Youth traffic-related injuries: a prospective study
Grivna et al. World Journal of Emergency Surgery
Youth traffic-related injuries: a prospective study
Michal Grivna 1 3
Hani O. Eid 1 2
Fikri M. Abu-Zidan 0 1
0 Department of Surgery, College of Medicine and Health Sciences, UAE University , Al-Ain , United Arab Emirates
1 This paper has been presented as a poster in the 12th World Conference on Injury Prevention and Safety Promotion , held on 18-21 September, 2016 in Tampere, Finland and published as an abstract in Injury Prevention 09/2016; 22(Suppl 2):A188
2 Department of Surgery, Trauma Group, College of Medicine and Health Sciences, UAE University , Al-Ain , United Arab Emirates
3 Institute of Public Health, College of Medicine and Health Sciences, UAE University , Al-Ain , United Arab Emirates
Background: Traffic-related injuries are the most common cause of morbidity and mortality of the youth. Our aim was to study epidemiology, risk factors and outcome of hospitalized youth patients injured in road traffic collisions in order to give recommendations for prevention. Methods: We prospectively studied all youth (15-24 years) patients having traffic-related injuries who were admitted to Al Ain or Tawam Hospitals, Al Ain City, or who died after arrival to these hospitals during an 18 months period. Demography, location and time of injury, injured body regions, severity, hospital and intensive care unit (ICU) stay and outcome were analyzed. Results: Three hundred thirty-three patients having a mean age (SD) of 20 years (2.5) were studied. 87% were males and 72% were UAE nationals. Majority of injured patients were drivers or front-seat passengers (70%), followed by back seat passengers (16%), motorcyclists (5%) and pedestrians (4%). Rollover was the most common crash mechanism (35%), followed by front crash (34%). Twenty seven patients (8%) were ejected during the crash, 14 during roll-over, 7 from quadribikes and three during front crash. 20% of the patients were admitted to the ICU. Median Glasgow Coma Scale was 15 (range 3-15), median Injury Severity Score was 5 (range 1-41), and median total hospital stay was 3 days (range 1-73). Nine (3%) patients died. Conclusions: Young UAE-national males are at a higher risk of being injured at traffic. Rollover crash was frequent with high risk of ejection. Promotion of traffic safety and enforcement of safety legislation is necessary.
Youth; RTC; Traffic injury; Traffic safety
Traffic-related injuries are the most common cause of
premature morbidity and a leading cause of death among the
youth in the Middle-East [1, 2]. These injuries have a high
impact on the affected victims, their families and societies
. According to the World Health Organization Global
Status Report on Road Safety 2015 there are over 1.2
million road traffic deaths worldwide every year . The
estimated road traffic death rate in 2013 in the United
Arab Emirates (UAE) was 10.9 per 100.000 population .
UAE is a fast developing country with a large proportion
of young population. It has a growing number of vehicles
(2.7 million in 2013)  and an expanding network of
Specific risk factors for road traffic injuries in youth
include inexperience, developmental changes with
increased emotionality, overestimation of driving skills,
increased risk taking, and response to peer pressure .
Prevention of road traffic collisions (RTCs), including
use of safety belts and creating safe road environment,
has been well-studied . However risk factors vary in
different settings. Despite legislation and increased
enforcement in the UAE, the use of restraints among the
youth is still very low . Information on traffic-related
injuries requiring hospitalization for this specific age
group in our region is highly needed. We aimed to study
the epidemiology, risk factors and outcomes of hospitalized
road traffic injured youth patients in order to give
recommendations for prevention.
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We prospectively studied all youth patients (15–24 year
old) who were admitted to Al Ain City’s two major trauma
centers or who died after arrival to these hospitals following
RTCs during the period of April 2006 to October 2007. Al
Ain City had about 460,000 inhabitants during study period
. Trauma patients were exclusively admitted to Al Ain
Hospital and Tawam hospital. Al Ain hospital has 412 beds
and provides a wide range of general and specialist clinical
services , whereas Tawam Hospital is a highly specialized
tertiary care center with 468 beds .
