Analysis of the characteristics of road traffic injuries in Guangzhou, China, in 2014–2018

doi:10.21203/rs.3.rs-2008027/v1

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Analysis of the characteristics of road traffic injuries in Guangzhou, China, in 2014–2018

https://doi.org/10.21203/rs.3.rs-2008027/v1

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Objective: To determine the epidemiological characteristics and influencing factors of road traffic injuries (RTIs) in Guangzhou, China.

Methods: RTI data for the period of January 2014–December 2018 were obtained from the Injury Surveillance System of Guangzhou. Multiple logistic regression modeling was conducted to estimate the risk factors of RTIs in Guangzhou.

Results: A total of 19,124 RTIs were reported in 2014–2018. The RTIs occurred mainly in summer and autumn, particularly in August. The male-to-female ratio of RTIs was 1.59:1. Many RTIs involved 20-year-olds working as businesspersons or service staff. The RTIs included multiple site injuries (30.22%) and lower limb (25.95%) and head (21.98%) injuries. Most RTIs were contusions or scratches (67.57%) and had mild (76.12%) and moderate (20.88%) outcomes. Most RTI cases involved motorcycles (35.20%). Regression results showed that gender, age groups, months, census registration, occupation, and alcohol consumption were associated with RTIs in Guangzhou, China.

Conclusion: The number of reported RTIs in Guangzhou increased year by year. The risk factors are male, 10–69 years of age, June to November, nonlocal residence registration, businesspersons or service staff, low education level, and alcohol consumption. The findings may help formulate scientific and effective preventive measures for enhancing road safety.

Road traffic injuries (RTIs)

epidemiological characteristics

Risk factors

surveillance

Road traffic injuries (RTIs) have become major causes of hospitalization and injury-related disability and death, and they result in considerable economic losses to individuals, their families, and to entire nations. In December 2018, the World Health Organization launched The Global Status Report on Road Safety, which indicates that the number of annual road traffic deaths has reached 1.35 million. According to the results of the Global Burden of Disease Study in 2016, RTIs ranked 8th out of 20 fatality causes and accounted for about 2.46% of total deaths worldwide¹, thus exceeding the numbers attributed to malaria, tuberculosis, and HIV/AIDS². Moreover, RTIs could make the average life expectancy decrease by more than half a year, and the expenses for medical care could plunge many families into poverty³.

RTIs are also the leading cause of death for children and young adults aged 5–29 years, and they pose a great burden on the health systems of different countries. Reports show that 93% of the world’s road fatalities occur in low and middle income countries (LMICs), even though these countries have approximately 60% of the world’s vehicles⁴. The latest world report on road safety reveals that the rate of traffic deaths is the highest in Africa and Southeast Asia at 26.6/100,000 and 20.7/100,000 people, respectively⁵. These regions bear a disproportionate burden of RTIs, with 85% of all fatalities and 90% of all disability-adjusted life years (DALYs) lost worldwide in relation to RTIs reported to occur therein. If appropriate and effective actions are not taken, RTIs are predicted to become the fifth leading cause of death in LMICs by 2030⁶.

As one of the largest developing countries, China covers wide territories with high-density populations, especially in the southern region. Since the reform and opening up in 1978, the gap between the rich and the poor has widened. Reports indicate that the gross domestic product (GDP) per person in the richest province is 13 times that in the poorest province. The motorization rate has grown rapidly, increasing from 0.023 vehicles per person in 1996 to 0.188 vehicles per person in 2015⁷. The rapid economic growth and intensive motorization have improved people’s lives in terms of comfort and convenience, but the benefits come with a price. Motor vehicle production in China has tripled since the early 1990s, but it has led to an increase in the prevalence of traffic-related injuries in the country. The proportion of all deaths due to traffic injuries increased from 15% in 1987–1988 to 34% in 2005–2006, and the corresponding death rates (standardized to the population in 2000) increased by 81% from 12.4 per 100,000 to 22.4 per 100,000, respectively⁸. Moreover, the direct economic loss from accidents in China reached 10,661.76 million RMB in 2007–2016⁹. Meanwhile, China’s health system has long been focused on infectious and chronic diseases, but more recently, the authorities have recognized that the health and sustainable development of the country are also associated with injuries, especially traffic-related injuries. The Chinese government is responding effectively to the problem and has taken several high-profile measures, including strengthening restrictions against speeding and drunk driving, in the past decade. According to the records by the traffic police of the Ministry of Public Security, which is mainly responsible for enumerating fatalities, road traffic-related fatalities peaked in 2002 and have since fallen by an average of 6% yearly¹⁰. Recently, studies have shown that the characteristics of RTIs are closely related to GDP. There are more traffic accidents, injuries, and economic losses in economically developed areas, such as Guangdong and Zhejiang provinces, than in economically backward areas^11,12. Obviously, joint efforts are needed to reduce the number of RTIs, which are considered as “a neglected epidemic” in China.

