Journal of Local and Global Health Science - Proceedings of the 24th World International Traffic Medicine Association Congress, Qatar 2015, November 2015

Ambulance use in low-and middle-income countries is very low. This study assesses characteristics of road traffic injury (RTI) victims coming to emergency departments (EDs) by ambulance and compares with RTI victims coming via alternative modes of transportation. The Pakistan National Emergency Departments Surveillance (Pak-NEDS) was a surveillance conducted in seven major tertiary-care EDs in six main cities of Pakistan from November 2010-March 2011. Univariate and multivariate logistic regression was carried out to investigate the factors associated with ambulance use in RTI patients. The variables used for regression gender, age groups, cities, hospital type, road user type and disposition. There were four age categories; ≤18 years, 19 -45 years, 45 – R years and ≥65 years. RTI patients were divided into two road-user groups; VRUs (pedestrian, motorcycle driver and passenger, bicyclists) and non-vulnerable road-users (non-VRUs) including four-wheel vehicles’ driver and passengers. Level of significance was set at 0.05. Ethical approval was obtained at all participating sites. Pak-NEDS enrolled 9769 RTI patients. The mode of arrival was known for 92.2% (n=9009) RTI patients, of which 9.1%(n=821) were brought to the ED by ambulance. The mean age was higher in the ambulance group (33.3±16.9 versus 28.8±14.1 years, p-value <0.001). The most common road-user in the ambulance group was motorcycle drivers (n=201,24.5%) and pedestrians (n=3131,38.2%) in the non-ambulance group. Head and neck injuries (n=240,32.9%) in ambulance and upper limb injuries (n=2470, 34.3%) in non-ambulance group were common. There were 3.7% (n=23) deaths in the ambulance group and only 0.6% (n=38) in the non-ambulance group. Patients of all age groups were more likely to use ambulance compared to those >65 years of age (p-value<0.001) adjusted for gender, cities, hospital type, road use type and disposition. The adjusted odds ratio of utilizing ambulances for VRUs was 1.3 times higher than non-VRUs (p-value0.008). Although the overall use of ambulance for RTI patients is very low in Pakistan, however, we found that RTI patients who used ambulance were more likely to be younger and VRUs. Majority of these patients had suffered from head and neck injuries and were more likely to die in the ED.

In 2010, road traffic injuries (RTIs) are the leading cause of deaths in those aged 1-19 years globally and half of those victims are vulnerable road users (VRUs), defined as pedestrians, bicyclists and motorcyclists. Low-income countries account for the highest proportion of VRU deaths. The change in distribution of the burden of RTI during recent decades is unclear. To highlight changes over time in RTI mortality among children and adolescents VRU and non-VRU globally, by region, and by country income level between 1990 and 2013. Country-level data were extracted from the global burden of disease study, split into seven geographical regions and four income levels (low-income [LICs], lower-middle [LMICs], upper-middle [UMICs] and high-income [HICs]). Mortality rates for 1990 and 2013 were calculated considering in turn all categories of road users aggregated, VRUs and non-VRUs. For all road users aggregated, at country level RTI mortality rates decreased sharply within each country income level and each region between 1990 and 2013, but an increase of 21% was found in LMICs of Sub Saharan Africa (SSA). Mortality rates for VRUs and nVRUs also decreased remarkably except among non-VRUs from LICs where the mortality rates increased by 16%. For VRUs, the reduction in mortality rates was more than twice as high in HICs (58%) and LICs (43%) than in UMICs (20%) or LMICs (23%). Considering country income level within regions revealed increased mortality rates for non-VRUs in LICs of South Asia by (26%) and for both non-VRUs (5%) and VRUs (35%) in the LMICs of SSA There have been considerable reductions in RTI mortality rates globally and by region of the world since 1990. While there is a need for enhanced RTI prevention globally, these findings call for the intensification of preventative efforts in specific parts of the world.

The Philippines is a low-middle income country with an estimated population of 102 Million and a 2.18 annual population growth rate. The consequent urbanization has rapidly increased the number of motor vehicles resulting in increased number of road traffic injuries in the country. According to the World Health Organization, next to assault, road traffic crashes are the second leading cause of injury deaths for all ages. Among 0 to 17 years old children, road traffic crashes is also the second leading causes of deaths, next to drowning. In 2004, Safe Kids Worldwide Philippines (SKWP) and FedEx worked hand in hand to address this problem using a pedestrian safety program called “Walk This Way”. The aims are to educate the children on pedestrian safety and improve the walking environment of the schools thereby improve the safety of children and other road users while on the roads. SKWP and FedEx started to organize and build coalitions in five cities and used the three E’s - Education, Engineering and Enforcement. For education, it tries to transfer the knowledge by giving training to principals, teachers, children and parents on pedestrian safety. The Engineering component looks into improvements in the walking environment of the children and their guardians to and from the schools by working with concerned government and non-government organizations. The Enforcement component on the other hand seeks to improve implementation of pertinent laws through dialogues, advocacies and events. The Walk This Way Program has been implemented in 6 cities in the span of 11 years, 5 in a given year. In 2014 a modified approach, the Young Road Safety Advocate Program (YRSAP) was introduced. This “peer to peer” approach enlists senior outstanding students to teach younger students in their own schools. The last two years saw the training of about 900 outstanding students on pedestrian safety who in turn taught approximately 100,000 younger students. The Safe School Zone Project was developed in 2009 and was able to improve four (4) public elementary schools through road safety environment education and the installation of road signs and permanent barriers. Safe Kids Worldwide Philippines through the partnership with FedEx has been recognized in the country in the field of injury prevention programs. SKWP has been invited by the Department of Health to be a member of the Technical Working Committee on Violence and Injury Prevention. Coalitions with the various cities and elementary schools have helped increase the knowledge of over a Million children on pedestrian safety. The National TV Networks have recognized and utilized SKWP in discussions about Road Safety and has become a main resource on the recently enacted helmet law for children. National and local governments together with the involved non-government organizations have looked to Safe Kids Worldwide Philippines as a key organization in Children’s Safety Programs.

