SafetyCube aims to develop an innovative road safety Decision Support System (DSS) that will enable policy-makers and stakeholders to select the most appropriate strategies, measures and cost-effective approaches to reduce casualties of all road user types and all severities. Work Package 7 of SafetyCube is dedicated to serious road traffic injuries, their health impacts and their costs. This Deliverable discusses health impacts of (serious) road traffic injuries.
BACKGROUND AND OBJECTIVES
Serious road traffic injuries are increasingly being adopted as an additional indicator for road safety, next to fatalities. Reducing the number of serious traffic injuries is one of the key priorities in the road safety programme 2011-2020 of the European Commission. Serious and other non-fatal injuries can have a major impact on the quality of life of a crash survivor and their relatives and also pose a burden to society. The consequences of injuries are very determinative for the costs of injuries for society. Moreover, consequences of injuries differ between casualties. To further optimize road safety policy, it is important to obtain greater insight into the consequences of different road traffic injuries, both for the individual and for society as a whole. This Deliverable discusses the impacts of non-fatal road traffic injuries in terms of:
- Physical/functional, psychological and socio-economic consequences for casualties
- Burden of injury (expressed in Years Lived with Disability)
METHODOLOGY AND RESULTS
Road traffic injuries have a wide range of potential consequences. The International Classification of Functioning, Disability and Health (ICF) provides a framework for discussing consequences for individual road traffic casualties. According to the ICF, road traffic injuries can result in disabilities related to one or more levels of human functioning:
- Problems in body function or structure (impairments), e.g. paralysis
- Activity limitations, e.g. being unable to walk
- Participation restrictions, e.g. being unable to work
The extent to which an injury influences activities and participation of a casualty also depends on personal and environmental factors. By means of a literature review and a number of additional case studies, disabilities due to road traffic injuries related to different levels of human functioning as well as the influence of personal and environmental factors are investigated.
The societal burden of injuries can be expressed in Disability Adjusted Life Years (DALYs). This measure integrates mortality, expressed in Years of Life Lost (YLL) and morbidity, expressed in Years Lived with Disability (YLD). This Deliverable focuses on non-fatal injuries (YLDs). The burden of non-fatal road traffic injuries is examined by means of a literature review and by estimating the burden of road injuries for six countries, applying a method that was developed within the European INTEGRIS study.
Literature review (Chapter 3)
The literature review aims to provide an overview of current knowledge on consequences of road traffic injuries for both individual casualties and their relatives and society as a whole. The review is based on a recent review conducted by SWOV. This review has been extended and updated, and now covers studies published between 2000 and August 2016.
The literature review shows that road traffic injuries can have major consequences for lives of casualties (and their families) and that they create a major burden to society as a whole. According to the Global Burden of Disease Study 2013 (Haagsma et al., 2016), non-fatal road traffic injuries account for 8.6 million Years Lived with Disability (YLD) worldwide. Reported prevalence of disability differs considerably between studies, depending on the characteristics of the casualties taken into account (e.g. injury severity), the duration of the follow-up and the type of disabilities that are taken into account. Self-reported prevalence of disabilities varies for example between 11% and 80% according to the most recent review.
Reported consequences relate to all three levels of human functioning (impairments, activity limitations and participation restrictions) defined in the ICF. Reported consequences of being injured in a crash include for example pain, fatigue, mobility problems, problems carrying out daily activities, impacts on the everyday life of the family and on leisure activities and sick leaves. Moreover, the literature shows that road traffic injuries also lead to psychological disorders, the most common disorder being Post Traumatic Stress Disorder (PTSD).
Consequences differ from one casualty to the other, depending on type and severity of injury, transport mode and several personal and environmental factors like age, gender, comorbidity and socio-economic status. Concerning injury severity, studies quite consistently show that the risks of mainly functional and socio-economic consequences increase as a function of the injury severity. However, minor injuries, like strain injuries to the spine, may also have grave long-term consequences. Moreover, as less severe injuries are much more common than severe ones, they are responsible for a high percentage of disabilities and consequently represent a large share in the burden of injury. Transport modes that are linked to a relatively high prevalence of long-term disabilities are pedestrians and motorcyclists. Concerning age, prevalence of physical health impacts appears to be lower for younger casualties and concerning gender, women experience more physical and psychological consequences than men.
