**2. Causes of trauma in the rural and semi-urban regions of LMICs**

## **2.1. Road traffic accidents**

the formal sector and transportation, trauma in LMICs particularly rural regions occurs in informal occupations that are seldom monitored by occupational health laws and regulations. For example, a majority of the working class in the developing rural regions are informally self-employed in agricultural and entrepreneurship activities that are not governed by any occupational health and safety regulations. It can fairly be perceived that there are more factors for physical trauma in LMICs, as compared with developed regions, and so prevention

Causes of physical trauma in the rural and semi-urban regions are as diverse as the diversity in geographical, cultural, and socioeconomic features of these areas. For this reason, even within the same country, strategies to prevent and manage physical trauma ought to consider these variations. Furthermore, rural traumatic causes of physical injuries are significantly different from those dominating big cities even though they may be in the same country. For example, activities that involve climbing trees (from which one may fall) or working in the farmyard, hence a risk of being bitten by venomous insects or animals, are rare in big towns and cities of the high income countries but common in rural LMICs. Furthermore, individuals living in these regions continuously face danger of being attacked by either a domestic or wild animals which may charge and cause injuries. In one study in Ethiopia, both hospitalized and nonhospitalized persons who had suffered a dog bite were enrolled, and it was shown that more than 655 persons had suffered such injuries in a period of 1 year only [1]. Regardless of the population size, it is obvious that this is a high incidence rate and reflects poor legislation governing domestic animal keeping in most LMICs. Legislations for keeping domestic animal which are either ill-stipulated or lightly implemented add a risk of animal-related trauma to individuals living in LMICs. Furthermore, environmental and socioeconomic activities that add to the risk of trauma to the inhabitants of the rural areas are living in unsafe buildings, cooking in open fires, frequent head loading, working with sharp cutting objects, and working up or under trees. Head loading is the act of carrying heavy load on the head as means of transferring objects over a considerable distance. Head loading is a very common act among LMICs rural inhabitants in their crucial attempt to collect water, firewood, cattle feed, and crops to the homes or market place. In one of the centers for rehabilitation for persons who are paralyzed in Bangladesh, it was shown that for 3 years at least 84 persons had suffered cervical spinal cord injury as a result of falling while carrying

Trauma is costly in terms of evacuation, transportation, and management, and it is even worse when the individual has to remain permanently disabled. In the LMICs, this cost is normally borne by the individual and or immediate family as most countries have weak social support for a disabled person. Bearing in mind that rural and semi-urban regions of LMICs are residences for the poorest, this cost is unbearable in most cases. This unmet cost could explain the reported unavailability and unaffordability of transport services for trauma victims in these regions [3]. Delays and mismanagement of a traumatized person due to lack of appropriate equipment adds to the risk of secondary injury and death. Poorly managed and or rehabilitated victim of any physical trauma is at higher risk of health complications, dependency and

is multifarious.

66 Current Issues in Global Health

heavy load on the head [2].

in the worst case scenario, death.

Road traffic accidents are reported to be the leading cause of trauma and death globally due to the resulting fatal injuries, worse in most parts of LMICs. A novel cohort study carried out in sub-Saharan Africa reported that most of serious injuries in rural and semi-urban regions were due to road traffic accidents [4]. In rural areas of Bangladesh, for each 1 million people, 8890 gets injured of whom 60 dies annually due to road traffic accidents alone. It was also found out that of those who sustain RTAs as pedestrians, one-third died [5]. Still, like in many other trauma epidemiologic studies in LMICs, those who died before arriving to the hospital were lost to the count. For this reason, the reported figures do not reflect the true magnitude of the problem.

