Hospital outpatient responses to potential driving impairment due to prescribed medications

Driving and using prescription medicines that have the potential to impair driving is an emerging research area. To date it is characterised by a limited (although growing) number of studies and methodological complexities that make generalisations about impairment due to medications difficult. Consistent evidence has been found for the impairing effects of hypnotics, sedative antidepressants and antihistamines, and narcotic analgesics, although it has been estimated that as many as nine medication classes have the potential to impair driving (Alvarez & del Rio, 2000; Walsh, de Gier, Christopherson, & Verstraete, 2004). There is also evidence for increased negative effects related to concomitant use of other medications and alcohol (Movig et al., 2004; Pringle, Ahern, Heller, Gold, & Brown, 2005). Statistics on the high levels of Australian prescription medication use suggest that consumer awareness of driving impairment due to medicines should be examined. One web-based study has found a low level of awareness, knowledge and risk perceptions among Australian drivers about the impairing effects of various medications on driving (Mallick, Johnston, Goren, & Kennedy, 2007). The lack of awareness and knowledge brings into question the effectiveness of the existing countermeasures. In Australia these consist of the use of ancillary warning labels administered under mandatory regulation and professional guidelines, advice to patients, and the use of Consumer Medicines Information (CMI) with medications that are known to cause impairment. The responsibility for the use of the warnings and related counsel to patients primarily lies with the pharmacist when dispensing relevant medication. A review by the Therapeutic Goods Administration (TGA) noted that in practice, advice to patients may not occur and that CMI is not always available (TGA, 2002). Researchers have also found that patients' recall of verbal counsel is very low (Houts, Bachrach, Witmer, Tringali, Bucher, & Localio, 1998). With healthcare observed as increasingly being provided in outpatient conditions (Davis et al., 2006; Vingilis & MacDonald, 2000), establishing the effectiveness of the warning labels as a countermeasure is especially important. There have been recent international developments in medication categorisation systems and associated medication warning labels. In 2005, France implemented a four-tier medication categorisation and warning system to improve patients' and health professionals' awareness and knowledge of related road safety issues (AFSSAPS, 2005). This warning system uses a pictogram and indicates the level of potential impairment in relation to driving performance through the use of colour and advice on the recommended behaviour to adopt towards driving. The comparable Australian system does not indicate the severity level of potential effects, and does not provide specific guidelines on the attitude or actions that the individual should adopt towards driving. It is reliant upon the patient to be vigilant in self-monitoring effects, to understand the potential ways in which they may be affected and how serious these effects may be, and to adopt the appropriate protective actions. This thesis investigates the responses of a sample of Australian hospital outpatients who receive appropriate labelling and counselling advice about potential driving impairment due to prescribed medicines. It aims to provide baseline data on the understanding and use of relevant medications by a Queensland public hospital outpatient sample recruited through the hospital pharmacy. It includes an exploration and comparison of the effect of the Australian and French medication warning systems on medication user knowledge, attitudes, beliefs and behaviour, and explores whether there are areas in which the Australian system may be improved by including any beneficial elements of the French system. A total of 358 outpatients were surveyed, and a follow-up telephone survey was conducted with a subgroup of consenting participants who were taking at least one medication that required an ancillary warning label about driving impairment. A complementary study of 75 French hospital outpatients was also conducted to further investigate the performance of the warnings. Not surprisingly, medication use among the Australian outpatient sample was high. The ancillary warning labels required to appear on medications that can impair driving were prevalent. A subgroup of participants was identified as being potentially at-risk of driving impaired, based on their reported recent use of medications requiring an ancillary warning label and level of driving activity. The sample reported previous behaviour and held future intentions that were consistent with warning label advice and health protective action. Participants did not express a particular need for being advised by a health professional regarding fitness to drive in relation to their medication. However, it was also apparent from the analysis that the participants would be significantly more likely to follow advice from a doctor than a pharmacist. High levels of knowledge in terms of general principles about effects of alcohol, illicit drugs and combinations of substances, and related health and crash risks were revealed. This may reflect a sample specific effect. Emphasis is placed in the professional guidelines for hospital pharmacists that make it essential that advisory labels are applied to medicines where applicable and that warning advice is given to all patients on medication which may affect driving (SHPA, 2006, p. 221). The research program applied selected theoretical constructs from Schwarzer's (1992) Health Action Process Approach, which has extended constructs from existing health theories such as the Theory of Planned Behavior (Ajzen, 1991) to better account for the intention-behaviour gap often observed when predicting behaviour. This was undertaken to explore the utility of the constructs in understanding and predicting compliance intentions and behaviour with the mandatory medication warning about driving impairment. This investigation revealed that