Guangzhou, located in the southern part of China, is a city of 18.74 million people residing in a total area of 7,434 km² in 2020. It serves as the political, economic, and cultural center of Guangdong Province. The median age of the population is 35 years, and the life expectancy is 82 years. The total length of city highways is 9,045 km, and the possession of civil vehicles is 3,081,809. The number of civil automobiles, including passenger vehicles, trucks, and motorcycles, increased from 2,146,364 in 2010 to 3,081,809 in 2020¹³.

Considering that Guangzhou only launched its injury monitoring system in 2014 under the National Injury Monitoring Program, the systematic investigation has not been carried out. The current research aims to describe the epidemiological characteristics and possible risk factors of RTIs in Guangzhou, China, on the basis of 2014–2018 data. We hope to provide some useful preventive suggestions for policy makers not only in China but also in other developing countries.

From 2014 to 2018, 173,999 individuals were injured in Guangzhou, and 19,124 or 10.99% of these cases were caused by road traffic accidents. The frequency of road traffic accidents maintained a steady trend despite the rapid development of urbanization (Table 1). Out of all the cases, 11,745 were male (61.41%) while 7,379 (38.59%) were female. The number of male cases was higher than that of female cases, and the ratio of male to female was 1.59:1. Most injured patients belonged to the 20–29 (21.73%) and 30–39 (18.72%) age groups. The vehicle types involved in RTIs can be divided into motor vehicles and nonmotor vehicles. More than half of the cases were caused by motor vehicles, including motorcycles (35.20%) and cars (24.04%) (Fig. 1).

Table 1

Distribution characteristics of road traffic injuries among injury patients in Guangzhou, China, 2014–2018
Years	Injury patients	RTIs patients	(%)	Order
2014	20,634	2,226	10.79	5
2015	26,544	3,259	12.28	4
2016	37,939	3,802	10.02	5
2017	42,303	4,819	11.39	5
2018	46,579	5,018	10.77	5
Total	173,999	19,124	10.99	5
Note: RTIs: Road traffic injuries.

The trends and characteristics of the monthly time series are presented in Fig. 2. The occurrence rate of RTIs in February was the lowest. It then rose gradually and reached the peak in August. In most of the accidents, the injured were businesspersons and service staff (32.03%) while some held other occupations(20.05%)and were operators of production and transportation equipment (19.81%). The occurrence rate in males was higher than that in females, except for the housekeeper group.

The chi-square test indicated statistically significant differences among the following variables: age groups, census registration, occupation, educational level, and alcohol consumption (all P < 0.001); hence, these five factors may be associated with RTIs (Table 2). As for the sites of injuries, multiple sites were the most common (30.22%), followed by injuries to the lower limbs (25.95%) and head (21.58%). Road traffic accidents mainly led to contusions/scratches or fractures, and most of them were mild (76.12%) and moderate (20.88%) injuries (Table 3). The multiple logistic regression indicated that the male gender, age range of 10–69 years, the months of June–November, nonlocal residence registration, occupation as commercial/service staff, low educational level, and alcohol consumption are risk factors of RTIs (Table 4).