The World Report on Road Traffic Injury Prevention of 2004 recommended that the newly motorizing countries establish road injury surveillance to define the burden, identify high-risk groups, plan intervention and monitor their impact. Despite its stated importance in the literature, very few examples of sustained surveillance systems are reported from low income countries. This presentation shares the results of an urban RTI surveillance program that has been running for the past 8 years since 2007 in the emergency departments of five major hospitals in Karachi, Pakistan. We describe the process of establishing the road injury surveillance system incorporating a multi-institution research group including physicians and transportation engineers. Data was collected from 5 city-wide hospitals with details of the injury, severity scoring and information of the circumstances of the crash. Site visits supplemented this data and the results were disseminated to municipal authorities along with low cost engineering solutions to rectify hazards in the road network. In the 8 years between 2007 and 2014, 262,269 road injury victims were registered by the surveillance system. Though 76% of the injuries were categorized as “minor”, 20% led to hospital admission and in 3% deaths occurred. The information on location of crashes and site visits led to an extensive catalogue of road network hazards and their rectification led to demonstrated reductions in crash frequency. Data was also used for safety advocacy in groups found to be vulnerable in the surveillance, such as motorcyclists, road sweepers and school going pedestrians. We demonstrate that a functional RTI surveillance program can be established and effectively managed in a developing country. The data collected and analyzed from the victim’s perspective can be a potent tool for effecting safety education and hazard rectification. Reference: Razzak J.A. , Shamim M.S. , Mehmood A. , Hussain S.A., Ali M.S. & Jooma R. (2012). A successful model of Road Traffic Injury surveillance in a developing country: process and lessons learnt. BMC Public Health, 12: 357

Road safety is a major public health concern. Between 2008 and 2010 an average of 220 people were killed each year and over 550 people were seriously injured in the State of Qatar because of road crashes. Qatar Red Crescent (QRC), as a member of The International Federation of Red Cross and Red Crescent (IFRC) which is the host of The Global Road Safety Partnership, has identified the road safety as one of its priorities to save lives and build safer communities. Methods used: • Advocate the prioritization of road safety on government's agenda. Internal road safety culture for the staffs and volunteers. • Public awareness campaigns on safe road use. Road safety education for students. • First aid courses for drivers, police officers, and the general public. QRC advocated for road safety through its involvement in the National Traffic Safety Committee. QRC volunteers and staffs, about 2500, committed to the ten road safety commitments of IFRC. The "On the Road of Safety" and "For a Safe Driving" public awareness campaigns targeted 5000. QRC school program promotes safe road practices between students, teachers, staffs, and the parents through the students. It targeted 1650 in 2014. QRC first aid training for students program "I am a paramedic" trained 16200 students between 2008 and 2015. QRC provides first aid training, with a special chapter about road safety, for about 4500 yearly. QRC assisted in writing the first aid chapter of the new driving manual in the State of Qatar. QRC is in the process of establishing partnership with the ministry of interior to provide first aid training for police officers and driving schools students. QRC will continue to have a strategic attention to continuous public education about road safety and first aid to bring death and injury down. References: 1. Global road safety partnership annual report 2013 2. Qatar National Road Safety Strategy 2013 -2022 3. IFRC 2010-2011 road safety program

The advent of the Big Data era has transformed the outlook of numerous fields in science and engineering. The transportation arena also has great expectations of taking advantage of Big Data enabled by the popularization of Intelligent Transportation Systems (ITS). The challenges in the transportation system are many, ranging from increase in travel demand, growth in congestion, need to improve safety to the reality of limited resources. Thus there is a need for more Pro-Active Traffic Management to dynamically manage recurrent and non-recurrent incident-related congestion based on prevailing traffic conditions. Processing this large data requires different analytical and data mining techniques. The presentation addresses several concepts and examples of using big data analytics. Dr. Abdel-Aty presents examples from many projects currently ongoing at the University of Central Florida (UCF). These projects deal with applications of big data analytics in safety and operation. The speech shows examples of UCF research using big data in safety analysis, adverse weather conditions and safety planning. Real-time safety, operation and adverse weather analysis are presented. For example, the viability of monitoring and improving traffic safety and operation on urban expressways in Central Florida using real-time Microwave Vehicle Detection System (MVDS) data is researched. From the perspectives of volume, velocity and variety, the MVDS should be regarded as one of the main sources of Big Data. The detection system archives spot speed, volume, lane occupancy, and vehicle type per lane on a minute basis. Real-time safety risk evaluation was developed for several expressways based on these data. Other big data applications involve combination of census, planning, safety, roadway and land use data to improve safety planning. This extensive research shows the promise and possibilities for the development of real time applications to primarily improve road safety in the context of Pro-active traffic management. It also demonstrates the transformation occurring in safety research and applications based on big data.

