Traffic Injury Prevention
ISSN: 1538-9588 (Print) 1538-957X (Online) Journal homepage: http://www.tandfonline.com/loi/gcpi20
Increased Inequality in Mortality From Road Crashes Among Arabs and Jews in Israel Avi Magid, Shalhevet Leibovitch-Zur & Orna Baron-Epel To cite this article: Avi Magid, Shalhevet Leibovitch-Zur & Orna Baron-Epel (2015) Increased Inequality in Mortality From Road Crashes Among Arabs and Jews in Israel, Traffic Injury Prevention, 16:1, 42-47, DOI: 10.1080/15389588.2014.908289 To link to this article: http://dx.doi.org/10.1080/15389588.2014.908289
Accepted author version posted online: 28 Mar 2014.
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Date: 13 November 2015, At: 10:25
Traffic Injury Prevention (2015) 16, 42–47 C Taylor & Francis Group, LLC Copyright ISSN: 1538-9588 print / 1538-957X online DOI: 10.1080/15389588.2014.908289
Increased Inequality in Mortality From Road Crashes Among Arabs and Jews in Israel AVI MAGID, SHALHEVET LEIBOVITCH-ZUR, and ORNA BARON-EPEL School of Public Health, University of Haifa, Haifa, Israel
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Received 13 November 2013, Accepted 22 March 2014
Objective: Previous studies in several countries have shown that the economically disadvantaged seem to have a greater risk of being involved in a car crash. The aim of the present study was to compare rates and trends in mortality and injury from road crashes by age among the Arab and Jewish populations in Israel. Methods: Data on road crashes with casualties (2003–2011) from the Israeli Central Bureau of Statistics were analyzed. Age-adjusted road crash injury rates and mortality rates for 2003 to 2011 were calculated and time trends for each age group and population group are presented. Time trend significance was evaluated by linear regression models. Results: Arabs in Israel are at increased risk of injury and mortality from road crashes compared to Jews. Road crash injury rates have significantly decreased in both populations over the last decade, although the rates have been persistently higher among Arabs. Road crash mortality rates have also decreased significantly in the Jewish population but not in the Arab population. This implies an increase in the disparity in mortality between Jews and Arabs. The most prominent differences in road crash injury and mortality rates between Arabs and Jews can be observed in young adults and young children. Conclusions: The reduction in road crashes in the last decade is a positive achievement. However, the reductions are not equal among Arabs and Jews in Israel. Therefore, an increase in the disparities in mortality from road crashes is apparent. Public health efforts need to focus specifically on decreasing road crashes in the Arab community. Keywords: road crashes, Israel, Jews, Arabs, minorities
Introduction Road crashes continue to be one of the leading causes of death and a considerable burden of disease worldwide (Peden et al. 2002). Previous studies have found racial differences in road crash injury and mortality in some countries (Agran et al. 1998; Braver 2003; Malhotra et al. 2008). An American study that compared road crash mortality rates of whites, blacks, and Hispanics when traveling in motor vehicles found that blacks, particularly black men, were at a greater mortality risk compared to white men. Hispanic men were also at greater risk compared to white men. However, their risk was less than that of black men (Braver 2003). A study in the UK found a decline over time in road crash mortality among whites, blacks, and Asians living in London. However, the decline was greater in the majority white population than in the black or Asian minority populations (Malhotra et al. 2008). These studies indicate that the economically disadvantaged seem to have a greater risk of being involved in a car crash. In Israel, road traffic crashes are one of the major causes of mortality, injury, and hospitalization, especially among adults
Address correspondence to Avi Magid, MSc, School of Public Health, University of Haifa, Haifa, Israel 52621. E-mail: [email protected]
aged 15–29 years (Jaffe et al. 2009). A comparison between 20 Western countries including Israel found that the decrease in the number of people killed in road traffic crashes in Israel between 2000 to 2009 was fifth from last (where the last was the country with the smallest decrease; National Road Safety Authority 2010). It was also found that the percentage of pedestrians killed in road traffic crashes was 33%, out of the total mortality from car crashes, one of the highest among the countries included in the comparison (National Road Safety Authority 2010). Israel is a high-income country. However, a large portion of Israeli towns are similar to low- and middleincome countries with respect to their infrastructure and their residents’ lifestyle. These towns are characterized by poor infrastructure, poor education systems, and high infant mortality. Therefore, this finding is consistent with the World Health Organization (WHO) report, which noted that over a third of road traffic fatalities in low- and middle-income countries are among pedestrians and cyclists (WHO 2013). The 2 major ethnic groups reside in Israel are Jews (75.5% of the Israeli population in 2009) and Arabs (20.3% of the Israeli population in 2009; Central Bureau of Statistics [CBS] 2010b). These 2 ethnic groups have different cultures, socioeconomic status (SES), and educational and health-related characteristics. For example, life expectancy in Jews in 2011 was 80.7 years for men and 83.9 years for women, whereas among Arabs life expectancy for men and women in 2011 was 76.5 years and
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Mortality From Road Crashes in Israel 80.9 years respectively (CBS 2012). In addition, the gap in life expectancy between Jews and Arabs in Israel has increased during the last 2 decades (CBS 2010a, 2010b). In 2008, 55.3% of the Jewish population aged 25 years and over had 13 years of schooling or more, compared to 22% of the Arab population (CBS 2010c). The Arab population has a lower mean income compared to the Jewish population. In 2008, the average monthly income of an Arab household was 57% of that of a Jewish household (CBS 2010a). Therefore, the Arab population is a deprived minority in the Israeli society. In addition, most Israeli Arabs live in separate communities from the Jewish majority, in towns and villages where most of the residents are Arabs. These towns and villages are characterized by poor quality of road safety infrastructure compared to Jewish towns, including lack of separation between roads and sidewalks, lack of road lanes, lack of traffic signs and markings, and items limiting the driver’s vision, such as walls, bushes, trash, parked cars (Or Yarok Association for Safer Driving in Israel 2012). The aim of the present study was to compare rates and trends in mortality and injury from road crashes by age among the Arab and Jewish populations and to assess trends in inequality between the 2 populations.
