Determinants of road traffic injury at Khulna division in Bangladesh : a cross sectional study of road traffic incidents

Road traffic injury (RTI) is one of the major causes of death, Background: injury and disability worldwide and most of which occur in developing countries like Bangladesh. The main objective of this study was to identify the role of various socio-demographic and economic factors regarding the knowledge and consciousness about RTI at Khulna division in Bangladesh. Primary data were collected from 200 respondents in Khulna Methods: Medical College Hospital and Satkhira Sadar Hospital and several private clinics, generated by interviewing people who had experienced a traffic accident in Khulna division, Bangladesh. The Chi-square test and logistic regression model were utilized in this study to analyze the data. The results show that there was a significant association between Results: education (primary to higher secondary school: OR = 3.584, 95% CI=0.907-14.155; higher educated: OR = 24.070, 95% CI=4.860-119.206); occupation (farmer and labor: OR=0.528,95% CI=0.208-1.340; others: OR=0.263, 95% CI=0.097-0.713); if they were driving a motorcycle (OR = 4.137, 95% CI=1.229-13.932); proper treatment (OR = 4.690, 95% CI=1.736-12.673); consciousness about the RTI (OR = 18.394, 95% CI=6.381-53.025); if they were an unskilled driver (OR = 8.169, 95% CI = 0.96-16.51), unfit vehicles (OR = 3.696, 95% CI = 1.032-13.234), if they were breaking traffic rules (OR = 6.918, 95% CI = 2.237-21.397), faulty road and traffic management (OR = 3.037, 95% CI = 1.125-8.196) with having knowledge about traffic rules in Khulna division, Bangladesh. According to the results of the study, by increasing knowledge Conclusion: and awareness about traffic rules among people through education and awareness programs, imposing strict traffic rules, not giving licenses to unskilled drivers, not allowing unfit vehicles on the road, reconstruction and proper road management RTI’s can be reduced.


Introduction
Road traffic Injury (RTI) is one of the leading causes of deaths, injuries and disabilities worldwide, for both developed and developing countries. Every year about 1.25 million of people die worldwide due to RTI's 1 , and a high burden of traffic fatalities and injuries occur in low and middle-income countries (LMICs); this burden is enhanced due to rapid urbanization and motorization 2 . Road traffic accident deaths are projected to increase to 2.1 million in 2030, mainly due to the increase in the use of motor vehicles related to economic growth in low and middle-income countries 3 . Bangladesh is a developing country situated in South Asia and its located between 20°34' to 26°38' north latitude and 88°01' to 92°42' east longitude, with an area of 1,47,570 sq.km. with a population of 162.9 million and density of 1251.5 people per sq.km. 4 . Presently the total length of roads in Bangladesh is 21,125.082 km 5 . In Bangladesh, road traffic accidents, injuries and fatalities are an area of great concern. According to the Bangladesh Road Transport Authority, the number of death stood at 2376 and injuries at 1958 as of 2015 in Bangladesh 6 . Khulna is an industrial and divisional city of Bangladesh, with an area of 45.65 km 2 . The total number of vehicles running in Khulna city is greater than 20990, including about 13360 non-motorized and 7630 motorized vehicles as of 2005 7 .
The World Health Organization (WHO), has reported on RTIs that "Approximately 1.3 million people die each year on the world's roads and between 20 and 50 million sustain non-fatal injuries" 8 . Developing countries carry the greatest share of the burden 9 . Reviewing literature across different countries, it shows that people aged 15-49 years are more vulnerable to road traffic deaths 10,11 . Men are involved in a greater proportion of road traffic accidents and fatalities in comparison to women [11][12][13][14]. Motorcycles are the most common vehicles to be associated with RTIs. According to Nantulya et al. 15 buses, trucks, pedestrians and passengers have the highest burden of morbidity and mortality in RTIs. For Asian countries, income, road design and management, and accidents involving vehicles are also important predictors of RTIs 16 . Different studies identified various reasons behind RTIs like excessive speed of the vehicles, inexperienced drivers, reckless driving, violation of traffic rules and signals etc. [17][18][19] . A study from the Accident Research Center (ARC) of Bangladesh University of Engineering and Technology found that the death rate of road accidents in Bangladesh is much higher, about sixty deaths per 10,000 vehicles per every year, as compared with rates of two in the USA 20 .
RTI's are the 2 nd most common cause of injury and deaths in Bangladesh 21 and the road traffic accident situation in Khulna city as well as the rest of Bangladesh is a vital issue, and the loss of lives and damage of valuable assets are expected to continue if proper measures are not adopted accordingly. Almost 1.8% to 2.2% of gross domestic product (GDP) is lost in road accidents in this country 22 , which itself demonstrates the severity both in terms of deaths and injuries. So, extensive research and investigation is needed urgently to improve the RTI situation. Therefore, the main purpose of this study is to find out the socio-demographic differentials and socio-economic factors related to RTI, as well as knowledge and awareness about RTI, and to recommend suggestions regarding study results.

Study design
In this study we performed a cross-sectional study of road traffic incidents.
Study setting and procedure Primary data were collected from orthopedics, neurosurgery and general wards of Khulna Medical College Hospital, Satkhira Sadar Hospital and several private clinics from Khulna and Satkhira district using purposive sampling. Socio-economic and demographic, injury information, data related to treatment and cost, effect on family and information related to knowledge and awareness were collected by questionnaires (Supplementary File 1 and Supplementary File 2) with face-to-face interviews from 200 respondents with a recent RTI. The inclusion and exclusion criteria applied included all respondents with a recent RTI in Khulna Division at the time of interview. The data was collected during January and February, 2017.

