regarding the risk factors of RTDs in the regions covered by the World Health Organization (WHO). Methods: This review study was conducted during 2008–2018 via searching in databases of PubMed, Science Direct, Scopus, Cochrane, Thomson Reuters, Web of Science, EMBASE, ProQuest, and Trip databases. Initially, a literature review was performed to find similar systematic reviews, followed by another literature review to retrieve the published or registered protocols. At the next stage, PECOTS was developed for the search strategy, followed by the quality assessment. The eligibility criteria in this study were the national-level studies about the risk factors related to RTDs, English-language studies, and studies published during 2008–2018. Results: In total, 169 articles were included in this study, with the highest and lowest number of the published articles in the United States and African countries, respectively. According to the reviewed studies, human factors accounted for the most common risk factors involved in RTDs. In the southeastern regions of Asia, the main road-related risk factor for RTDs was reported to be the type of roads. Furthermore, roadside departure to the right side and long roads were denoted in the national data of the Western Pacific region on the incidence of RTDs. Differences were observed between the six regions covered by the WHO in terms of the time-related risk factors for RTDs. Conclusions: Several risk factors have been reported for RTDs in the countries covered by the WHO, and each risk factor is considered to have various subcategories. Therefore, it could be concluded that there are different epidemiological patterns for road traffic accidents and RTDs.
How to cite this article: Razzaghi A, Soori H, Kavousi A, Abadi A, Khosravi A, Alipour A. Risk factors of deaths related to road traffic crashes in World Health Organization regions: A systematic review. Arch Trauma Res 2019;8:57-86
How to cite this URL: Razzaghi A, Soori H, Kavousi A, Abadi A, Khosravi A, Alipour A. Risk factors of deaths related to road traffic crashes in World Health Organization regions: A systematic review. Arch Trauma Res [serial online] 2019 [cited 2024 Mar 5];8:57-86. Available from: https://www.archtrauma.com/text.asp?2019/8/2/57/268662
Road traffic accidents are considered to be a major health concern and cause of mortality across the world, especially in low-and middle-income countries. Road traffic deaths (RTDs) are reported to be the third leading cause of mortality.,, The consistent and effective prevention of road traffic accidents and subsequent injuries need proper planning and comprehensive efforts. Efforts to diminish the rate of road traffic accidents and RTDs could be successful with access to accurate data on the epidemiology of road traffic injuries. Such data enable countries to employ proper intervention to achieve their goals of preventing road traffic accidents and minimize associated injuries.
Adequate knowledge of the influential factors in road traffic accidents enables countries to progressively decrease the rate of RTDs. The success rate of the measures to prevent RTDs varies across the globe. According to statistics, the highest success rate in the reduction of RTDs has been achieved in middle-and high-income countries, while no reduction in RTDs has been reported in low-income countries. The countries in Africa and southeastern Asia are reported to have the highest rate of RTDs (26.6 and 20.7 cases per 100,000, respectively). On the other hand, the lowest rate of RTDs has been reported in East Mediterranean countries and Western Pacific regions (18 and 16.9 cases per 100,000, respectively). Among the six regions covered by the World Health Organization (WHO), a descending trend in RTDs has been reported in the United States, Europe, and Western Pacific regions since 2013. It is notable that there are differences in the rates of RTDs in the regions covered by the WHO. For instance, the rate of RTDs in the high-and low-income countries in the United States has been estimated at 11.8 and 18.3 cases per 100 000, respectively. In Africa, the rates of RTDs in low-and middle-income countries have been reported to be 29.3 and 23.6 cases per 100 000, respectively. In Europe, the rate of RTDs in middle-and high-income countries has been estimated 23.6 and 14.4 cases per 100 000, respectively.
The experience of the nations that have succeeded in the promotion of road safety and reduction of road accident injuries and RTDs shows that road traffic accidents are avoidable and preventable. Road traffic accidents are not inadvertent and are mainly caused by disruptions in the systemic interaction between humans, vehicles, roads and environmental factors. In high-income countries, injury surveillance systems make it possible to attain high-quality data regarding RTDs, road traffic accidents, and the associated risk factors. As a result, the risk factors involved in road traffic accidents could be properly recognized and be incorporated into prevention and control programs. However, many low-and middle-income countries lack sufficient, accurate epidemiological data regarding RTDs due to the absence of valid registry systems. Therefore, it is not possible to determine the incidence rate of road traffic injuries and identify the risk factors involved in RTDs directly and accurately.