43 Statistical Analysis Arab and Jewish road crash injury rate ratios (age adjusted), as well as Arab and Jewish road crash mortality rate ratios (age adjusted), for each year (from 2003 to 2011) were calculated. Jewish–Arab annual road crash injury rate ratios were calculated by dividing the annual Arab injury rate by the annual Jewish injury rate. Jewish–Arab age-specific road crash injury rate ratios were calculated by dividing the age-specific Arab injury rate by the age-specific Jewish injury rate. Jewish–Arab annual road crash mortality rate ratios were calculated by dividing the annual Arab mortality rate by the annual Jewish mortality rate. Jewish–Arab age-specific road crash mortality rate ratios were calculated by dividing the age-specific Arab mortality rate by the age-specific Jewish mortality rate.We also calculated 95% confidence intervals (CIs) for each age-specific rate ratio. These were calculated using the following formulas: SE(log RR) =
d b + a (a + b) c (c + d)
95%CI(log RR) = log RR ± 1.96 × SE(log RR) ⎡ 95%CI(RR) = exp ⎣log RR ± ⎛
⎞⎤ b d +
⎠⎦ ×⎝1.96 ×
a a+b c c+d
Methods The current analysis is based on data from the Israeli CBS. The Israeli CBS publishes data on road crashes with casualties (CBS 2012). The data include information on the road crash, date, and place, as well as information on injured persons, including age, gender, religion, population group (in Israel there are 2 main population groups: Jews and Arabs), and injury severity. The CBS database is based on an administrative file received each month from the Israeli police and on a file received from the Israeli trauma registry. The police file contains road crashes that were reported to the police and for which an accident file was opened by the police. The trauma registry contains information on people injured in a road crash and hospitalized for at least 24 h. A person killed in a road crash is defined by the CBS as a person who died as a result of a road crash or died of his or her injuries within 30 days. Information on people killed in a road crash is also included in the trauma registry. Data were obtained by the authors by using the CBS report generator on the CBS website. The CBS also publishes an annual abstract of statistics, where data on age distribution of each population group in Israel can be obtained.
Road Crashes Injury Rates and Mortality Rates Jewish and Arab annual road crash injury rates and mortality rates for 2003 to 2011 were calculated per 1,000 residents for injury and per 100,000 residents for mortality, after adjusting for age, where the reference age distribution was of the Jewish population in Israel as of 2003. Jewish and Arab age-specific road crash injury rates and mortality rates for 2003 to 2011 were also calculated per 1,000 residents for injury and per 100,000 residents for mortality.
In addition, injury rate time trends and mortality rate time trends for each population group are presented. The significance of the time trend in each population group was calculated by applying a linear regression model (where calendar year was used as the independent variable and the corresponding annual rate was used as the dependent variable) and calculating the P value of the slope, assuming alpha = .05.
Results The annual age-adjusted road crash injury rates in Israel decreased between 2003 and 2011 in both the Jewish population and Arab population. The rate of decrease was almost identical in the 2 populations, where for the Jewish population the linear regression slope was −0.27 (P < .001), and for the Arab population the linear regression slope was −0.29 (P < .001; Figure 1a). Because the rates of decrease were statistically identical, the gap between the 2 populations persisted. The rate in the Jewish population decreased by 40%, falling from 5.24 per 1,000 in 2003 to 3.17 per 1,000 in 2011, and the rate in the Arab population decreased by 30%, falling from 6.93 per 1,000 in 2003 to 4.86 per 1,000 in 2011. Unlike injury rates, annual age-adjusted mortality rates from road crashes have significantly decreased in the Jewish population (slope = −0.34, P < .001), but in the Arab population they showed no clear trend (slope = −0.13, P = .311; Figure 1b). Therefore, the gap between the 2 populations in mortality rate increased and the disparity in mortality from road crashes increased (Figure 1b).
44
Magid et al. Table 1. Arab and Jewish road crash injury rate, mortality rate and rate ratio by year, adjusted for age
8 Rate/1,000
7
y = -0.2888x + 7.4931 R² = 0.9076
6
Injury rate Number of injured per 1,000 Year
Jews
Arabs
Rate ratio
Jews
Arabs
Rate ratio
2003 2004 2005 2006 2007 2008 2009 2010 2011
5.24 5.11 4.80 4.75 4.24 4.11 8.85 3.40 3.17
6.93 6.98 6.52 6.73 6.24 5.56 5.76 4.86 4.86
1.32 1.37 1.36 1.42 1.47 1.35 1.50 1.43 1.53
5.09 5.92 5.42 4.99 4.28 4.14 3.15 3.44 3.22
8.50 10.79 10.12 8.66 10.13 9.96 8.80 8.31 8.81
1.67 1.82 1.87 1.74 2.37 2.41 2.79 2.41 2.73
5 4
y = -0.2658x + 5.6258 R² = 0.9812
3 2
Jews age adjusted injury rate
1
Arab age adjusted injury rate
0
Mortality rate Number of killed per 100,000
2011
2010
2009
2008
2007
2006
2005
2004
2003 12 10 Rate/100,000
8
y = -0.1257x + 9.9706 R² = 0.1453
6 4 y = -0.3378x + 6.0958 R² = 0.8444
2
Jews
Arabs
0 2011
2010
2009
2008
2007
2006
2005
2004
2003
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Year a. Injury rate
Year b. Mortality rate
Fig. 1. Time trends in road crash injury rate and mortality rate by population group, adjusted for age.
Table 1 describes the Arab–Jewish injury and mortality rate ratios. There was an increase in the injury rate ratio, rising from 1.32 in 2003 to 1.53 in 2011, and a greater increase in the mortality rate ratio, rising from 1.67 in 2003 to 2.73 in 2011. In other words, the gap between the 2 populations increased in both injury and mortality and a greater increase in mortality can be observed. Moreover, one can observe that the Jewish injury rates decreased by an average of 3.5% per annum, where the Arab injury rates decreased by an average of 4.8% per annum. Unlike injury rates, the Jewish mortality rates decreased by an average of 7.6% per annum, where the Arab mortality rates decreased by only 1.3% per annum (all of the differences in average percentage change were found to be statistically significant). The next step toward understanding the differences between the 2 populations is looking at the age-specific injury and mortality rates.
Figure 2a depicts the Jewish and Arab age-specific injury rates between 2003 and 2011. In most age groups the Arab injury rate is greater than the Jewish injury rate. However, the most prominent difference is in age group 20–24. Both the Jewish age-specific injury rate trend and Arab age-specific injury rate trend show similar behaviors: a slightly low rate of injury for ages 0–14, a steep increase for ages 15–19, a peak at ages 20–24, and a decrease in for ages 25–29, which continues in the older age groups. Figure 2b depicts road crash age-specific mortality rates of the Jewish population and the Arab population between 2003 and 2011. In most age groups the Arab mortality rate is greater than the Jewish mortality rate, where prominent differences can be observed in all age groups except 10–14. Unlike age-specific injury rates, Jewish and Arab age-specific mortality rates have different patterns for ages 0–14. At ages 0–4 there is a large difference between Arabs and Jews regarding mortality; that is, the Arab mortality rates are much higher than Jewish mortality rates for this age group. This gap continuously decreases until age 14 (the Jewish rate continuously increases and the Arab rate continuously decreases). From age 14 on, both trends have similar patterns. The Arab–Jewish age-specific mortality rate ratios suggest that there are 2 age groups in which the gaps in mortality between Arabs and Jews are the largest (Table 2). These age groups are 0–4, where the rate ratio is 8.81, and 60–64, where the rate ratio is 3.08. This observation led us to the conclusion that road crashes may result in more fatalities in the Arab population than in the Jewish population mainly in these age groups.
