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ORIGINAL ARTICLES
Can Business Road Travel Be Safe? Experience of an International Organization ¨ Selod, MD,∗ Jian Ye, MD, PhD,∗ Lennart Jasminka Goldoni Laestadius, MD, PhD,∗ Anne Gaelle † ‡ Dimberg, MD, PhD, and Anthony G. Bliss, MA ∗
Joint Bank Group/Fund Health Services Department, The World Bank Group, Washington DC, USA; † Department of Primary Healthcare, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden; ‡ Energy, Transport and Water Department, The World Bank Group, Washington DC, USA DOI: 10.1111/j.1708-8305.2010.00491.x
Background. Globally, more than 1.2 million people die on the roads every year, and unfortunately so do one or two operational travelers for the World Bank Group (WBG). Methods. To investigate potentially preventable factors and improve the institution’s road safety policies and practices, an electronic survey was designed in 2008 targeting about 16,000 WBG staff worldwide to inquire about road crashes and near crashes over the 3-year period. Also, questions were asked pertaining to contributing circumstances. Staff was encouraged to provide comments on prevention. A combined index based on the number of reported crashes and near crashes divided by person-days spent on mission in each country was used to rank the countries. Results. A total of 3,760 responses were collected. There were 341 road crashes reported, about 1 in 175 missions. Seventy percent took place in taxis, and 40% of crash victims reported that seatbelts were not used. Contributing factors included driver’s decision error, speeding, or road/weather conditions. On the basis of a combined index, a list of 36 high-risk countries is presented. A high correlation between crashes and near crashes (r = 0.89) justifies the method. Conclusions. Improved corporate policies will need to be developed to address preventable risk factors identified in the study.
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n estimated 1.2 million people died in road traffic crashes globally in 2002 and 20–50 million related nonfatal injuries are estimated to occur each year.1,2 In 2002, 90% of the road traffic deaths occurred in low- and middle-income countries. While the number of road crashes has been cut in high industrialized countries, road traffic fatalities are predicted to increase sharply over the coming years in the low- and middleincome countries as traffic density increases over the same time.3 As a result, deaths from road traffic injuries are expected to rise from the ninth leading cause of death in 2004 to the fifth in 2030, unless additional safety measures are implemented.4 As a consequence, road crashes represent an important cause of mortality and morbidity among international travelers. A French study analyzing the causes of death among French citizens abroad revealed Corresponding Author: Lennart Dimberg, MD, PhD, Institute of Medicine, Department of Primary Healthcare, University of Gothenburg, Box 454, 40350 Gothenburg, Sweden. E-mail:
[email protected]
that road crashes represented the second cause of death after cardiovascular disease.5 Hargarten, studying the cause of injury death of US citizens abroad, found similar results: motor vehicle crash was at the top of the list (27% of all) among 601 deaths of US citizens abroad between 1975 and 1984.6 In a more recent study (2009) of 2,361 deaths of US citizens abroad, 40% were due to vehicle crashes. This was twice the rate of low to middle income citizens in the United States.7 In a 2007 study in Greece, foreign drivers were at an increased risk of motor vehicle crashes compared with the local residents.8 However, very few epidemiological data exist on the risks faced by international business travelers.9 The World Bank Group (WBG) has a population of approximately 16,000 employees and 70% of the staff travel routinely as part of their work, cumulating in over 300,000 days of international travel annually. The travel destinations are mostly low- and middleincome countries representing the principal clients of the organization. Current corporate road safety © 2011 International Society of Travel Medicine, 1195-1982 Journal of Travel Medicine 2011; Volume 18 (Issue 2): 73–79
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performance gives cause for concern, as on average one or two staff die annually and significantly more are injured on the roads while working in client countries. With a view to improve road safety policies and practices in the institution, we conducted a staff survey worldwide to collect epidemiological data on our business travelers’ exposure to road safety risks, their experience of road crashes and near crashes, and their suggestions for improved organizational road safety policies and practices. Our study presents a unique ranking of high-risk countries in terms of road safety and suggestions for improved corporate road safety practices. Aims/Objectives The aim of the study was to investigate road safety problems among WBG business travelers, identify highrisk countries with respect to road safety and traveler safety concerns, and to suggest preventive strategies. Methods Baseline Survey Design A questionnaire was developed by the WBG Staff Road Safety Task Force to include questions about demographics, travel-related information, road safety concerns, crash and near crash situations, safety experience with taxis, Bank vehicles and drivers, and other road safety issues in the Bank system. After initial testing and revision, the questionnaire (available on request) was adapted into an online survey. Subjects E-mail addresses of all 15,962 employees were obtained from the Human Resource (HR) Office, including 12,129 regular staff members and 3,833 consultants from the WBG. Data Collection The online survey was e-mailed to all subjects on March 12, 2008 and was after three reminders closed on April 13, 2008. In addition to data collected from the survey, data about WBG mission travel were extracted from the HR database for validation of self-reported travel history and analysis of reported events. The HR dataset contained information for the past 3 years on destination country and number of days so that risk exposure in each country could be measured in aggregate by ‘‘person-days.’’ Data Analysis Initially, several indicators were used to measure the risk profile of countries with respect to road safety: 1. Number of reported road crashes The top 10 countries with number of reported crashes were identified from survey responses. J Travel Med 2011; 18: 73–79
Goldoni Laestadius et al.