The Qatar Mobility Innovations Center (QMIC) has defined an integrated innovations strategy for developing and deploying local solutions and applications that tackle road safety in Qatar and the region. This strategy is based on utilizing distributed data and connected devices to deliver intelligent user-centric services and applications that will tackle different problems contributing to road accidents in Qatar and the region. In this presentation we will review key elements of this strategy, solutions, and applications that have been deployed to-date in Qatar and the ones which are under-development and pilot deployments. In particular, we will highlight the progress made in deploying a national traveler info system for delivering relevant location-based services and alerts, and a national telematics platform and services in support of monitoring driver performance. In addition, we will review the solutions being developed and deployed to minimize the use of mobile phones while driving for both consumers and enterprise segments which are part of the Salamtek (Innovations for Distracted Driving) national initiative which was launched in 2014. Finally, we will discuss the progress made in realizing a connected vehicle program in Qatar (based on using standard-compliant car-to-car and car-to-infrastructure communication protocols and technologies) and the significant potential impact in reducing road accidents in Qatar.

Traffic crashes are the obvious and tragic outcome of a complex process of which traffic, human factors, roadway engineering and surrounding environment are all contributing factors. Traffic operations, however, inflict more physical and psychological harm on human health, albeit, it is not immediately obvious as crashes. Some of those harms show symptoms over longer terms, possibly a lifetime. That, however, does not change the fact that such harms are serious infractions of public health and community wellbeing. Is there a case for traffic medicine to expand scope and involve coverage of other traffic harms? Literature and studies have now clearly demonstrated the strong direct and indirect influence of transport planning, design, and operations- including travel choices and traffic operations--on public health including traffic crashes. Beyond crashes, long term-health impacts of transport decisions and practices are now established facts. This talk will make the point that the scope of traffic safety need to move beyond the prevention (and management) of serious crashes and injuries to the promotion and adoption of transport policies and traffic operation measures that, in addition, preserve and promote public health and community wellbeing in a broader sense. It is argued that such policies and measures will, in the mid- to long-term and as a matter of necessity and logical connectedness, result in travel decisions—as in trip making and mode and route choices—and traffic operation measures—as provision of space and junction control—that, collectively, foster calmer and more equitable thus “healthier” traffic operations. The result is both short- and long-term public health improvements including reduced risks of serious crash injuries. A case study of health impacts of traffic congestion is presented. While reduction of serious crash is an urgent need the world around, the notion of traffic polices and operations as a tool to promote public health is not as obvious nor has it been part of the domain of traffic/transportation engineering or planning. The case is made that traffic operations impact public health and community wellbeing well beyond crashes, and that the professions of traffic/transport and public health collaboratively must adopt a more holistic approach to traffic safety and health: one that goes beyond immediate concerns with serious traffic crashes to one that promotes long-term healthy living of which managing serious crashes is only a part. Towards this end, changes in policies, culture, education, planning, engineering, and systems operations will be necessary, as is a systems approach.

Trauma systems have been shown to improve outcomes for trauma victims with severe and multiple complex injuries in many Western settings. This same effect have not been adequately demonstrated in rapidly developing economies nor specifically for patients with road traffic injuries [RTI's]. This session will present temporal trends in the development of the trauma system and their effect on RTI patient outcomes in Qatar. A review of each of the components of the trauma system, from pre-hospital services, emergency room care, ICU indicators, quality improvement programs, trauma registry, continuing staff education, clinical research, injury prevention and rehabilitation and their measureable impact in RTI’s will be presented and recommendations will be made for the next steps in the continued development of a national trauma system for Qatar.

Oman has undergone a rapid epidemiological transition, and has witnessed substantial social and economic changes in the last four decades. Based on oil revenues, the government of Oman has accelerated the development, in the present context, of road network and rapid growth of motorization. Despite the positive side of the substantial development, however, there are other challenges appeared on the scene that have negative impacts. Today, road traffic crashes, injuries and fatalities are a public health challenge in Oman in terms of immeasurable human suffering along with the huge economic and social costs incurred as well as becoming a burden on health sector i.e. main external cause of morbidity, particularly among young and adults. Oman presents a fertile ground to explore the contributory factors of road traffic crashes and their consequences of injuries and fatalities. Recognizing the importance of research to understand road traffic injuries and provide effective interventions, The Research Council initiated a strategic program for road safety research within Oman in April 2010, the Road Safety Research Program (RSRP). The main objective of the RSRP is to promote scientific research and build national capacity in road safety research for the purpose of supporting decision makers in implementing evidence-based solutions to combat road traffic injuries in the Sultanate of Oman. The RSRP has operated on the basis of competitive and commissioned research grants as means to promote innovative research projects that would have a direct bearing on reducing the burden of road traffic injuries (RTI) in Oman. This presentation will highlight major projects funded within the RSRP that address low enforcement and traffic policing as a major intervention for road safety. In particular, this presentation will present findings from projects exploring traffic policing in Oman, evaluation of the deterrence practices for heavy vehicle safety, and traffic enforcement for novice driver safety. The presentation will also present some of the findings of a series of qualitative observations and interviews were conducted in Oman with 47 truck drivers. One objective of these observations was to explore the role enforcement strategies by the police in mitigating the risk of road traffic crashes of heavy vehicles using the deterrence theory. In addition, the presentation will show some of the findings from a study sought to explore the relationship between policing enforcement as well as current licensing system and young driver behavior using Akers' social learning theory. The study was conducted among 1319 Omani young drivers (72.9% Male and 27.1% female). Finally the presentation will discuss the implication of the findings of these studies suggest recommendations for improving deterrence and police enforcement in Oman and the region to improve road safety.

