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observational studies on how the degree of surface irregularity impacts vehicle speed anddirection could be useful to assess crash risk with similar road conditions [11].Mechanical problems, in particular tyre bursts, were identified as important causes of fatalcrashes in both settings. Tyre bursts were previously identified as an important vehicle factorinvolved in crashes in LMICs [145]. In most LMICs, car owners prefer using used tyres dueto financial constraints [50]. Previous research has clearly shown that these countries do nothave an effective vehicle inspection system [19, 92]. Irregular road surface conditions oninterurban roads may facilitate frequent tyre burst in LMICs [11]. The relative contribution oftyre problems in crashes indicated that realistic inspection system on interurban road sectionsin LMICs, keeping in mind that car owner might not be able to afford the correspondingmaintenance costs [50]. Road surface improvement may help reduce crashes attributed to tyreproblems in these countries.Traffic demands on the road sector and consistently augmenting in LMICs. Highway traffic isexpected to triple in Pakistan over a period from 2005 to 2015 [81]. The reconstruction andupgrading of highways will certainly increase in these countries. The study on HWZ safety inPakistan, for the first time showed a significantly high traffic crash and fatality burden due tosuch conditions. Guidelines for work zone management exist but so far no mechanism forHWZ design, performance, and enforcement evaluation has been defined or implemented inPakistan [146]. Indeed, there is a need to improve institutional capacity, as well as inspectionmechanisms, so that road agencies could be accountable for ensuring HWZ safety [81, 99,146]. Further, it was observed that lengthy work zones lasted for over 10 months. Thus,efforts are required to reduce HWZ duration to impact crash risks [146].Moreover, one of two HWZ crashes occurred between opposite-direction vehicles; the likelyexplanation was the high volume un-separated traffic conditions and hazardous overtaking.This points out the need to carefully plan and execute the safe flow of traffic duringmaintenance works [147]. Enforcing harsher penalties for overtaking, providing alternatelanes, and traffic separation may be some useful measures to decrease hazardous situationsleading to HWZs crashes in Pakistan [146].Our study showed that pedestrians were significantly involved in HWZ crashes. Sudden entryonto the highway was reported as the major cause of such crashes. Similarly, wet surfacesincreased the risk of HWZ crashes. Such involvements, although less important, were foundin HWZ crashes elsewhere [100]. Human judgement error is indeed one of the principal factoridentified in HWZ crashes [100, 101]. These results indicated that provision of advancewarning area, clear zones to enhance visibility, road markings, and hazard signage in the workarea can be useful interventions to reduce HWZ crashes in Pakistan [94, 146].Adverse weather conditions were involved in a significant proportion of interurban roadcrashes in Cameroon and Pakistan. We observed that there were no specific speed-restrictionsimposed for such conditions on both road sections. Hazard perception for rainy conditionswas lower for high-risk crash sites compared to low-risk sites. These results point out the needfor measures that would help drivers better identify hazards in such conditions at high-risksites. Specific measures, such as all-weather pavement markings, reduced speed limits, andsurface improvements may help reduce such crashes in LMICs [99].The hazard perception study showed that drivers were able to identify only half of high-risksites. A reciprocal relationship of road and traffic hazard perception with reported speed wasobserved. The finding that hazard perception of high-risk sites was significantly differentfrom that of low-risk sites for some of the site factors may have implications for road safety.Hazard perception of high-risk crash sites, for instance with hazard signs, was significantly60
higher than that of low-risk sites. It is likely that drivers perceived a high-risk crash site morehazardous when road furniture and hazard signage was available on such site [11, 17].Interurban road maintenance has not received adequate attention in LMICs as shown by fewroad signs observed in Cameroon and Pakistan. These results suggested that development andimplementation of interventions improving hazard perception may be useful in reducing thecrash risk on interurban road sections in LMICs [14].Further, we observed that hazard perception was higher for Cameroonian sites as compared toPakistani sites. This could be explained by traffic conditions, separated in Pakistan comparedto non-separated in Cameroon. A higher hazard perception of sites with work zones inPakistan, where traffic was not separated showed a similar trend for higher hazard perception[148, 149]. Further, mountainous terrain, unfamiliarity with the road section, and right-handdriving could augment hazard perception for Cameroonian site videos [150, 151]. Theseresults showed that hazard perception measures developed elsewhere should be validatedcross culturally and video methods can be useful to conduct such studies.7. Limitations and perspectivesIn line with the increasing crash burden in LMIC, the United Nations has declared the nextdecade as the “Decade of Action for Road Safety 2011-2020” [3]. Such actions should bemonitored with valid and reliable indicators. The police data that we used in Cameroon mighthave two limitations for estimating traffic fatality. Firstly, all police reports were not collectedand secondly, reported injured patients were followed at most for eight days. This leads tounderestimation of our rates, which could not be corrected in the analyses [3]. Although wewere able to record all police reported injuries on the Pakistani road section, we observed thatpolice recording of traffic fatalities and injuries was very low when compared to ambulanceor ED data [64]. The record linkage helped to estimate overall injury rates but failed toidentify high-risk crash sites or other information that could be useful for implementingpreventive interventions [152]. Furthermore, information on safety equipment use by vehicleoccupants and motorcycle rider was almost never reported in police data. All this showed thatthere is a need to improve the existing interurban road injury surveillance system so that wecould measure the impact of safety interventions in the future. The police should be providedwith adequate resources and training to collect information as is the case in HICs [55].Preliminary results from this thesis were communicated to the NHMP and a complementarystudy is currently undergoing to evaluate the impact of strict seat-belt law implementation atKarachi-Hala road section. We hope to work with them in the future on my return to Pakistan,so that we can plan other studies to better understand which factors impede safety equipmentuse and are responsible for the high fatality among passenger occupants.Associations of situational factors with injury crash sites did not imply a causal relationship.As road design and furniture improvements are planned on Yaoundé-Douala road section, wewould like to reassess the road burden on the same road section in coming years. Few studieshave reported the effectiveness of road interventions in LMICs [90], and such data collectionin Cameroon and possibly on other interurban roads in Pakistan will help measure the impactof interventions, particularly with respect to specific situational factors.In the studies described here, most injury patients came to the hospital on their own, on bothroad sections. In Pakistan, slightly higher proportion of the patients was transported by theambulance service. In connection with the field work in Pakistan, a study was conducted toassess the quality of pre-hospital care available to RTI patients on interurban roads in theprovince of Sindh. Trauma care quality has rarely been assessed in LMICs [2, 3]. Ourevaluation of trauma care in a Moroccan region identified several opportunities forimprovement in the current healthcare system [153]. Results from such a study can be useful61
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Université Victor Segalen Bordeaux
Page 4 and 5:
Publications (peer-reviewed).......