2. Number of reported near crash situations The question about near crashes was as follows: ‘‘During the past 3 years, how many times have you been in a near hit situation (nearly had a crash) while traveling on mission?’’ The same analysis was conducted as above. 3. Perception of road safety risk A count of responses to question ‘‘Please check all the countries where you felt more at risk from the road safety view point while traveling on mission in the past 3 years’’ was used to identify high-risk, medium-risk, and low-risk countries with respect to safety concerns. 4. Incidence of described road crashes Incidence rates were calculated using the formula Incidence rate of crashes in one country = Number of reported crashes/person-days spent on mission in this country. 5. Incidence of described near crash situations The same analysis was performed, using the formula Incidence rate of near crashes in one country = Number of reported near crashes/person-days spent on mission in this country 6. Summary index of all indicators 1–5 According to how frequently one country appears on the country lists, a summary table of highrisk countries based on all these five indicators was developed. 7. Total number of crashes and near crashes The top 15 countries, accounting for 50% of all reported crashes and near crashes, were identified. 8. Incidence rate of total number of crashes and near crashes The formula used was Incidence rate of all reported events in one country = Number of reported crashes and near crashes/person-days spent on mission in this country. This combined factor (indicators 4 and 5) was introduced to enlarge the number of reported events in each country, since the number of road crashes alone was too small to allow conclusions regarding distribution of risk per countries. SAS 9.1 was used for all statistical analysis and DevInfo 5.0 was used to develop maps. The cut-off rate for low, medium, and high risk was arbitrarily developed to provide similar-sized groups. For reasons of limited space, we only present a table and a map of high-risk countries based on the incidence rate of total number of crashes and near crashes (indicator 8). The map was developed to show the distribution of high-risk, medium-risk, and low-risk countries. Countries rarely traveled in by the Bank staff, with person-days lower than 147 (15 percentile) within 3 years, were not included in the incidence calculation and were marked as ‘‘not enough travel data’’ to map.
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Can Business Road Travel Be Safe? Table 1 Demographic and travel-related characteristics of respondents Questions Age 29 or younger 30–39 40–49 50–59 60 or older Gender Female Male Contract type Staff Consultant Vendor/contractor Current base Washington DC Country office Number of missions in a typical year 0 1–3 4–6 7–9 10–20 >20 Skipped
N
Table 2 List of high-risk countries (incidence rate of total number of crashes and near crashes ≥12 per 1,000 person-days)
Percentage
315 1,196 1,218 818 184
8.4 32.1 32.6 21.9 4.9
1,918 1,796
51.6 48.4
3,219 501 12
86.3 13.4 0.3
2,070 1,622
56.1 43.9
512 1,178 982 279 586 84 139
13.6 31.3 26.1 7.4 15.6 2.3 3.7
Follow-up Survey A follow-up survey was distributed to the 341 staff reporting at least one road crash over the past 3 years, asking for more detailed descriptions of crash circumstances. The questions addressed who was driving, use of seatbelts, speed of the car, other circumstances of the crash, response time of assistance, need for medical treatment, use of first aid kit, use of cardiopulmonary resuscitation (CPR), need for sickleave, and nature of the injuries.
