This article was downloaded by: [73.172.14.228]On: 30 September 2014, At: 22:09Publisher: Taylor & FrancisInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK

Traffic Injury PreventionPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/gcpi20

Burden of Road Traffic Injuries in TurkeyP. Puvanachandra a , C. Hoe a , Türker Özkan b & Timo Lajunen ba Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School ofPublic Health , Baltimore , Marylandb Safety Research Unit, Middle Eastern Technical University , Ankara , TurkeyAccepted author version posted online: 09 Nov 2011.Published online: 13 Mar 2012.

To cite this article: P. Puvanachandra , C. Hoe , Türker Özkan & Timo Lajunen (2012) Burden of Road Traffic Injuries inTurkey, Traffic Injury Prevention, 13:sup1, 64-75, DOI: 10.1080/15389588.2011.633135

To link to this article: http://dx.doi.org/10.1080/15389588.2011.633135

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained inthe publications on our platform. Taylor & Francis, our agents, and our licensors make no representations orwarranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Versionsof published Taylor & Francis and Routledge Open articles and Taylor & Francis and Routledge Open Selectarticles posted to institutional or subject repositories or any other third-party website are without warrantyfrom Taylor & Francis of any kind, either expressed or implied, including, but not limited to, warranties ofmerchantability, fitness for a particular purpose, or non-infringement. Any opinions and views expressed in thisarticle are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. Theaccuracy of the Content should not be relied upon and should be independently verified with primary sourcesof information. Taylor & Francis shall not be liable for any losses, actions, claims, proceedings, demands,costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly inconnection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Terms & Conditions of access anduse can be found at http://www.tandfonline.com/page/terms-and-conditions It is essential that you check the license status of any given Open and Open Select article to confirmconditions of access and use.

Traffic Injury Prevention, 13(S1):64–75, 2012Copyright C©© 2012 Taylor & Francis Group, LLCISSN: 1538-9588 print / 1538-957X onlineDOI: 10.1080/15389588.2011.633135

Burden of Road Traffic Injuries in Turkey

P. PUVANACHANDRA,1 C. HOE,1 TURKER OZKAN,2 and TIMO LAJUNEN2

1Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland2Safety Research Unit, Middle Eastern Technical University, Ankara, Turkey

Objective: Road traffic injuries (RTIs) are one of the leading causes of global deaths, contributing to 1.3 million liveslost each year. Although all regions are affected, low- and middle-income countries share a disproportionate burden. Thesignificance of this public health threat is growing in Turkey, where current estimates show that 2.0 percent of all deaths inthe country are due to RTIs. Despite the significance of this growing epidemic, data pertaining to RTIs in Turkey are limited.In order to address the gap in knowledge, this article presents an overview of the epidemiology of RTIs in Turkey through ananalysis of available secondary data sets and a comprehensive review of scientifically published studies.

Methods: A literature review was performed during December 2010 using PubMed, Embase, and ISIS Web of Knowledgedatabases and Google search engines. Peer-reviewed literature pertaining to Turkey and RTIs were selected for screening.Secondary data were also procured with assistance from Turkish colleagues through an exploration of data sources pertainingto RTIs in Turkey.

Results: The literature review yielded a total of 70 studies with publication years ranging from 1988 to 2010. Secondarydata sources were procured from the ministries of Health and Interior as well as the Turkish Statistical Institute. These datasources focus primarily on crashes, injuries, and fatalities (crash rate of 1328.5 per 100,000 population; injury rate of 257.9per 100,000 population; fatality rate of 5.9 per 100,000). Risk factor data surrounding road safety are limited.

Conclusion: The findings reveal the significant burden that RTIs pose on the health of the Turkish population. Theintroduction of new technologies such as the novel digital recording systems in place to record pre-hospital services andGlobal Positioning System (GPS) tracking of road traffic crashes by the police have allowed for a more accurate picture of theburden of RTIs in Turkey. There are, however, some considerable gaps and limitations within the data systems. Incorporationof standardized definitions, regular data audits, and timely review of collated data will improve the utility of RTI data andallow it to be used for policy influence.

Keywords Road traffic injuries; Turkey; Injury epidemiology; Road traffic crashes; Low-income countries; Middle-incomecountries

INTRODUCTION

Injury is one of the leading causes of mortality and disabil-ity worldwide, contributing to 5.8 million lives lost each year(World Health Organization [WHO] 2004). This translates to10 percent of the world’s deaths—surpassing, by 32 percent,the number of HIV, malaria, and tuberculosis-related fatalities(WHO 2010). Among all of the causes of injury-related deaths,road traffic injuries (RTIs) are responsible for 23 percent ofthe lives lost and was the ninth leading contributor to globaldeaths in 2004 (WHO 2004, 2010). The significance of thispublic health issue is expected to grow significantly; RTIs areprojected to become the fifth leading cause of death by 2030,resulting in an estimated 2.4 million lives lost (WHO 2004).