Patients or their caregivers were interviewed by a full
time Research Fellow. We collected data on demography
(age, gender, nationality), crash mechanism, place of injury,
road user type, position in the vehicle, speed of the vehicle,
use of safety equipment, time of the crash, anatomical body
part(s) injured, severity, Revised Trauma Score (RTS),
Glasgow coma scale (GCS), intensive care unit (ICU)
admission, length of hospital stay, and outcome (survival or
Injury severity of different regions was calculated
manually using The Abbreviated Injury Scale (AIS) of
the Abbreviated Injury Scale Handbook . This scale
assigns each region a severity ranging from 1-6 (minor
= 1, moderate = 2, serious = 3, severe = 4, critical = 5,
unsurvivable = 6). The Injury Severity of the patients was
assessed using the ISS . The revised trauma score
(RTS) was calculated using the systolic blood pressure,
pulse rate, respiratory rate and GCS at arrival to the
Nationality was divided into two categories (UAE nationals
and non-UAE nationals) because the traffic risks differ
between these two groups [6, 13, 14]. Comparison of
continuous or ordinal data was performed using the
MannWhitney U-test for two groups or the Kruskal-Wallis for
more than two groups. Fisher’s exact test or Pearson Chi
square test were used to compare categorical data of two or
more independent groups as appropriate. A p value of less
than 0.05 was needed to refuse the null hypothesis and
accepting significant differences between the groups. Data
were analyzed using Statistical Package for the Social
Sciences (IBM-SPSS version 21.0, Chicago, Il, USA).
Personal risk factors: gender, age and nationality
There were 333 patients, 290 males (87%). The mean
age (SD) was 20 (2.5) years. Majority were UAE nationals
(72%). The annual incidence of RTC hospitalizations using
census data was estimated to be 279.4 per 100 000
personyears. Higher incidence was among males (411.1) than
females (88.4). Although male to female population ratio
was 1.5:1, the traffic-related injury ratio in our study was
Injuries by type of road user and vehicle type
Majority of injured patients were drivers or front-seat
passengers (70%), followed by rear seat passengers (16%),
motorcyclists (5%), and pedestrians (4%) (Table 1). The
percentage of drivers were significantly higher among
UAE nationals comapred with non-UAE nationals (p <
0001, Fisher’s Exact test). In contrast the percentage of
rear seat passengers, pedestrians, and bicycle riders were
significantly higher among non-UAE nationals comapred
with UAE nationals (p = 0.04, p < 0.001, and p = 0.006
consequetivly, Fisher’s Exact test) (Table 1).
There was no significant difference in age, GCS, RTS
and ISS between vehicle occupants and vulnerable road
users (pedestrians, bicyclists, motorcyclists, and
quadribike users). Mortality among vehicle occupants was 2%
compared with 4% in vulnerable road users.
Motorcyclists and cyclists were all males (100%). Table 2
compares those patients who were less than 18 years old
Vulnerable road user
p Fisher’s Exact test
*Information on road user type was missing in 1 patient
Numbers may not add to 100 due to rounding
Type of patient
Back seat passenger
Hospital stay (days)
Data are presented as number (%) or median (range) as appropriate
p Fisher’s Exact test or Mann Whitney test as appropriate, ICU Intensive Care
Unit, GCS Glasgow Coma Scale, RTS Revised Trauma Score, ISS Injury
and those who were ≥18 years old. Back seat passengers
and motorcyclists were significantly higher in those less
than 18 years old (p < 0.001, Fisher’s Exact test). Twelve
drivers (8%) and 6 motorcyclists (35%) were under the
licensing age in the UAE (18 years old). There were also 6
(50%) quadrubike users less than 18 years old. Underaged
motorcyclists were injured off-road and in the parking or
housing areas. Two underaged quadrubike users were
injured on highway or street while four were injured
Fifty three percent (150/285) vehicle occupants were
injured in sedan cars, 44% (124/285) in sport utility
vehicles (SUVs) and 4% (11/285) in other vehicles. Male
drivers were significantly more injured driving SUVs
compared with females (70/148 (39%) comapred with 0/
6 (0%), p = 0.032, Fisher’s Exact test). Females were
driving only sedan cars. Sixty six percent (103/155) of
drivers were driving alone; 64% (7/11) of drivers who
were less then 18 years old were driving alone.
Rollover of the vehicle was the most common crash
mechanism of injury (35%), followed by front impact
collision (34%) (Table 3). Secondary roll-over of the car
was in 50% of rear-end, 37% of side and of 18% of
frontimpact crashes. Twenty seven patients (8%) were ejected
during the crash. More UAE nationals were injured in
Table 2 Demographic and severity variables by age category
(<18 and ≥18), Al Ain, 2006–2007, n = 333
rollover crashes compared with front or side angle (p =
0.002) (Table 3). Patients in rollover crashes had a longer
stay in the hospital compared with front and side angle
crashes (p = 0.03) (Table 3).