There are unique environmental, economic, and sociocultural factors that make RTAs prevalent in these regions of the LMICs. First, the number of vehicles does not match the available road space; hence, there is a congestion of pedestrians, cyclists, trees, and two motorcyclists. Most African rural and semi-urban regions have witnessed an influx of three- and twowheeled motorized vehicles as means of public transport, while the number of roads and structures remains more or less the same. Following the increase of motorized vehicles in limited road space in the LMICs, especially in the rural regions, the incidence of RTAs in the recent years has been escalated. A recent population-based study in one of the Tanzanian rural areas indicated that most road traffic injuries (RTIs) were due to motorcycle accidents, affecting males in their twenties [6]. Furthermore, most roads in LMICs have neither traffic lights nor warning signs and neither pedestrian walkways nor cyclist pathways. For this reason, motorized and nonmotorized vehicles and pedestrians share the same narrow road adding to the risk of accidents and trauma.

and cultural values of the people. For example, local wine is one of the business relied on by families in one of the sub-regions of Tanzania and Angola and also such brews has social and cultural values [15, 16]. This means to reduce alcohol use in such regions requires extra effort in convincing people to change behavior and also encourage them to engage in alternative

Physical Trauma and Its Consequences in Rural and Semi-Urban Regions of Low and Middle…

http://dx.doi.org/10.5772/intechopen.79545

69

There has been emergence of two- and three-wheeled motorized vehicles for public and private transport in many LMICs, particularly in rural and semi-urban regions [9, 17, 18]. These additional motorized vehicles have made the traffic denser and account for increase in the incidence of RTAs and injuries, especially in the lower limbs [10]. In Gambia for example, two-thirds of the RTA involved pedestrian, bicyclist, or motorcyclist [19]. Together with limited road space, there are several other safety issues to be addressed when motorcycles are used as means of public transport. Among such issues are adherence to safe use road by the cyclists. There are many cyclists in these regions who do not wear helmets and many of those who does, have inappropriate ones. For this reason, motorcycle accidents in these areas expose both the driver and passenger to head trauma. Furthermore, significant number of motorcyclists overloads the motorcycle by either carrying more than one passenger or other heavy loads beyond its ability [7, 17, 18]. It is therefore difficult for the driver to control the motorcycle especially in the case of emergency stop or changing direction, leading to accident and trauma. Most motorcycle drivers are young men in their teens and twenties, who are normally overconfident and feel proud to ride fast to catch up with "the next passenger" as soon as possible. In doing so, they add to the risk of accident and severity of the resulting

When these factors which precipitate the occurrence of RTAs in rural and semi-urban regions of LMICs are closely observed, it is noticeable that there are many which are modifiable. Some of these trauma precipitating factors can be addressed in the short-term and others in long-term plans. For example, while it may take long time to make better safer roads and a review on current driving regulations (where necessary), short-term efforts could be directed to correcting human errors such as speeding and drunk-driving. In order to reduce human errors that lead to accidents and trauma, the first step would be educating the public on safe road use and guiding them into perceiving of accident and trauma. People are more likely to respond if they perceive that they can sustain accidents and injuries and that this would affect their lives significantly. This is very much possible especially when it is done by engaging schools, spiritual institutions, and potential people who are trusted by the people such as political and faith leaders. In this way, road users (drivers, passengers, and pedestrians) will know their responsibilities and perceive the risk of trauma, injuries, and death linked to violation of road regulations. Hughes and colleagues presents a summary of models that have been used to reduce RTAs which can (selectively) be applicable in rural and semi-urban regions of LMICs as well [20]. Although rural and semi-urban regions of LMICs are understaffed with traffic police, civilians could be empowered to report on violated road regulations such as speeding, suspected drunk-driving, and overloading by calling or sending text messages to the nearby police station. In one study in Uganda, it was reported that almost a half of RTAs were precipitated by reckless driving [21]. This is possible because significant

number of people in these regions have access to a cellular phone.

income generating activities.

trauma.

