Solomon M.

Nzioka (International Masters in Public Health (MPH), Israel

Topic:
Needs Assessment for Centralized Road Traffic Accidents Surveillance Unit As Basis For Evidence-
Based Public Healthy Policy Management On Road Traffic Accidents In Nairobi, Kenya.

Background:
Kenya is located within the Africa continent at coordinates between latitude 30 North and 50 South
and longitude 340 and 410 degrees East. The country lies across the equator on the East coast of
Africa. It borders Somalia, Ethiopia and Sudan to the North, Uganda to the West, Tanzania to the
South and the Indian Ocean to the East. Kenya covers about 582,500km² with its capital being
Nairobi (10 170 S, 360 490 E). The administrative units are divided into 7 provinces and 1 area namely;
Central, Coast, Eastern, Nairobi Area, North Eastern, Nyanza, Rift Valley, Western. (see annex 1). The
provinces are further divided into Districts or constituencies. Villages are the smallest administrative
structures while constituencies are the parliamentary electoral units with wards being the smallest
constitutional organs.

In Kenya, the literacy level (those with age 15 and over able to read and write) is rated at 85.1% in the
total population (male: 90.6% and female: 79.7%) as per 2003 estimates (1). Notably, even though 98%
of the of primary school entrants reach grade 5 as per the administrative data, between 2000-2005,
secondary school enrolment ratio was 50% and 46% for gross male and female respectively.
According to the same report, the 2006 estimates on GDP is US$ 40.77 billion and US$1,350 per head
with a total expenditure on health being 8.3% of GDP and a per capita expenditure on health of
$115.

Problem Statement/Problem Definition:

One of the current government visions is to transform Nairobi city into a metropolis by 2030. This
will not only come with increased traffic flow but should also make road traffic accidents management
a central concern for the health systems. Road traffic injuries are currently ranked 9th globally among
the leading causes of disease burden, in terms of disability adjusted life years (DALYs) lost. In the year
2020, road traffic injuries are projected to become the 3rd largest cause of disabilities in the world (2).
Developing countries bear the brunt of the fatalities and disabilities from road traffic crashes,
accounting for more than 85% of the world’s road fatalities (2). An economic burden review by Jacobs
et al (3) found that the annual cost of road crashes is in excess of US $500 billion. They acknowledged
that due to the scarcity of costing data for African countries, it was difficult to make a precise cost of
road crashes in Sub-Saharan Africa. However, the estimated costs as a percentage of the national
Gross National Product (GNP) ranged from 0.8% in Ethiopia, 1% in South Africa, 2.3% in Zambia,
2.7% in Botswana and almost 5% in Kenya.

1
Epidemiological Basis for Decision Making in Health Administration
 Solomon M. Nzioka (International Masters in Public Health (MPH), Israel

This paper presents review of the current literature on linkages and challenges between health research
and public healthy policy management on road traffic accidents (RTAs) in Kenya, provides an outline
of the analytic framework for which evidence can contribute to public healthy policy on RTAs
management and identifies data gaps that needs to be addressed within vision 2030 framework.

Literature Review/Conceptual Framework:

Nairobi is the most populous city in East Africa, with an estimated urban population of about 3.5
million in 2007 (1999 census). Nairobi is reputed to be the 4th fastest growing city in the world after
Guadaloupe, Mexico City (Mexico) and Maputo (Mozambique). According to the 1999 Census, the
city congestion was approximately 2925 persons/km². The Nairobi land use and transport Network
has not been revised since its development in 1973 (see annex 2). According to a recent report (4), there
are 7.5 million person trips per day translating to 2.1 trips per person per day (2007 population
projection). The report further stated that home bound trips account for 46.5%, work 25%, school
9.8%, while other trips e.g. hospital account for 18.7%. The report further noted that 93% of traffic
within Nairobi boundary at any day is destined to Nairobi while only 7% is a pass through traffic (see
annex 3). The following figures summarize the Nairobi traffic as further presented in the report: -
Fig. 1: Nairobi Trip Composition by Travel Mode Fig. 2: Nairobi Daily Traffic Volume by Road Name