Several studies have been focused on the severity of road traffic accidents. The risk factors in this regard could be classified into four main categories, including human factors, vehicle-related factors, road-related factors, and environmental factors. Identification of the risk factors involved in RTDs could help policymakers and managers adopt effective strategies for the control and prevention of road traffic injuries and the associated outcomes. Lack of data on these risk factors makes it difficult for countries to properly recognize the problems and implement effective interventions in this regard. This systematic review aimed at assessing the risk factors of RTDs based on the national studies conducted in this regard.
This study was conducted during 2008–2018 via searching in databases PubMed, Science Direct, Scopus, Cochrane, Thomson Reuters, Web of Science, EMBASE, ProQuest, and Trip databases. Initially, a preliminary search was carried out to find similar systematic reviews, followed by the review of the literature to retrieve 3–5 related studies to collect the required data.
In the PubMed database, the search of articles was done with no limitations, and the search resulted in five articles. However, the review of the titles and abstracts of these articles indicated that they were irrelevant to the research subject. The literature search resulted in four articles in the Scopus database, none of which were relevant to the research subject. A review of the literature was also conducted in PubMed, Scopus, and PROSPERO databases to retrieve published or registered similar protocols. At this stage, no relevant protocols were found in PubMed.
To investigate the registered protocols, search for the relevant protocols was performed in the PROSPERO database using specific keywords, such as road accident risk factor. However, the search results showed no relevant protocols.
To search for related articles, the PECOTS search strategy was adopted based on the sample populations, exposure, comparison, outcomes, and type of relevant studies. The inclusion criteria in this study were as follows: the national-level studies about the risk factors related to RTDs, English language studies, and the studies published during 2008–2018. The search strategy was developed, and the search for the articles was performed in PubMed, Science Direct, Scopus, Cochrane, Thomson Reuters, Web of Science, EMBASE, ProQuest, and Trip databases. Moreover, the references of relevant articles were reviewed. The search results were investigated to find the relevant articles in two phases of screening and selection. The screening was carried out based on the titles and abstracts of the articles, and the selection of relevant articles was performed based on the full-text review of the articles. The flowchart of the literature search process is depicted in [Figure 1].
Figure 1: The flowchart of searching in systematic review
Duplicate studies were determined based on the titles, abstracts, and authors of the articles. The research stages were completed by two independent researchers. In case of disagreement regarding the selection of the articles, consensus or expert opinions were applied. In addition, the reasons for the inclusion or exclusion of each article were recorded.
The quality of the retrieved studies was assessed using the STROBE checklist for cross-sectional, cohort, and case–control studies by two researchers who were experts in the research projects regarding road traffic accidents. In case of disagreement, consensus or expert opinions were applied.
The data of the selected studies were extracted by two subject experts independently. Considering the difference in the quality of the studies, the third-quartile STROBE score (≥15) was determined to synthesizing the studies with acceptable quality.
In total, 169 articles were included in the present study. The distribution of the included articles in the six regions covered by the WHO was as follows: 108 articles from America, 33 articles from Europe, 10 articles from the Western Pacific region, one article from Africa, nine articles from Eastern Mediterranean, and eight articles from Southeastern Asia. Moreover, various observational studies were detected among the retrieved articles. The distribution of the reviewed articles is presented in [Table 1].
Table 1: Number and type of studies in 6 World Health Organization regions
Due to a large number of the studies (169 articles) to be presented in detail in a table, only the features of the selected cohort studies are shown in [Table 2] considering the high evidential level of observational studies. The characteristics of all the reviewed articles are presented in the Appendix section.