the theoretical constructs related to intention and planning to avoid driving if an effect from the medication was noticed were useful. Not all the theoretical model constructs that had been demonstrated to be significant predictors in previous research on different health behaviours were significant in the present analyses. Positive outcome expectancies from avoiding driving were found to be important influences on forming the intention to avoid driving if an effect due to medication was noticed. In turn, intention was found to be a significant predictor of planning. Other selected theoretical constructs failed to predict compliance with the Australian warning label advice. It is possible that the limited predictive power of a number of constructs including risk perceptions is due to the small sample size obtained at follow up on which the evaluation is based. Alternately, it is possible that the theoretical constructs failed to sufficiently account for issues of particular relevance to the driving situation. The responses of the Australian hospital outpatient sample towards the Australian and French medication warning labels, which differed according to visual characteristics and warning message, were examined. In addition, a complementary study with a sample of French hospital outpatients was undertaken in order to allow general comparisons concerning the performance of the warnings. While a large amount of research exists concerning warning effectiveness, there is little research that has specifically investigated medication warnings relating to driving impairment. General established principles concerning factors that have been demonstrated to enhance warning noticeability and behavioural compliance have been extrapolated and investigated in the present study. The extent to which there is a need for education and improved health messages on this issue was a core issue of investigation in this thesis. Among the Australian sample, the size of the warning label and text, and red colour were the most visually important characteristics. The pictogram used in the French labels was also rated highly, and was salient for a large proportion of the sample. According to the study of French hospital outpatients, the pictogram was perceived to be the most important visual characteristic. Overall, the findings suggest that the Australian approach of using a combination of visual characteristics was important for the majority of the sample but that the use of a pictogram could enhance effects. A high rate of warning recall was found overall and a further important finding was that higher warning label recall was associated with increased number of medication classes taken. These results suggest that increased vigilance and care are associated with the number of medications taken and the associated repetition of the warning message. Significantly higher levels of risk perception were found for the French Level 3 (highest severity) label compared with the comparable mandatory Australian ancillary Label 1 warning. Participants' intentions related to the warning labels indicated that they would be more cautious while taking potentially impairing medication displaying the French Level 3 label compared with the Australian Label 1. These are potentially important findings for the Australian context regarding the current driving impairment warnings about displayed on medication. The findings raise other important implications for the Australian labelling context. An underlying factor may be the differences in the wording of the warning messages that appear on the Australian and French labels. The French label explicitly states "do not drive" while the Australian label states "if affected, do not drive", and the difference in responses may reflect that less severity is perceived where the situation involves the consumer's self-assessment of their impairment. The differences in the assignment of responsibility by the Australian (the consumer assesses and decides) and French (the doctor assesses and decides) approaches for the decision to drive while taking medication raises the core question of who is most able to assess driving impairment due to medication: the consumer, or the health professional? There are pros and cons related to knowledge, expertise and practicalities with either option. However, if the safety of the consumer is the primary aim, then the trend towards stronger risk perceptions and more consistent and cautious behavioural intentions in relation to the French label suggests that this approach may be more beneficial for consumer safety. The observations from the follow-up survey, although based on a small sample size and descriptive in nature, revealed that just over half of the sample recalled seeing a warning label about driving impairment on at least one of their medications. The majority of these respondents reported compliance with the warning advice. However, the results indicated variation in responses concerning alcohol intake and modifying the dose of medication or driving habits so that they could continue to drive, which suggests that the warning advice may not be having the desired impact. The findings of this research have implications for current countermeasures in this area. These have included enhancing the role that prescribing doctors have in providing warnings and advice to patients about the impact that their medication can have on driving, increasing consumer perceptions of the authority of pharmacists on this issue, and the reinforcement of the warning message. More broadly, it is suggested that there would be benefit in a wider dissemination of research-based information on increased crash risk and systematic monitoring and publicity about the representation of medications in crashes resulting in injuries and fatalities. Suggestions for future research concern the continued investigation of the effects of medications and interactions with existing medical conditions and other substances on driving skills, effects of variations in warning label design, individual behaviours and characteristics (particularly among those groups who are dependent upon prescription medication) and validation of consumer self-assessment of impairment.

