AN EPIDEMIOLOGICAL STUDY OF ROAD TRAFFIC INJURY CASES AT A TERTIARY CARE HOSPITAL IN RURAL HARYANA

ABSTRACT
Background- Accidents occur not only due to ignorance but also due to carelessness, thoughtlessness and over confidence. Human, vehicularand environmental factors play role before, during and after a RTA. Evidence from studies show that like all other injuries road traffic injuries are partially predictable and hence preventable.

Objectives- To study the pattern of road traffic accidents, socio demographic profile of road traffic injury victims seeking care at Maharishi Markandeshwar Institute of Medical Sciences And Research, Mullana and to study the antecedent factors influencing the road traffic accidents.


Material And Methods-The present cross sectional study was carried out at Maharishi Markandeshwar Institute Of  Medical Sciences And Research (MMIMSR), Mullana (Ambala). All the victims who reported MMIMSR emergency and various OPD clinics of the institute between September 2009 to February 2011 were included in the study. Various parameters like age and sex distribution, time of occurrence, protective gears worn, injuries sustained, receipt of First -Aid, alcohol consumption, category of road user, vehicles involved in RTA, types of Road Traffic Injuries(RTI), road conditions, environmental conditions etc were studied and valid conclusions were drawn.

Results- There was a marked male preponderance (88.77 %) with maximum involvement of younger age groups. Most of the accidents had taken place in the evening hours (6.1pm - 12.00 midnight). The vulnerable road users like motorized two wheeler, LMV and pedestrians constituted 41.52%, 19.39% and 13.41% respectively. Only 158 of 545 two-wheeler users wore a helmet at the time of injury. 16.24% of drivers did not had valid driving license. Not using indicator lights and not following speed limits were two most common factors responsible for these RTA.
Keywords: Road Traffic Injuries, Accidents, Factors, Epidemiological study.

INTRODUCTION
Road Traffic injuries have emerged as a major global public health problem of this century and are now recognised as “veritable neglected pandemic”. The problem is so severe that, by 2020, it is projected that road traffic disability-adjusted life years(DALYs) lost will move from being the 9th leading cause of disability-adjusted life years lost to the 3rd leading cause in the world and will be 2nd leading cause developing countries.1,2

The magnitude ofRoad traffic accidents(RTAs)and fatalities in India is alarming. In 2009, 4.22 lakh road traffic accidents and 1.27 lakh road traffic fatalities were reported. These numbers translate into one road accident every minute and one road accident death every four minutes. However, this is an underestimate, as not all injuries are reported to the police.3

Human, vehicular and environmental factors play roles before, during and after a trauma eventtherefore accidents have to be studied in terms of an epidemiological model (agent, host and environmental factors) and analyzed in relation to time, place and person distribution. The objective of this study is to find out the pattern of road traffic accidents, socio demographic profile of road traffic injury victims and antecedent factors influencing these RTAsreported to the hospital.

MATERIALS AND METHODS
The present cross sectional study was carriedout at Maharishi Markandeshwar Institute Of  Medical Sciences And Research (MMIMSR), Mullana (Ambala). All the victims who reported MMIMSR emergency and various OPD clinics of the institute between September 2009 to February 2011 were included in the study.

For the purpose of study, a road traffic accident was defined as any vehicle accident occurring on a public road or highway and includes vehicle accidents where the place of occurrence is unspecified.Information was collected by interviewing victim or his/her attendant using a structured interview schedule.

A detailed proforma for the purpose of recording socio-demographic profile of victims, epidemiological data, details of circumstances leading to accidents and other relevant data etc was prepared for the purpose of filling observations of the present study. The collected data wasentered in Microsoft Excel. Coding of the variables was done. SPSS version 11.5 was used for analysis.Interpretation of the collected data was done by using appropriate statistical methods like percentage and proportions.

RESULTS

(A) Socio-demographic profile of the victims
Total 1238 accident cases were included in the study. Majority of the victims (984 cases) were in the younger age group of 15-50 years (79.47%).433 cases(34.97%) were recorded in the age group of 25-39 years. Children less than 14 yrs and elderly (>60yrs of age) made up a little 176 cases (14.21%).1099 (88.77%) of the victims were males with 139 (11.23%) of them being females.
Majority of the victims were Hindus998 (80.62%) with Muslims and Christians forming 18.98% and 0.40% respectively. Of the 1238 victims interviewed 925 (74.72%) were married accounting for 74.72% of the victims, while 313 (25.28%) were not married (for analysis purpose even victims less than marriageable age were included in the not married group).

Majority of the victims had had a primary level of education 31.02%, while 20.27% of the victims were illiterates. 14.46% of the victims had a degree only one victim had a professional degree. 27.95% of the victims had a secondary education. 22.62% of the victims were unskilled labourers like manual labourers and farmers etc. 25.53% of the victims were semi skilled, which included drivers (taxi, auto, maxi cab etc) all the female victims were housewives accounting for 6.70% of the injuries.