Rank
Area name
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
Oman Guyana Yemen Bangladesh Cameroon Papua New Guinea Sao Tome and Principe Cambodia Togo Benin Gabon Honduras Malawi Angola Egypt Jamaica Albania Guinea Timor-Leste Niger Grenada Iran Afghanistan Guinea-Bissau Georgia Bhutan India Dominican Republic Sri Lanka Vietnam Madagascar Saint Lucia Sierra Leone Nigeria Zimbabwe ˆ d’Ivoire Cote
Person-day
No. of events
Incidence rate (per 1,000 person-days)
161 484 2,657 3,586 2,190 655 243 3,471 431 986 186 1,255 1,761 950 6,750 512 1,858 1,004 757 900 211 1,203 2,168 362 1,251 749 22,102 848 3,116 9,142 1,914 321 1,529 6,682 329 580
4 12 65 82 41 11 4 57 7 16 3 20 28 15 106 8 28 15 11 13 3 17 30 5 17 10 288 11 40 115 24 4 19 83 4 7
24.84 24.79 24.46 22.87 18.72 16.79 16.46 16.42 16.24 16.23 16.13 15.94 15.90 15.79 15.70 15.63 15.07 14.94 14.53 14.44 14.22 14.13 13.84 13.81 13.59 13.35 13.03 12.97 12.84 12.58 12.54 12.46 12.43 12.42 12.16 12.07
Results The Baseline Survey A total of 3,760 people took the online survey (response rate = 25.6%). More than half of the respondents have at least four travel missions in a year and around 18% of the respondents traveled at least or more than 10 times during a year. Table 1 shows the demographic and travel-related profiles of respondents. Of 3,109 survey respondents who reported that they made at least one mission in a typical year, we were able to match 3,004 with HR staff travel data. All analyses were conducted among the 3,004 matched travelers. A total of 4,100 near crashes were reported by WBG staff, which can be converted to 1 near crash per 15 missions. There were 341 road crashes reported, or 1 in 175 missions. The most often stated contributing factors included driver’s decision errors, speeding, and road or weather conditions. Forty percent of crash
victims reported that seatbelt was not in use at the time of crash. Seventy percent of crashes took place in taxis. The distribution of high-risk countries, regardless of the indicator used to measure risk profile, reflected the pattern of typical travel destinations in the Bank, including mostly low- and middle-income countries. Responses to the question about perception of road safety were mapped to show overall picture of safety concerns of countries around the world (indicator 3). The top 10 high-risk countries with respect to perception of risk were India, Kenya, South Africa, Egypt, Nigeria, Vietnam, Indonesia, Pakistan, Bangladesh, and Tanzania. The reported crashes and near crashes were highly associated. The correlation coefficient was 0.89, which is a strong positive association. Therefore we selected indicator 8 (incidence rate of total number of crashes J Travel Med 2011; 18: 73–79
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Figure 1 Road safety risk per country, based on the incidence rate of reported crashes and near crashes.
and near crashes), as a main indicator of road safety risk by country. The list of high-risk countries for this indicator is presented in Table 2, the map in Figure 1. In response to the question ‘‘Do you have any suggestions to provide better road safety for Bank travelers?,’’ 1,068 suggestions and safety comments were collected and categorized in Table 3. Similar responses were compiled under the most common statement to avoid redundancies, and finally condensed to themes. With regard to the driver, travelers suggested to improve training, education, and introduce medical clearance for company drivers. With regard to passengers, travelers advised using preferred car companies respecting safety norms, putting on seatbelts, carefully planning travels, and reporting any incident to the management. Finally, with regard to employers, travelers suggested that a strict road safety policy and culture be implemented and enforced. The Follow-up Survey Of 341 distributed surveys, 122 (36%) were completed for analysis. During the most recent crash, 14 of the respondents (11%) reported being injured, 3 respondents were hospitalized, and 2 were medically evacuated. The injuries comprised fractures, cuts and bruises, and several cases of whiplash traumas. First aid kit or CPR was not used. Only four individuals reported sick-leave as a consequence. Lack of available seatbelts was commented on by several of the injured. The respondents, commenting on their most recent road crash, ranked the most common causes as follows: (1) unforeseen circumstances (rear-ending, animals running out, and other vehicles breaking traffic rules) (n = 18); (2) lack of driver attention (n = 11); J Travel Med 2011; 18: 73–79