Speed of the car
The mean (SD) of car speed was 97.2 (35.8) km/hr, 42%
were higher than the legal speed limit of 100 km/hr (Fig. 1).
Place and time of injury
Majority of traffic-related injuries occurred on highways
and streets (276/333;83%), 7% (24/333) off road, 6% (20/
333) around homes in residential areas, and 4% (13/333)
in other locations. Thirty three percent (5/15) of
pedestrians and 29% (5/17) of motorcyclists were injured in
housing areas. Seventy five percent of quadrubike users
(9/12) and 24% of motorcyclists (4/17) were injured off
Evening (6–12 pm) was the most common time of
crashes (34%) and Friday the most common day of
crashes (20%) (Fig. 2). Most of injuries occured in the
period of May to October.
Safety equipment, distraction, sleep and alcohol
Only 12% (n = 18) of the drivers, and 4% (3) of front seat
passengers were restrained. No back seat passenger used
a setabelt. Five motorcyclists used a helmet (17%) and
two wore protective clothing (7%). No byclist or
quadrubike user used a helmet. Eight drivers (5%) were using
mobile phones. Seven drivers were sleepy when they
crashed (4%). Alcohol use was found only in one patient.
Severity and anatomical location of injuries
There were 66 patients (20%) admitted to the ICU.
Median GCS was 15 (range 3–15), median ISS was 5
(range 1–41), median RTS was 12 (range 7–12) and
median total hospital stay was 3 days (range 1–73). Nine
patients (2.7%) died.
The head was the most common injured region (67%)
followed by extremities and chest (Table 4). The highest
AIS score was in the chest (mean AIS 2.5) followed by
the spine (mean AIS 2.3) (Table 4). Eighty percent of
ejected patients sustained a head injury.
Youth is the active period of life with major
developments affecting adult health . Traffic-related injuries
are the most common cause of morbidity and mortality
in the youth. In our study, young UAE-national males
were at higher risk of being injured in traffic. Rollover
crash was common with a high risk of ejection. Restraint
use was extremly low in our study population.
The youth male preponderance has been described in
many studies [2, 3, 15, 16]. Young male drivers have a
Hospital stay (days)
Data are presented as number (%), mean (SD) or median (range) as appropriate
Other mechanisms include back crash or crash with motorcycle or bicycle
p Fisher’s Exact test, Pearson chi square, or Kruskall Wallis test as appropriate, ICU Intensive Care Unit, GCS Glasgow Coma Scale, RTS Revised Trauma Score, ISS
Injury Severity Score
higher collision rate than women  and their death rate
is double compared with women . In the UAE, young
women drive less and usually drive small cars, which are
less prone to rollover. During the cognitive development
the ability of youth to make safe decisions on the road is
not mature [16, 18]. Adolescents are known to seek out
risks when driving . They have lower compliance with
restraint use in our region [6, 16].
Despite legislation and increased law enforcement, seat
belt use remains low in our setting, especially among
young UAE nationals . Only 12% of drivers and 4% of
front seat passengers were restrained in our study. This
poses a serious risk to all vehicle occupants. There is a
high risk of severe injury and fatality for unrestrained
passangers, especially in front collisions and rollovers
Rollover crash was the most common crash mechanism
in our study with 8% of the passengers being ejected. SUV
is a very popular vehicle in the UAE, especially among
UAE national families, who like to drive in the desert and
off-road. These cars tend to roll-over during collision,
because they have a higher center of gravity. Ejection rate
is high because of the low use of restraints in our
community. Quadrubike use by teenagers in our study caused 4%
of all crashes, 75% of them sustained a head injury. Head
injury was also common among other vulnerable road
Table 4 Traffic-related youth injury hospitalisations by anatomical
region and AIS severity, Al Ain, 2006–2007 (n = 333)
*Maximum Abbreviated Injury Scale – only the most severe injury per body
region was counted for each patient; Some patients have injury in more than
users (bicyclists and motorcyclists) who did not use
helmets. Bicyclists in our study were only non-UAE nationals.