Case studies on impacts of road traffic injuries on casualties’ lives (Chapter 4)
Some of the SafetyCube partners have access to additional studies/data on impacts of injuries obtained in road traffic crashes. The results of the following five studies are included in this Deliverable:
- The Spanish study on the Health Impacts of Road traffic crashes; a nationwide household survey conducted among 213,626 respondents, including 473 persons who reported one or more disabilities due to a road traffic crash.
- The ESPARR study; a prospective cohort follow-up study in the Rhône region in France that determined the long term health impacts of road traffic crashes. 1972 participants, including 433 MAIS3+ casualties have been followed up to five years after the crash.
- An analysis of two datasets from the UK:
1) a dataset collected as part of a PhD research, that followed 50 road crash casualties who were admitted to hospitals in the UK Midlands until one year after the crash, and;
2) data collected for the Impact of Injury study, a multi-centre follow-up study, including 114 road traffic casualties, that explored the impact of unintentional injuries up to 1 year.
- Information collected one year after the crash by the Hannover Medical School for 608 respondents that were involved in crashes that were included in the GIDAS in-depth database.
- The MyLAC (‘My Life After the Crash’) study; an international retrospective survey that aimed to investigate medical, psychological, social and economic consequences of road traffic injuries. 755 road traffic casualties from 20 different countries responded to a questionnaire.
Most of these case studies, as most studies discussed in the literature review, are follow-up studies in which road traffic casualties were asked to fill out a questionnaire on perceived impacts of sustained injuries. The main limitation of such questionnaires is that non-response is often quite high and might introduce a bias, overestimating the proportion of casualties that experience negative consequences. Moreover, none of the studies provides a full picture of all possible impacts of road traffic injuries for different groups of injuries, on different moments in time. However, they all provide some interesting information. The ESPARR cohort study appears to be the most comprehensive study available concerning impacts of road traffic injuries. The case studies confirm the conclusion from the literature review that (serious) road traffic injuries experience all kinds of functional, psychological and soci0-economic consequences. According to the ESPARR study for example, three quarters of the MAIS3+ casualties and one third of the MAIS<3 casualties is not fully recovered three years after the crash.
Pain is the most often reported functional consequence in the ESPARR cohort study. In the Spanish study most reported disabilities due to road traffic crashes (all severities) are related to mobility and home life. Psychological consequences include PTSD, chronic depression or anxiety and fears. Socio-economic consequences discussed in the case studies include being unable to work, financial consequences, negative impact on family life and impacts on the housing situation. In Germany for example, 7% of the people involved in a crash reported that they were not able to return to their old job, 8% reported a slow restart and 2% had to modify their home or to move. The MyLAC study also provide information on the consequences of crashes for relatives of the road traffic casualties. More than one third of the casualties reported that the crash had had consequences on at least one of their relatives’ personal or professional life.
Most of the case studies also include less severe injured casualties. In the ESPARR study and the UK case studies it is possible to compare the consequences for serious road traffic injuries with consequences perceived by people that are less severely injured. This analysis shows that also MAIS<3 casualties quite often encounter negative consequences, although less often and less long lasting than MAIS3+ casualties do. Looking at different types of road users, consequences appear to be larger for pedestrians and motorized two-wheelers.
Burden of injury calculation (Chapter 5)
The burden of injury has been calculated for road traffic casualties in Austria, Belgium, England, The Netherlands, the Rhône department of France and Spain. Each road traffic casualty has been assigned to one of the 39 EUROCOST injury groups. On the basis of the age of a casualty and disability information for the injury group from the INTEGRIS study, the burden of injury was calculated for each casualty. By summing the burden of injury of all individual casualties, the total burden of injury for a country has been estimated. Burden of injury body profiles were created to visualize the distribution of injuries and burden of injury over the body The average burden of injury per MAIS3+ casualty varies between 2.4 YLD in Spain and 3.2 YLD in the Netherlands, with an average of 2.8 YLD per casualty for the six countries together. About 90% of the burden of injury is due to lifelong disabilities that are encountered by 19% (Spain) to 33% (Netherlands) of the MAIS3+ casualties.