Discussion Arabs in Israel are at increased risk of injury and mortality from road crashes compared to Jews. In addition, in both Jewish and Arab populations, road crash injury rates have decreased over the last decade. In both population groups, the decrease in rates of road crash injuries was similar. However, the rates have been persistently higher among Arabs. Moreover, road crash mortality rates decreased significantly but
Mortality From Road Crashes in Israel
45
120
Jews injury
100
Arabs injury
80 Rate/1,000
60 40 20 0 70+
60-64
50-54
40-44
30-34
20-24
10-14
0-4
Rate/100,000
160
Jews mortality
140
Arabs mortality
120 100 80 60 40 20 0 70+
60-64
50-54
40-44
30-34
20-24
10-14
0-4
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a. Injury rate
b. Mortality rate
Fig. 2. Age-specific road crash injury incidence rate and mortality rate by population group and age group, 2003–2011.
only in the Jewish population. Among Arabs, only a slight and statistically nonsignificant decrease was observed. The most prominent differences in road crash injury rates between Arabs and Jews can be observed in young adults, and for road crash mortality rates the differences between Arabs and Jews can be observed in young children as well as in adults aged 60–64 years. The reasons for the high mortality ratio in young children will be discussed later. The reasons for the high mortality ratio in adults aged 60–64 are currently unknown and require further research. The increased risk of involvement in a car crash in the Arab community can be attributed to many risk factors. Among these factors are SES factors, lifestyle factors, infrastructure factors, and other cultural factors. In addition, risky driving behaviors among Arabs may explain the increased risk. The Arab population in Israel is an underprivileged minority and is characterized by low SES (Myers-JDC-Brookdale Institute 2012). Previous studies have associated SES with rates of road crash. For example, Braver (2003) showed that lower SES was a strong determinant of road crash fatalities. Men and women without high school diplomas were found to be at about 3-fold increased risk of death from road crashes compared to those who completed high school (Braver 2003). Therefore, the lower SES of the Arab community may contribute to higher rates of vehicle crashes, resulting in high rates of both injury and mortality. Low SES may serve to directly increase exposure due to driving less safe vehicles than the higher SES population. In addition, lower SES is characterized by lower education, and those with lower education have been reported to be at a higher risk of being involved in a severe or fatal road crash compared to people with higher levels of education (Factor et al. 2008). It is not clear why this association exists, though it may be that there are more frequent traffic law violations among less educated individuals, exposing them to traffic crashes. Some lifestyle factors, such as occupation, army service, and distance from workplace, are significantly different between the Arab and Jewish populations in Israel and may also serve as exposure factors that explain the higher risk among
Table 2. Arab and Jewish age-specific road crash injury rates, mortality rates, and rate ratios, 2003–2011 Injury rates Number of injured per 1,000 Jews Age 0–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70+
Mortality rates Number of killed per 100,000
Arabs
Jews
Arabs
N
Rate
N
Rate
Rate ratio (CI)
N
Rate
N
Rate
Rate ratio (CI)
4,906 5,696 5,448 18,427 27,374 23,328 17,052 12,735 10,631 9,971 9,768 8,567 5,473 4,000 7,927
9.81 12.53 12.87 44.28 61.87 53.86 42.26 37.13 33.50 30.79 29.84 29.55 27.50 22.06 17.37
2,744 3,091 2,596 8,065 11,519 8,313 6,391 4,979 3,825 2,749 1,979 1,325 900 605 590
13.80 16.03 15.56 58.35 100.58 75.97 63.78 58.57 53.37 50.37 48.92 4.57 36.84 33.72 20.52
1.41 (1.3–1.5) 1.28 (1.2–1.3) 1.21 (1.2–1.3) 1.32 (1.3–1.4) 1.63 (1.6–1.7) 1.41 (1.4–1.4) 1.51 (1.5–1.6) 1.58 (1.5–1.6) 1.59 (1.5–1.7) 1.64 (1.6–1.7) 1.64 (1.6–1.7) 1.40 (1.3–1.5) 1.34 (1.3–1.4) 1.53 (1.4–1.7) 1.18 (1.1–1.3)
24 36 43 150 237 156 135 91 98 99 114 105 74 91 357
4.80 7.92 10.16 36.04 53.57 36.02 33.45 26.53 30.88 30.57 34.83 36.22 37.19 50.19 78.23
84 44 27 91 156 87 58 46 47 42 25 28 28 20 34
42.26 22.81 16.18 65.84 136.21 79.50 57.88 54.11 65.58 76.96 61.79 9.66 114.62 111.46 118.23
8.81 (5.6–13.9) 2.88 (1.9–4.5) 1.59 (1.0–2.6) 1.83 (1.4–2.4) 2.54 (2.1–3.1) 2.21 (1.7–2.9) 1.73 (1.3–2.4) 2.04 (1.4–2.9) 2.12 (1.5–3.0) 2.52 (1.8–3.6) 1.77 (1.2–2.7) 2.42 (1.6–3.7) 3.08 (2.0–4.8) 2.22 (1.4–3.6) 1.51 (1.1–2.1)
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46 Arabs. There is evidence that Arabs drive longer distances, especially young adults (National Road Safety Authority 2012). This may be associated with low SES and living in the periphery, far from their workplace. There is also evidence that more Arabs work as professional drivers and spend more time driving than Jews and therefore may be exposed for longer periods and be at a greater risk of vehicle crashes (CBS 2010a). This greater exposure may explain the differences in injury and mortality. Moreover, spending more time on the road during the day may reduce a driver’s concentration and quality of driving and increase the risk of injury and mortality (Lyznicki et al. 1998). Young adults are always at higher risk of involvement in vehicle crashes (WHO 2004). Moreover, our results show that among Arabs this risk is even higher than among Jews. Army service is mandatory in Israel for young adults between ages 18 and 21. However, most Arab Moslem young adults are exempt from army service and do not serve in the Israeli army. As a result, Arab young adults have a higher rate of exposure to the road at this age (18–21) compared to Jewish young adults and therefore they may be at a higher risk of being involved in a road crash. Most Arabs (about 90% of the Arab population in Israel) reside in Arab villages and towns, which are separated from the Jewish communities and in most cases are geographically far from the major cities where most of the employment is (CBS 2010a). Most Arabs do not work in the vicinity of the towns where they reside and need to commute to work, but in the Jewish cities commute distances may be shorter. Consequently, Arabs commute further distances compared to Jews, an increased exposure that may also explain their increased risk of injury and mortality demonstrated in our results. Another cause of involvement in vehicle crashes is risky driving behaviors. Studies found that 3 out of 5 crashes are caused by risky driving behaviors. Moreover, driver behavior contributes to 95% of all crashes (Evans 1996; Petridou and Moustaky 2000). There is evidence that Arabs in Israel have higher rates of traffic law violations, such as driving above the speed limit, and less use of car seat restraints than Jews (Or Yarok Association