Received 15 July 2011; accepted 14 October 2011.Address correspondence to P. Puvanachandra, Department of International

Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St.,Baltimore, MD 21205. E-mail: ppuvanac@jhsph.edu

Although RTIs can affect all regions of the world, the globaldistribution is biased toward low- and middle-income coun-tries (LMICs) such that they share a disproportionate burden ofRTI-related morbidity and mortality (Nantulya and Reich 2003;WHO 2004, 2010). Low-income countries witness road trafficfatality rates of 21.5 per 100,000 population compared to thatof high-income countries, which have a fatality rate of 10.3 per100,000 (WHO 2009). In addition to being a grave public healthconcern, RTIs are tremendously costly for both developed anddeveloping countries. The global cost is estimated to be aboutUS$518 billion (Jacobs et al. 2000; WHO 2010).

In 2004, road traffic crashes were ranked as the WHOEuropean Region’s (EUR) sixth leading cause of burden ofdisease contributing to 3.7 million disability-adjusted life years(DALYs) lost, 129,000 deaths, and 2.4 million injuries. Low-and middle-income European countries suffered a heavier bur-den compared to high-income (HIC) European countries. Of the129,000 deaths, 91,000 (70.5%) were from the region’s LMICsand 38,000 (29.5%) were from EUR’s HICs (WHO 2004).

64

Dow

nloa

ded

by [

73.1

72.1

4.22

8] a

t 22:

09 3

0 Se

ptem

ber

2014

BURDEN OF ROAD TRAFFIC INJURIES IN TURKEY 65

Similarly, the average RTI mortality rate was 18.7 per 100,000population and 7.9 per 100,000 population for the region’sLMICs and HICs, respectively (Jacobs et al. 2000). Similar toglobal trends, young people tend to share a greater burden ofRTIs. In fact, during 2004, they were the leading cause of deathfor EUR’s 5 to 14 and 15 to 29 age groups and the third leadingcause of death for those between 30 and 44 years (Jacobs etal. 2000; WHO 2004). Males also experienced a higher riskof RTI-related mortality compared to females, accounting forthree fourths of the total deaths (Jacobs et al. 2000).

As with other regions, the economic impact of RTIs for EURis tremendous. Studies have shown that the costs vary from0.4 to 3.1 percent of the gross domestic product. Unfortunately,many countries currently lack systems that would allow for moreaccurate measurements of the economic burden (Jacobs et al.2000).

The Republic of Turkey is a middle-income country locatedwithin the WHO European Region (World Bank). With an areaof 783,562 km2, it is divided into 81 administrative provincesand 923 districts. As of July 2010, the total population of thecountry was estimated to be over 77 million with a growth rateof 1.3 percent, birth rate of 18.3 births per 1000 population,and death rate of 6.1 per 1,000 population (Central IntelligenceAgency). In 2004, the first National Burden of Disease and CostEffectiveness Study showed that RTIs were an important causeof death contributing to 2.0 percent of all fatalities (2.6% of allmale fatalities), 3.8 percent of all years of life lost (YLL; 4.8%for males) and 2.4 percent of all DALYs (3.3% for males). Thesignificance of this public health issue was more pronouncedwhen the disease burden of children and individuals in the mosteconomically productive age group were examined; RTIs werethe sixth leading cause of death for children under 15 years andthird for those between 15 and 59 years (Ministry of Healthof Turkey, Refik Saydam Hygiene Center Presidency School ofPublic Health).

Unfortunately, data pertaining to the national burden of RTIsin Turkey are scarce, and written reports are not readily acces-sible to the public. What does exist is limited to small-scale,city-based studies. Though a partially functioning civil registra-tion system has greatly improved over the past 5 to 10 years,major gaps in data collection continue to exist in Turkey, partic-ularly with respect to RTIs. Such incomplete vital registrationhas necessitated the use of statistical modeling and epidemiolog-ical data to estimate mortality and morbidity in Turkey (Akgunet al. 2007).

The primary goal of this article is to review the secondarydata sources available in Turkey in order to present an overviewof the epidemiology of RTIs in Turkey. We identify some ofthe strengths and weaknesses of datasets pertaining to RTIs inTurkey through a basic strengths, weaknesses, opportunities,and threats (SWOT) framework. A secondary goal is to presentthe findings of a comprehensive review of scientifically pub-lished studies because currently there are no systematic reviewsor summary papers published in the scientific literature on thenational burden of RTIs in Turkey.