(B) Pattern of injuries
Out of the total 1238 (100%) RTA cases, 118(9.53%) had injuries of upper limb, 297 (23.99%) had injury of lower limb, 495 (39.98%) had injury on the abdomen and 328 (26.49%) had multiple injuries at more than one site. (Table-1)
Table -1:Pattern of injuries
Part involved in RTI
Number of victims(%)
Upper limb
118 (9.53)
Lower limb
297 (23.99)
Abdominal
495 (39.98)
Multiple
328 (26.49)
Total(%)
1238 (100)

Severity of RTI/TIS

Mild
688   (55.58)
Moderate
389    (31.42)
Severe
161    (13)
Total (%)
1238 (100)

VULNERABLE  ROAD USERS
Pedestrian
166 (13.41)
Cyclist
112 (9.05)
Motorized two-wheeler
514 (41.51)
3 wheeler
112 (9.05)
LMV
240 (19.39)
HMV
68 (5.49)
Tractor
13 (1.05)
Others
13 (1.05)
Total
1238 (100)

Severity of injuries
The severity of injuries suffered by the victims was graded according to the “Trauma Index”4. According to this index injuries are classified as mild injuries (0-7), moderate (8-18) and severe injuries (more than 18). So in this study it was observed that 688 (55.58%) had a score of 0-7 and categorized under minor injuries, 389 (31.42%) had a score of 8-18 and categorized under moderate injuries and 161 (13%) had > 18 injuries and put under the category of severe injuries. (Table-1)
Ailment at the time of injury
Among the victims 223 (18.01%) of them gave a history of having consumed alcohol within 6 hours before the RTI, whereas 1015 (81.99%) of them had not consumed. children were grouped under ‘NO’ for simplification, however, no information was collected as to the type or quantity of alcohol consumed.
Type of vehicle involved Majority of the victims were two wheeler occupants (riders or pillions) and occupants of Light Motor vehicles 41.51% and 19.39% respectively. Pedestrians became victims in 13.41% of cases. Cyclists and occupants of 3 wheelers made up 9.05% each. (Table-1)

(C) Antecedent Factors
 Days of occurrence of injury:In the present study, 670 (54.12%) accident cases were reported on week days i.e. Monday-Fridays and remaining 568 (45.88%) on weekends i.e. Saturdays and Sundays.
Time of occurrence of injury:497 (40.15%) of the RTIs took place between 6.1pm-12midnight, followed by 357 (28.84%) between 6am-12 noon. 114 caseswith least RTIs occurred between12.1am -6 am (9.21%). (Table-2)

Table -2:Antecedent Factors
Time of Injury
Percentage
Morning(6am-12 noon)
357 (28.84)
Afternoon(12.1pm -6pm) 
270 (21.80)
Evening(6.1pm-12midnight)
497 (40.15)
Night(12.1am -6 am)
114 (9.21)
Total
1238 (100)

What hit you?
Unknown
32 (2.58)
Cycle
20 (1.62)
Motorized two-wheeler
260 (21.0)
Three wheeler
130 (10.50)
LMV ( car, jeep, van)
322 (26.01)
HMV(bus/truck)
160 (12.92)
Tractor
44 (3.55)
Other vehicle
25 (2.02)
Self fall
89 (7.19)
Animal
36 (2.91)
Trees
111 (8.97)
Electric pole
09 (0.73)
Total
1238 (100)

Type of collision
Head on         
204 (16.48)
Sideways
650 (52.50)
From behind         
173 (13.98)
NA
211 (17.04)
Total
100

Place of injury
48% of the RTIs occurred outside the city, whereas 32% of the injuries occurred inside the city. 20% of the RTIs took place on the outskirts of Ambala.

Where injury occurred?
Majority of the RTIs took place on main roads 73.8%, followed by near junctions, 14.2% and cross roads 12.0%.

What hit you?
The vehicles involved in injuring the victims were LMVs most of the times 322
(26.01%) followed by motorized two wheelers 21.0% of the times. HMV hit the victims in 12.92% of the cases. 18 (7.19%) victims said that they sustained injury by self-fall, followed by tractor hitting the victim in 3.55% of the time.

Type of collision Majority of the times it was a sideways collision 52.50% of the times, followed by head on collision 16.48% of the times. 13.98% of the times the victims were hit from behind. (Table-5)

Local environmental condition of the place of injury: Majority of the victims 1045 (84.41%) responded that the road on which the RTI took place was tarred. 149 (12.04%) of the victims responded that the road was rough  and 48 (3.88%) of them responded that the road was wet at the time of injury. 822 (66.2%) of the victims said that the lighting was adequate at the time of occurrence RTI (Injuries that took place during day time were included under ‘adequate’ lighting for analysis). 340 (27.46%) of the victims said that there was no lighting at the site of injury occurrence and 77 (6.22%) of them said that the lighting was inadequate.