Introduction: Road traffic injuries are the leading cause of death among young people, aged 15-29 years (1). It is generally accepted that the high rate of adolescent injuries may be due to a variety of factors. Studies have shown young drivers are more likely to underestimate the probability of specific risks caused by traffic situations, as well as to overestimate their own driving skills making them more vulnerable to trauma. It has also been hypothesized that adolescents are more prone to motor vehicle collisions due to their risk-taking attitudes (2). There is consensus among experts in the field of road safety that the best road safety strategies and programs are based on research-driven and psycho-social theories of behavior (3). The P.A.R.T.Y. (Prevent Alcohol and Risk-Related Trauma in Youth) Program is one of those programs. Developed in 1986, P.A.R.T.Y. is a one day, in hospital injury awareness and prevention program for youth aged 15 and older. The goal is to provide young people with information about trauma that will enable them to recognize their injury risks, make prevention-oriented choices and adopt behaviours that minimize unnecessary risks through vivid clinical reality. Attitudes towards risk taking in traffic have been correlated with aggressive driving behavior, speeding, and intention to commit traffic law violations. Thus, an effective intervention to increase road safety may be to change the attitudes that influence the driving behavior of adolescents. This is consistent with the cognitive dissonance theory, which states that changing the beliefs that underlie certain behaviors can cause a behavioral change (2). From these theories, one can expect that changing the risk taking attitudes of adolescents can lead to a decrease in the probability of collisions. A recent meta-analysis suggested interventions aimed at influencing attitudes might be the most effective measure to improve safety on the roads (2). Methods: Several research studies have been undertaken to determine effectiveness and changes in attitudinal risk behavior from youth attending the P.A.R.T.Y. A ten-year longitudinal study was conducted to determine whether students who attended P.A.R.T.Y. had a reduction in injuries compared with a matched control group of students based on age, gender and geographic area who did not attend the program. Students follow the course of injury from occurrence through transport, treatment, rehabilitation and community re-integration phases. Additionally by augmenting a didactic format through a technologically innovative approach including but not limited to vivid clinical reality, social media, interactive websites and simulators we see attitudinal and behavioural changes. Results: The 10 year longitudinal study showed P.A.R.T.Y. participants had a lower incidence of traumatic injuries than a control group of non-P.A.R.T.Y. participants of the same age, gender, residential area, and initial year in database, during the 10-year study (4). Conclusion: Research-driven, psycho-social theories of behavior and technologically innovative approaches have proven it is possible to influence behavior through the delivery of well-designed and well-executed road safety strategies, programs and campaigns. Providing students with real-life education to depict the vivid clinical reality of injuries was shown to be a compelling and effective method of education. References 1. Road safety basic facts. World Health Organization. 2013 [cited July 28, 2015]. Available from:http://www.who.int/violence_injury_prevention/publications/road_traffic/Road_safety_media_brief_full_document.pdf 2. Pal Ulleberg, T.R., Risk-taking attitudes among young drivers: The psychometric qualities and imensionality of an instrument to measure young drivers' risk-taking attitudes. Scandinavian Journal of Psychology, 2002. 43(3): p. 227-237. 3. Road Safety Campaigns: What the research tells us. Traffic Injury Research Foundation.2015 [cited July 7, 2015]. Available from: http://www.tirf.ca/publications/PDF_publications/2015_RoadSafetyCampaigns_Report_2.pdf 4. Banfield JM, Gomez M, Kiss A, Redelmeier DA, Brenneman F. Effectiveness of the P.A.R.T.Y. (prevent alcohol and risk-related trauma in youth) program in preventing traumatic injuries: A 10-year analysis. J Trauma. 2011 Mar;70(3):732-5.

Qatar is one of the 20 countries of the IDF MENA region. Three hundred and eighty seven million people have diabetes worldwide and more than 37 million people in the MENA Region; by 2035 this will rise to 68 million. There were 303,700 cases of diabetes in Qatar in 2014. Large number of diabetic patients will seek or currently hold a license to drive. Most of these patients are either on oral medications or insulin to control their diabetes. Hypoglycemia is one of the major complications related to diabetes treatment. Many large studies have shown an increased risk of hypoglycemia with tight blood sugar control. Unfortunately most diabetes medication can cause hypoglycemia. Hypoglycemia has been associated with cardiac arrhythmia, a decreased ability to drive and driving mishap. Recent meta-analysis of 15 studies showed a risk road traffic collisions (RTC) of 12-19% greater than general populations. The most significant subgroup of persons with diabetes is those on insulin therapy. The single most significant factor associated with RTC appears to be history of recent severe hypoglycemia. Government regulations have not been established in most of GSC and MENA in general. All EU countries do have regulations for diabetes and driving. Many US states have a restrictive license program for drivers with medical conditions including diabetes. These regulations include more frequent medical examination to denial of driving license, e.g.in those patients with hypoglycemia unawareness. Also more restriction regulations have been established for drivers who are using insulin and buses and heavy goods trucks.