Nairobi Daily Traffic Volume By Main Road

Nairobi Trip Composition by Travel Mode
Networks to CBD
Others, 0.20% Waiyaki Way
Langata Road
10% 10% Jogoo Road
16%

Walking, 47% Matatu, 29% Mbagathi Road

10% Outering Road
17%
Bus, 3.70%

Private
School or Haile Selassie
Car/Taxi/Truck, Road Thika Road
College Bus, 13%
15.30% 11%
3.10% KR(Railway), Two – wheel
mode, 1.20% Mombasa Road
0.40% 13%

A Global Road Safety Project (GRSP) study (5) showed that 4% of global vehicles are registered in
Sub-Saharan Africa and contributed about 10% of global road deaths in 1999. Comparatively, 60%
of all globally registered vehicles are in developed world where only 14% of global road deaths
occurred (4). From Odero et al (6) review of the GRSP study, they noted that the adjusted true
estimate of total road deaths for all Sub-Saharan African countries for the year 2000, based on the
police department’s records, ranged between 68,500 and 82,200. They further stated that the
estimated fatality of 190,191 for Sub-Saharan Africa presented in the 2004 World Report, based on
health care data was much higher, and reflected the magnitude of under-reporting in police statistics.
They acknowledged that given the widely recognized problem of under-reporting of road deaths in
Africa, "the true figures were likely to be much higher, as the police-reported road fatalities represent
only the tip of the injury pyramid".
2
Epidemiological Basis for Decision Making in Health Administration
 Solomon M. Nzioka (International Masters in Public Health (MPH), Israel

Another related report on road traffic accidents and injury in Kenya (7) reported that people killed
in road accidents increased by 578%, while non-fatal casualties rose by 506% between 1962 and
1992. In addition, fatality rate per 10,000 vehicles increased from 50.7 to 64.2, while fatality per
100,000 population ranged between 7.3 and 8.6. More over, the report stated that 66% of the
accidents occurred during daytime. Regarding causes of road traffic accidents, the same report noted
that human factors were responsible for 85% of all causes whereby vehicle-to-pedestrian collisions
were most severe and had the highest case fatality rates of 24%. In addition, only 12% of injuries
resulting from vehicle-to-vehicle accidents were fatal. In the said study, public service vehicles were
involved in 62% of the injuries. In addition, of all traffic fatalities reported, pedestrians comprised
42%, passengers 38%, drivers 12%, and cyclists 8%. The report concluded that the high pedestrian
and passenger deaths implied the need to investigate the underlying risk factors, operational and
policy issues involved in the transport system, and to develop and implement appropriate responsive
road safety interventions.

A 2003 related publication (8) stated that a "four-fold increase in road fatalities had been
experienced over the last 30 years with over 3,000 people being killed annually on Kenyan roads
within whom more than 75% are economically productive young adults". It further noted that
pedestrians and passengers were the most vulnerable accounting for 80% of the deaths. The report
inferred that "road safety interventions have not made any measurable impact in reducing the
numbers, rates and consequences of road crashes". It added that "despite the marked increase in
road crashes in Kenya, little effort has been made to develop and implement effective
interventions". The report adds that "impediments to road traffic injury prevention and control
include ineffective coordination, inadequate resources and qualified personnel, and limited capacity
to implement and monitor interventions". Acknowledging most of the drawbacks, the report
recommended that "there is need to improve the collection and availability of accurate data to help
in recognising traffic injury as a priority public health problem, raising awareness of policymakers on
existing effective countermeasures and mobilizing resources for implementation. Establishment of
an effective lead agency and development of stakeholder coalitions to address the problem are
desirable".