Road safety in Singapore

Singapore is a highly developed country that has a well connected island-wide road transport system including a network of expressways. The road standards of Singapore are generally good and road safety level is very high by international standards. This chapter discusses road safety status in Singapore and highlights the practices that have been undertaken to enhance the road safety. Statistics show that road traffic fatalities were decreasing over the years, albeit an increasing trend for total crashes. Motorcyclists and pedestrians were two vulnerable road user groups and shared significant proportions respectively about 49% and 28% of total road traffic deaths. In particular, young riders and pedestrians had a higher crash potential. To enhance safety of those vulnerable road users, Singapore has taken several initiatives including infrastructure improvements like paving better skid-resistant materials at crash-prone sites, providing more rain shelters for motorcyclists, and installation of reflective signs and markings near school zones; safety campaigns and awareness programs like ride safe programme, the road courtesy campaign, and the anti-drink drive campaign. While Land Transport Authority (LTA) looks into road safety through engineering solutions and road infrastructure developments, the Traffic Police of Singapore is responsible for law enforcements and regulations. A number of non-government organizations, private companies, and university research groups are also continuously working with the Traffic Police to study, promote, and educate the general public on road safety matters.

The influence of motorcyclist behavior in crash involvement

Introduction: In Singapore, motorcycle crashes account for 50% of traffic fatalities and 53% of injuries. While extensive research efforts have been devoted to improve the motorcycle safety, the relationship between the rider behavior and the crash risk is still not well understood. The objective of this study is to evaluate how behavioral factors influence crash risk and to identify the most vulnerable group of motorcyclists. Methods: To explore the rider behavior, a 61-item questionnaire examining sensation seeking (Zuckerman et al., 1978), impulsiveness (Eysenck et al., 1985), aggressiveness (Buss & Perry, 1992), and risk-taking behavior (Weber et al., 2002) was developed. A total of 240 respondents with at least one year riding experience form the sample that relate behavior to their crash history, traffic penalty awareness, and demographic characteristics. By clustering the crash risk using the medoid portioning algorithm, the log-linear model relating the rider behavior to crash risk was developed. Results and Discussions: Crash-involved motorcyclists scored higher in impulsive sensation seeking, aggression and risk-taking behavior. Aggressive and high risk-taking motorcyclists were respectively 1.30 and 2.21 times more likely to fall under the high crash involvement group while impulsive sensation seeking was not found to be significant. Based on the scores on risk-taking and aggression, the motorcyclists were clustered into four distinct personality combinations namely, extrovert (aggressive, impulsive risk-takers), leader (cautious, aggressive risk-takers), follower (agreeable, ignorant risk-takers), and introvert (self-consciousness, fainthearted risk-takers). “Extrovert” motorcyclists were most prone to crashes, being 3.34 times more likely to involve in crash and 8.29 times more vulnerable than the “introvert”. Mediating factors like demographic characteristics, riding experience, and traffic penalty awareness were found not to be significant in reducing crash risk. Conclusion: The findings of this study will be useful for road safety campaign planners to be more focused in the target group as well as those who employ motorcyclists for their delivery business.