Young drivers run a greater risk everywhere. Better understanding of the underlying processes to this problem are a useful tool in preventive endeavors. An understanding that a person’s life ambition and context of driving mostly influence young drivers in terms of traffic safety more than their ability of mastering different driving situations and their skill of vehicle maneuvering is important to understand young drivers overrisk. Research has indicated that a hierarchical approach to the task of driving can help to identify specifically which skills a driver needs to avoid crashes and injuries. Keskinen (1996) divided the task of driving into four separate levels (4. goals for life and skills for living, 3. goals and context of driving, 2. mastering traffic situations and 1. vehicle maneuvering) in which the higher levels are considered to always affect behavior on the lower levels.The idea behind a hierarchical approach is that success as well as failure on the higher levels will affect the demand on lower levels (Hatakka et al. 2002). Keskinen and others later developed a proficiency model comprising Goals for Driver Education (GDE) (Hatakka et al. 2002). The GDE matrix states specifically what driver training should focus on in order to produce the safest possible new drivers. Understanding the GDE matrix offers the possibility to use it to develop different countermeasures for young drivers. If this is adapted as closely as possible to this group and their driving situations, it should be possible to significantly enhance safety. Driver education or communication campaigns cannot be expected to radically change a young person’s life goals. Special courses for young drivers designed to make individuals conscious of their personal tendencies and the type of social context that affects their driving behaviour could be helpful, whether offered via the ordinary school system or at driving schools.To change a young driver’s goals behind driving and the context in which it is done, a variety of different methods of persuasion should be used. For example, communication campaigns and increased enforcement may be used simultaneously and in particular target young males. (Engström et al. 2003). Communication campaigns that employ persuasive, emotional messages are most effective where young drivers are concerned. Attitudes about safety are formed at an early age, long before legal driving, and therefore it would also be important also to target young adolescents. Laws need enforcement to be effective and should target areas of particular risk to young drivers References Engström I, Gregersen NP, Hernetkoski K, et al. (2003) Young novice drivers, driver education and training: A literature review. Linköping, Sweden: Swedish National Road and Transport Research Institute. Hatakka M, Keskinen E, Gregersen NP, et al. (2002) From control of the vehicle to personal self-control; broadening the perspectives to driver education. Transportation Research Part F 2002;5:201–15. Keskinen, E. (1996). Why do young drivers have more accidents? Junge Fahrer und Fahrerinnen. Referate der Ersten Interdiziplina¨ren Fachkonferenz, December 12–14, 1994 in Cologne. Berichte der Bundesanstalt fur Strassenwesen. Mensch und Sicherheit, Heft M 52, 1996.

As President of the German Road Safety Association and Vice President of the German Road Safety Council, I strongly force the way of the Vision Zero as a permanent strategy to reduce accidents and to avoid victims of the fast-growing road traffic. In this strategy are some components which have to be realized. One is an intensive campaigning for more safety by changing the behavior of the car users inside the traffic and the mobility of passengers, but also strict rules which have to be accepted by car owners and users. The third main aspect is the construction of roads with a self explaining structure (to be secure by using them). Last but not least we need a functioning rescue system for the victims of accidents which helps to save life in the worst case. All those measures have to be implement in a short time in order to achieve educational effects on the one hand and to reduce accidents on the other. Our international experience in Europe, Iran and China are good basements for the necessary roll out processes.

Within the German road traffic safety system, the Medical-Psychological Assessment (MPA) has a more than six-decade-old history and tradition. According to the German traffic law system a driver has to make sure to drive only in a good physical and mental condition and to obey the traffic regulations. If drivers are sanctioned for driving under the influence (alcohol), driving while intoxicated (illegal drugs) or received offences for reverse or repeated violations to traffic rules etc. they have to pass the MPA before getting their driving license back or to avoid a withdrawal of their driving license. The MPA is an integrated medical and psychological examination usually containing the elements •Questionnaire (biography, driving history, knowledge of driving rules) •Medical examination (medical history, physical examination, laboratory analysis) •Psychological interview ((alcohol or drug consumption style, change of behaviors and attitudes, perception of problems in future) •Psychophysical computer-based test of cognitive functions (reaction capacity, visual perception, concentration, vigilance) The examination can be complemented by a driving test in real traffic under defined conditions. The integration of the data from different sources is outlined in a basic manual, the MPA-Expert-Manual, which is published. Inspection principles and rating criteria to identify the quality and intensity of the drivers personal problems (e.g. alcohol addiction, abuse of alcohol, habituation of high consume levels, risky attitudes to drive under the influence), the process of change and the stability of the behavior in future funds the interdisciplinary decision-making procedure, and lead to a MPA-report that is transparent and traceable for public servants or court members. Due to the importance of this measure for the applicants and for traffic safety the MPA has repeatedly been evaluated in terms of its effectiveness (recidivism rates after a probation period of 3 years, data from the Central Index for Traffic Offenders of the Federal Motor Transport Agency). The results show over the years a decrease of the percentage DUI- and DWI-offenders with a relapse (current state A 8 %) and therefore indicate the predictive reliability of the MPA. There are still problems with drivers with multiple traffic offences (e.g., speeding, tail gaiting), who have a relapse rate of more than 40 %. Altogether the MPA-system in Germany can be regarded as an effective measure in the German licensing procedure in preventing recidivism and an important approach for improving traffic safety.

