intervention being visible enforcement of current seat belt laws and pedestrian right of way laws within the capital city of Yerevan. Efforts to reduce traffic injuries ...
Vol 56 • October 2012
Practices, Attitudes and Perceptions Toward Road Safety in Yerevan, Armenia Republic of Sharon Anoush Chekijian, MD, MPH Yale University School of Medicine, Department of Emergency Medicine
Nune Truzyan DVM, MPH
American University of Armenia __________________________________ ABSTRACT – Objectives: To determine knowledge and attitudes regarding traffic safety devices, measures, and legislation in the general population in Yerevan, Republic of Armenia. Methods: We conducted a baseline random digit dial fixed line telephone verbal survey of Yerevan households in April 2009 with a follow-up survey in May 2010. Survey domains included restraint use, motor vehicle crash experiences, and attitudes regarding traffic safety. Results: In the initial survey, of 2137 numbers dialed, 436 persons were reached and 390 (90%) agreed to participate. Of survey respondents, 90% percent of household cars had seatbelts, while 47% had airbags. Twenty-four percent always or usually wore a seatbelt when driving, 21% wore a belt as a passenger. 39% were unaware of child restraints. Of the 61% who were aware of child restraints, only 32% had ever used one. A follow-up survey was conducted one year later after enforcement efforts were increased. In the follow-up survey, 81% percent always or usually wore a seatbelt when driving, and 69% wore a belt as a passenger. There was no significant increase of awareness or use of child restraints in the follow-up survey. Conclusions: Although cars in Yerevan have seat belts, the majority of drivers and passengers prior to the intervention did not use them. Knowledge and use of child restraints was poor. The follow-up survey conducted after an enforcement campaign was underway in Yerevan showed that improved enforcement greatly increased awareness and compliance with current legislation. This study provides vital baseline information for the formulation of future policy. It also highlights the need for a multi-dimensional road traffic safety initiative through public educational campaigns, enforcement of current laws, and development of novel prevention policies and regulations.
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INTRODUCTION
In recent years, the upward spiral of development has meant a shift in the global burden of diseases. It is a well documented fact that the burden of tropical diseases, HIV and TB will soon be supplanted by the global burden of road traffic injuries which is expected to rise to the third leading cause of death by 2020. [Murray, 1996] While progress in traffic safety policy and road engineering have been made in highincome countries, low and medium income countries such as the Republic of Armenia remain disproportionately affected by traffic injuries. It is estimated that 90% of road traffic fatalities occur in low and middle income countries. [WHO, 2011]. These fatalities and injuries disproportionately affect young and productive members of society. [WHO, 2001]. Low to middle income countries face particular challenges related to lack of resources to address safety concerns including infrastructure and enforcement efforts, cultural usage norms for safety devices, and compromised road engineering due to lack of innovation and upkeep. [Forjuoh, 2003]. Areas of opportunity for impact include introduction
and enforcement of legislation governing driving while intoxicated, traffic speed limits, mandated safety device presence and usage in cars and two wheeled vehicles, including seatbelts, child restraints, and helmets. Equally important, is careful work with road safety engineers to eliminate hazards introduced by roads and road conditions as well as development and maturation of emergency medical systems. As we welcome the United Nations’ General Assembly’s declaration of the Decade of Action for Road Safety, remarkably little is known about current conditions and public policy efforts underway in the ex-Soviet Republics. Even less is known about the current population based acceptance and awareness of the concept of road safety and the use of safety devices. As part of the Decade of Action the World Health Organization (WHO) has set goals to strengthen global efforts towards road safety. Pillar 4 of the WHO action plan focuses of the development of “safe road users” by developing “comprehensive program to improve road user behavior. Sustaining or increasing enforcement of laws and standards, combined with public awareness/education to increase seatbelt and helmet wearing rates, and to
th 56 AAAM Annual Conference Annals of Advances in Automotive Medicine October 14‐17, 2012
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Annals of Advances in Automotive Medicine reduce drunken driving, speed and other risk factors.” [WHO 2011]. This project aims to both understand the scope of efforts underway as well as to understand where these measures lie in the public consciousness in Yerevan, the capital city of the Republic of Armenia. Armenia is facing many challenges since it’s newly found independence in 1991. First and foremost is its evolution to a democracy concurrent with development and reform of entire economy. The government and its citizens have undertaken a reform of entire legislative system including laws governing health and healthcare financing. Much of this reform is being guided by the WHO National Health Planning Program. In short, Armenia is facing a crisis of prioritization on many levels. Trauma management and the emergency medical response system deserve prioritization as the country moves forward. We undertook a survey to ascertain attitudes towards and understanding of current safety recommendations, regulations and devices. Coincidental with the conclusion of the first phase of the survey was a concerted effort by law enforcement in the capital city of Yerevan to enforce legislation that had here-to-fore not been enforced. The enforcement efforts centered on visible static stationing of police cars throughout the capital city. Officers were mandated to pull over any one observed to not be using retraints. They were authorized to ticket violators. In addition, officers stationed at busy intersections were instructed to ticket those who did not give the pedestrians right of way. Observationally, these enforcement efforts coupled with a high profile pedestrian fatality seemed to have sparked a public awareness of the issues we had just examined and created a favorable environment for change. In order to measure whether enforcement efforts had been fruitful, we chose to readminister the initial survey. The two survey periods thus formed a pre and post enforcement study. The intervention being visible enforcement of current seat belt laws and pedestrian right of way laws within the capital city of Yerevan. Efforts to reduce traffic injuries are fall under three rubricks, “education, enforcement or engineering.” [Dandona, 2005]. The scope of this paper will approach the first two of these factors and explore how they can and how they already have been successfully applied to the situation in Armenia. METHODS We administered a comprehensive survey with crosssectional analytical study design to evaluate