for Safer Driving in Israel 2012). In a qualitative study aimed at identifying attitudes and beliefs of Israeli Arabs regarding road crashes, the major themes showed that Arabs perceived their driving behaviors as unsafe, impolite, careless, irresponsible, disrespectful, and impatient and generally worse compared to Jews (Moran et al. 2010). Adoption of prevention measures is also lower among Arabs. The use of restraint systems is much less common within the Arab population than within the Jewish population. A study published by the Israel National Road Safety Authority in 2005 reported that 49% of adult Arabs driving and 52% of front seat passengers used the restraint system when driving on rural roads, compared to 90 and 84% of adult Jews. The situation is even worse within the Arab towns, where only 28% of adult drivers wear safety seat belts. Our results demonstrate an increased risk of mortality from road crashes among the Arab population in Israel compared to the Jewish population, a fact that may imply an increased severity of road crashes in which Arabs are involved. BEcause the use of seat belts among vehicle occupants is a significant
Magid et al. determinant of crash severity and fatality (Braver 2003), it may have a direct effect on the severity of injuries in the Arab population and may explain the differences in injury and mortality between the 2 populations. Not restraining children may also explain the differences in injury and mortality among children. Not using restraint systems while driving is dangerous for all ages, but it is especially dangerous for young children. In a study assessing the patterns of age-appropriate child restraint system (CRS) use in Israel, 4,396 children aged 0–14 in 9 Arab towns were observed while seated in vehicles. Ageappropriate restraint rate was measured. Low age-appropriate restraint rates were observed in all age groups, where the rates for infants aged zero to one year old, children aged 1–4 years old, and children aged 5–9 years old were 31.2, 12.4, and 1.3%, respectively (Baron-Epel et al. 2012). This low rate of CRS use may partially explain the higher rate of injury and mortality among Arab children in vehicle crashes. Backover crashes are a phenomenon that is common in Arab towns but not in Jewish towns and may also contribute to the higher mortality from road crashes among Arab young children (National Road Safety Authority 2011). Backover crashes are accidents occurring in the vicinity of residential houses, when a driver back up does not notice children playing in the yard. Backover crashes are mostly reported in the Arab population in Israel (National Road Safety Authority 2011). According to the National Road Safety Authority, 38 Arab children were killed in backover crashes between 2007 and 2010, and 9 Arab children were killed in backover crashes in 2011 (National Road Safety Authority 2014). Moreover, 16% of Arab children injured in road crashes were injured in backover crashes, where only 6% of Jewish children injured in road crashed were injured in backover crashes (Beterem 2008). Backover crashes may be related to human behavioral factors (low levels of supervision) and environmental factors. Lack of playgrounds for children within the Arab towns and the lack of separation between car parking areas and play areas may explain the higher mortality among Arab children from backover crashes (National Road Safety Authority 2011). Unlike Jewish towns, which have an abundance of playgrounds, playgrounds are scarce in Arab towns. Consequently, parking areas serve also as play areas. Poor road infrastructure within the Arab towns may also be a cause of backover crashes, which may be associated with drivers’ limited vision and lack of ability to see children playing in the vicinity of the vehicle. Culture may also play a role in the difference in road crash involvement among Arabs and Jews in Israel. Social norms in a specific community may promote risky driving behaviors. Several studies found that risky driving is more common among those in the Mediterranean region compared to Americans (Brindis et al. 1995). Fatalism may also inhibit adoption of traffic laws and prevention behaviors. Arabs have higher levels of fatalistic beliefs compared to Jews. In a study among Israeli Arab children, Khir and Baron-Epel (2013) showed that drivers with fatalistic beliefs had a lower odds ratio of restraining their children in the car and therefore Arab children are at increased risk of injury and mortality in a road crash. This study has some limitations. First, the rates used in this study were rates per population, rather than rates per distance or rates per vehicle, due to lack of such data on the national
Mortality From Road Crashes in Israel
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level. However, because the main objectives of this study were to identify various at-risk groups in Israel and to estimate the trends in injury and mortality, rates per population were satisfactory. Second, differences in restraint use between the 2 populations may explain the differences in mortality between Jewish and Arab young children. However, due to lack of data regarding the number of Arab children killed as pedestrians or as occupants, we cannot assess the exact contribution of these factors to the differences in mortality. Because the rate of unrestrained Arab children is extremely high, we do believe that it may contribute to the differences in mortality between Jewish young children and Arab young children. However, further research is required to assess the exact contribution of this factor. Implications of the Study Public health efforts to decrease road crash casualties and fatalities in Israel should focus on diminishing the disparities in injury between Jews and Arabs and on significantly decreasing mortality among Arabs, which currently does not show a decreasing trend. Interventions to tackle this problem may focus mainly on eliminating exposures of the Arab population. Such interventions may adopt various strategies. This may reduce the existing gap in injury. Another strategy may include empowering the Arab community to develop interventions appropriate for their unique culture and enabling them to implement it themselves. An emphasis should be placed on Arab young children, who, according to our results, are more involved in fatal road crashes compared to Jewish young children. Eliminating yard accidents within the Arab towns may significantly reduce the fatal injury rate of young Arab children. This may be achieved by implementing appropriate intervention programs and by improving the physical environment within the Arab towns and creating an environment that is more suitable for children to play in. An example of such an environment is one that includes playgrounds designated for children and a clear separation between playing areas and parking areas.