The burden of injury for an individual casualty depends on the nature of the injury and on the age of the casualty. The average burden per casualty is by far the highest for spinal cord injuries (24.4 – 30.0 YLD). Spinal cord injuries also have a large share in the total burden of injury, as have ‘other skull-brain injuries’, hip fractures, femur shaft fractures, and fractures in knees and lower legs. The average burden per casualty decreases with age, because life expectancy and thus years lived with permanent disability decrease with age. Moreover, in most countries, the average burden per MAIS3+ casualty is higher for men than for women. Men also have a higher share in the number of MAIS3+ casualties than women; therefore their total burden of injury is higher than for women.
Since the age distribution and the distribution of injuries over the EUROCOST injury groups differ between transport modes, the average burden of injury per casualty also differs between transport modes. For the six countries together, the average burden per MAIS3+ casualty is highest for car/van occupants (3.4 YLD) and lowest for cyclists (2.3 YLD on average for Belgium, Spain and the Rhone region). It should be noted however that the YLD figures per transport mode differ between countries. Moreover, the distribution of the total burden of injury over transport modes differs between countries, mainly due to differences in the distribution of MAIS3+ casualties over transport modes.
As expected, the average burden per casualty is lower for less severely injured (MAIS<3 and ED treated) casualties. However as there are relatively many less severely injured casualties, they have a high share in the total burden of injury in a country. On the basis of data from the Netherlands and the Rhone region we estimated that less severely injured casualties (including casualties that were only treated at the Emergency department) are responsible for 67-74% of the burden of non-fatal road traffic injury.
CONCLUSIONS AND RECOMMENDATIONS
The literature review, health impact studies and burden of injury calculations presented in this SafetyCube deliverable show that non-fatal (serious) road traffic injuries have a substantial impact, both at the individual level as for society as a whole. The ESPARR cohort study for example shows that about 75% of the MAIS3+ road traffic casualties and about 33% of the MAIS<3 casualties are not fully recovered three years after the crash. The burden of injury calculations that are discussed in this Deliverable show that a MAIS3+ casualty on average has a burden of injury of 2.8 years lived with disability and that 19% to 33% of the MAIS3+ casualties experience lifelong disabilities. Reported consequences of road crashes include:
- Functional consequences: e.g. pain, fatigue, mobility problems, and problems carrying out daily activities.
- Psychological consequences: e.g. PTSD, major depressive disorders and anxiety/fear
- Socio economic consequences: e.g. impacts on everyday life of the family and on leisure activities, sick leaves from work or study and financial problems.
Consequences differ considerably between casualties, depending on the injury sustained and several personal and environmental factors.
Ideally, road safety policies should also be aimed at reducing health impacts in addition to reducing the number of casualties. This could imply a different prioritization of transport modes, and increased focus on certain types of injuries, like spinal cord injuries. It should be further analysed which crash types and risk factors –related to road safety behaviour, infrastructure and vehicleshave relative large health impacts for individual casualties and/or contribute substantially to the burden of injury. Road safety measures could be (additionally) aimed at preventing or limiting the consequences of these crash types and risk factors. Additionally, measures could be developed that specifically aim at reducing the health impacts of crashes that already have occurred, for example aimed at early detection and treatment of injuries that are known to have large long term impacts.
In this respect, it should be noted that also less severe injuries are very relevant from a health burden perspective. MAIS3+ casualties are responsible for less than half of the total burden of non-fatal road traffic injury. We recommend countries that also have information about less severe injuries, to monitor developments and burden of injury for this group of casualties as well. Moreover, countries that do not yet have information on the incidence of less severe injuries could consider the options for registering less serious injuries as well.
Finally, further research is needed. We recommend repeating the burden of injury calculations for a larger number of countries. Besides, additional analyses could be helpful when further improving road safety policy. It seems useful to create burden of injury body profiles for different transport modes, age categories, genders and combinations of these variables. Furthermore, a Europeanwide follow-up study would be very useful, both for obtaining more information on individual impacts of road traffic injuries and for deriving road traffic injury specific disability information for calculating the burden of injury.