A review of system safety failure probability objectives for Unmanned Aircraft Systems

Unmanned Aircraft Systems (UAS) are one of a number of emerging aviation sectors. Such new aviation concepts present a significant challenge to National Aviation Authorities (NAAs) charged with ensuring the safety of their operation within the existing airspace system. There is significant heritage in the existing body of aviation safety regulations for Conventionally Piloted Aircraft (CPA). It can be argued that the promulgation of these regulations has delivered a level of safety tolerable to society, thus justifying the “default position” of applying these same standards, regulations and regulatory structures to emerging aviation concepts such as UAS. An example of this is the proposed “1309” regulation for UAS, which is based on the 1309 regulation for CPA. However, the absence of a pilot on-board an unmanned aircraft creates a fundamentally different risk paradigm to that of CPA. An appreciation of these differences is essential to the justification of the “default position” and in turn, to ensure the development of effective safety standards and regulations for UAS. This paper explores the suitability of the proposed “1309” regulation for UAS. A detailed review of the proposed regulation is provided and a number of key assumptions are identified and discussed. A high-level model characterising the expected number of third party fatalities on the ground is then used to determine the impact of these assumptions. The results clearly show that the “one size fits all” approach to the definition of 1309 regulations for UAS, which mandates equipment design and installation requirements independent of where the UAS is to be operated, will not lead to an effective management of the risks.

Navigational safety in port waters: Techniques for modeling collision risk

Navigational collisions are one of the major safety concerns for many seaports. Continuing growth of shipping traffic in number and sizes is likely to result in increased number of traffic movements, which consequently could result higher risk of collisions in these restricted waters. This continually increasing safety concern warrants a comprehensive technique for modeling collision risk in port waters, particularly for modeling the probability of collision events and the associated consequences (i.e., injuries and fatalities). A number of techniques have been utilized for modeling the risk qualitatively, semi-quantitatively and quantitatively. These traditional techniques mostly rely on historical collision data, often in conjunction with expert judgments. However, these techniques are hampered by several shortcomings, such as randomness and rarity of collision occurrence leading to obtaining insufficient number of collision counts for a sound statistical analysis, insufficiency in explaining collision causation, and reactive approach to safety. A promising alternative approach that overcomes these shortcomings is the navigational traffic conflict technique (NTCT), which uses traffic conflicts as an alternative to the collisions for modeling the probability of collision events quantitatively. This article explores the existing techniques for modeling collision risk in port waters. In particular, it identifies the advantages and limitations of the traditional techniques and highlights the potentials of the NTCT in overcoming the limitations. In view of the principles of the NTCT, a structured method for managing collision risk is proposed. This risk management method allows safety analysts to diagnose safety deficiencies in a proactive manner, which consequently has great potential for managing collision risk in a fast, reliable and efficient manner.

Road trauma perceptions and the potential influence of the media

The United Nations Decade of Action for Road Safety (2011-2020) recognises the urgency of addressing global road trauma. Road crashes and attempts to reduce risky driving, including public education campaigns, receive media attention in many countries. In Australia, road fatalities have declined significantly. However, the extent of awareness about this success and of fatalities overall is unclear. A survey of 833 Australian drivers revealed the majority of participants under-estimated fatalities. Unexpectedly, some under-estimates appear based on recollections of media reports. The findings suggest lack of awareness of the extent of road deaths and that, paradoxically, media reports might contribute to underestimations. This represents a major public health challenge. Engaging community support for road safety, relative to other health/safety messages, may prove difficult if the extent of road trauma is misunderstood. Misperceptions about fatality levels may be a barrier to road users adopting safety precautions or supporting further road safety countermeasures.

Developing guidelines for intervention to reduce risk of low-speed vehicle run-overs of young children

