World and South African perspective on road traffic accidents

1. World and South African perspective on road traffic accidents.

The world health organisation estimates 1,3 million people die yearly as a result of road traffic accidents, it further reports that this cost countries 3% of their gross domestic product(GDP) annually(1). This means that with South Africa's 1,586,213,743,000 rands GDP(2), this health problem costs the country 47,586,412,290 rands. The South African Road Accident Fund (RAF) distributes around R15 billion annually to victims of road accidents(3). Road crashes cost the South African economy over R176bn in the year 2019(4)
Between 20 and 50 million additional people have non-fatal injuries in the world, with many developing disabilities as a result. Individuals, their families, and nations as a whole incur significant economic losses due to road traffic accidents. These losses result from the cost of treatment and missed production for individuals killed or crippled by their injuries, as well as for family members who must miss work or school to care for the injured(1).

In 2022, Zutobi, an international driver education firm, conducted a research study. The study was based on parameters including the estimated road traffic death rate (per 100,000 population), the maximum motorway speed limit (kph), the seat belt wearing rate (front seat), alcohol-related road traffic deaths, the blood alcohol concentration (BAC) limit for drivers (g/dl), and the overall safety driving score. Driving in South Africa has been recognized as the most dangerous in the world. It had an extremely high percentage of fatal traffic accidents involving alcohol, 57.5%. We also had the second-highest rate of fatal traffic accidents, with an estimated range of 22,2 to 25,9 per 100,000 people(5).

Road Traffic Management Corporation (RTMC) analyzed fatal crashes reported to the South African Police Services (SAPS) between January and December 2017 and reported a total of 14,050 road traffic related fatalities, with pedestrians contributing 38 percent, passengers 33 percent, drivers 26 percent, and cyclists 2.6 percent of the total number of fatalities(6).

2. Causes of road traffic accidents in south Africa
Road traffic accidents are caused by a combination of elements relating to the system's roads, environment, cars, and road users, as well as their interaction(7). Crash causation includes elements such as the quality of driving instruction, the overall attitude of drivers, driver behaviour, and the level of driver self-discipline. Other factors, such as speeding and reckless driving, exacerbate the consequences of collisions and thus contribute to the severity of injuries, but some factors may not appear to be directly related to road traffic accidents(7).

However, there are certain immediate causes that may be supported by medium- and long-term structural causes. Developing the risk factors that lead to road traffic accidents is essential for identifying actions that can lower the related hazards.
In this report we will focus on three and strategies on how to mitigate them

Distracted driving
A quarter of all car accidents in South Africa are caused by texting and phone calls. According to studies, using a cell phone while driving might lower concentration by up to 37%. The average time required to read and respond to a text message is 52 seconds. This is the equivalent of driving blind for one kilometre at 60km/h and increases the likelihood of an accident by fourfold(8,9).

Alcohol
South Africa ranks among the top 50 countries with the highest alcohol consumption in the world(10). The alcohol industry is an integral part of the South African economy. The alcohol industry employs approximately one million people, generates R72 billion in tax revenue, and contributes R173 billion to the country's gross domestic product(11).

The risk of a drink driving related fatality is highest in South Africa(5). South Africa has the highest amount of alcohol (blood alcohol concentration exceeding 0.05 grams per 100 millilitres) related road traffic deaths, at 57.5% as mentioned above.

In 2016, a five-year analysis of a retrospective descriptive research involving 672 road-users in Ga- Rankuwa was conducted by a South African forensic team. BAC levels 0.01 g/100 ml were considered positive. In 338 (50.3%) incidents of road traffic fatalities, a positive BAC result was recorded(12).

Alcohol impairs reflexes and response times. It impairs one's capacity for concentration. Alcohol impairs the function of eye muscles, diminishing one's capacity to see. It impairs hand-eye coordination and impairs the capacity to make logical decisions(8).

Reckless driving
Accidents occur when drivers disobey the laws of the road totally. This includes speeding, swerving, weaving in and out of traffic, passing oncoming traffic, tailgating, passing on blind curves, ignoring red lights, braking abruptly, doing U-turns, and speeding(8).

3. Suggested Strategies and Recommendations
For this Good Governance and health literacy as the main pillars of health promotion will be relevant to tackle such health problem.
Improving Literacy on road traffic accidents

Proper introduction of road safety instructions in schools

Road traffic injuries are the leading cause of death for children and young adults aged 5 to 29 worldwide(1).