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awareness and practice of the general population of Yerevan, the capital city of Armenia, regarding pedestrian and driving safety measures. The purpose of the study was to determine knowledge and attitudes regarding traffic and pedestrian safety and safety devices in order to inform future safety interventions. The project included baseline and follow-up surveys to assess the efforts of the Government of Armenia toward enforcement of current laws and prevention policies and regulations regarding traffic safety Sampling Strategy In order to have a representative sample for the one million adult inhabitants of Yerevan with a confidence interval of 95%, we calculated a sample size of 384 for both the baseline and follow-up study surveys. Inclusion criteria was anyone over the age of 18 who answered the household phone. A random digit sampling telephone survey was used to collect the data from the general population in both baseline and follow-up groups. The six-digit telephone numbers were generated randomly using a computerized program that used valid interchanges for fixed lines in the city of Yerevan. Survey Instrument The research team developed a interviewer administered questionnaire that includes questions regarding knowledge, attitude and practices of the general population towards safety devices and measures, their exposure to road traffic injuries, availability of seat belts and airbags in motor vehicles, use of child restraints, perceptions of law enforcement, alcohol use, as well as baseline sociodemographic data. The study instrument also included open-ended questions to identify the best way improve traffic safety. The same questionnaire was used for the follow-up survey which was administered one year later. The questionnaire was developed in English and then translated into Armenian. It was pilot tested and revised accordingly. Data Collection Two trained research assistants conducted a random digit dial fixed line telephone survey of households in Yerevan. The survey was administered in two rounds, a baseline and a follow-up survey in April-May 2009 and in May-June 2010 respectively. Inclusion criteria were any responder over the age of 18 who answered the telephone call. If the initial telephone responder was under 18, the interviewer asked to speak with the
Vol 56 • October 2012 next available person over 18 in the house at that time. All 11 regions of Yerevan were sampled. The calls were placed at varying times of the day, seven days a week. This strategy allowed us to reach a representative sample and aimed to avoid a selection bias. In this way we hoped to include those who work at home and those who work outside the home as well as between male and female responders, assuming that males spend more of their time outside the home. Ethical Considerations The study was granted an exemption by the Yale School of Medicine HIC and was approved by the IRB at the American University of Armenia. Administration of the survey was contingent on initial oral consent. A verbal script was developed to provide participants with information including the project description, and assurance of confidentiality. They were also informed regarding the risks and benefits of participation. Data Analysis SPSS 11 statistical software package (SPSS Corporation 2008) was used for data entry and analysis. Both descriptive and analytic statistics were run. Statistical tests including independent t-test of means, chi-square test, and non-parametric two independent samples test, were used. The comparison was conducted between baseline participants (April 2009) and the participants in the follow-up study (May 2010). RESULTS Characteristics of the Study Population In total, 390 respondents participated in the baseline (April 2009) and 390 in the follow-up surveys (May 2010). Of 2137 numbers dialed, 436 persons were reached and 390 agreed to participate at baseline. At follow-up of 1972 numbers dialed, 407 persons were reached and 390 agreed to participate. The response rates were 90% and 96%, respectively. The main reasons for non-response were absence of an eligible respondent over the age of 18. The two study populations were similar in sociodemographic characteristics such as gender distribution, level of education, employment and marital status. They were also comparable in family size. (p> 0.05). (Table 1). The mean age of the interviewed responders at baseline was 39 and at follow-up 40 years old. The majority of participants
had either secondary special or graduate education at both baseline and follow-up (86% at baseline and 84% at follow-up). At baseline, 45% and at followup 49% of participants were employed. Table 1 – Study Population Socio-Demographic Characteristics Characteristics Baseline Follow-up Gender %: male 40.5 45.6 female 59.5 54.4 Age, mean (SD) 38.7 (15.0) 39.6 (14.9) Education %: school 11.8 10.3 secondary special 29.0 24.7 graduate degree 56.6 59.4 higher degree 2.6 5.7 Married % 73.1 66.4 Number of children in a family %: one 35.2 35.7 two 56.2 55.9 three 7.9 7.9 four 0.7 0.4 Knowledge, Attitudes, and Practices of Traffic Safety Out of all 780 participants in both surveys, 53% had a car in the household. Half of these cars, in both baseline and follow-up assessments, had cars produced before 2000. In both surveys, about 42% of respondents had ever driven a car. For 40% of respondents walking is the primary mode of transportation. Among drivers only 82% at baseline and 77% at follow-up attended drivers’ education classes. There was no significant difference between baseline and follow-up. The percent of household cars in Yerevan that had seatbelts was 90% at baseline and 99% at follow-up (p