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Index of figuresFigure 1. Traffic f
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AbbreviationsAKUAVCIBMIEASESSDALYDW
Page 10 and 11: AbstractBackground: Interurban traf
Page 12 and 13: L'objectif de cette thèse était d
Page 14 and 15: 2. Background2.1 Road injury burden
Page 16 and 17: 2.4 Multiple factors involved in tr
Page 18 and 19: Figure 4. Percentage difference of
Page 20 and 21: 2.7 Interurban road safety research
Page 22 and 23: ObjectivesThe objectives of this fi
Page 24 and 25: ResultsCrash burdenA total of 935 R
Page 26 and 27: Figure 7. Monthly trend of traffic
Page 28 and 29: Injury outcome patternsMost of inju
Page 30 and 31: MethodsThe study setting was 196-km
Page 32 and 33: patients. In the ED, those with NIS
Page 34 and 35: Table 6. Traffic injuries reported
Page 36 and 37: 5. Analytical StudiesPrevious liter
Page 38 and 39: under supervision of Dr. Sobngwi-Ta
Page 40 and 41: Table 9. Situational variables at c
Page 42 and 43: MethodsStudy design and settingStud
Page 44 and 45: to Dec 08 were retrieved and photoc
Page 46 and 47: normal zones. However, this associa
Page 48 and 49: MethodsStudy design and settingsThe
Page 50 and 51: Figure 14. Picture extracted of a h
Page 52 and 53: located in built-up area in Pakista
Page 54 and 55: Table 15. Differences in hazard per
Page 56 and 57: 6. Discussion6.1 Originality of stu
Page 58 and 59: Although adjustments are possible,
Page 62 and 63: to understand the deficiencies in t
Page 64 and 65: [24] Damsere-Derry J, Afukaar FK, D
Page 66 and 67: [69] Central Intelligence Agency. T
Page 68 and 69: [111] Geurts K, Wets G, Brijs T, Va
Page 70 and 71: [154] Rosenbloom T, Shahar A, Elhar
Page 72 and 73: 4. Farooq U, Bhatti JA, Siddiq M, M
Page 74 and 75: Appendix 1: Literature review on in
Page 76 and 77: they identified a cluster of long b
Page 78 and 79: more cost-effective than redesignin
Page 80 and 81: Table 18. Traffic injury interventi
Page 86 and 87: Appendix 3: Study I supplementary r
Page 88 and 89: Appendix 4: Manuscript in preparati
Page 90 and 91: BACKGROUNDPakistan, located at the
Page 92 and 93: patients were recorded during their
Page 94 and 95: This might motivate police officers
Page 96 and 97: 12. Peden M, Scurfiled R, Sleet D,
Page 98 and 99: Table 1. Traffic injuries reported
Page 100 and 101: Table 3. Ascertainment of police, a
Page 102 and 103: Appendix 5: Article published - Stu
Page 104 and 105: 104
Page 106 and 107: 106
Page 108 and 109: 108
Page 110 and 111:
Appendix 6: Article under review -
Page 112 and 113:
1. INTRODUCTIONWith the aging of hi
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A total of 180 crashes were identif
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conspicuity at HWZs in Pakistan. 2
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21. Sobngwi-Tambekou J, Bhatti J, K
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Table 2. Highway work zone crash fa
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122
Page 124 and 125:
ABSTRACTObjectives: Interurban road
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oad). A matched strategy was used t
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SitesOut of 131 crash sites identif
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Similarly, it was shown previously
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Majdzadeh, R., Khalagi, K., Naraghi
Page 134 and 135:
Table 2. Characteristics of Pakista
Page 136 and 137:
Table 4. Factors associated with ha
Page 138 and 139:
Table 21. Situational factors at hi
Page 140 and 141:
Table 23. Situational factors assoc
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