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47 Central Bureau of Statistics. The Arab Population in Israel 2008 [in Hebrew]. Jerusalem, Israel: 2010a. Available at: http://www.cbs.gov.il/ www/statistical/arab pop08.pdf. Accessed May 28, 2013. Central Bureau of Statistics. The Israeli population—demographic characteristics 1990–2009 [in Hebrew]. Jerusalem, Israel: 2010b. Available at: http://www.cbs.gov.il/www/statistical/isr pop heb.pdf. Accessed May 28, 2013. Central Bureau of Statistics. Statistical Abstract of Israel [in Hebrew]. 2010c. Publication No. 61. Central Bureau of Statistics. Statistical Abstract of Israel [in Hebrew]. 2012. Publication No. 63. Evans L. The dominant role of driver behaviour in traffic safety. Am J Public Health. 1996;86:784–786. Factor R, Mahalel D, Yair G. Inter-group differences in road-traffic crash involvement. Accid Anal Prev. 2008;40:2000–2007. Jaffe DH, Savitsky B, Zaistev K, Hiss J, Peleg K. Alcohol and driver fatalities in Israel: an examination of the current problem. Israel Med Assoc J. 2009;11(Pt 12):725–729. Khir O, Baron-Epel O. Low rates of child restraint system use in cars may be due to fatalistic beliefs and other factors. Trans Res Part F Traffic Psychol Behav. 2013;16:53–59. Lyznicki JM, Doege TC, Davis RM, Williams MA. Sleepiness, driving and motor vehicle crashes. J Am Med Assoc. 1998;279 (Pt 23):1908–1913. Malhotra N, Hutchings A, Edwards P. Does the decline in road traffic injury in London vary by ethnicity? Inj Prev. 2008;14:333– 337. Moran M, Baron-Epel O, Assi N. Causes of road accidents as perceived by Arabs in Israel: A qualitative study. Transp. Res. Part F. 2010;13:377–387. Myers-JDC-Brookdale Institute. The Arab population in Israel: facts & figures. 2012. Available at: http://brookdale.jdc.org.il/ Uploads/dbsAttachedFiles/Myers-JDC-Brookdale–Facts-and-Figureson-Arab-Israelis-March-2012(2).pdf. Accessed May 28, 2013. National Road Safety Authority. Wearing seatbelts—a comparison between populations [in Hebrew]. 2005. Available at: http://rsa.gov.il/MachkarimDoc/Safetybeltsmigzarim2007.ppt National Road Safety Authority. Road safety measures: an international comparison [in Hebrew]. 2010. Available at: http://www.rsa.gov.il/ meidamechkar/pirsumim/Documents/NekudatTazpit9.pdf. Accessed May 28, 2013. National Road Safety Authority. Injury from road crashes in the Arab population [in Hebrew]. 2011. Available at: http://www.rsa.gov.il/ meidamechkar/pirsumim/Documents/tazpit12.pdf. Accessed May 28, 2013. National Road Safety Authority. Trends in road safety in Israel [in Hebrew]. 2012. Available at: http://www.rsa.gov.il/ meidamechkar/meidastatisti/Documents/Megamot2001 2005.pdf. Accessed May 28, 2013. National Road Safety Authority website [in Hebrew]. Available at: http://www.rsa.gov.il/chadartikshoret/chadashot/Pages/YardAccidents.aspx. Accessed March 12, 2014. Or Yarok Association for Safer Driving in Israel. Road accidents in the Arab population [in Hebrew]. 2012. Available at: http://www.oryarok. org.il/webfiles/fck/file/dohot matzav 2012/arab section 2012.pdf. Accessed May 28, 2013. Peden M, McGee K, Krug EG. Injury: A Leading Cause of the Global Burden of Disease. Geneva, Switzerland: World Health Organization; 2002. Petridou E, Moustaky M. Human factors in the causation of road traffic crashes. Eur J Epidemiol. 2000;16:819–826. World Health Organization. World Report on Road Traffic Injury Prevention. Geneva, Switzerland: Author; 2004. World Health Organization. Global Status Report on Road Safety 2013: Supporting a Decade of Action. Geneva, Switzerland: Author; 2013.
ISSN: 1538-9588 (Print) 1538-957X (Online) Journal homepage: http://www.tandfonline.com/loi/gcpi20
Increased Inequality in Mortality From Road Crashes Among Arabs and Jews in Israel Avi Magid, Shalhevet Leibovitch-Zur & Orna Baron-Epel To cite this article: Avi Magid, Shalhevet Leibovitch-Zur & Orna Baron-Epel (2015) Increased Inequality in Mortality From Road Crashes Among Arabs and Jews in Israel, Traffic Injury Prevention, 16:1, 42-47, DOI: 10.1080/15389588.2014.908289 To link to this article: http://dx.doi.org/10.1080/15389588.2014.908289
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Date: 13 November 2015, At: 10:25
Traffic Injury Prevention (2015) 16, 42–47 C Taylor & Francis Group, LLC Copyright ISSN: 1538-9588 print / 1538-957X online DOI: 10.1080/15389588.2014.908289
Increased Inequality in Mortality From Road Crashes Among Arabs and Jews in Israel AVI MAGID, SHALHEVET LEIBOVITCH-ZUR, and ORNA BARON-EPEL School of Public Health, University of Haifa, Haifa, Israel
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Received 13 November 2013, Accepted 22 March 2014
Objective: Previous studies in several countries have shown that the economically disadvantaged seem to have a greater risk of being involved in a car crash. The aim of the present study was to compare rates and trends in mortality and injury from road crashes by age among the Arab and Jewish populations in Israel. Methods: Data on road crashes with casualties (2003–2011) from the Israeli Central Bureau of Statistics were analyzed. Age-adjusted road crash injury rates and mortality rates for 2003 to 2011 were calculated and time trends for each age group and population group are presented. Time trend significance was evaluated by linear regression models. Results: Arabs in Israel are at increased risk of injury and mortality from road crashes compared to Jews. Road crash injury rates have significantly decreased in both populations over the last decade, although the rates have been persistently higher among Arabs. Road crash mortality rates have also decreased significantly in the Jewish population but not in the Arab population. This implies an increase in the disparity in mortality between Jews and Arabs. The most prominent differences in road crash injury and mortality rates between Arabs and Jews can be observed in young adults and young children. Conclusions: The reduction in road crashes in the last decade is a positive achievement. However, the reductions are not equal among Arabs and Jews in Israel. Therefore, an increase in the disparities in mortality from road crashes is apparent. Public health efforts need to focus specifically on decreasing road crashes in the Arab community. Keywords: road crashes, Israel, Jews, Arabs, minorities
Introduction Road crashes continue to be one of the leading causes of death and a considerable burden of disease worldwide (Peden et al. 2002). Previous studies have found racial differences in road crash injury and mortality in some countries (Agran et al. 1998; Braver 2003; Malhotra et al. 2008). An American study that compared road crash mortality rates of whites, blacks, and Hispanics when traveling in motor vehicles found that blacks, particularly black men, were at a greater mortality risk compared to white men. Hispanic men were also at greater risk compared to white men. However, their risk was less than that of black men (Braver 2003). A study in the UK found a decline over time in road crash mortality among whites, blacks, and Asians living in London. However, the decline was greater in the majority white population than in the black or Asian minority populations (Malhotra et al. 2008). These studies indicate that the economically disadvantaged seem to have a greater risk of being involved in a car crash. In Israel, road traffic crashes are one of the major causes of mortality, injury, and hospitalization, especially among adults
Address correspondence to Avi Magid, MSc, School of Public Health, University of Haifa, Haifa, Israel 52621. E-mail: [email protected]
aged 15–29 years (Jaffe et al. 2009). A comparison between 20 Western countries including Israel found that the decrease in the number of people killed in road traffic crashes in Israel between 2000 to 2009 was fifth from last (where the last was the country with the smallest decrease; National Road Safety Authority 2010). It was also found that the percentage of pedestrians killed in road traffic crashes was 33%, out of the total mortality from car crashes, one of the highest among the countries included in the comparison (National Road Safety Authority 2010). Israel is a high-income country. However, a large portion of Israeli towns are similar to low- and middleincome countries with respect to their infrastructure and their residents’ lifestyle. These towns are characterized by poor infrastructure, poor education systems, and high infant mortality. Therefore, this finding is consistent with the World Health Organization (WHO) report, which noted that over a third of road traffic fatalities in low- and middle-income countries are among pedestrians and cyclists (WHO 2013). The 2 major ethnic groups reside in Israel are Jews (75.5% of the Israeli population in 2009) and Arabs (20.3% of the Israeli population in 2009; Central Bureau of Statistics [CBS] 2010b). These 2 ethnic groups have different cultures, socioeconomic status (SES), and educational and health-related characteristics. For example, life expectancy in Jews in 2011 was 80.7 years for men and 83.9 years for women, whereas among Arabs life expectancy for men and women in 2011 was 76.5 years and
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Mortality From Road Crashes in Israel 80.9 years respectively (CBS 2012). In addition, the gap in life expectancy between Jews and Arabs in Israel has increased during the last 2 decades (CBS 2010a, 2010b). In 2008, 55.3% of the Jewish population aged 25 years and over had 13 years of schooling or more, compared to 22% of the Arab population (CBS 2010c). The Arab population has a lower mean income compared to the Jewish population. In 2008, the average monthly income of an Arab household was 57% of that of a Jewish household (CBS 2010a). Therefore, the Arab population is a deprived minority in the Israeli society. In addition, most Israeli Arabs live in separate communities from the Jewish majority, in towns and villages where most of the residents are Arabs. These towns and villages are characterized by poor quality of road safety infrastructure compared to Jewish towns, including lack of separation between roads and sidewalks, lack of road lanes, lack of traffic signs and markings, and items limiting the driver’s vision, such as walls, bushes, trash, parked cars (Or Yarok Association for Safer Driving in Israel 2012). The aim of the present study was to compare rates and trends in mortality and injury from road crashes by age among the Arab and Jewish populations and to assess trends in inequality between the 2 populations.