Medical aid at the site of injury
Only 4.12% of the victims mentioned that there was medical aid available at the site of injury (within 500 meters from the site of injury).

How injury occurred?
Majority of the victims were injured while there crossing a road 875 (70.68%), 231 (18.66%) of them were injured while they were walking or riding by the side of the road (foot path). 131(10.58%) of them were injured while they were boarding or alighting a vehicle.

Use of helmets and seat belts:
Among the 545 two-wheeler users (riders and pillion) only 158 (28.99%) of them wore a helmet when they were injured, whereas 387 (71.01%) ofthem did not wear a helmet. 693 (55.98%) of them were other road users.
Between the 492 HMV and LMV users only 66 (13.42%) of them used seat belt. Rest of them did not use a seat belt.

Presence of driving licence among drivers:  201(16.24%) of drivers did not had valid driving license.

Cause of event:
Causesresponsible for these road traffic accidents are shown in figure-1 . Not using indicator lights, not following speed limits, no proper road signs were most common causes responsible for road traffic accidents.

Figure-1: Bar diagram showing causes responsible for these road traffic accidents


Post-Injury Factors
Transportation used for reaching Medical Centre
The victims were brought to the hospital by auto 390(31.50%) of the instances, followed by private vehicle 314 (25.36%). The police used their vehicles to bring 220 (17.77%) of the victims to the hospital. 103 (8.32%) of the victims were transported using a taxi, whereas 61(4.93%) victims reached the hospital by bus/minibus. Ambulances brought the victims to the hospital 150 (12.12%) of the instances.


Discussion:
The present study revealed that majority of the RTA victims were in the age group of 15 to 50 years (79.47%) showing maximum involvement of younger age group. Tendency of this age group to show scarce attention to traffic rules & regulations and use of safety devices like helmets, seatbelts, restraints etc can be a possible explanation for the same. In a hospital based study by Ganveer GB majority of the victims were in the age group 18-37 years.5 This shows that the people of the most active and productive age group are involved in RTAs, which adds a serious economic loss to the community. Similar observations were also made by Balogun JA.6
Not surprisingly our study shows the overwhelming majority of the victims (88.77%) were males. It is due to greater male exposure on streets. According to the study done by Nilamber J et al in JIPMER7 study 83% (603) were males and 123 (85.8%) were females.
Regarding educational level of victims this study confirms the results concludedby others.8Above observation indicates that lack of road traffic senses resulting either from illiteracy or poor literacy may have been a significant contributory factor to the causation of road traffic accidents.
It was found in this study that majority of the victims 41.52 %( 514) were two wheeler occupants. Occupants of Heavy motor vehicles accounted for 9.8% of the victims. Cyclists accounted for 5.8% of the victims. According to the community based study done by others.9  Majority of the victims were Two-wheeler users 46.3% (315) and pedestrians 24.9%(169), followed by cycle users (14.1%). Olukoga A.10observed that, 61% of the victims were pedestrians. Findings translate that the pedestrians, cyclists and two wheeler users are vulnerable road users and need to take extra precautions when on road.
Regarding time of occurrence of injury, findings of our studymimics with the findings presented by a report (2009) prepared by Transport Research Wing (TRW), Ministry of Road Transport & Highways, Government Of India, New Delhi.3
In the present study, the higher number of reported accident cases occurred on week days (Monday-Fridays) 54.12%, when compared to weekends (Saturdays and Sundays) 45.88%.Similarly others11,12also observed more accident cases on a weekend Saturday. In another study from Delhi, the highest number of RTAs were observed on Mondays and Wednesdays.13
It was observed in this study that the maximum numbers of injuries were seen in the abdomen and the least in the upper limb. This is in contrast to the study by Biswas G 14who cited that the maximum (56.4%) injuries were found on head and neck, followed by thorax (54.5%) and abdomen (44.5%). External injuries were found more than 905% cases. Other studies15,16also showed a high incidence of head injuries in their series on RTAs. These studies contradict the observations on this aspect of the study.
It was seen that not following speed limits and not using indicator lights were two main causes in more than half of the total RTIs. Since one accident had one or many predisposing factors so these factors are more than the actual cases. Clarke DD17 found high speed vehicle predisposing factor in 65% of  accidents.

Conclusion
Present study showed that RTAs were more common in the younger age groups.Good numbers of drivers were found without valid driving license.The study highlights the need of compulsory implementation of helmet wearing for motorcyclist and necessitates the needfor taking urgent steps for establishing ambulance services and provision of pre-hospitalcare & trauma services. Strict legislation should be adopted in dealingwith rash, negligent driving and driving under theinfluence of alcohol.





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