There is evidence that road safety instruction in schools has a favourable effect on children's attitudes toward road safety and heightens their awareness of both their own and others' safety. School-based road safety education should be introduced thoroughly with purpose of improving students' comprehension of traffic laws and regulations(13). These road safety lessons should be incorporated into both private and public-school curricula and should target children as young as four or five years old and continue through the elementary and secondary school years(13).

In partnership with the Department of Basic Education, the South African Department of Transport developed a road safety program in five primary schools in the Pietermaritzburg region(14). A study was conducted to investigate the teachers' perspectives on the implementation of the road safety education program. Utilizing a qualitative research approach and an interpretive paradigm, the study was conducted. Five teachers from five distinct schools were chosen to participate in the study and semi-structured interviews were used. The data were analysed qualitatively, and six themes were discovered. The results suggested that teachers were enthusiastic about the road safety education program, but that they did not always have the required support from colleagues and resources to successfully administer the program. In addition, they lacked any program-related comments or reflections from management, co-workers, or students to improve the implementation process. It is advised that schools provide resources for the program's implementation. The study further showed leadership support plays a pivotal role as principals must also foster an atmosphere conducive to dialogue and reflection on the implementation process(14).

Israel falls under top ten safest countries to drive in(5). The "Zahav Bagan" (ZBP) program is a one-of- a-kind road safety program for kindergarteners in Israel. It is offered weekly in kindergartens during the academic year(15). A telephone survey was conducted to examine the behaviour, awareness, and knowledge of two groups of parents about child road safety: those whose children participated in the ZBP group (76-sample) and those whose children did not (56-control group)(15). The survey revealed that ZBP had no effect on parents' understanding of child road safety regulations and guidelines, but it did have a substantial effect on parents' observance of safe behaviour and awareness of road safety in daily life. The world's most safest country to drive in(5), Norway, also has similar program.

These findings demonstrate the significance of road safety education programs, particularly as triggers and reminders for children and their parents to behave safely on the road(15).

3.1.1.1 Teaching on both direct and indirect factors that are involved in occurrence and outcomes of road traffic accidents.
Alcohol and drug abuse, mental health, and other topics can be taught in schools and as part of the school's road safety education program or general teaching programs.
A systematic review study and meta-analysis of the link between weight indices and injuries and fatalities caused by motor vehicle accidents revealed that obesity and overweight directly increase the road traffic accident mortality rate(16). So, obesity programs can also be strengthened.

Teaching/Training of investigative officers

In South Africa, those whose role is to keep the roads safe, such as the traffic police, should also be well-trained. In addition, advanced training aimed at repeat offenders/re-offenders should be considered alongside crash investigation training for police personnel in order to accurately document accident reasons and collect trustworthy crash data(13).

All fatal road traffic incidents in Finland, one of the 20 safest countries to drive in the world(5), are thoroughly investigated on-site by interdisciplinary Accident investigation units maintained by the Finnish Motor Insurers' centre(17). The aim of the teams is to determine what caused the accident, to identify the risk factors that transformed an average driving condition into a major accident, and to provide safety suggestions for enhancing road safety.
The general objective of road accident investigations in Finland is to prevent future accidents and minimize their severity by learning from past incidents. Police, road and vehicle professionals, a physician, and a psychologist compose the core of the team. The investigation focuses on the pre- accident events, but also investigates the crash and its aftermath(17).
Each case is compiled investigation files comprise investigation forms from each member, pre- investigation process, autopsy and toxicology forensic reports, photographs, sketches, and other materials.
The investigation focuses on the pre-accident events, but also investigates the crash and its aftermath. The gathered data constitute an accident database. Risk-factor-related safety recommendations are generated by teams.
In accordance with the investigation process, teams seek both immediate and background risk factors that contributed to the accident. The road user, vehicle, environment, and traffic system are investigated for safety factors and recommendations and submit an investigation report.
These findings can be utilized to develop safety initiatives and ideas, and the information is incorporated into statements, working groups, and other collaboration efforts(17). The information will then be used for government safety policies, safety research, teaching, and public awareness campaigns.

Adjustment and introduction of policies.
Technology legislations around car manufacturing specifications and mandatory aftermarket installations post traffic offence in South Africa
The enforcement of traffic laws can be conducted either via the use of technology or by patrolling and police visibility. Officers can utilize technology to enforce the law through either covert or very visible patrolling, which includes halting violators on the side of the road.