Most public busses in the rural and semi-urban regions are of poor quality due to aging or lack of maintenance service. As such vehicles are normally few when matched with the number of commuters, they are normally overloaded with passengers to alarming levels. It is also the scarcity of appropriate passenger vehicles that leads to the use of trucks and tractors which are not meant for passengers. Accidents involving such trucks and tractors normally causes massive trauma and deaths as the passengers are not secured at all. It is also not uncommon for drivers to be found without a driving license, driving drunk, or over-speeding and other human errors that contributes to risk of accident. Two studies carried out in LMICs reported that driving drunk, not applying protective measures, and over speeding were associated with increasing incidents of RTAs [7, 8]. The combination of human errors, vehicle defect, and risky infrastructure describes the reported high RTA incidents in the LMICs. Up to 74% of fatal RTAs in LMICs involve pedestrians [9]. Police road traffic accident data in Ghana showed that more than 40% of fatal RTA involved pedestrians, the majority being women [10]. Women being more affected as pedestrians in the LMICs can be explained by the fact that they are common venders and hawkers of food and items such as used clothes in rural and semi-urban LMICs. To carry out these activities, they have to walk or station themselves on the roadside to attract customers. On daily basis, many women share the insufficient road space with the four-, three-, and two-wheeled motorized and nonmotorized vehicles on their way to or from market, farm, or other places where they earn their living. In these situations, accommodate the current traffic, enforcement of the present laws, risk awareness, and behavior change campaigns by road users (particularly drivers of the motorized vehicles) may significantly reduce these such women are continuously exposed to risk of RTAs and trauma as pedestrians, while male subjects may be involved in RTAs as passengers or drivers. While it is costly and may take long to correct the infrastructure (increasing road space), immediate programs such as mass campaigns to promote safe use of roads by drivers and pedestrians could reduce RTAs.

There are other factors to road traffic accidents and trauma predominantly in the rural and semi-urban regions. Excessive alcohol consumption increases not only the odds of RTA but also assaults and falls which altogether accounts for incidents of physical trauma [4, 11]. Drunk-driving is one of the known major factors of RTAs, especially among youths in the rural and semi-urban regions of LMICs [12–14]. In one of the studies carried out in Tanzania, in which all injured drivers were tested for alcohol use it was found that up to 30% had exceeded the allowed levels [11]. This situation can be explained by the fact that there is quite a few number of road traffic police officers in these regions to monitor drivers behavior including alcohol consumption. On top of that, alcohol is easily accessible in these regions due to presence of alcohol outlets (bars) in almost every corner and people can drink at any time they wish. Some countries such as Tanzania have passed a law that restricts alcohol business during working hours with the aim of increasing productivity and crime reduction. This restriction can also reduce incidents of drunk-driving and minimize alcohol-related RTAs. Still, reducing the number of alcohol outlets and its frequent use in the rural and semi-urban LMICs is complex as it has to do with behavioral change and interferes with socioeconomic and cultural values of the people. For example, local wine is one of the business relied on by families in one of the sub-regions of Tanzania and Angola and also such brews has social and cultural values [15, 16]. This means to reduce alcohol use in such regions requires extra effort in convincing people to change behavior and also encourage them to engage in alternative income generating activities.

lights nor warning signs and neither pedestrian walkways nor cyclist pathways. For this reason, motorized and nonmotorized vehicles and pedestrians share the same narrow road