(3) speeding (n = 9); (4) poor sight (bad weather, dusk, dark) (n = 4); (5) vehicle (poor brakes or tires) (n = 3); and (6) poor roads (n = 2). A combination of two or more of the ranked causes was mentioned in about one third of the situations. Discussion and Conclusions A major strength of this study is its ranking of countries in terms of road safety, drawing on the experience of a large and worldwide traveling population. This contribution is unique in the existing literature, especially for developing countries. Official statistics for most developing countries are either old and/or unreliable due to poor reporting practices and professional travelers have a different traffic exposure than the general population.10 This study therefore fills a gap in the knowledge about road hazards, and highlights the risks of road travel in developing countries for business travelers. We have opted to present several ways of classifying the risk. All have their limitations, but together they complete the picture. Whether a road incident actually leads to a crash or not is a matter of a stochastic chance. The higher number of near crashes in some countries shows that the traffic situation is chaotic, and sooner or later an incident will convert to a crash. In our study, this is validated by the high correlation between crashes and near crashes (r = 0.89). The number of crashes and near crashes is in itself important information, but probably more reflects the travel pattern than the risk. An ideal way to standardize road travel would have been to relate crashes to the distance traveled. Unfortunately, this information was
Can Business Road Travel Be Safe? Table 3 Comments and recommendations related to road safety by survey respondents Drivers The local prevailing driver culture varies Always fasten seatbelts Adhere to speed limits—drive slowly Warnings and tips prior to trip Road safety training and drill of company drivers Rest stops on long drives keeping driver alert Medical check-ups of drivers Impose standards for hired drivers Guidelines for drivers and travelers Drivers under influence of drugs Practice defensive driving Passengers Sometimes better to fly than use car for longer travel Do not rush—allow time for traveling Be aware of road conditions Do not travel on the road by night or bad weather Avoid rush hours if possible Sit in the back just behind the driver and wear a seatbelt Safety as a pedestrian is of equal concern Staff should undergo driver awareness training Communicate to drivers expected speed limits Manage taxi by a combination of polite request, tips, and pressure Report crashes and near crashes Vehicles Use hotel cars, generally safer Many cars do not have seatbelts, especially in the rear seats Many cars do not have headrest Preferably travel by a larger car Do not use tin box cars Employer/travel agency Policy on the use of rental cars Provide do’s and don’ts for travelers Develop FAQs on road safety issues Prequalified taxi service and use of rental cars Provide information about safe and reliable taxi service in advance Mission office provides special agreements with companies with good drivers and safe cars Instruction on what to do if you have an accident Ensure safe pick-ups at airports Provide emergency phone numbers Provide adequate number of institutional drivers The drivers should be monitored Alert travelers before departure of road conditions Lift the daily maximum rates for car and driver rental Promote careful driving Provide statistics on road accidents/fatalities to countries to be traveled Greater risks are a hazard of working in developed countries, but insurance coverage should be adequate Others Invent a portable seatbelt!
not obtainable from this study. The perception of risk is another aspect, but has its limitations because even if most surveyed staff members are seasoned travelers, few have traveled to all reported countries, which will bias the rankings.