The above referenced reports are a sample of what has been documented and one will notice that
some of the widely referenced publications are not only based on assumptions that conditions
remained the same over the long comparative periods (like comparing 1962-1992) but others
generalize sub-saharan Africa and developed countries and treat each of them as homogeneous
societies and make strong comparative inferences. Notably, the utility of the combined evidence at
policy level will be limited given the methodological weaknesses and inconsistency in variable
definitions amongst researchers.
3
 Solomon M. Nzioka (International Masters in Public Health (MPH), Israel

The problem of consistency and comparability is compounded by the fact that there is no single
accepted indicator that accurately describes the overall road safety in a particular country. As pointed
out by Odero (7), the number of fatal crashes per million vehicle kilometres travelled per annum (as
a measure of exposure to motor vehicle traffic) is the most common method often used in highly
motorized countries. The report acknowledged that "because of the absence of accurate data on
vehicle usage in most African countries, it is not possible to apply this method. Instead, fatality rates,
the number of reported fatalities per 10,000 registered motor vehicles, or calculated as the number
of deaths per 100,000 population per annum, is the indicator commonly used by the WHO and the
ministries of health sector to report diseases and causes of death". As pointed out in the report,
these rates are subject to several errors, including variations in the definition of road accident deaths,
under-reporting of crashes, the resulting injuries and deaths, lack of uniform definition of variables
(e.g. what constitutes a case) amongst others (7). Agreeing with Odero's concerns, it is notable that
fatality rates are biased indicators since they depend on quality of emergency and post-trauma
services which are definitely superior in developed countries and comparison with developing
countries is misleading. At best, healthy policy management will benefit from standardized rates.

The methodological challenges mentioned previously not withstanding, it was necessary to review
publications that had temporality as required in a cause-effect inference. In one "prospective" study
in Kenya lasting 3 months (9), 240 injury patients were analysed, it was reported that road injury
admissions formed 31% of all injury admissions, the mean pre-hospital time was 2.56 hours and the
Emergency Department disposition time was 3.36 hours with the pace of care not matching severity
of the injuries as determined by injury severity score (ISS). In addition, only 17.5% reached their
areas of definitive care within 1 hour. The study concluded that though injuries following road
traffic accidents are common in Nairobi, the response to injury is slow and haphazard and that the
institution of a care incorporating the city's health centres and pre-hospital triage may improve post
accident care outcomes. Notably, these time lapses are not near acceptable international standards.

In a related study (10) in Kenya, it was found out that males comprised 63.1% of the injured,
predominantly, vehicle occupant was frequently the road user injured (70%) whereas pedestrians
constituted only 21.3%. Major city roads or highways were the commonest scenes of injury (38.3%).
It further highlighted that most of the responsible vehicles were small personal cars (65.8%) whereas
the public service vehicles caused 20% of the injuries. The report consistently with previous
publications found that even though most of the injuries were mild, transport of the injured to
hospital was uniformly haphazard. In addition, it was noted that trauma documentation was poor
with less than 30% accuracy in most parameters and the report concluded that pre-hospital and
initial care of the injured is not systematized and called for re-orientation of trauma care
departments to the care of the injured.
4
 Solomon M. Nzioka (International Masters in Public Health (MPH), Israel

One will further notice that most of these studies were rather cross-sectional in design (gathering of
cases) with prolective timing of data collection rather than prospective as stated in their published
reports which would imply follow-up of exposed and non-exposed groups for the outcome of
interest. These included some publications that reported random sampling of blood alcohol
concentration of drivers (11) while others reported pattern of alcohol use in subjects admitted
following RTAs (12).

Justification/Analytic Framework on Why Systematic Data is required:

In one of the most documented studies outside Kenya on analysis of temporal distribution of deaths
done by San Francisco group (13), it was reported that there were three occasions in which trauma
patients die after the road crash. It is a classical trimodal distribution with first peak comprising
immediate deaths (45%) primarily due to central nervous system (CNS) and major vascular trauma.
The second peak included the early hospital deaths (34%), which occurred within a few hours after
injury, principally caused by CNS injuries and exsanguinations1. The third peak of deaths (20%) were
late deaths (occur after one week) caused by sepsis-related multi-organic failure (MOF). This
evidence was used in supporting the need for interventions in the post-event phase related with the
physical environment including improved access to the medical systems and improvement in trauma
units (14). This reduced the incidence of preventable2 deaths within trauma units to a lower
incidence of 2% of preventable deaths as compared to 8% of incidence of preventable deaths
amongst the non-trauma hospitals (14). In a related study, the Denver group for trauma (15), found
out that out of all deaths, 34% occurred in the pre-hospital setting, out of the remaining 66%
patients that were transported to the hospital, 84% died in the first 48 hours (acute), 5% within three
to seven days (early) and 11% after seven days (late).