In a general sense Traffic Medicine in the Netherlands concerns multidisciplinary research about how to reduce traffic crashes and injuries following a “systems approach”. Several universities and research institutes are involved, including the SWOV research institute of traffic safety( 1). In a specific sense Traffic Medicine in the Netherlands concerns researching and applying regulations and methods for assessing and improving fitness to drive in persons with impairments in physical and mental functions which are relevant for driving. Important recent developments in the general and specific field are discussed. Because the Netherlands is a flat country with a moderate climate and generally small distances between destinations, bicycling is a very important mode of transport also for older persons. In general traffic safety has improved tremendously over the last years but much less so for older (65+) cyclists. This is particularly problematic because the older population is increasing and with the arrival of the e-bike, cycling is increasingly popular. Several approaches to improve bicycle safety have been proposed. The Netherlands is part of the European Union (EU) and medical aspects of driver licensing are based on Directives (2) of the European Parliament and Council. The European directive is not very detailed with regard to medical fitness to drive and individual countries can have more specific regulations. For example with regard to neurological disorders and dementia the EU directive states that: “driving licenses shall not be issued to, or renewed for, applicants or drivers suffering from a serious neurological disease or severe behavioural problems due to ageing, unless the application is supported by authorized medical opinion, and if necessary, subject to regular medical check-ups”. It will be discussed how, based on medical consensus and multidisciplinary research, this requirement has been implemented in the Netherlands. In empirical research persons with moderately severe visual (visual acuity < 0.5; homonymous hemianopia) and cognitive impairments (traumatic brain injury; stroke) have been systematically observed when actually driving. On average, driving was poorer in patients than in healthy subjects but many subjects in the patient groups drove safely and fluently and performance was not predicted sufficiently from medical and psychological characteristics (3,4). They appeared to compensate effectively, sometimes also helped by technology, for example the bi-optic telescope, and by visual training and special driving lessons. This has led to changes in regulations such that in the case of moderately severe visual and cognitive impairments on-road tests of “practical fitness to drive” have become important additions to the conventional medical and psychological assessments. Developments in intelligent driver support and autonomous vehicles promise further opportunities for compensating driver impairment but unwanted behavioural changes (adaptation) must be avoided (5). References: 1.SWOV publishes great overviews of recent developments in traffic safety research in its factsheets: http://www.swov.nl/uk/Research/factsheets.htm 2.Directive 2006/126/EC of the European Parliament and of the Council of 20 December 2006 on driving licenses including more recent amendments: http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=URISERV:l24141 3.Coeckelbergh T.R.M, Brouwer W.H., Cornelissen F.W., Kooijman A.C. 2004).Predicting practical fitness to drive in drivers with visual field defects caused by ocular pathology. Human Factors,46, p.748-760. 4.Brouwer, W.H., & Withaar, F.K. (1997). Fitness to drive after traumatic brain injury. Neuropsychological Rehabilitation, 7, p.177-193. 5.Dotzauer, M., Caljouw, S. R., De Waard, D., & Brouwer, W. H. (2015). Longer-term effects of ADAS use on speed and headway control