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We have thus chosen to rank road safety risks by using the incidence rate of total number crashes and near crashes (Table 2; Figure 1) as our main outcome, since this indicator is standardized by the number of travel days. The person-days is our analysis unit for incidence calculation and it provides the estimate of impact/burden of road traffic events. From that perspective, multiple crashes with one person involved in each are equivalent to one crash involving several employees. We base our recommendations for improved road safety practices on this ranking. However, it is unfortunately not possible to directly compare our incidence rates with existing statistics, which typically provide rates of crashes or deaths per number of motor vehicles, or per 100,000 persons.10 In comparison with the latest available World Health Organization (WHO) statistics for the year 2009, none of our top 10 countries only were also ranked among the top 10 on the corresponding WHO country ranking measured by traffic deaths per 100,000 persons.10 This may also be a reflection of a different travel pattern for business travelers than for the general population. In a literature review awaiting the Sydney 2000 Olympics, Wilks identified from several studies that tourists, compared with the local residents, were at an increased risk on the roads. Particular risk factors included unfamiliarity with the roads, driving on the left side, poor adherence to traffic rules, and alcohol abuse. Being jet lagged and dehydrated from an international flight would also be a risk factor.11 However, a review of all deaths among Peace Corps volunteers (PCV) between 1984 and 2003 did show a different pattern.12 PCV are exposed to unique risks, but these risks have become significantly less fatal over the past 20 years and compared to the US population. There is obviously a difference of risk between tourists with a more relaxed lifestyle and professional business travelers backed up by an international organization. Although the risk for pedestrians represents an important area of road safety risk for travelers, we did not address it in our study at this time. In the road safety literature, risk factors are typically attributed to the driver, the vehicle, and the environment.13 On the basis of the comments from our travelers, drivers seem to be a major factor. Lack of driver attention, aggressive driving, speeding, and lack of concentration including tiredness and cell phone usage were mentioned in 42% of the crashes. This is slightly less than the findings of Rumar, who in 1985 found that 57% of the crashes were due solely to errors of the drivers.14 The use of alcohol and other drugs by drivers often leads to car crashes, and is in many countries poorly controlled.15 While drivers of Bankowned vehicles in general get high marks, taxis can come with poorly rested drivers and substandard vehicles. Seventy percent of the reported crashes took place in taxis, although it is not clear what proportion of travel J Travel Med 2011; 18: 73–79
78 Table 4
Goldoni Laestadius et al. Seven recommendations issued by the Task Force based on the staff road safety survey results
Recommendations
Summary
Build a stronger organizational focus on results
The goal should be ‘‘as far as is practicable’’ to ensure that the traveling staff are not exposed to unacceptable risks.
Adopt a systematic and accountable approach
A systematic, measurable, and accountable approach is required, which links management functions and related interventions with the desired focus on results.
Specify management and staff responsibilities
Management and staff responsibilities for improved staff road safety should be clearly specified (across headquarters and throughout regions to countries).
Improve monitoring and evaluation
Monitoring and evaluation procedures should include: • Mandatory reporting of all road safety incidents • Investigation of all crashes to ensure that relevant lessons are learned and any recurrence of such events are eliminated • Monitoring and evaluation of the health status of WBG drivers • Monitoring and evaluation of safety standards of WBG vehicles.
Prepare staff road safety programs
Three broad dimensions to be covered: • Road environment factors • Vehicles, drivers, and passengers • Emergency medical services
Implement staff road safety programs in high-risk countries
Rapid implementation of programs in a sample of identified high-risk countries, to pilot their operational development, and to identify country differences and issues to be addressed in the organization-wide program delivery. Promotion through: • Targeted management and staff consultation • Education and training initiatives • Regular staff communications channels
Promote staff road safety programs
occurred in these vehicles. Only 60% reported that the front seatbelts were always available and only 30% reported functional back seatbelts to be always present, which are obvious problems for safety. The roads in these high-risk developing countries are generally poor. In about half of the most recent crashes, unforeseen circumstances such as animals running out and other vehicles breaking the law were mentioned. These environmental factors are difficult to address from the business travelers’ perspective. On the basis of the findings of this study, the WBG is introducing an upgraded staff road safety policy to address the identified needs collected by the Road Safety Task Force.16 Strategic recommendations will center on improving the safety of vehicles, drivers, and passengers in the WBG offices worldwide; introducing an implementation framework for promoting awareness and providing training; and monitoring results for compliance and continuous improvement (Table 4). As a vital component of road safety, individual staff will share the responsibility to ensure their own safety by taking all necessary precautions while on road travel. The findings of our survey reflect the poor and deteriorating road safety performance in developing countries and this is being addressed as a global development priority. For example, the WBG has published comprehensive guidelines to strengthen the road safety management capacity in developing J Travel Med 2011; 18: 73–79
countries and at a regional level has, in a recent publication, made the case for the challenges and opportunities in addressing road safety in Europe and the Central Asia Region.17,18 However, until road safety performance is significantly improved in developing countries and sustainably brought under control, the increasing incidence of deaths and serious injuries on the roads will need to be in focus for all international business travelers and their employers to ensure effective protective measures are taken. Acknowledgments This study was fully funded by the World Bank Group. We do appreciate the support by Dr Bernard Demure, Director of the Joint Bank/Fund Health Services Department to have this paper published. Disclaimer The conclusions of this study are those of the authors, and may not reflect those of the World Bank, its Executive Directors, or the countries they represent. Declaration of Interests The authors state they have no conflicts of interest to declare.
Can Business Road Travel Be Safe?
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