In Kenya, the above framework is not feasible due to data inconsistencies coupled by the fact that
most of the published reports are cross-sectional and hence not strong methodology for cause-effect
relationship. Consequently, informational evidence for RTAs related policy management was found
to be wanting. A more informative and less biased measure for causality inference is the use of
case/incidence reports coupled by case cross-over study methodology with the accidents victims
providing control and hazard periods. This can only be possible if there is a coordinated mechanism
to define the operational variables across the various agencies currently involved in record keeping
and reporting. Such efforts will produce more reliable data bank for long-term use in monitoring of
interventions including policies so as to produce evidence-based management of RTAs for Nairobi
city that can be scaled up to other towns in the country as well as in sub-saharan Africa.

1 Mode of death in which blood loss exceeds the body's ability to compensate and provide adequate tissue perfusion and oxygenation, frequently is due

to trauma. Bozeman, W. Shock, Hemorrhagic. [online] http://www.emedicine.com/emerg/TOPIC531.HTM. [Cited: May 25 2008].

2 “Preventable death was defined as any death that might have been prevented if optimal care had been delivered: The following three implicit criteria

should be met before a death is assessed as preventable: 1) the injury or sequelae of injury must be survivable; 2) the care delivered must be judged
suboptimal; and 3) identified errors in delivery of care must be directly and indirectly affected on the death.” (13).
5
 Solomon M. Nzioka (International Masters in Public Health (MPH), Israel

Sustainability of such interventions will require community oriented road safety policy development
and reviews, good surveillance and information system and coordinated monitoring and reporting of
trends. These efforts will be in line with the 2004 WHO appeal to Member States to institute
concrete measures aimed at reducing road traffic injuries and the pledged support for implementing
effective interventions (16). The following section outlines the objectives, data requirements and
sources for such a centralized surveillance and information system.
Aim:
To provide evidence basis for public healthy road safety policy management within Nairobi city.

Broad Objective:
To identify information gaps and undertake ongoing systematic collection, analysis, interpretation
and dissemination of health information on RTAs for public healthy policy management in Nairobi.

Specific Objectives:
1. Identify baseline indicators on the epidemiology and management of injuries in Nairobi city
a. Number of cases of road traffic accidents and related injuries by type and severity
b. Proportional morbidity and mortality by time, age group and gender
c. The populations at risk specified by age, occupation and cause of accident
d. Proportionate use of WHO recommended RTAs management protocol
e. Barriers in adherence to use of WHO recommended RTAs management protocol
2. To reduce road accidents by monitoring cause-specific trends and compliance to policy-based
prevention measures: -
a. Increase proportion of drivers adhering to speed limits, safety belt use and pedestrian
crossing codes.
b. Reduce proportion of drunk-driving drivers
c. Increase proportionate road safety adherence by pedestrians and cyclists
d. Reduce proportion of road accidents by cause
3. To reduce RTAs related preventable deaths by increasing use of WHO recommended treatment
protocol on RTAs: -
a. Increase proportion of trained Basic Life Support (BLS) personnel
b. Increase proportionate adherence to standardize severity score system for injuries
c. Increase proportion of RTAs receiving BLS within 5 minutes (pre-hospital services)
d. Increased proportion of RTAs registered at ER within 15 minutes of road crash.
e. Increase proportion of people accessing post-road accidents rehabilitation services
4. Provide continuous information feedback loop on information and knowledge gaps for public
healthy policy management based on proportional occurrence and severity of various types of
injuries over-time.
6