Table 2

The general information of distribution characteristics of road traffic injuries in different gender in Guangzhou, China, 2014–2018
Variables	Total		Male		Female		_χ²	P
Variables	n	%	n	%	n	%	_χ²	P
Age groups							179.035	< 0.001
0~	1,757	9.19	1,062	60.44	695	39.56
10~	1,830	9.57	1,304	71.26	526	28.74
20~	4,156	21.73	2,675	64.36	1,481	35.64
30~	3,580	18.72	2,219	61.98	1,361	38.02
40~	3,424	17.90	2,069	60.43	1,355	39.57
50~	2,343	12.25	1,349	57.58	994	42.42
60~	1,298	6.79	699	53.85	599	46.15
70~	736	3.85	368	50.00	368	50.00
Months							2.865	> 0.05
3 ~ 5	4256	22.25	2636	61.94	1620	38.06
6 ~ 8	5600	29.28	3470	61.96	2130	38.04
9 ~ 11	5609	29.33	3427	61.10	2182	38.90
12 ~ 2	3659	19.13	2212	60.45	1447	39.55
Census register							77.699	< 0.001
Guangzhou	8,365	43.74	4,843	57.90	3,522	42.10
Non-Guangzhou	10,759	56.26	6,902	64.15	3,857	35.85
Occupation							1266.132	< 0.001
Businessmen and service staffs	6,125	32.03	3,403	55.56	2,722	44.44
Operators of production and transportation equipment	3,788	19.81	3,017	79.65	771	20.35
Students	1,693	8.85	1,153	68.10	540	31.90
Preschool children	1,317	6.89	779	59.15	538	40.85
Housekeepers	1,186	6.20	341	28.75	845	71.25
Pensioners	1,180	6.17	590	50.00	590	50.00
Other	3,835	20.05	2,462	64.20	1,373	35.80
Education level							163.821	< 0.001
Illiterate/Preschool children/Other	1,858	9.72	1,018	54.79	840	45.21
Primary school	3,402	17.79	1,947	57.23	1,455	42.77
Junior school	7,516	39.30	4,945	65.79	2,571	34.21
High school	4,172	21.82	2,638	63.23	1,534	36.77
College degree and above	2,176	11.38	1,197	55.01	979	44.99
Alcohol							283.046	< 0.001
Yes	1164	6.09	985	84.62	179	15.38
No	17958	93.90	10760	59.91	7200	40.09
Total	19,124	100.00	11,745	61.41	7,379	38.59

Table 3

The site, nature and severity distribution characteristics of road traffic injuries in different gender in Guangzhou, China, 2014–2018
Variables	Total		Female		Male		_χ²	P
Variables	n	%	n	%	n	%	_χ²	P
Site of injury							17.194	< 0.001
Upper limb	2,106	11.01	1,373	65.19	733	34.81
Lower limbs	4,963	25.95	3,013	60.71	1,950	39.29
Head	4,127	21.58	2,533	61.38	1,594	38.62
Trunk	2,042	10.68	1,258	61.61	784	38.39
Multi-site	5,780	30.22	3,497	60.50	2,283	39.50
Other	106	0.55	71	66.98	35	33.02
Nature of injury							89.714	< 0.001
Contusion/scratch	12,923	67.57	7,656	59.24	5,267	40.76
Fracture	2,682	14.02	1,795	66.93	887	33.07
Concussion/brain contusion	1,423	7.44	930	65.35	493	34.65
Sharp/bite/open injuries	1,273	6.66	860	67.56	413	32.44
Other	823	4.30	504	61.24	319	38.76
Severity of injury							71.762	< 0.001
Mild	14,557	76.12	8,707	59.81	5,850	40.19
Moderate	3,993	20.88	2,630	65.87	1,363	34.13
Severe	574	3.00	408	71.08	166	28.92