It is a problem that car technologies keep on getting advanced for pleasure of the customer, mostly these advancements are for convenience and aesthetic purposes than safety advancements that will change driver behaviour on the roads(13).

Introduction of breath alcohol ignition interlock device -Alcolocks
Breath alcohol ignition interlock device(BAIID) ,popularly known as Alcolock is a breathalyser for an individual's vehicle. Before starting or continuing to operate the vehicle, the driver must blow into the device's mouthpiece. The gadget prohibits the engine from starting if the resultant breath- alcohol concentration is higher than the programmed blood alcohol concentration. Inside the vehicle, near the driver's seat, the interlock device is directly connected to the ignition system(18).
Alcolock initiatives were implemented in Sweden in 1999 to reduce drunk driving(19). The program has been employed as both a primary and secondary preventive method for driving while intoxicated offenders. The primary prevention program was first initiated in commercial transport

services (taxis,buses,trucks) accepted by employers ,passengers and drivers . The secondary prevention program is a two-year voluntary program for drivers who have been charged with driving while intoxicated with the goal of modifying their drinking habits. The program has stringent medical requirements, which include counselling and frequent medical check(19).
As evaluated by five biological alcohol markers, overall alcohol consumption reduced considerably during the training. After one year in the program, the number of individuals reporting unsafe or harmful alcohol habits fell from 68% at baseline to 14%. Recidivism for driving while intoxicated dropped from about 5% to practically 0% (p 0.001). These recidivism effects are mirrored by significantly lower rates of police-reported traffic accidents involving injuries and hospital admissions as a result of road accidents (p 0.01). Those who finish the program successfully have a lower rate of recidivism for driving while drunk 2.5 years after exiting the program(19). In 2022,Sweden ranked number eight in the top safest countries to drive in and number three in year 2022(5)

South African policies should make it a standard to have all new car models to be inserted with device as a primary prevention strategy and for all drivers who do not have cars installed with the device and convicted of drinking and driving should be, as part of penalty be required to install the device in their cars as aftermarket installation. This will have a ripple effect of children seeing the practice as they grow and out of inquisitiveness asking why such practice and then be told about how one should not drive whilst under the influence of alcohol. This will set an active participation of road safety by manufacturers, drivers and regulatory bodies.
Introduction of built-in car speeding radar and camera.
Numerous existing technologies have the capacity to automatically issue fines to lawbreakers (primarily for speeding). These technologies (i.e., cameras and radars) can be fixed throughout the road network or mobile controlled by police officers, either mounted in their vehicles or as hand- held equipment(20).

Although fixed speed cameras and radars are vital and useful, mobile deployment of technology can be more successful because drivers will not slowdown in areas where they anticipate these radars to be located. Some technology, such as point-to-point or average speed cameras, may measure the average speed of drivers between two places, so addressing the issue of drivers slowing down at recognized radar locations(13).

South Africa should mandate that every automobile model come equipped with a dual radar and camera system. The radar, which is connected to the central traffic surveillance system, will monitor speeding cars and deliver a number of warnings to allow the driver to slow down according to speed zones. If the vehicle continues to speed despite receiving multiple warnings, a violation ticket will be issued.
A camera facing both the road and the driver should be installed to monitor the driver's driving behaviour, phone use, and seatbelt usage.
The records of these should be a requirement for accident reports for those on new models under this manufacturing law, and those with incriminating traffic violations using older models should be obliged to install them as an aftermarket as part of their penalty.
Policies around alcohol branding and advice alcohol health levy.

A study showed that the overall economic and intangible costs of alcohol impairment to the economy were estimated to be between 10 and 12 percent of the gross domestic product in 2009(21). The tangible financial cost of hazardous alcohol use was projected to be R37.9 billion in 2009, or 1.6% of the gross domestic product(11,21).

Combined with the fact that alcohol is implicated in 57.5% of fatal road accidents. Similar to the Health Promotion Levy (HPL) on sugary drinks containing more than four grams of sugar per 100 ml(22), the HPL on non-medicinal and non-industrial alcoholic products should be implemented and paid by consumers, with strategic collection of the income.