Variables, Data Items and Sources:
Result/ Variable
Broad Objective:
Outcome 1:
Identify number of cases of road
traffic accidents and related
injuries by type and severity
Outcome 2:
Identify proportional morbidity
and mortality by time, age group
and gender
Outcome 3:
Identify populations at risk
specified by age, occupation and
cause of accident
Outcome 4:
Identify proportionate use of
WHO recommended RTAs
management protocol
Outcome 5:
Identify barriers in adherence to
use of WHO recommended
RTAs management protocol
Outcome 6:
Increase proportion of drivers
adhering to speed limits, safety
belt use and pedestrian crossing
codes.
Outcome 7:
Reduce proportion of drunk-
driving drivers
Outcome 8:
Increase proportionate road
safety adherence by pedestrians
and cyclists
Outcome 9:
Reduce proportion of road
accidents by cause
Outcome 10:
Increase proportion of trained
Basic Life Support (BLS)
personnel
Outcome 11:
Increase proportionate
adherence to standardize
severity score system for injuries
Outcome 12:
Increase proportion of RTAs
receiving BLS within 5 minutes
(pre-hospital services)
Outcome 13:
Increased proportion of RTAs
registered at ER within 15
minutes of road crash.
Outcome 14:
Increase proportion of people
accessing post-road accidents
rehabilitation services
Outcome 15:
Proportional occurrence and
severity of various types of
injuries over-time
Solomon M. Nzioka (International Masters in Public Health (MPH), Israel
Objective Verifiable Indicator
(OVI)
To identify information gaps and undertake ongoing systematic collection, analysis, interpretation
and dissemination of health information on RTAs for public healthy policy management in Nairobi.
X number of cases of road traffic
accidents and related injuries by
type and severity
X% morbidity and mortality by
time, age group and gender
X% cases of road traffic accidents
and related injuries by type and
severity
X% of BSL and ER personnel
using WHO recommended RTAs
management protocol
Tabulate barrier type and
frequency by source
X% of drivers adhering to speed
limits, safety belt use and
pedestrian crossing codes per unit
hour at rush peak time.
X% drunk-driving drivers per unit
hour at late night
X% of pedestrians and cyclists
adhering to road safety
requirements per unit hour at rush
peak time
X% of road accidents by cause
X% of trained Basic Life Support
(BLS) personnel
X% of personnel adhering to
standardize severity score system
for injuries
X% of RTAs receiving BLS within
5 minutes (pre-hospital services)
X% of RTAs registered at ER
within 15 minutes of road crash.
X% of people accessing post-road
accidents rehabilitation services
Standard data collecting format at
various points of RTAs services
7
Source of Data
(Baseline)
Emergency/casualty
department records review on records in major hospitals
in major hospitals within
Nairobi
Emergency/casualty and
in-patient department
records review in major
hospitals within Nairobi
Emergency/casualty
department records review on records in major hospitals
in major hospitals within
Nairobi
Emergency/casualty and
in-patient department
records review in major
hospitals within Nairobi
ER/casualty staff peer
performance review reports plenary reviews with
in major hospitals within
Nairobi
Drivers in major roads to
and within Nairobi CBD at in major roads to and within
rush peak time.
Drivers in major roads to
and within Nairobi CBD at
late night.
Pedestrians and cyclists in
major roads to and within
Nairobi CBD at rush peak
time
RTAs cases registered at
ER/casualty units in major
hospitals within Nairobi
Trained Basic Life Support
(BLS) personnel in major
hospitals within Nairobi
Personnel adhering to
standardize severity score
system for injuries in major
hospitals within Nairobi
Ambulance department
records review in major
hospitals within Nairobi
Emergency/casualty
department records review
in major hospitals within
Nairobi
Physiotherapy department
records review in major
hospitals within Nairobi
Centralised surveillance
unit based on standardised
data collection forms
Means of verification and
frequency
Repeat cross-sectional study
within Nairobi
Repeat cross-sectional study
on records in major hospitals
within Nairobi
Repeat cross-sectional study
within Nairobi
3 month prospective study at
interval times
Focus group discussions and
ER/casualty staff
Repeat cross-sectional study
Nairobi CBD at baseline.
Repeat cross-sectional study
in major roads within and
outside Nairobi CBD at
baseline.
Repeat cross-sectional study
in major roads within and
outside Nairobi CBD at
baseline.
Case-cross over study of
RTAs cases for hazard and
control periods
Repeat cross-sectional study
on personnel in major
hospitals within Nairobi
Repeat cross-sectional study
on personnel in major
hospitals within Nairobi
Repeat cross-sectional study
on ambulance records in
major hospitals within
Nairobi
Repeat cross-sectional study
on Emergency/ casualty
records in major hospitals
within Nairobi
Repeat cross-sectional study
Physiotherapy department
records in major hospitals
within Nairobi
RTAs stakeholders steering
committee reports on trends
over-time
 Solomon M. Nzioka (International Masters in Public Health (MPH), Israel