High-risk drivers (HRDs) prone to repeat episodes of dangerous driving are over-represented in road traffic morbidity, making them important targets for selective prevention. Better understanding of why some drivers engage in risky behavior is a necessary precursor to the design of effective prevention programs. Nevertheless, HRD research has traditionally focused on healthy young drivers and their self-reported personality features and driving behavior or intentions, and not on bona fide HRD populations and direct observation of their risk-taking behaviors of most concern. In total, the complex nature of HRD is not adequately addressed. A contemporary paradigm for understanding HRD behavior is to identify meaningful subgroups whose members share common characteristics and pathways to risk taking, and thus are likely to show selective treatment responsivity. For this approach, a more integrative, deep-level approach (i.e., beyond reliance on subjective reports) is advantageous. Previous studies by our group into different forms of HRD reveals dysregulation in two neurobiological systems, executive control related to the prefrontal cortex (e.g., 1,2,3), and the cortisol stress response related to the hypothalamic-pituitary-adrenal axis (e.g., 4,5). While promising, the findings are fragmented. We recently recruited three distinct HRD groups (males, N = 138, aged 19-39 years) based upon documented driving behavior: 1) drivers who engage in multiple forms of risk taking; 2) speeders/reckless drivers; and 3) alcohol impaired drivers, as well as a healthy, aged-matched, non-HRD control group. Assessment included psychosocial adjustment, personality, functional tests and assays of the above neurobiological processes, and simulated driving behavior. Our main hypothesis was that each HRD subgroup possesses a distinct biosocial profile. Preliminary results supported our hypothesis. The mixed profile closely resembles a ‘cold’ antisocial phenotype in which chronic under arousal interferes with avoidance learning - which leads to asocial risk seeking. The speeders/reckless drivers comprise a phenotype involving the most dangerous behavior and externalizing features, including competitiveness, impulsivity, reward driven decision-making, and weak inhibitory control. Interestingly, the impaired drivers showed poor inhibitory control, alcohol misuse, yet safe driving in simulation. This suggests that their risk taking involves and interaction between alcohol misuse and poor inhibitory control. Overall, these findings signal that development of novel and targeted HRD interventions may come from more integrative research approaches. References: 1. Bouchard SM, Brown TG, Nadeau L. Decision-making capacities and affective reward anticipation in DWI recidivists compared to non-offenders: A preliminary study. Accident Analysis & Prevention. 2012;45(2):580-7. 2. Ouimet MC, Brown TG, Nadeau L, et al. Neurocognitive characteristics of DUI recidivists. Accident Analysis & Prevention. 2007;39(4):743-50. 3. Dedovic K, Pruessner J, Tremblay J, Nadeau L, Ouimet MC, Lepage M, Brown T.G. Examining cortical thickness in male and female first-time driving while impaired with alcohol offenders. Neuroscience Letters. 2015; In review. 4. Brown TG, Gianoulakis C, Tremblay J, et al. Salivary cortisol: a predictor of convictions for driving under the influence of alcohol? Alcohol & Alcoholism. 2005;40(5):474-81. 5.Ouimet M, Brown TG, Guo F, et al. Higher crash and near-crash rates in teenaged drivers with lower cortisol response: An 18-month longitudinal, naturalistic study. JAMA Pediatrics. 2014;168(6):517-22.

Safe driving campaigns in Qatar are in their infancy. The first campaigns were fear appeals that typically involved pictures of vehicles that had been smashed almost beyond recognition in accidents posted on signs around the capital city, Doha. A second generation of campaigns has recently been developed that are also fear appeal based, but feature more sophisticated messaging and visuals than the first group did. While laudable in their goals, both set of campaigns are not based on either a theoretical framework or research on the target audience. Evaluation research on the specific campaigns has not been conducted making assessment of message efficacy difficult. Even if the campaigns have had some effectiveness, 18-25 year old Qatari men, our target audience, continue to be the highest risk group, involved in a disproportionate number of MVCs, suggesting the campaigns are not working for this cohort at all. One of the common reasons message campaigns fail to have the intended effect is the lack of correspondence between the message content, form and design and the audience’s attitudes and beliefs (Yzer, 2012). The stronger the match is between the message and the audience, the higher the likelihood of persuasion. Creating a message that is closely tailored an audience requires an understanding of the way they think and are likely to respond to messages. We conducted focus group discussions with 18-25 year old Qatari male drivers to discover their driving attitudes and behaviors to provide guidance for tailored message campaigns designed to change their attitudes and behavior. We discovered that the perceived capability of actually changing one’s behavior is seriously impeded by a couple of characteristics our respondents shared and that they typically engage in quite risky driving behaviors. The two characteristics our respondents reported are fatalism and high sensation seeking. Fatalism is a belief that what happens to a person is not as a result from their own behaviors but rather is caused by an entity higher that them, typically God, but non-religious people can nonetheless still have high levels of fatalism (Shen & Condit, 2012). A high level of fatalism presents a challenge to message campaigns because the message recipients, who believe they do not have control over their own fate, may reject the desired behavioral change. High sensation seeking increases the resistance to a more negative attitude toward reckless driving – because it is rewarded by both the psychological pleasure derived from dangerous actions and by young men’s peers. Driving at excessive speeds and refusing to wear seat belts are some of the high-risk behaviors our respondents reported. The combination of fatalism and high sensations seeking coupled with routine engagement in risky driving behaviors makes our respondents a particularly difficult group in which to inspire behavioral change. Message campaigns must take these factors into account to increase their likelihood of success and decrease the high MVC rates that are taking too many young lives in Qatar. References Shen, L. & Condit, C. (2012). Addressing fatalism with health communication messages. In Health Communication Message Design, Ed. H. Cho, Sage. Yzer, M., (2012). The integrative model of behavioral prediction as a tool for designing health messages. In Health Communication Message Design, Ed. H. Cho, Sage.