Most public busses in the rural and semi-urban regions are of poor quality due to aging or lack of maintenance service. As such vehicles are normally few when matched with the number of commuters, they are normally overloaded with passengers to alarming levels. It is also the scarcity of appropriate passenger vehicles that leads to the use of trucks and tractors which are not meant for passengers. Accidents involving such trucks and tractors normally causes massive trauma and deaths as the passengers are not secured at all. It is also not uncommon for drivers to be found without a driving license, driving drunk, or over-speeding and other human errors that contributes to risk of accident. Two studies carried out in LMICs reported that driving drunk, not applying protective measures, and over speeding were associated with increasing incidents of RTAs [7, 8]. The combination of human errors, vehicle defect, and risky infrastructure describes the reported high RTA incidents in the LMICs. Up to 74% of fatal RTAs in LMICs involve pedestrians [9]. Police road traffic accident data in Ghana showed that more than 40% of fatal RTA involved pedestrians, the majority being women [10]. Women being more affected as pedestrians in the LMICs can be explained by the fact that they are common venders and hawkers of food and items such as used clothes in rural and semi-urban LMICs. To carry out these activities, they have to walk or station themselves on the roadside to attract customers. On daily basis, many women share the insufficient road space with the four-, three-, and two-wheeled motorized and nonmotorized vehicles on their way to or from market, farm, or other places where they earn their living. In these situations, accommodate the current traffic, enforcement of the present laws, risk awareness, and behavior change campaigns by road users (particularly drivers of the motorized vehicles) may significantly reduce these such women are continuously exposed to risk of RTAs and trauma as pedestrians, while male subjects may be involved in RTAs as passengers or drivers. While it is costly and may take long to correct the infrastructure (increasing road space), immediate programs such as mass campaigns to promote safe use of roads by drivers and pedestrians could reduce RTAs. There are other factors to road traffic accidents and trauma predominantly in the rural and semi-urban regions. Excessive alcohol consumption increases not only the odds of RTA but also assaults and falls which altogether accounts for incidents of physical trauma [4, 11]. Drunk-driving is one of the known major factors of RTAs, especially among youths in the rural and semi-urban regions of LMICs [12–14]. In one of the studies carried out in Tanzania, in which all injured drivers were tested for alcohol use it was found that up to 30% had exceeded the allowed levels [11]. This situation can be explained by the fact that there is quite a few number of road traffic police officers in these regions to monitor drivers behavior including alcohol consumption. On top of that, alcohol is easily accessible in these regions due to presence of alcohol outlets (bars) in almost every corner and people can drink at any time they wish. Some countries such as Tanzania have passed a law that restricts alcohol business during working hours with the aim of increasing productivity and crime reduction. This restriction can also reduce incidents of drunk-driving and minimize alcohol-related RTAs. Still, reducing the number of alcohol outlets and its frequent use in the rural and semi-urban LMICs is complex as it has to do with behavioral change and interferes with socioeconomic

adding to the risk of accidents and trauma.

68 Current Issues in Global Health

There has been emergence of two- and three-wheeled motorized vehicles for public and private transport in many LMICs, particularly in rural and semi-urban regions [9, 17, 18]. These additional motorized vehicles have made the traffic denser and account for increase in the incidence of RTAs and injuries, especially in the lower limbs [10]. In Gambia for example, two-thirds of the RTA involved pedestrian, bicyclist, or motorcyclist [19]. Together with limited road space, there are several other safety issues to be addressed when motorcycles are used as means of public transport. Among such issues are adherence to safe use road by the cyclists. There are many cyclists in these regions who do not wear helmets and many of those who does, have inappropriate ones. For this reason, motorcycle accidents in these areas expose both the driver and passenger to head trauma. Furthermore, significant number of motorcyclists overloads the motorcycle by either carrying more than one passenger or other heavy loads beyond its ability [7, 17, 18]. It is therefore difficult for the driver to control the motorcycle especially in the case of emergency stop or changing direction, leading to accident and trauma. Most motorcycle drivers are young men in their teens and twenties, who are normally overconfident and feel proud to ride fast to catch up with "the next passenger" as soon as possible. In doing so, they add to the risk of accident and severity of the resulting trauma.

When these factors which precipitate the occurrence of RTAs in rural and semi-urban regions of LMICs are closely observed, it is noticeable that there are many which are modifiable. Some of these trauma precipitating factors can be addressed in the short-term and others in long-term plans. For example, while it may take long time to make better safer roads and a review on current driving regulations (where necessary), short-term efforts could be directed to correcting human errors such as speeding and drunk-driving. In order to reduce human errors that lead to accidents and trauma, the first step would be educating the public on safe road use and guiding them into perceiving of accident and trauma. People are more likely to respond if they perceive that they can sustain accidents and injuries and that this would affect their lives significantly. This is very much possible especially when it is done by engaging schools, spiritual institutions, and potential people who are trusted by the people such as political and faith leaders. In this way, road users (drivers, passengers, and pedestrians) will know their responsibilities and perceive the risk of trauma, injuries, and death linked to violation of road regulations. Hughes and colleagues presents a summary of models that have been used to reduce RTAs which can (selectively) be applicable in rural and semi-urban regions of LMICs as well [20]. Although rural and semi-urban regions of LMICs are understaffed with traffic police, civilians could be empowered to report on violated road regulations such as speeding, suspected drunk-driving, and overloading by calling or sending text messages to the nearby police station. In one study in Uganda, it was reported that almost a half of RTAs were precipitated by reckless driving [21]. This is possible because significant number of people in these regions have access to a cellular phone.