References:
1. Kenya statistics (2004). Available at:
http://www.unicef.org/infobycountry/kenya_statistics.html#0. Accessed on 8/6/08.
2. Murray CJL, Lopez AD. The global burden of disease. World Health Organization/ Harvard
school of Public Health/World Bank. Harvard University Press, 1996.
3. Jacobs G, Aeron-Thomas A. (TRL Limited). Africa Road Safety Review: Final Report. Global
Road Safety Partnership; 2000. Available at: www.safety.fhwa.dot.gov/fourthlevel/toc.htm.
Accessed on 31/5/08.
4. King’ori Z.I. nairobi urban transportation challenges – learning from Japan. JICA Training Course
Final report. 2007. Available at: http://www.scribd.com/doc/2369220/FINAL-REPORT-
NAIROBI-CITY. Accessed 27/6/08
5. World Report 2004 on Road Traffic Injuries. World Health Organization/World Bank. Geneva.
Available at: www.who.int/violence_injury_prevention.
6. Odero W, Garner P, Zwi A. Road traffic injuries in developing countries: a comprehensive review
of epidemiological studies. Tropical Medicine & International Health, 1997: 2(5);445-460.
7. Odero W. Road traffic accidents in Kenya: an epidemiological appraisal. East Afr Med J. 1995
May;72(5):299-305.
8. Odero W, Khayesi M, Heda PM. Road traffic injuries in Kenya: magnitude, causes and status of
intervention. Inj Control Saf Promot. 2003 Mar-Jun;10(1-2):53-61.
9. Saidi H. S. Initial injury care in Nairobi, Kenya: A call for trauma care regionalisation. East Afr
Med J. 2003;80 (9):480-483
10. Saidi H.S, Kahoro P. Experience with road traffic accident victims at The Nairobi Hospital. East
Afr Med J. 2001 Aug;78(8):441-444.
11. Odero W, Zwi AB. Drinking and driving in an urban setting in Kenya. East Afr Med J. 1997
Nov;74(11):673-679.
12. Hassan S, Macharia WM, Atinga J. Self reported alcohol use in an urban traffic trauma population
in Kenya. East Afr Med J. 2005 Mar;82(3):144-147.
13. Baker C, Oppenheimer L, Stephens B, Lewis F, Trunkey D. Epidemiology of Trauma Deaths. Am
J Surg. 1980; 140(1):144-150
14. Haddon W. The changing approach to the epidemiology prevention and amelioration of trauma:
Transition to approaches etiologically rather than descriptive based. Inj. Prev. 1999; 5;231-235.
15. Sauaia, A, Moore F, Moore E, Moser K, Brennan R, Read R, Pons P. Epidemiology of Trauma
Deaths: A Reassessment. The Journal of Trauma Injury, Infection and Critical Care.
1995;38(2):185-193
16. WHO/AFRO Statement to mark 2004 WHO day. Availlable from
http://www.afro.who.int/press/2004/pr20040406.html. Accessed on 8/6/08.

8
 Solomon M. Nzioka (International Masters in Public Health (MPH), Israel

Annex 1: Kenya Location Map

9
 Solomon M. Nzioka (International Masters in Public Health (MPH), Israel

Annex 2: Land use and transport network for Nairobi Central Business District
(CBD) (developed in 1973 and no revision to date).

10
 Solomon M. Nzioka (International Masters in Public Health (MPH), Israel

Annex 3: Main Road Network To Nairobi Central Business City (CBD)

11