43 Statistical Analysis Arab and Jewish road crash injury rate ratios (age adjusted), as well as Arab and Jewish road crash mortality rate ratios (age adjusted), for each year (from 2003 to 2011) were calculated. Jewish–Arab annual road crash injury rate ratios were calculated by dividing the annual Arab injury rate by the annual Jewish injury rate. Jewish–Arab age-specific road crash injury rate ratios were calculated by dividing the age-specific Arab injury rate by the age-specific Jewish injury rate. Jewish–Arab annual road crash mortality rate ratios were calculated by dividing the annual Arab mortality rate by the annual Jewish mortality rate. Jewish–Arab age-specific road crash mortality rate ratios were calculated by dividing the age-specific Arab mortality rate by the age-specific Jewish mortality rate.We also calculated 95% confidence intervals (CIs) for each age-specific rate ratio. These were calculated using the following formulas: SE(log RR) =
d b + a (a + b) c (c + d)
95%CI(log RR) = log RR ± 1.96 × SE(log RR) ⎡ 95%CI(RR) = exp ⎣log RR ± ⎛
⎞⎤ b d +
⎠⎦ ×⎝1.96 ×
a a+b c c+d
Methods The current analysis is based on data from the Israeli CBS. The Israeli CBS publishes data on road crashes with casualties (CBS 2012). The data include information on the road crash, date, and place, as well as information on injured persons, including age, gender, religion, population group (in Israel there are 2 main population groups: Jews and Arabs), and injury severity. The CBS database is based on an administrative file received each month from the Israeli police and on a file received from the Israeli trauma registry. The police file contains road crashes that were reported to the police and for which an accident file was opened by the police. The trauma registry contains information on people injured in a road crash and hospitalized for at least 24 h. A person killed in a road crash is defined by the CBS as a person who died as a result of a road crash or died of his or her injuries within 30 days. Information on people killed in a road crash is also included in the trauma registry. Data were obtained by the authors by using the CBS report generator on the CBS website. The CBS also publishes an annual abstract of statistics, where data on age distribution of each population group in Israel can be obtained.
Road Crashes Injury Rates and Mortality Rates Jewish and Arab annual road crash injury rates and mortality rates for 2003 to 2011 were calculated per 1,000 residents for injury and per 100,000 residents for mortality, after adjusting for age, where the reference age distribution was of the Jewish population in Israel as of 2003. Jewish and Arab age-specific road crash injury rates and mortality rates for 2003 to 2011 were also calculated per 1,000 residents for injury and per 100,000 residents for mortality.
In addition, injury rate time trends and mortality rate time trends for each population group are presented. The significance of the time trend in each population group was calculated by applying a linear regression model (where calendar year was used as the independent variable and the corresponding annual rate was used as the dependent variable) and calculating the P value of the slope, assuming alpha = .05.
Results The annual age-adjusted road crash injury rates in Israel decreased between 2003 and 2011 in both the Jewish population and Arab population. The rate of decrease was almost identical in the 2 populations, where for the Jewish population the linear regression slope was −0.27 (P < .001), and for the Arab population the linear regression slope was −0.29 (P < .001; Figure 1a). Because the rates of decrease were statistically identical, the gap between the 2 populations persisted. The rate in the Jewish population decreased by 40%, falling from 5.24 per 1,000 in 2003 to 3.17 per 1,000 in 2011, and the rate in the Arab population decreased by 30%, falling from 6.93 per 1,000 in 2003 to 4.86 per 1,000 in 2011. Unlike injury rates, annual age-adjusted mortality rates from road crashes have significantly decreased in the Jewish population (slope = −0.34, P < .001), but in the Arab population they showed no clear trend (slope = −0.13, P = .311; Figure 1b). Therefore, the gap between the 2 populations in mortality rate increased and the disparity in mortality from road crashes increased (Figure 1b).
44
Magid et al. Table 1. Arab and Jewish road crash injury rate, mortality rate and rate ratio by year, adjusted for age
8 Rate/1,000
7
y = -0.2888x + 7.4931 R² = 0.9076
6
Injury rate Number of injured per 1,000 Year
Jews
Arabs
Rate ratio
Jews
Arabs
Rate ratio
2003 2004 2005 2006 2007 2008 2009 2010 2011
5.24 5.11 4.80 4.75 4.24 4.11 8.85 3.40 3.17
6.93 6.98 6.52 6.73 6.24 5.56 5.76 4.86 4.86
1.32 1.37 1.36 1.42 1.47 1.35 1.50 1.43 1.53
5.09 5.92 5.42 4.99 4.28 4.14 3.15 3.44 3.22
8.50 10.79 10.12 8.66 10.13 9.96 8.80 8.31 8.81
1.67 1.82 1.87 1.74 2.37 2.41 2.79 2.41 2.73
5 4
y = -0.2658x + 5.6258 R² = 0.9812
3 2
Jews age adjusted injury rate
1
Arab age adjusted injury rate
0
Mortality rate Number of killed per 100,000
2011
2010
2009
2008
2007
2006
2005
2004
2003 12 10 Rate/100,000
8
y = -0.1257x + 9.9706 R² = 0.1453
6 4 y = -0.3378x + 6.0958 R² = 0.8444
2
Jews
Arabs
0 2011
2010
2009
2008
2007
2006
2005
2004
2003
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Year a. Injury rate
Year b. Mortality rate
Fig. 1. Time trends in road crash injury rate and mortality rate by population group, adjusted for age.
Table 1 describes the Arab–Jewish injury and mortality rate ratios. There was an increase in the injury rate ratio, rising from 1.32 in 2003 to 1.53 in 2011, and a greater increase in the mortality rate ratio, rising from 1.67 in 2003 to 2.73 in 2011. In other words, the gap between the 2 populations increased in both injury and mortality and a greater increase in mortality can be observed. Moreover, one can observe that the Jewish injury rates decreased by an average of 3.5% per annum, where the Arab injury rates decreased by an average of 4.8% per annum. Unlike injury rates, the Jewish mortality rates decreased by an average of 7.6% per annum, where the Arab mortality rates decreased by only 1.3% per annum (all of the differences in average percentage change were found to be statistically significant). The next step toward understanding the differences between the 2 populations is looking at the age-specific injury and mortality rates.
