Abstract

Objective

     To examine the association between visual impairment and sustaining an injurious Motor Vehicle Accident (MVA) among drivers seen at the Accident & Emergency Department of Al-Ain Hospital, United Arab Emirates, (UAE).  

Design

     A cross-sectional hospital based study.

Setting

     Accident Emergency Department [AED], Al-Ain Hospital, UAE.

Subjects

     Male and females aged 18 years and above interviewed during the period January 1996 to December 1997.  A total of 1542 drivers were examined and treated, but only 1428 drivers gave consent for the study. 

Methods

     Socio-demographic data, visual acuity, level of injury, data about driving behavior and data from police reports were collected and analyzed.  Study subjects were classified into two groups based on visual acuity: normal vision and visually impaired.

Results

    A total of 1428 drivers were included in our study.   Of these, 1221 patients (85.6%) had normal vision, 207 patients (14.5%) were visually impaired at the time of sustaining MVA.  The majority of victims (77%) were males.  Most of the drivers (55%) were young and under the age of 40 years; 39.7% were UAE nationas; 32 % had a primary school education; 37.5 % had less than 2 years driving experience and 17.2 % always used seat belts.  Most (59%) admitted to crossing red traffic lights, 61.3% excessive speeding; 32.6% smoking while driving; 29.8 % to using telephones while driving; 32.1% to putting their child in the front seat.  Significantly higher risk was observed for careless driving [RR=1.29; 95% CI=1.10-1.66, p=0.049], speeding violations [RR=1.32; 95% CI=1.01-1.73, p=0.041] , and property damage [RR=1.80; 95% CI=1.31-2.48; p=0.005] among drivers having  vision impairment. 

Conclusion

     Visual impairment is considered a risk factor for MVA.  Further investigation is essential and will require close inter-sectoral collaboration between traffic police, health, law, and transport authorities. 

Introduction

     Driving is a very important practice in United Arab Emirates (UAE) for multiple purposes including working, social life and, most importantly, pleasure and entertainment. The inability to drive in UAE for medical reasons is a source of hardship for many residents, as the weather is extremely hot and humid during most of the year. 

     Motor vehicle accidents (MVA) is considered a major and common cause of  injury, death, and disability in many countries.  For more than twenty years the role of disease as a cause of MVAÕs has been investigated(1). Human error has been blamed as the cause of 90-95 percent of MVA's(2). However, according to Western literature, disease frequently affects driving ability and causes MVA's(2,3,4).

     One of the most important questions of the drivers’s medical condition is the ophtalmological one(5).  It is well known that the state of a driver's visual system is a very imortant factor of traffic safety(6-12), although, the attempts to find correlation between traffic accidents and visual defects gave controversial results(13-16).  MVA is of a multifactorial nature, one of the most important factors is impaired vision(17).  Data on vision reported for 1000 British drivers(18) showed an association between the vision status and sustaining a motor vehicle accident. 

     Driving is the primary mode of travel in many countries. It facilitates the performance of routine daily activities and is thus integral with the concept of quality of life(19).  In fact vision is inarguably a fundamental component of safe driving.  Poor eye vision or visual defect increases the risk of crashes in motor vehicle accidents.  Hansotia and Broste(20) reported that drivers with medical conditions increases the risk of traffic accidents.  Based on current observation, MVA in the Gulf area is a common and serious problem. Driving attitude and habits in this region was one of the factors contributing to MVA(3,4), which has been under investigation for a period of time.  We are concerned in this study with the effect of visual status on traffic accidents, trying to find a significant association between visual disability and sustaining MVA.

     The main objective of this study is to evaluate the significance of visual impairment as a risk factor- among drivers sustaining MVA, and who were seen and admitted to ER department / Al-Ain hospital. Identifying driving behavior and attitude among included drivers is also another objective of this study, which could be utilized in future research projects in this field. 

Subjects And Methods

     All male and female driver patients, aged 18 years and above, who were seen at Al-Ain Hospital for accidents and trauma during the period January 1st 1996 till the 31st of December 1997.  A total of 1542 drivers were examined and treated, but only 1428 drivers gave consent for the study.  All male and female driver patients who sustained a measurable body injury secondary to MVA, and were examined and admitted to the ER department were included as study subjects.  Exclusion was made for drivers under 18 years of age and those who did not give consent for the study.  All subjects were drivers (private cars, taxi, buses and trucks) admitted to the ER department after sustaining a MVA.  For the purpose of environmental circumstances standardization, study subjects were selected from the AED and surgery wards. 

     A standardized questionnaire was created and attached to the patient's file, which was filled out by the casualty officers and/or staff nurses. Different types of data were then collected: these were:

1.  Personal data including age, sex, nationality, marital status, educational level and occupation

2.  Data about driving attitude, which included driving experience, adherence to traffic laws (including speed limits, and wearing seat belts) and driving habits. These data were mainly self-reported; occasionally, and when available, data was obtained from police records.

3.  Data about the accident, which was obtained from police records. It included place, time of accident and description of damage occurred secondary to MVA

4.  Patient's visual acuity using standard Snellen's chart.  Further classification of the study population was done according to the level of visual acuity.  Blindness and low vision are both defined according to the WHO classification, which defines blindness as a best corrected visual acuity of < 3/60 in the better eye.  Low vision is defined as best corrected visual acuity ranging between less than 6/18 and over or equal to 3/60 in the better eye(29).   