Table 2: The risk factors related to road traffic crashes deaths in cohort studies
According to this systematic review, most of the studies regarding RTDs were conducted in the United States, followed by Europe, the Western Pacific region, East Mediterranean, Southeastern Asia, and Africa. The investigation of the risk factors involved in RTDs was performed based on the quality assessment of the reviewed studies. Only one article in this regard has been published in Africa, which was not considered acceptable in the quality assessment. Moreover, nine articles have been published in this regard in the East Mediterranean, one of which required qualification to be further reviewed. There were 4, 17, and 50 qualified articles published in Southeastern Asia, Europe, and the United States, respectively.
According to the results of the present study, human factors were the most significant risk factor for RTDs in the reviewed studies. Some of the most important human factors have been reported to be age, male gender, education level, alcohol consumption, obesity, not using helmets by motorcyclists, driving without a driver's license, and high-speed driving. Obesity was reported to be a risk factor for RTDs in the United States and Europe. Moreover, ethnicity was considered to be a risk factor for RTDs only in the United States. In Southeastern Asia and the Western Pacific region, old age was reported to be a major risk factor for RTDs in motorcyclists. In the Middle East, the distraction of the driver was considered to be the only risk factor for RTDs.
Some of the main road-related risk factors for RTDs were reported to be urban roads, unpaved roads, off-road driving, and poor road conditions, which were extracted from the national data of the United States. In European countries, these factors included divided roads, two-way roads, and poor roadway design, which contributed to RTDs. In the southeastern regions of Asia, the main road-related risk factor for RTDs was reported to be the type of roads (local roads, highways, and freeways). Furthermore, roadside departure to the right side and long roads were denoted in the national data of the Western Pacific region on the incidence of RTDs. The only qualified study in East Mediterranean contained no data on the road-related risk factors for RTDs.
Environmental factors were considered to be among the risk factors involved in RTDs only in the United States. On the other hand, location-related factors were denoted in the United States (e.g., low-income areas), Europe (e.g., non-signalized zebra crosswalks, areas that were not built-up, geographic variations, and mid-block crosswalk location), Southeastern Asia, and Western Pacific region (e.g., interchange roads and rural areas).
Differences were observed between the six regions covered by the WHO in terms of the time-related risk factors for RTDs. Some of these factors were reported to be as follows: the United States (hour of the day, time of the accident, early-morning accidents, non-school night driving, driving in daylight hours), Europe (darkness [especially the lack of street lighting] and summertime), Southeastern Asia (time of the accident and motorcyclists involved in accidents at nighttime), and Western Pacific region (darkness hours).
In terms of the law-related factors, the most significant influential factors in the incidence of RTDs were reported to be restraint, high gasoline prices, driver's license law, renewal of the driver's license, and alcohol consumption policies. In Europe, helmet legislation was denoted as the only law-related factor in this regard.
According to the reviewed studies, the economic influential factors in the incidence of RTDs were mainly reported in the United States, Europe, Southeastern Asia, and the Western Pacific region. [Table 3] shows the distribution of the influential factors in the incidence of RTDs.
Table 3: The risk factors of road traffic accidents deaths extracted in national studies in World Health Organization regions
According to the current systematic review, the epidemiological pattern of road traffic crashes (RTCs) and the associated consequences vary in the six regions covered by the WHO.
Adequate knowledge of the risk factors involved in RTDs is essential to determining the priorities and implementing effective interventions. In the six regions covered by the WHO, available data are insufficient regarding the risk factors for RTDs in the low-and middle-income countries. According to these statistics, many countries in the world may be unable to reach their sustainable development goals in reducing RTDs up until the middle of 2020. Meanwhile, the number of vehicles has increased drastically across the world, with the rate of RTDs reaching from 135 cases per 100 vehicles in 2000 to 64 cases in 2016. Furthermore, the reduced rate of RTDs by 50% within the past 15 years could be due to progress in road safety although such progress is not considered acceptable considering the growing number of motor vehicles.