Table 4

Factors associated with road traffic injuries from logistic regression models among 173,999 injuries in Guangzhou, China, 2014–2018
Variables	β	Wald	p	OR^a	95%CI
Variables	β	Wald	p	OR^a	Lower	Upper
Gender
Female				Reference
Male	0.066	15.379	< 0.001	1.068	1.034	1.104
Age groups
70~				Reference
0~	-0.274	9.995	< 0.001	0.760	0.642	0.901
10~	0.276	16.251	< 0.001	1.318	1.152	1.507
20~	0.286	22.916	< 0.001	1.330	1.184	1.495
30~	0.269	20.520	< 0.001	1.309	1.165	1.470
40~	0.239	16.965	< 0.001	1.271	1.134	1.424
50~	0.319	33.533	< 0.001	1.376	1.235	1.533
60~	0.542	114.183	< 0.001	1.720	1.557	1.900
Months
12 ~ 2				Reference
3 ~ 5	0.006	0.055	> 0.05	1.006	0.959	1.054
6 ~ 8	0.046	4.038	< 0.05	1.047	1.001	1.095
9 ~ 11	0.053	5.512	< 0.05	1.055	1.009	1.103
Census register
Guangzhou				Reference
Non-Guangzhou	0.043	6.414	< 0.05	1.043	1.010	1.078
Occupation
Other				Reference
Businessmen and service staffs	0.083	12.892	< 0.001	1.087	1.039	1.137
Operators of production and transportation equipment	-0.244	82.540	< 0.001	0.783	0.743	0.826
Students	-0.600	148.359	< 0.001	.549	.498	0.604
Preschool children	-0.796	76.755	< 0.001	.451	0.378	0.539
Housekeepers	-0.306	53.494	< 0.001	.737	0.679	0.800
Pensioners	-0.728	233.655	< 0.001	0.483	0.440	0.530
Education level
College degree and above				Reference
Illiterate/Preschool children/Other	0.648	122.768	< 0.001	1.911	1.704	2.143
Primary school	0.662	375.224	< 0.001	1.939	1.813	2.073
Junior school	0.628	487.390	< 0.001	1.874	1.772	1.981
High school	0.313	118.039	< 0.001	1.367	1.292	1.447
Alcohol
No				Reference
Yes	0.272	65.209	< 0.001	1.313	1.229	1.402
Note: Road traffic injuries = 1; Other injuries = 0;
OR = Odds ratio; 95%CI = 95% confidence interval;
^a Adjusted for all other variables included in the table.

Case report trend of RTIs in Guangzhou

RTIs are predicted to become one of the main factors contributing to disability-adjusted life expectancy by 2030¹⁴. In Guangzhou, the numbers of motor vehicles and drivers are on the rise, along with traffic jams and road traffic accidents. Our study indicated that a large number of people get injured in traffic accidents. Data collected from five surveillance hospitals show that RTI patients account for 10.99% of all injury cases and that road traffic accidents rank fifth among the leading causes of injuries. Wang et al.¹⁵ used data from China’s disease surveillance points system to analyze road traffic deaths in China and reported that the overall age-standardized road traffic mortality increased from 2006 to 2011 and then decreased in 2016. In Guangzhou, the RTI cases remained relatively stable from 2014 to 2018.

Time trend of RTIs in Guangzhou

Our results show that the number of RTIs in Guangzhou during the study period was the lowest in February, gradually increasing and finally reaching the peak in August. The incidence of RTIs in the summer months was higher than that in the winter months. Some studies have examined the associations of meteorological factors with RTIs^9,16. In our study, there were more RTIs during the summer (June–August) and winter months (December–February). However, the summer months had a higher mortality rate for RTIs than the winter months. This result may be due to the fact that Guangzhou has subtropical monsoon climate wherein summer lasts for a long time and the temperature is high. Extreme temperatures and long hours of sunlight could cause heat stress, fatigue, and emotional fluctuation among drivers and thus increase the risk of traffic injuries¹⁷. Existing data show that every 1 degree Celsius increase in monthly average temperature can increase the number of mild injuries per 100,000 people by 0.7¹⁶. In China, the period of July–August is people’s summer vacation, during which they have more opportunities to engage in outdoor activities. This season is also prone to bad weather, including rainstorms and typhoons, which bring inconvenience to drivers and increase the incidence of road traffic accidents.

Population distribution trend of RTIs in Guangzhou

The 20–29 and 30–39 age groups had the highest frequency of RTIs, representing 40% of the cases. Existing reports indicate that in China, about 60% of total deaths among young adults aged 16–45 years are road traffic deaths¹⁸. Productive young adults are the most vulnerable to traffic accidents, which may impose devastating economic impact on themselves and even their families.