Figure 2a depicts the Jewish and Arab age-specific injury rates between 2003 and 2011. In most age groups the Arab injury rate is greater than the Jewish injury rate. However, the most prominent difference is in age group 20–24. Both the Jewish age-specific injury rate trend and Arab age-specific injury rate trend show similar behaviors: a slightly low rate of injury for ages 0–14, a steep increase for ages 15–19, a peak at ages 20–24, and a decrease in for ages 25–29, which continues in the older age groups. Figure 2b depicts road crash age-specific mortality rates of the Jewish population and the Arab population between 2003 and 2011. In most age groups the Arab mortality rate is greater than the Jewish mortality rate, where prominent differences can be observed in all age groups except 10–14. Unlike age-specific injury rates, Jewish and Arab age-specific mortality rates have different patterns for ages 0–14. At ages 0–4 there is a large difference between Arabs and Jews regarding mortality; that is, the Arab mortality rates are much higher than Jewish mortality rates for this age group. This gap continuously decreases until age 14 (the Jewish rate continuously increases and the Arab rate continuously decreases). From age 14 on, both trends have similar patterns. The Arab–Jewish age-specific mortality rate ratios suggest that there are 2 age groups in which the gaps in mortality between Arabs and Jews are the largest (Table 2). These age groups are 0–4, where the rate ratio is 8.81, and 60–64, where the rate ratio is 3.08. This observation led us to the conclusion that road crashes may result in more fatalities in the Arab population than in the Jewish population mainly in these age groups.
Discussion Arabs in Israel are at increased risk of injury and mortality from road crashes compared to Jews. In addition, in both Jewish and Arab populations, road crash injury rates have decreased over the last decade. In both population groups, the decrease in rates of road crash injuries was similar. However, the rates have been persistently higher among Arabs. Moreover, road crash mortality rates decreased significantly but
Mortality From Road Crashes in Israel
45
120
Jews injury
100
Arabs injury
80 Rate/1,000
60 40 20 0 70+
60-64
50-54
40-44
30-34
20-24
10-14
0-4
Rate/100,000
160
Jews mortality
140
Arabs mortality
120 100 80 60 40 20 0 70+
60-64
50-54
40-44
30-34
20-24
10-14
0-4
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a. Injury rate
b. Mortality rate
Fig. 2. Age-specific road crash injury incidence rate and mortality rate by population group and age group, 2003–2011.
only in the Jewish population. Among Arabs, only a slight and statistically nonsignificant decrease was observed. The most prominent differences in road crash injury rates between Arabs and Jews can be observed in young adults, and for road crash mortality rates the differences between Arabs and Jews can be observed in young children as well as in adults aged 60–64 years. The reasons for the high mortality ratio in young children will be discussed later. The reasons for the high mortality ratio in adults aged 60–64 are currently unknown and require further research. The increased risk of involvement in a car crash in the Arab community can be attributed to many risk factors. Among these factors are SES factors, lifestyle factors, infrastructure factors, and other cultural factors. In addition, risky driving behaviors among Arabs may explain the increased risk. The Arab population in Israel is an underprivileged minority and is characterized by low SES (Myers-JDC-Brookdale Institute 2012). Previous studies have associated SES with rates of road crash. For example, Braver (2003) showed that lower SES was a strong determinant of road crash fatalities. Men and women without high school diplomas were found to be at about 3-fold increased risk of death from road crashes compared to those who completed high school (Braver 2003). Therefore, the lower SES of the Arab community may contribute to higher rates of vehicle crashes, resulting in high rates of both injury and mortality. Low SES may serve to directly increase exposure due to driving less safe vehicles than the higher SES population. In addition, lower SES is characterized by lower education, and those with lower education have been reported to be at a higher risk of being involved in a severe or fatal road crash compared to people with higher levels of education (Factor et al. 2008). It is not clear why this association exists, though it may be that there are more frequent traffic law violations among less educated individuals, exposing them to traffic crashes. Some lifestyle factors, such as occupation, army service, and distance from workplace, are significantly different between the Arab and Jewish populations in Israel and may also serve as exposure factors that explain the higher risk among
Table 2. Arab and Jewish age-specific road crash injury rates, mortality rates, and rate ratios, 2003–2011 Injury rates Number of injured per 1,000 Jews Age 0–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70+
Mortality rates Number of killed per 100,000
Arabs
Jews
Arabs
N
Rate
N
Rate
Rate ratio (CI)
N
Rate
N
Rate
Rate ratio (CI)
4,906 5,696 5,448 18,427 27,374 23,328 17,052 12,735 10,631 9,971 9,768 8,567 5,473 4,000 7,927
9.81 12.53 12.87 44.28 61.87 53.86 42.26 37.13 33.50 30.79 29.84 29.55 27.50 22.06 17.37
2,744 3,091 2,596 8,065 11,519 8,313 6,391 4,979 3,825 2,749 1,979 1,325 900 605 590
13.80 16.03 15.56 58.35 100.58 75.97 63.78 58.57 53.37 50.37 48.92 4.57 36.84 33.72 20.52
1.41 (1.3–1.5) 1.28 (1.2–1.3) 1.21 (1.2–1.3) 1.32 (1.3–1.4) 1.63 (1.6–1.7) 1.41 (1.4–1.4) 1.51 (1.5–1.6) 1.58 (1.5–1.6) 1.59 (1.5–1.7) 1.64 (1.6–1.7) 1.64 (1.6–1.7) 1.40 (1.3–1.5) 1.34 (1.3–1.4) 1.53 (1.4–1.7) 1.18 (1.1–1.3)
24 36 43 150 237 156 135 91 98 99 114 105 74 91 357
4.80 7.92 10.16 36.04 53.57 36.02 33.45 26.53 30.88 30.57 34.83 36.22 37.19 50.19 78.23
84 44 27 91 156 87 58 46 47 42 25 28 28 20 34
42.26 22.81 16.18 65.84 136.21 79.50 57.88 54.11 65.58 76.96 61.79 9.66 114.62 111.46 118.23
8.81 (5.6–13.9) 2.88 (1.9–4.5) 1.59 (1.0–2.6) 1.83 (1.4–2.4) 2.54 (2.1–3.1) 2.21 (1.7–2.9) 1.73 (1.3–2.4) 2.04 (1.4–2.9) 2.12 (1.5–3.0) 2.52 (1.8–3.6) 1.77 (1.2–2.7) 2.42 (1.6–3.7) 3.08 (2.0–4.8) 2.22 (1.4–3.6) 1.51 (1.1–2.1)
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46 Arabs. There is evidence that Arabs drive longer distances, especially young adults (National Road Safety Authority 2012). This may be associated with low SES and living in the periphery, far from their workplace. There is also evidence that more Arabs work as professional drivers and spend more time driving than Jews and therefore may be exposed for longer periods and be at a greater risk of vehicle crashes (CBS 2010a). This greater exposure may explain the differences in injury and mortality. Moreover, spending more time on the road during the day may reduce a driver’s concentration and quality of driving and increase the risk of injury and mortality (Lyznicki et al. 1998). Young adults are always at higher risk of involvement in vehicle crashes (WHO 2004). Moreover, our results show that among Arabs this risk is even higher than among Jews. Army service is mandatory in Israel for young adults between ages 18 and 21. However, most Arab Moslem young adults are exempt from army service and do not serve in the Israeli army. As a result, Arab young adults have a higher rate of exposure to the road at this age (18–21) compared to Jewish young adults and therefore they may be at a higher risk of being involved in a road crash. Most Arabs (about 90% of the Arab population in Israel) reside in Arab villages and towns, which are separated from the Jewish communities and in most cases are geographically far from the major cities