Data analysis
To analyze the data, SPSS windows version 23.0 was used. Cross tables were used to study the association of what was known about traffic rules by the respondents with their background characteristics. χ2-test was used to test the significance of the association. Moreover, to identify the determinants of RTI of the respondents, a logistic regression model was fitted. Here, knowledge of traffic rules is treated as the dependent variable which is addressed as follows:

Model validation technique
To test out the validity of the logistic regression analysis over the population, the cross validity prediction power (CVPP), cv 2 ρ , was applied. The mathematical formula for CVPP is 2 cv n 1 n 2 n 1 1 1 R n n k 1 n k 2 Where, n is the number of classes, k is the number of repressors in the fitted model and the cross-validated R is the correlation between observed and predicted values of the dependent variables 23 . The shrinkage (α) of the model is the positive value of ( cv 2 ρ -R 2 ); where cv 2 ρ is CVPP and R 2 is the coefficient of determination of the model. Furthermore, the stability of R 2 of the model is (1-α). The information of shrinkage coefficients is presented at the bottom of the respective tables. It is noted that this technique is also used as model validation technique [24][25][26][27] .

Results
The results of association between knowledge about traffic rules among the selected socio-demographic and economic characteristics of respondents in Bangladesh are presented in Table 1 and Table 2. In this study, 58% of the respondent had knowledge about traffic rules. Most of the victims were aged 15-44 years (65%), and most (58%) of the respondents had   14.5% of people were illiterate and 45% and 40.5% of people had completed "primary to higher secondary school (HSC) level education and higher level of education, respectively and of which 4.3%, 37.1% and 58.6%, respectively, knew about traffic rules. It appears that knowledge of traffic rules increase with level of education. 47% of respondents belong to the occupation group job and business, of which 62% have knowledge about traffic rules. A total of 49.5% of the respondents had a monthly family income of 10001-25000 taka, termed as middle class families, of which 49.1% of the respondents had knowledge of traffic rules.
Most of the participants had RTI's on urban roads (37.5%), followed by rural (33%) and highway roads (29.5%). 37.9% and 35.3% of respondents who had RTI's on urban and rural roads, had known about traffic rules. We can define motorcycles as the most vulnerable vehicle based on this study. In this case, 47.4% reported a motorcycle as their RTI vehicle. 7.8% of respondents whose accident vehicle was a bicycle had prior knowledge of traffic rules. In the case of victim's position during the RTI, passersby were most affected (39%) followed by passengers (34.5%). In this study area, 72% of participants received proper treatment, 81% of them had knowledge of traffic rules, and 68% claimed that they had a negative effect on family due to the RTI, especially financial 40.5%. With regards to the reasons behind RTIs, respondents who had knowledge of traffic rules said unskilled drivers (30.2%), unfit vehicles (20.7%), breaking traffic rules (32.8%) and faulty roads and road management (39. 7%). The number of participant who believed current traffic rules were not sufficient (71%) was significantly higher than those who believed the rules were sufficient (29%). 63.8% had knowledge of the current traffic rules and they felt traffic rules were not sufficient. 65.5% of the participants said government rules inadequate and 66.5% of respondents indicated about NGO roles adequate.
A logistic regression analysis was applied to identify the factors which were significantly associated with knowledge of traffic rules. The results of the logistic regression analysis are presented in Table 3 and Table 4. In this study, the regression odd ratio for primary to HSC educated respondents was 3.584 (95% CI = 0.907-14.155), and for higher educated was 24.070 (95% CI = 4.860-119.206), indicated that primary to HSC level educated respondents had 3.584 times more chances, and higher educated respondents had 24.070 times more chances to know traffic rules, when compared to illiterate respondents. So it was clear that higher educated people were more likely to know traffic rules than others. In the case of occupation, the regression odds ratio for farmers and labors was 0.528 (95% CI = 0.208-1.340), and for others was 0.263 (95% CI = 0.097-0.713) times less likely to know traffic rules than the respondents who were engaged in job and business.
The respondents injured by motorcycles had 4.137 (95% CI = 1.229-13.932) times more knowledge about traffic rules than those who were injured by trucks. Respondents who received proper treatment had a regression odds ratio of 4.690 (95% CI = 1.736-12.673) indicating that those who got proper treatment were 4.690 times more likely to know traffic rules than the respondents who had not received proper treatment. People who were conscious during their RTI had an odds ratio of 18.394 (95% CI = 6.381-53.025), which indicated that those who were conscious during their RTI were 4.690 more likely

Discussion
Knowledge about traffic rules is a very important factor in reducing RTIs 17,28 . According to this study, it is observed that the age group at most risk of being involved in an RTI in Khulna division is 15-44 years. Similar results showed up in Ethiopia in 2014 29 and in Nigeria 30 as well as India 31 . It was observed that those aged 15-44 years had more knowledge than the other age groups. Males were at relatively higher risk when compared to females, like other developing countries 14,32 . Similarly, deaths from RTIs was higher for males in Iran 33 , and in India 34 , and knowledge of traffic rules was higher in the male population. In Khulna, the majority of victims are from the rural areas, this is similar to the findings of Mishra et al. 35 , with an education level of "primary to HSC level". Most of the individuals This study did not mention potential confounders. Potential bias sources in the study, are not included. Please explain how missing data was addressed.
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