In low- and middle-income countries, there is a lack of systematic enforcement to collect data on RTDs. Human factors were the most significant risk factor for RTDs in the reviewed studies. From an epidemiological perspective and based on the assessment of the causal network of injuries, the main influential factors in RTDs could be classified as the predisposing factors, enabling factors, precipitating factors, and reinforcing factors. Some of these factors (e.g., age, gender, marital status, and education level) are regarded as the predisposing factors, which may be essential to causality relationships although they may not be sufficient. Some of the interventional enforcements regarding these factors include proper training and alcohol consumption, which are modifiable. Causality networks are also affected by enabling factors, which facilitate the development of diseases and the associated outcomes. Some of these factors are income status, climatic conditions, and access to health services, which may play a key role in causality network and are rarely sufficient. Enabling factors are often modifiable, and their modification could prevent RTCs. Precipitating factors are also considered in the investigation of the causality network of diseases and the associated outcomes. These factors contribute to disease development and the occurrence of injuries. Due to the wide range of these factors, one factor may be prioritized and regarded as the necessity factor. Some key precipitating factors include exposure to special diseases, physical shocks, occupational stimulators, and knowledge. In road traffic accidents, each human, road-related, vehicle-related, and environmental factor could play the role of a precipitating factor. For instance, in human factors, driver distraction could be considered a precipitating factor. Among the other examples in this regard are road flows, vehicle defects, snowy/rainy weather, and road slippage, which could be regarded as precipitating factors.
Reinforcing factors lead to the persistence of increased severity of diseases, as well as disabilities, impairments, and the subsequent behavioral patterns. These factors may be repeatable or consistent and not necessarily similar to predisposing, precipitating, and enabling factors. In terms of road traffic crash, some of these factors include incidental roads, poor awareness of road users regarding road safety, high-risk driving behaviors, motor vehicle defects, and low safety. According to the results of this systematic review in the regions covered by the WHO, human factors were the most common risk factors involved in RTDs; some of these factors were old age, male gender, low education level, alcohol consumption, obesity, not using safety helmets, driving without a driver's license, and high-speed driving.
Obesity has been reported to be a risk factor for RTDs in the United States and Europe. Accordingly, the risk of RTDs is higher in obese individuals compared to overweight and underweight individuals, as well as those with normal weight. The epidemic of obesity in the United States and Europe is considered to be a major challenge, which could be considered a risk factor in the countries with the growing trend of obesity as well.
Ethnicity has been reported to be a human risk factor for RTDs only in the United States. In addition, the beliefs of fatalism are reported to be more widespread in Hispanic and African populations. Based on this belief, when they are driving, they have no control over the probability of an accident, which exposed these individuals to a high risk of death due to fatal crash. In Southeastern Asia and the West Pacific region, old age of motorcyclists has been reported to be a risk factor for RTDs. On the other hand, the findings of a study conducted in France indicated that elderly drivers are at a lower risk in terms of the lost life year compared to middle-aged and young drivers. With respect to this association, some studies have denoted that attention deficits in elderly drivers play a pivotal role in road traffic crash.
In an article published in the East Mediterranean region, driver distraction was reported to be a major risk factor for RTDs. Driver distraction mainly involves the driver not watching the road carefully while driving, which is often associated with the significant risk of road traffic crash.
However, we only found one article regarding this risk factor, and further investigation is required to obtain detailed data in EMRO countries. Driver distraction could have various causes depending on time, place, and demographic characteristics; except age and gender, the mentioned demographic factors are all modifiable. Efficient planning on modifiable factors is essential to the prevention of road traffic crash and RTDs. Unfortunately, there were few qualified studies in this regard in Africa and East Mediterranean, while these regions mostly consist of low- and middle-income countries. These countries often lack effective registry systems for road traffic crash; this leads to numerous problems in planning and decision-making regarding road traffic crash.
One of the limitations of the present study was that we only reviewed English articles. Moreover, we selected a specific publication period for the articles.
There are similarities in the findings regarding the influential factors in the incidence of RTDs in the countries covered by the WHO. In addition, variable patterns are observed in the subcategories of each of the main factors in this regard, indicating the differences in the epidemiological patterns of road traffic accidents and RTDs. Therefore, researchers, managers, and policymakers must pay special attention to these discrepancies in the analysis of the related data, as well as planning, policymaking, and implementation of the related interventions.
We acknowledged all the people who helped us in accessing to the full text of articles.
Financial support and sponsorship
This article is derived from PhD thesis, which is funded by Shahid Beheshti University of Medical Sciences and Iran National Science Foundation.
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