In Australia, research suggests that up to one quarter of child pedestrian hospitalisations result from driveway run-over incidents (Pinkney et al., 2006). In Queensland, these numbers equate to an average of four child fatalities and 81 children presenting at hospital emergency departments every year (The Commission for Children, Young People and Child Guardian). National comparison shows that these numbers represent a slightly higher per capita rate (23.5% of all deaths). To address this issue, the current research was undertaken with the aim to develop an educative intervention based on data collected from parents and caregivers of young children. Thus, the current project did not seek to use available intervention or educational material, but to develop a new evidence-based intervention specifically targeting driveway run-overs involving young children. To this end, general behavioural and environmental changes that caregivers had undertaken in order to reduce the risk of injury to any child in their care were investigated. Broadly, the first part of this report sought to: • develop a conceptual model of established domestic safety behaviours, and to investigate whether this model could be successfully applied to the driveway setting; • explore and compare sources of knowledge regarding domestic and driveway child safety; and • examine the theoretical implications of current domestic and driveway related behaviour and knowledge among caregivers. The aim of the second part of this research was to develop and test the efficacy of an intervention based on the findings in the first part of the research project. Specifically, it sought to: • develop an educational driveway intervention that is based on current safety behaviours in the domestic setting and informed by existing knowledge of driveway safety and behaviour change theory; and • evaluate its efficacy in a sample of parents and caregivers.

Multiuser virtual safety training system for tower crane dismantlement

Tower crane dismantling is one of the most dangerous activities in the construction industry. Tower crane erection and dismantlement causes 10–12% of the fatalities of all crane accidents. The nature of the task is such that off-the-job training is not practicable, and the knowledge and expertise needed has to be gained on the job. However, virtual trainers such as Microsoft Flight Simulator for airplane pilots and mission rehearsal exercise (MRE) for army personnel have been developed and are known to provide a highly successful means of overcoming the risks involved in such on-the-job learning and clearly have potential in construction situations. This paper describes the newly developed multiuser virtual safety training system (MVSTS) aimed at providing a similar learning environment for those involved in tower crane dismantlement. The proposed training system is developed by modifying an existing game engine. Within the close-to-reality virtual environment, trainees can participate in a virtual dismantling process. During the process, they learn the correct dismantling procedure and working location and to cooperate with other trainees by virtually dismantling the crane. The system allows the trainees to experience the complete procedure in a risk-free environment. A case study is provided to demonstrate how the system works and its practical application. The proposed system was evaluated by interviews with 30 construction experts with different backgrounds, divided into three groups according to their experience and trained by the traditional and virtual methods, respectively. The results indicate that the trainees of the proposed system generally learned better than those using the traditional method. The ratings also indicate that the system generally has great potential as a training platform.

Human factors at the interface between road and rail systems

Railway level crossings present an arguably unique interface between two transport systems that differ markedly in their performance characteristics, their degrees of regulation and their safety cultures. Railway level crossings also differ dramatically in the importance they represent as safety issues for the two modes. For rail, they are the location of a large proportion of fatalities within the system and are therefore the focus of much safety concern. For the road system, they comprise only a few percent of all fatalities, although the potential for catastrophic outcomes exist. Rail operators and regulators have traditionally required technologies to be failsafe and to demonstrate high levels of reliability. The resultant level of complexity and cost has both limited their extent of application and led to a need to better understand how motorists comprehend and respond to these systems.

Do people gamble with their lives : The relationship between risky driving behaviour and other risky behaviours

General risky behaviour is explored for correlation with risky driving behaviour in light of two theories, self-control and cross-situational consistency. Identification of general risky behaviours associated with risky driving behaviour, and the theory that best predicts the behaviours, will enable better targeting of intervention and education strategies to reduce driving related fatalities and injuries. A correlational study using participants (N=152) drawn from first year university undergraduates and the public surveyed their lifestyle and behaviours. Relationships were found between risky driving behaviours and other risky behaviours such as alcohol consumption, cannabis use and performing unlawful activities. No significant differences were found between genders, with the exception that males were more likely to believe that they were at risk of injury from their employment, χ2 (1, N = 152) = 4.49, p = .03, were more likely to have performed an unlawful offence, χ2 (1, N = 152) = 11.77, p = .001 and were more likely to drink drive, t (55.41) = -3.87, p < .001, mean difference = -0.63, CI 95% (-0.9, -0.37). People engaged in risky driving behaviours were more likely to engage in other risky behaviours. The theories that were explored were unable to accurately predict an association between general risky behaviour and driving without a license or when disqualified. Cross-situational consistency explained 20% (R2adj = .16) of the variance in which people engaged in risky driving with low self-control theory explaining an additional 0.3% variance (R2change = .003), F (8,143) = 6.92, p < .001. Driving while under the influence of alcohol could be predicted by risky behaviours in lifestyle, health, smoking, cannabis use and alcohol consumption, F (8,143) = 6.92, p < .001. The addition of self-control was not significant.