International statistics show that Australia is one of the top 10 countries in terms of road crashes per 100,000 population. In spite of this, four people are killed and 90 seriously injured every day on Australian roads. In 2011, the Australian Transport and Infrastructure Council released a National Road Safety Strategy (NRSS) for Australia, calling for a reduction of at least 30 percent of deaths and serious injuries on our roads by the year 2020. The strategy is based on Safe System principles embracing the principle that in the longer term, no person should be killed or seriously injured on Australian roads. It accepts that people using the road network will inevitably make mistakes and that the road system must be more forgiving of these errors. It relies on better management of crash energy within the system to keep this within human tolerance. This adherence to what is generally known as Vision Zero aligns Australia with international best practice. To help achieve the immediate goal outlined in the strategy, a National Road Safety Action Plan (NRSAP) was recently adopted for the first three years from 2015 to 2017 focusing on four key areas – Safe Roads; Safe Speeds; Safe Vehicles; and Safe People. The action plan is focused on national efforts and activities to achieve long-term and permanent reductions in road trauma in line with the NRSS target. It aims to achieve these improvements through strategic investment in infrastructure and vehicle safety initiatives using best practice and capacity building as shown below: 1.Safe Roads: The plan calls for short- and long-term initiatives for road improvements based on best available evidence on road authorities at all government levels is necessary to ensure that Safe System principles are applied to all new road projects. 2.Safe Vehicles: Comprehensive regulatory and consumer tests are called for to ensure that proven safety design features and technologies are mandated in new Australian vehicles as quickly as possible. 3.Safe Speeds: Speed enforcement has been shown to be an effective management tool against speed-related crashes. The plan calls for a number of initiatives aimed at reducing speed-related risk. 4.Safe People: Various initiatives were outlined to improved driver and rider risk such as supervised learner driving hours, provisional licence periods, passenger night time restrictions, sanctions for speed and alcohol offences, and mobile phone bans. The strategy notes that there is potential to achieve large and lasting road safety benefits for all Australians, providing there is significant commitment by government and non-governments in implementing the actions outlined. If the strategy is to be successful, it will be necessary to maintain this trend in fatal and serious injury improvements, achieving a target of around 860 deaths and associated serious injuries by 2020. It will be quite a challenge to maintain this trend over this decade but clearly important in terms of road trauma improvement in Australia. Disclaimer: The views expressed in this paper are those of the author and do not necessarily reflect those of the Australian Transport and Infrastructure Council, its partners, and Monash University.

Road deaths and injuries are increasing in India due to unprecedented motorization and expansion of infrastructure amidst absence of strong road safety policies and programmes. In 2014, 141,000 persons died and 4,77,731 persons were injured as per official reports (1). However, data from World Health Organization, Global Burden of Disease 2013 and independent Indian studies estimate these numbers to be much higher due to underreporting of Road Traffic Injuries (RTIs). Nearly 10-30% of hospital registrations are due to RTIs and majority of them are discharged with varying levels of disabilities. Individuals in the age group of 15-44 years, men and, middle and poorer sections of society are affected most in RTIs. Pedestrians, motorcycle riders / pillions and bicyclists, the vulnerable road users, are killed and disabled in large numbers. The economic losses from road crashes are estimated to be 3% of GDP and are increasing from year to year (2). Amidst significant regional variations, many Indian states have road deaths much above the national average. Indian states that have progressed in development, infrastructure, education and per capita incomes also have the highest rates. While urban deaths account for nearly a fifth of total deaths and injuries, Indian highways account for more than 50% of deaths and injuries and are likely to increase with further growth in infrastructure (1). This distribution clearly implies that transport and mobility growth should be accompanied by road safety as well. Road crashes occur due to a complex interaction of human, vehicle and environmental factors in heterogeneous transport environments. Despite the growing number of crashes, the understanding of road crashes in India has been limited. All official reports till date indicate ‘human error, driver negligence, rash driving, careless driving’ as the major cause, thereby implicating human behaviour to a larger extent. However, independent limited research in recent years has informed that several issues in road environment, vehicle safety, behaviour of road users, enforcement of safety laws, availability and affordability of trauma care and others are responsible for both causation and poor outcomes in road crashes (3). Most glaringly, the absence of an efficient road safety management system has resulted in piecemeal and fragmented solutions. Many high-income countries implemented systematic interventions based on a scientific understanding of road safety (Haddon’s matrix, safe systems approach, public health understanding, and others) and successfully demonstrated that road crashes are predictable and preventable (4). As the causes for road crashes are multiple, interventions need to be several and needs prioritisation in India. Road safety management through a clearly defined road safety policy, a central coordinating agency to guide-coordinate-monitor-direct-implement and evaluate activities, improving human/financial/ physical resources are urgently required to develop a road map for future activities. Safe infrastructure development through low cost and sustainable engineering solutions that are geared for people’s needs and travel patterns addressing both mobility and safety is critical. Vehicle safety that adheres to safety standards is vital to make people safer. Strict implementation of proven and effective interventions (e.g., helmets and safety belt laws, drink drive laws, speed control measures, and visibility related measures) are required to make people safe and reduce poor outcomes. Good trauma care practices that include rehabilitation services are highly essential to save the injured. Undoubtedly, all these activities need to be driven by evidence based practices and data driven systems. As road safety is the shared responsibility of different ministries and departments at this time, it requires participation from health and all other sectors to develop integrated, intersectoral and coordinated approaches (5). References: 1.National Crime Records Bureau. Accidental deaths and suicides in India 2014. Ministry of Home Affairs, Government of India, New Delhi, 2015 2.Gururaj G. Road safety in India- A framework for action. Publication No. 83, National Institute of Mental Health and Neuro Sciences, Bangalore, 2012 3.Gururaj G and Bangalore Injury Surveillance Collaborators Group. Bangalore Road Safety and Injury Prevention Program: Results and Learning, Publication no 81, National Institute of Mental Health and Neuro Sciences, Bangalore, 2011 4.World Health Organization. Global status Report on Road Safety, Geneva, 2013 5.World Health Organization .Global plan for the Decade of Action for Road Safety 2011 – 20, http://www.who.int/roadsafety/decade_of_action/plan/plan_english.pdf?ua=1, accessed on 28th July 2015