They are usually poor workers using bicycles for their
transport. The percentage of pedestrian injuries were also
higher among non-UAE nationals comapred with UAE
nationals. UAE nationals tend to use the car even for very
short distances compared with non-UAE nationals who
generally walk to perform their duties.
Distractive driving is a major contributing factor for
traffic collisions. US Transportation Department reported
that nearly 20% of all crashes involve some distractive
driving . Distractive driving causes impairement in
driving performance and prolongs reaction time . In
our study, 5% of drivers were using mobile phones when
they crashed. Despite legislation, use of mobile and smart
phones while driving is common in the UAE. Alcohol use
in the youth was less than 0.5% in the present study.
Overall alcohol use in road traffic injuried patients in our city
was 2.1% . This is attributed to legislation, religious
believes, and limited accessibility to alcohol.
The age for obtaining driving license in the UAE is
18 years. 8% of injured drivers in our study were younger
than this age and 64% of them were driving alone when
they crashed. Families ignore the need for a license for
short trips and use adolescents for bringing siblings from
school and for shopping. A study in Oman found that
33% of students had driven without a license and 34%
liked to speed . 35% of motorcycle riders and 50% of
quadrubike riders were under 18 years old in our study.
Unlicensed driving is a major problem for traffic safety as
it often correlates with high-risk behaviors such as
speeding, failure to wear a seat belt or motorcycle
helmets. Unlicensed drivers were three times more
likely to be involved in a collision than licensed drivers
Most of our patients were injured at night (64%). This
is possibly contributed to impaired visibility during night
and a possibility to drive with high speed because of
presence of fewer vehicles. Violation of speed limits is
another important contributing factor to RTCs . The
traffic design in Al Ain with long roads having 3 lanes
between roundabouts allows the youth to speed. Drivers
who drive faster or slower than the mean speed of traffic
have a higher risk of crash .
There was a sharp increase of injuries during the
weekend (Thursday and Friday) and in October which was the
fasting month of Ramadan during the study period. The
Canadian study  which assessed the increased crashes
during the weekends and holidays, found three main risky
behaviors: unsafe speeding, non-use of restraints, and driver
intoxication. There is increased risk for traffic collisions
during the fasting month of Ramadan, epecially in the
evenings when tired drivers after a day without food or
drinks are rushing home for breaking fast [25, 26].
Sleepeness occured in 4% of drivers involved in road traffic
collisions in our city. This risk increased during the fasting
month of Ramadan .
The police, transportation and the health sectors in
the UAE have made active efforts to reduce the burden
of RTCs over last decades. This included introduction of
new laws and regulations, enforcement of speed limits,
improved road design, and educational campaigns .
Plans are underway to introduce mandatory seat belts
for rear seat passengers and child safety restraints .
Limitations of the study
We have to acknowledge that there are certain
limitations in our study. We studied only patients who were
admitted to the hospital or those who died in the
Emergency Department following road traffic collisions.
More seriously injured patients may have died before
arriving to our hospitals. Furthermore, our study
population was from Al Ain City, limiting the generalizability
of our results for other parts of the UAE. Finally, our
study was a specific time limited research project supported
by the UAE University before 2007. It may be questioned
whether our results reflect the present situation. We think
that risk factors for youth traffic injuries are still the same
in our city.
Young UAE-national males are at a higher risk of
being injured at traffic. Rollover crashes have high risk
of ejection. There is a need for implementation of
cultural relevant evidence-based educational programs
for all new and existing youth drivers. Promotion of
traffic safety and enforcement of safety legislation is
neccesary. Distractive and underage driving should be
We would like to thank Faisal Aziz from the Institute of Public Health, College of
Medicine and Health Sciences, UAU University for assistance in data analysis
and design of tables.
Availability of data and materials
There is no additional data available to share with the readers. Data can be
shared with the Editor of the Journal if requested.
Conceived and designed the experiments: MG HOE FAZ. Retrieved and
coded the data: HOE. Analyzed the data: MG HOE FAZ. Wrote the paper: MG
FAZ. Critically read the paper: MG HOE FAZ. Approved final version: MG HOE
Consent for publication
The authors declare that they have no competing interests.
Ethics approval and consent to participate
The data collection was approved by the Ethics Committee of Al-Ain Health
District Area (UAE RECA/02/44). Patients or their caregivers signed a written
consent allowing using their anonymous data for research purposes.
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