Similar to previous studies^19,20, males (61.45%) outnumbered females (38.59%) in all cases across all regions regardless of age group, occupation, and education level. This is largely because most drivers are males who are more likely than females to be outdoors for work. However, some studies have pointed out that even relatively minor RTIs can lead to a significantly lower health-related quality of life (HRQoL), especially among women in young age groups who may not recover their HRQoL in the same way as men^21,22.

Distribution characteristic trend of vehicle types in Guangzhou

Among the vehicles that lead to RTIs, the most common ones are motorcycles (35.20%), automobiles (24.04%), electric bicycles (17.09%), and bicycles (16.78%). A cross-sectional study conducted in southern Europe²³ found that motorcycles are the most dangerous mode of transportation, public transportation is the safest, and traffic accidents often cause serious injuries and poor prognosis. For male and female groups, the incidence rates of RTIs involving motorcycles are 178 and 189 times those involving public transportation, respectively. With the rapid development of logistics and the take-out industry in recent years, the number of electric bicycles has greatly increased, along with the number of traditional motorcycles,. Couriers and take-out riders are the main drivers of electric bicycles. In Guangzhou, China, electric bicycle-related fatalities and injuries are increasing the traffic injury burden. From 2004 to 2015, police data showed that the number of deaths from electric vehicles in China increased by 11 times from 589 to 6,539 and that the number of nonfatal injuries increased by 5 times from 5,295 to 30,532, respectively²⁴. Moreover, bike sharing in Guangzhou has grown year by year, and it has become a common commuting tool for residents. However, this mode of transportation suffers from several problems, including parking and littering, overspeeding, non-wearing of helmets, and exceeding passenger capacity. In a field survey on bike sharing²⁵, 83. 80% of the subjects reported at least one dangerous cycling behavior, including retrograding, riding slowly side by side with others, riding with one hand, running a red light, using a mobile phone while cycling, and riding after consuming alcohol. Helmet wearing rate in bike sharing is also far lower than that among private bicycle users²⁶. Given their increasing popularity, electric bicycle safety may become an increasingly serious problem unless appropriate countermeasures are implemented.

Risk factor trend of RTIs in Guangzhou

Our logistic regression model indicated that the risk factors of RTIs in Guangzhou were male gender, age range of 10–69 years, the months of June–November, nonlocal residence registration, occupation as commercial/service stuff, low educational level, and alcohol consumption. Most studies show that the risk of RTIs in men is higher than that in women possibly because of the fact that motor vehicle drivers are mainly male²⁷; moreover, the risk of RTIs and death in women in pedestrian groups is higher than that in men in these groups²⁸. Consistent with previous studies^29,30, well-educated people were found to have a lower risk of RTIs than those with low education level. This population has higher levels of road safety knowledge, which is a strong protective factor for RTIs. Socioeconomic status is closely related to the occurrence of RTIs^28,31, and education level and occupation are important manifestations of socioeconomic status. A survey of Shanghai residents showed that the rates of traffic-related injuries and deaths among people with primary school education and below are 146.88/10,000 and 27.05/100,000, which are 6.41 and 2.42 times higher than those among people with college education or above³². Among all alcohol-attributable injuries, RTIs account for over one quarter (27.5%) of the total DALYs and more than half of all unintentional injuries³³. Reports have also shown that alcohol impairs driving performance at blood alcohol concentrations as low as 0.02%³⁴. This measure is useful in preventing RTIs and strictly investigating drunk driving cases, including their punishments. Since the implementation of the aggravated punishment for drunk driving in China in 2011, the traffic accident mortality rate of the total population and male and female populations decreased before and after the intervention, and the mortality rate decreased more significantly after the intervention³⁵.

The findings are insightful, but the study itself has some limitations. First, the data in this study were obtained from the monitoring results of sentinel hospitals, and all the cases were patients with injuries who visited outpatient and emergency departments. There were other limitations, such as limited monitoring scope, inability to calculate the incidence of injuries, and incomplete injury information; hence, the results did not fully and completely reflect the epidemiological characteristics and disease burden of RTIs. Moreover, the research on traffic accidents lacks in-depth analysis of the specific causes of traffic accidents, such as drivers’ behavior, road types, and infrastructure. Hence, follow-up investigations should be conducted to understand the epidemiology of injuries and further improve such data in combination with medical and cause-of-death surveillance data.