For instance, an R2.50 charge will apply to every 250 ml, 125 ml, and 50 ml of beer, cider, wine, and spirits (any beverage containing more than 30% alcohol), respectively. This would be in addition to the alcohol and tobacco excise levies already paid by alcohol manufacturers and suppliers in South Africa. It can be charged at the distribution level, and customer prices will increase accordingly. This tax will be used only for public health funding, and will be administered in a manner that permits healthcare funding, public health research, interventions, and health mitigation initiatives.

Introduction of focused motor vehicle accident medical examination to increase deterrence from driving under the influence of alcohol.
Studies comparing crime and its punishment and weighing the advantages and disadvantages of lawbreaking reveal that penalties do not alter an individual's personality, his or her sense of right and wrong, or his or her general propensity to obey the law, but they do increase the likelihood of deterring from committing an offense, particularly when stricter methods of evidence are used to convict an individual. For deterrence to be effective, each person must recognize that committing a crime is a risk that is not worth taking(23).

The presumption underlying deterrence is that threats can diminish crime by inducing a change of heart due to the discomfort of the particular consequences threatened. According to the theory of simple deterrence, individuals who are tempted by a certain type of behaviour that is threatened will not commit a crime because the pleasure they might receive from committing that crime is outweighed by the risk of something very bad happening, which is communicated through a legal threat(23).

Since driving under the influence of alcohol is prohibited in SA and is a criminal offence(24,25). An insurance claims are rejected if one was found with such an offence. The current system in south Africa however does not make blood test mandatory after car accidents and this causes a huge gap in trying to quantify effects of alcohol on road traffic accidents. There should be an introduction of motor vehicle medical accident report, both for autopsies and injuries. this form should be filled by medical doctor attending the patient and blood alcohol should be a compulsory test for this exam and should always be required for any compensation or insurance claim purposes. This will help all drivers to stay conscientized about impacts thereof. There can be an additional surveillance system from this to help collect data of nature of injuries (fatal, disabling, debilitating) and will also reduce burden of overwhelming RAF claims .

4. Conclusion

South Africa has a variety of road safety procedures and laws(Table 1), but their execution is hampered by a number of problems, including pedestrian education difficulties, infrastructural, human resources, educational systems and regulatory or enforcement authorities. This is why the recommendations and suggested techniques above distribute responsibility at every level of individuals involved in road safety, seeking solutions from manufacturing to the scene of an accident.

To promote public acceptability of a road safety policy, road safety media campaigns and enforcement programs should be implemented simultaneously. This raises public awareness of the road safety issue being addressed and the countermeasures employed. According to the Global Road Safety Partnership, the fear of being detected and punished for traffic violations is a stronger motivator for slowing down than the fear of being involved in an accident(13). Educating the public about the severity of the dangers involved with dangerous driving lends legitimacy to the implementation of these new measures and may influence driver behaviour.

Evidence-based practice is the careful, explicit, and prudent use of the best available evidence in making judgments regarding individual patient treatment, program design, and public health and healthcare decisions. this means we will integrate clinical, legal, investigative and administrative experience with the best available evidence from systematic research. This can prevent wasting time and resources on a program that is less productive.

Typically, initiatives that involve a variety of providers, government institutions, agencies, and investors in their programs are more successful. The participation of multiple community levels will give road safety program with a connection to the community, promotes knowledge of community issues, and demonstrates the program's desire to solve community problems.

In addition to garnering community support, the strategy will establish robust connections with other organizations. Organizations with similar missions might form partnerships and collaborate to attain similar objectives.

In addition to maximizing the utilization and allocation of resources, partnerships can also give expert viewpoints and community support for road safety measures. Local education systems, community-based organizations, hospitals, medical centers/clinics, forensic bodies, law enforcement bodies, and local government agencies can develop collaborations as a result of this report. For instance, if obesity programs have partnered with local schools to serve as implementation sites for their programs, this will align with reducing other public health impacts of obesity like severe injuries from car crashes, even though the original objective was to reduce obesity-related health impacts which are mainly metabolic diseases.

Visibility of police has been proven to be an effective deterrent against reckless driving(26). Campaigns are intended to increase awareness and encourage road users to alter their behaviour. They take the shape of enforcement and safety programs.

On the one side, road safety campaigns are frequently aimed at either increasing public awareness of a road safety issue or altering attitudes about a specific road behaviour, such as drinking and driving, speeding, using a mobile phone, etc. On the other side, the purpose of enforcement campaigns is to inform the public about existing or newly implemented traffic regulations and the legal ramifications of breaking them(26,27).

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