Accident risk identification and its impact analyses for strategic construction safety management

The study presented in this paper reviewed 9,358 accidents which occurred in the U.S. construction industry between 2002 and 2011, in order to understand the relationships between the risk factors and injury severity (e.g. fatalities, hospitalized injuries, or non-hospitalized injuries) and to develop a strategic prevention plan to reduce the likelihood of fatalities where an accident is unavoidable. The study specifically aims to: (1) verify the relationships among risk factors, accident types, and injury severity, (2) determine significant risk factors associated with each accident type that are highly correlated to injury severity, and (3) analyze the impact of the identified key factors on accident and fatality occurrence. The analysis results explained that safety managers’ roles are critical to reducing human-related risks—particularly misjudgement of hazardous situations—through safety training and education, appropriate use of safety devices and proper safety inspection. However, for environment-related factors, the dominant risk factors were different depending on the different accident types. The outcomes of this study will assist safety managers to understand the nature of construction accidents and plan for strategic risk mitigation by prioritizing high frequency risk factors to effectively control accident occurrence and manage the likelihood of fatal injuries on construction sites.

Development of an innovative technology-based youth passenger safety program : an evidence-based approach

Young drivers are overrepresented in motor vehicle crash rates, and their risk increases when carrying similar aged passengers. Graduated Driver Licensing strategies have demonstrated effectiveness in reducing fatalities among young drivers, however complementary approaches may further reduce crash rates. Previous studies conducted by the researchers have shown that there is considerable potential for a passenger focus in youth road safety interventions, particularly involving the encouragement of young passengers to intervene in their peers’ risky driving (Buckley, Chapman, Sheehan & Davidson, 2012). Additionally, this research has shown that technology-based applications may be a promising means of delivering passenger safety messages, particularly as young people are increasingly accessing web-based and mobile technologies. This research describes the participatory design process undertaken to develop a web-based road safety program, and involves feasibility testing of storyboards for a youth passenger safety application. Storyboards and framework web-based materials were initially developed for a passenger safety program, using the results of previous studies involving online and school-based surveys with young people. Focus groups were then conducted with 8 school staff and 30 senior school students at one public high school in the Australian Capital Territory. Young people were asked about the situations in which passengers may feel unsafe and potential strategies for intervening in their peers’ risky driving. Students were also shown the storyboards and framework web-based material and were asked to comment on design and content issues. Teachers were also shown the material and asked about their perceptions of program design and feasibility. The focus group data will be used as part of the participatory design process, in further developing the passenger safety program. This research describes an evidence-based approach to the development of a web-based application for youth passenger safety. The findings of this research and resulting technology will have important implications for the road safety education of senior high school students.

Speed enforcement in China : national, provincial and city initiatives and their success

China is motorizing rapidly, with associated urban road development and extensive construction of motorways. Speeding accounts for about 10% of fatalities, which represents a large decrease from a peak of 17.2% in 2004. Speeding has been addressed at a national level through the introduction of laws and procedural requirements in 2004, in provinces either across all road types or on motorways, and at city level. Typically, documentation of speed enforcement programmes has taken place when new technology (i.e. speed cameras) is introduced, and it is likely that many programmes have not been documented or widely reported. In particular, the national legislation of 2004 and its implementation was associated with a large reduction in fatalities attributed to speeding. In Guangdong Province, after using speed detection equipment, motorway fatalities due to speeding in 2005 decreased by 32.5% comparing with 2004. In Beijing, the number of traffic monitoring units which were used to photograph illegal traffic activities such as traffic light violations, speeding and using bus lanes illegally increased to 1958 by April 1, 2009, and in the future such automated enforcement will become the main means of enforcement, expected to account for 60% of all traffic enforcement in Beijing. This paper provides a brief overview of the speeding enforcement programmes in China which have been documented and their successes.