Reducing road traffic mortality is not an easy task. For health gains to be realized, improvements must be made on multiple aspects, including safe infrastructure, emergency rescue and treatment network, regulations, and public awareness. Over the past decade, relevant Chinese government departments and traffic administration bureaus have made great efforts to reduce the incidence of road traffic accidents and deaths from traffic injuries. To improve the emergency response system for traffic accidents, comprehensive trauma specialization must be developed and deployed in hospitals, particularly large general hospitals, and applied to the medical school curriculum and training programs³⁶. Public health prevention approaches play a crucial role in reducing RTIs. Authorities should remain active in policy and public education programs to enhance road traffic safety. These programs need to target not only citizens’ knowledge, perceptions, and behaviors but also the improvement of traffic conditions around school settings to reduce RTIs among children.

The number of reported RTI cases in Guangzhou increases year by year. The results show that male gender, age range of 10–69 years, months of June–November, nonlocal residence registration, occupation as businessperson or service staff, low education level, and alcohol consumption are risk factors of RTIs in Guangzhou, China. These findings may help formulate scientific and effective prevention measures to enhance road safety.

Study design

A cross-sectional study of RTIs between 2014 and 2018 was conducted in Guangzhou, China, and the RTI data were exported from the Guangzhou Injury Monitoring System. All records of injuries due to road traffic accidents were entered in the study. In terms of the traffic police departments around China, road traffic accident categories include all traffic-related crashes (motor vehicle traffic accidents, nonmotor vehicle traffic accidents, pedestrian- and passenger-related traffic accidents, and other traffic categories).

Data source

In this study, the data included cases of patients diagnosed with RTIs, as reported by the Guangzhou Injury Monitoring System between January 1, 2014, and December 31, 2018. Guangzhou launched its injury monitoring system in 2014 under the National Injury Monitoring Program, which covers five sentinel hospitals. All injury cases recorded at first visit to the sentinel hospitals and all injury diagnoses are reported to the Guangzhou Injury Monitoring System. A three-level supervision system was established to ensure the quality of the data of the Guangzhou Injury Monitoring System. The supervision projects include false report rates (5%) and missing report rates (10%). In 2014–2018, the false and missing report rates in Guangzhou, China, were lower than 5% and 10%, respectively.

Ethics statement

Ethical approval for this survey was obtained from the Ethics Committee of the Center for Disease Control and Prevention of Guangzhou. All methods were performed in accordance with the relevant guidelines and regulations. Written informed consent was obtained from each study participant before the investigation.

Statistical analysis

Microsoft Office Excel and SPSS 21.0 (SPSS Inc., Chicago, IL) were used for data analysis. The descriptive statistics for the prevalence of events and quantitative variables were used, and the differences between demographics and injury profiles were calculated using a chi-square test. A multiple logistic regression model was established to assess the association between factors and RTIs. A two-sided P value of less than 0.05 was considered statistically significant.

Acknowledgments

This study was supported by National Natural Science Foundation of China (72104061;72072191); Science and Technology Plan Project of Guangzhou (202201010022); The Key Project of Medicine Discipline of Guangzhou (No.2021-2023-12); Basic Research Project of Key Laboratory of Guangzhou (No.202102100001), and The Science Technology Project of Guangzhou Municipal Health Commission (20201A011058, 20201A011064).

Author Contributions

WQL, YOY, TYH, MYS, FJQ, DW and CW supervised the study data collection and quality control. WQL, HL, XNF, and GZL conducted the literature review. WQL and LLP conducted the data analyses. WQL, XNF, and LLP drafted the manuscript, WQL and HL finalized the manuscript with inputs from all authors.

Conflicts of Interest

The authors declare no conflict of interest.

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Analysis of the characteristics of road traffic injuries in Guangzhou, China, in 2014–2018

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Abstract

Figures

Introduction

Results

Discussion

Case report trend of RTIs in Guangzhou

Time trend of RTIs in Guangzhou

Population distribution trend of RTIs in Guangzhou

Distribution characteristic trend of vehicle types in Guangzhou

Risk factor trend of RTIs in Guangzhou

Conclusion

Methods

Declarations

References

Additional Declarations

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