where most of the employment is (CBS 2010a). Most Arabs do not work in the vicinity of the towns where they reside and need to commute to work, but in the Jewish cities commute distances may be shorter. Consequently, Arabs commute further distances compared to Jews, an increased exposure that may also explain their increased risk of injury and mortality demonstrated in our results. Another cause of involvement in vehicle crashes is risky driving behaviors. Studies found that 3 out of 5 crashes are caused by risky driving behaviors. Moreover, driver behavior contributes to 95% of all crashes (Evans 1996; Petridou and Moustaky 2000). There is evidence that Arabs in Israel have higher rates of traffic law violations, such as driving above the speed limit, and less use of car seat restraints than Jews (Or Yarok Association for Safer Driving in Israel 2012). In a qualitative study aimed at identifying attitudes and beliefs of Israeli Arabs regarding road crashes, the major themes showed that Arabs perceived their driving behaviors as unsafe, impolite, careless, irresponsible, disrespectful, and impatient and generally worse compared to Jews (Moran et al. 2010). Adoption of prevention measures is also lower among Arabs. The use of restraint systems is much less common within the Arab population than within the Jewish population. A study published by the Israel National Road Safety Authority in 2005 reported that 49% of adult Arabs driving and 52% of front seat passengers used the restraint system when driving on rural roads, compared to 90 and 84% of adult Jews. The situation is even worse within the Arab towns, where only 28% of adult drivers wear safety seat belts. Our results demonstrate an increased risk of mortality from road crashes among the Arab population in Israel compared to the Jewish population, a fact that may imply an increased severity of road crashes in which Arabs are involved. BEcause the use of seat belts among vehicle occupants is a significant
Magid et al. determinant of crash severity and fatality (Braver 2003), it may have a direct effect on the severity of injuries in the Arab population and may explain the differences in injury and mortality between the 2 populations. Not restraining children may also explain the differences in injury and mortality among children. Not using restraint systems while driving is dangerous for all ages, but it is especially dangerous for young children. In a study assessing the patterns of age-appropriate child restraint system (CRS) use in Israel, 4,396 children aged 0–14 in 9 Arab towns were observed while seated in vehicles. Ageappropriate restraint rate was measured. Low age-appropriate restraint rates were observed in all age groups, where the rates for infants aged zero to one year old, children aged 1–4 years old, and children aged 5–9 years old were 31.2, 12.4, and 1.3%, respectively (Baron-Epel et al. 2012). This low rate of CRS use may partially explain the higher rate of injury and mortality among Arab children in vehicle crashes. Backover crashes are a phenomenon that is common in Arab towns but not in Jewish towns and may also contribute to the higher mortality from road crashes among Arab young children (National Road Safety Authority 2011). Backover crashes are accidents occurring in the vicinity of residential houses, when a driver back up does not notice children playing in the yard. Backover crashes are mostly reported in the Arab population in Israel (National Road Safety Authority 2011). According to the National Road Safety Authority, 38 Arab children were killed in backover crashes between 2007 and 2010, and 9 Arab children were killed in backover crashes in 2011 (National Road Safety Authority 2014). Moreover, 16% of Arab children injured in road crashes were injured in backover crashes, where only 6% of Jewish children injured in road crashed were injured in backover crashes (Beterem 2008). Backover crashes may be related to human behavioral factors (low levels of supervision) and environmental factors. Lack of playgrounds for children within the Arab towns and the lack of separation between car parking areas and play areas may explain the higher mortality among Arab children from backover crashes (National Road Safety Authority 2011). Unlike Jewish towns, which have an abundance of playgrounds, playgrounds are scarce in Arab towns. Consequently, parking areas serve also as play areas. Poor road infrastructure within the Arab towns may also be a cause of backover crashes, which may be associated with drivers’ limited vision and lack of ability to see children playing in the vicinity of the vehicle. Culture may also play a role in the difference in road crash involvement among Arabs and Jews in Israel. Social norms in a specific community may promote risky driving behaviors. Several studies found that risky driving is more common among those in the Mediterranean region compared to Americans (Brindis et al. 1995). Fatalism may also inhibit adoption of traffic laws and prevention behaviors. Arabs have higher levels of fatalistic beliefs compared to Jews. In a study among Israeli Arab children, Khir and Baron-Epel (2013) showed that drivers with fatalistic beliefs had a lower odds ratio of restraining their children in the car and therefore Arab children are at increased risk of injury and mortality in a road crash. This study has some limitations. First, the rates used in this study were rates per population, rather than rates per distance or rates per vehicle, due to lack of such data on the national
Mortality From Road Crashes in Israel
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level. However, because the main objectives of this study were to identify various at-risk groups in Israel and to estimate the trends in injury and mortality, rates per population were satisfactory. Second, differences in restraint use between the 2 populations may explain the differences in mortality between Jewish and Arab young children. However, due to lack of data regarding the number of Arab children killed as pedestrians or as occupants, we cannot assess the exact contribution of these factors to the differences in mortality. Because the rate of unrestrained Arab children is extremely high, we do believe that it may contribute to the differences in mortality between Jewish young children and Arab young children. However, further research is required to assess the exact contribution of this factor. Implications of the Study Public health efforts to decrease road crash casualties and fatalities in Israel should focus on diminishing the disparities in injury between Jews and Arabs and on significantly decreasing mortality among Arabs, which currently does not show a decreasing trend. Interventions to tackle this problem may focus mainly on eliminating exposures of the Arab population. Such interventions may adopt various strategies. This may reduce the existing gap in injury. Another strategy may include empowering the Arab community to develop interventions appropriate for their unique culture and enabling them to implement it themselves. An emphasis should be placed on Arab young children, who, according to our results, are more involved in fatal road crashes compared to Jewish young children. Eliminating yard accidents within the Arab towns may significantly reduce the fatal injury rate of young Arab children. This may be achieved by implementing appropriate intervention programs and by improving the physical environment within the Arab towns and creating an environment that is more suitable for children to play in. An example of such an environment is one that includes playgrounds designated for children and a clear separation between playing areas and parking areas.
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