Fatalism, superstition, religion, and culture : road user beliefs and behaviour in Pakistan

Road traffic crashes have emerged as a major health problem around the world. Road crash fatalities and injuries have been reduced significantly in developed countries, but they are still an issue in low and middle-income countries. The World Health Organization (WHO, 2009) estimates that the death toll from road crashes in low- and middle-income nations is more than 1 million people per year, or about 90% of the global road toll, even though these countries only account for 48% of the world's vehicles. Furthermore, it is estimated that approximately 265,000 people die every year in road crashes in South Asian countries and Pakistan stands out with 41,494 approximately deaths per year. Pakistan has the highest rate of fatalities per 100,000 population in the region and its road crash fatality rate of 25.3 per 100,000 population is more than three times that of Australia's. High numbers of road crashes not only cause pain and suffering to the population at large, but are also a serious drain on the country's economy, which Pakistan can ill-afford. Most studies identify human factors as the main set of contributing factors to road crashes, well ahead of road environment and vehicle factors. In developing countries especially, attention and resources are required in order to improve things such as vehicle roadworthiness and poor road infrastructure. However, attention to human factors is also critical. Human factors which contribute to crashes include high risk behaviours like speeding and drink driving, and neglect of protective behaviours such as helmet wearing and seat belt wearing. Much research has been devoted to the attitudes, beliefs and perceptions which contribute to these behaviours and omissions, in order to develop interventions aimed at increasing safer road use behaviours and thereby reducing crashes. However, less progress has been made in addressing human factors contributing to crashes in developing countries as compared to the many improvements in road environments and vehicle standards, and this is especially true of fatalistic beliefs and behaviours. This is a significant omission, since in different cultures in developing countries there are strong worldviews in which predestination persists as a central idea, i.e. that one's life (and death) and other events have been mapped out and are predetermined. Fatalism refers to a particular way in which people regard the events that occur in their lives, usually expressed as a belief that an individual does not have personal control over circumstances and that their lives are determined through a divine or powerful external agency (Hazen & Ehiri, 2006). These views are at odds with the dominant themes of modern health promotion movements, and present significant challenges for health advocates who aim to avert road crashes and diminish their consequences. The limited literature on fatalism reveals that it is not a simple concept, with religion, culture, superstition, experience, education and degree of perceived control of one's life all being implicated in accounts of fatalism. One distinction in the literature that seems promising is the distinction between empirical and theological fatalism, although there are areas of uncertainty about how well-defined the distinction between these types of fatalism is. Research into road safety in Pakistan is scarce, as is the case for other South Asian countries. From the review of the literature conducted, it is clear that the descriptions given of the different belief systems in developing countries including Pakistan are not entirely helpful for health promotion purposes and that further research is warranted on the influence of fatalism, superstition and other related beliefs in road safety. Based on the information available, a conceptual framework is developed as a means of structuring and focusing the research and analysis. The framework is focused on the influence of fatalism, superstition, religion and culture on beliefs about crashes and road user behaviour. Accordingly, this research aims to provide an understanding of the operation of fatalism and related beliefs in Pakistan to assist in the development and implementation of effective and culturally appropriate interventions. The research examines the influence of fatalism, superstition, religious and cultural beliefs on risky road use in Pakistan and is guided by three research questions: 1. What are the perceptions of road crash causation in Pakistan, in particular the role of fatalism, superstition, religious and cultural beliefs? 2. How does fatalism, superstition, and religious and cultural beliefs influence road user behaviour in Pakistan? 3. Do fatalism, superstition, and religious and cultural beliefs work as obstacles to road safety interventions in Pakistan? To address these questions, a qualitative research methodology was developed. The research focused on gathering data through individual in-depth interviewing using a semi-structured interview format. A sample of 30 participants was interviewed in Pakistan in the cities of Lahore, Rawalpindi and Islamabad. The participants included policy makers (with responsibility for traffic law), experienced police officers, religious orators, professional drivers (truck, bus and taxi) and general drivers selected through a combination of purposive, criterion and snowball sampling. The transcripts were translated from Urdu and analysed using a thematic analysis approach guided by the conceptual framework. The findings were divided into four areas: attribution of crash causation to fatalism; attribution of road crashes to beliefs about superstition and malicious acts; beliefs about road crash causation linked to popular concepts of religion; and implications for behaviour, safety and enforcement. Fatalism was almost universally evident, and expressed in a number of ways. Fate was used to rationalise fatal crashes using the argument that the people killed were destined to die that day, one way or another. Related to this was the sense of either not being fully in control of the vehicle, or not needing to take safety precautions, because crashes were predestined anyway. A variety of superstitious-based crash attributions and coping methods to deal with road crashes were also found, such as belief in the role of the evil eye in contributing to road crashes and the use of black magic by rivals or enemies as a crash cause. There were also beliefs related to popular conceptions of religion, such as the role of crashes as a test of life or a source of martyrdom. However, superstitions did not appear to be an alternative to religious beliefs. Fate appeared as the 'default attribution' for a crash when all other explanations failed to account for the incident. This pervasive belief was utilised to justify risky road use behaviour and to resist messages about preventive measures. There was a strong religious underpinning to the statement of fatalistic beliefs (this reflects popular conceptions of Islam rather than scholarly interpretations), but also an overlap with superstitious and other culturally and religious-based beliefs which have longer-standing roots in Pakistani culture. A particular issue which is explored in more detail is the way in which these beliefs and their interpretation within Pakistani society contributed to poor police reporting of crashes. The pervasive nature of fatalistic beliefs in Pakistan affects road user behaviour by supporting continued risk taking behaviour on the road, and by interfering with public health messages about behaviours which would reduce the risk of traffic crashes. The widespread influence of these beliefs on the ways that people respond to traffic crashes and the death of family members contribute to low crash reporting rates and to a system which appears difficult to change. Fate also appeared to be a major contributing factor to non-reporting of road crashes. There also appeared to be a relationship between police enforcement and (lack of) awareness of road rules. It also appears likely that beliefs can influence police work, especially in the case of road crash investigation and the development of strategies. It is anticipated that the findings could be used as a blueprint for the design of interventions aimed at influencing broad-spectrum health attitudes and practices among the communities where fatalism is prevalent. The findings have also identified aspects of beliefs that have complex social implications when designing and piloting driver intervention strategies. By understanding attitudes and behaviours related to fatalism, superstition and other related concepts, it should be possible to improve the education of general road users, such that they are less likely to attribute road crashes to chance, fate, or superstition. This study also underscores the understanding of this issue in high echelons of society (e.g., policy makers, senior police officers) as their role is vital in dispelling road users' misconceptions about the risks of road crashes. The promotion of an evidence or scientifically-based approach to road user behaviour and road safety is recommended, along with improved professional education for police and policy makers.