     The statistical package program, Statistical Package for Social Sciences(23), was used to calculate Chi-square and Fisher exact test, to examine driving profiles, violation rates and injury assessment among visually impaired licensed drivers and those with normal vision. Relative risk (RR) and their 95% confidence intervals (CI) was calculated by using Mantel-Haenszel test.  The level p<0.05 was considered as the cut-off value for significance.

Results

     A total of 1542 vehicle drivers were examined and questioned.  Only 1428 drivers were included, 144 driver patients were excluded according to selection criteria. 207 patients (14.5%) were found to have eye disease.  The majority of victims (77%) were males.  The sex ratio was Female / Male 1:3.4 

     Table 1 shows the distribution of the characteristics of the 1428 drivers studied.  Most (55%) were young and under the age of 40 years; 39.7% were UAE national; 32 % had a primary school education; 48.8% had a primary school education; 48.8% had a full license to drive private cars or commercial taxi; 37.5 % had less than 2 years driving experience and 17.2 % always used seat belts. 

TABLE -1 SOCIO-DEMOGRAPHIC OF DRIVERS SURVEYED WITH NORMAL VISION AND IMPAIRED/POOR VISION (TOTAL SUBJECTS = 1428)

     Table 2 gives the characteristics of driving behavior of studied population.  Most drivers (59%) admitted to crossing red traffic lights, 61.3% excessive speeding; 32.6% smoking while driving; 29.8 % to using telephones while driving; 32.1% to putting their child in the front seat.  These types of behaviors are common among drivers of both normal vision and visual impairment groups.

TABLE -2 EVALUATION OF SOME DRIVING BEHAVIORS AND ATTITUDES 
AMONG THE STUDY GROUP

     Table 3 gives the comparison of licensed drivers with impaired / poor vision and all other licensed drivers without eye disease.  Significantly higher risk was observed for careless driving [RR=1.29; 95% CI=1.10-1.66, p=0.049], speeding violations [RR=1.32; 95% CI=1.01-1.73, p=0.041], and property damage [RR=1.80; 95% CI=1.31-2.48; p=0.005] among drivers having impaired/poor vision.  However, pedestrian injury, traffic violations and drug related accident showed no significant increases in risk of accident among drivers with eye injuries compared with the rest of the population.

TABLE - 3 DRIVING BEHAVIORS AMONG DRIVERS OF BOTH NORMAL AND
 IMPAIRED VISION GROUPS 

Discussion

     Automobile driving safety can be dependent on  good vision. Drivers with certain eye conditions reduce their safety and increase the risk of crashes.  In recent years , there has been substantial papers in medical journals stressing that there is a strong association between poor vision and the greater chance of involvement in MVA's crashes(1,5,19).  In this study, male drivers under 40 years are the main victim of these accidents.  Vision related motor vehicle accidents comprise about 6.8% of MVA, the higher proportion being relevant for motorways. 

     In the present study, MVA is strongly associated with visual impairment of the driver involved in these crashes.  Many authors have found similar results confirming the association between MVA and visual disability(8).  Moreover,  related trauma accounts for a significant percentage of ocular trauma(1,8,11,26) and is a risk for serious visual loss(9,11,27).

    Significantly higher risk was observed in the present study for careless driving, speeding violations and property damage among drivers with visual impairment.  Recently, a study in UAE showed that monitoring radar systems and video cameras reduced traffic accidents, casualties and fatalities related to excessive speeding(28). There has been no clear strategy to prevent people with impaired visual acuity from driving in the UAE community.  A previous study has suggested that drivers with visual defeciencies,(5-19) have higher accident rates than the rest of the driving public.  And that was also evident in this study, as a significant number of those studied were driving while having impaired visual acuity, which strongly underlines the association between eye diseases and MVA.  

     Many countries restrict the issue of driving licenses in people prone to medical illnesses.  Regulations are deemed necessary because research has repeatedly shown an increased rate of road traffic accidents and casualties (and accident deaths) in drivers with certain medical conditions(2,4).  Ideally legislation should balance the increased risk of driving against the social and psychological disadvantage to people prohibited from driving.  Achieving this balance is difficult, and regulations vary widely among countries(3).  Therefore, when driving is considered, physicians should always ask the patients if they drive in order to assess the risk of the drugs they prescribe; potential risks associated with the underlying disease must also be considered.  Special attention should be paid to the visual assessment procedures for individuals seeking driving privileges for the first time and/or those current drivers who developed visual problems while their driving privileges were still valid. 

     The effect of vision on MVA and driving, constitute a major public health problem, and a major health hazard, leading to a high rate of disability and mortality.  Also MVA's have a great socio-economic impact on the victim, his family, and the nation as a whole (3,28).  The problem is treatable and the toll could be greatly reduced if appropriate measures were taken. This study is the first to report the association between MVA's and eye disease in the Gulf States.

Conclusion

     In conclusion the present study showed that visual impairment is a risk factor for MVA's.  Health education and vision screening programs should be considered to address the nature of visual impairment. 

Acknowledgments

We are very grateful to Al-Ain Hospitals Accident Emergency Department Physicians and Consultant for their great help and interest in this study.

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