Linking the fifth pillar to the first in the UN Decade of Action

The UN Decade of Action outlines five pillars of activity within a safe system framework to achieve the goal of slowing and then reversing the global growth in road traffic fatalities, especially in low-income and middle-income countries. The first four pillars - road safety management, safer roads and mobility, safer vehicles, and safer road users – have a strong focus on prevention of road traffic crashes and mitigation of energy exchange when a crash occurs. The fifth pillar – post-crash response – is far more specific, focusing only on crash victims in the event of a safe system failure. The victims appear to be relevant to the first four pillars only insofar as their numbers can be used to evaluate the success of road safety programs and identify the target groups and contributing factors. This paper argues that a better understanding of the lived experience of long term disability from traffic crashes has the potential to provide a feedback loop from the fifth pillar to the first. Research conducted in Thailand with male crash victims with spinal injury demonstrates that patterns of attribution and social and cultural factors have important implications for road safety management and for interventions aimed at influencing behaviour. In addition, the mobility constraints experienced by people with long term disability can point to systemic issues that might otherwise go unnoticed. The UN Decade of Action can benefit from a more thorough exploration of the experiences and circumstances of people with long term disability as the result of a road traffic crash. Rather than being evidence of the failure of the safe system, they can inform the development of more effective road safety management on low-income and middle-income countries.