METHODS

A thorough literature review was performed during Decem-ber 2010 using PubMed, Embase, and ISIS Web of Knowl-edge databases; Google search engines; and gray literature. Thesearch was conducted using terms such as motor vehicle, roadsafety, traffic accident, traffic injury, traffic death, traffic fatality,seat belt, child seat, child restraint, OR speeding with Turkey forthe years 1988 to the current year. The “related articles” link andthe references of reviewed articles were searched for additionalreferences. Initial screening of titles and abstracts excluded caseseries and non-English-language studies as well as literature thatwas not accessible electronically. Studies pertaining to Turkeyand RTIs were all included. Full texts were then reviewed usingthe same inclusion and exclusion criteria to obtain relevant data(Figure 1).

In addition to the literature review, an exploration of datasources pertaining to RTIs in Turkey was carried out. Figure2 illustrates the governmental organizations in Turkey that areresponsible for collecting primary and secondary RTI-relateddata.

Each data source was reviewed and accessible data were en-tered into a master database using Microsoft Excel as a platform.From this, each data set was carefully checked for consisten-cies and spurious results and cross-checked with the originaldata sets as a means of quality control. We assessed each datasource for validity, reliability, timeliness of reporting, and con-sistency. Absolute numbers of annual crashes, injuries, and fa-talities were converted to rates using population statistics for thecorresponding year. Simple tables and frequencies for RTIs wererun through Stata and disaggregated analysis, where possible,was carried out for gender and age differences. In addition, weapplied a standard SWOT framework to our overall assessmentof each data source, which is presented in Table I.

RESULTS

Analysis of available secondary data sources revealed that3 governmental entities—the Turkish Statistical Institute, Min-istry of Interior, and Ministry of Health—are responsible forthe collection of road traffic injury–related data. We present adescription of the main sources used for the purposes of thisarticle, including a review of their strengths and limitations(Table I).

Ministry of InteriorTwo departments under the Ministry of Interior collect RTI-related information: the General Directorate of Security (GDS)and the gendarmerie. The Turkish gendarmerie is a branch of theTurkishArmedForces and it is responsible for the maintenanceof the public order in areas that fall outside the jurisdiction ofpolice forces (generally in rural areas). As required by law, roadtraffic crash reports are completed after every crash (TurkStat2008b). Raw data are then compiled and sent to TurkStat foranalysis. Information regarding road traffic crashes, injuries,and fatalities are collected by both entities. The data from the

Dow

nloa

ded

by [

73.1

72.1

4.22

8] a

t 22:

09 3

0 Se

ptem

ber

2014

66 PUVANACHANDRA ET AL.

Figure 1 Literature review flowchart for road traffic injuries in Turkey.

gendarmerie, however, were not readily accessible for purposesof this article because it does not report to TurkStat on a regularbasis and therefore most of the presented data are from the trafficpolice jurisdiction only.

It is important to note that, unlike the annual traffic statisticsreport, data from the Ministry of Interior are raw data and notpresented in summary tables. Unfortunately, this information isgenerally difficult for the public to access.

Ministry of HealthIn 2008, to improve postcrash care in Turkey, a Digital TakeCalls and Operation Management System was developed bythe Ministry of Health Crisis Center. This 24-h system coversall 81 provinces and tracks emergency vehicles using GlobalPositioning Systems (GPS). Various indicators are recorded,including the number of emergency calls taken, number of cases,hospital situations, as well as response time. Both national- andprovincial-level information are available. These data are limitedto emergency call-outs and therefore do not include deaths post-hospital care. Although some risk factor information can bedetermined by reviewing the type of injuries or medical exams

required by road traffic victims, these are not recorded in aconsistent manner and have not been utilized for the purposesof this article.

Turkish Statistical InstituteThe Turkish Statistical Institute (TurkStat) is a governmentagency charged with collecting, compiling, and disseminatingnational statistics. Each year, TurkStat and the GDS preparean annual traffic accident statistics report from raw police, gen-darmerie, and insurance data. The purpose of this publicly avail-able document is to assemble statistics related to road trafficcrashes, deaths, injuries, and material loss in the country suchthat the data can help inform key decision makers and allowfor international comparisons (TurkStat 2008b). Currently, roadtraffic crash reports are completed after every crash and com-piled monthly as required by Highway Traffic Law No. 2918.Key variables include crashes, injuries, fatalities, and variousrisk factors (i.e., age, gender, seat belt use, and speed). Despitethe range of variables available, the annual traffic statistics reportpresents these data in summary tables. Raw data are inaccessibleto the public.

Dow

nloa

ded

by [

73.1

72.1

4.22

8] a

t 22:

09 3

0 Se

ptem

ber

2014

BURDEN OF ROAD TRAFFIC INJURIES IN TURKEY 67

Table I Overview of the strengths and weaknesses of select data sources for road traffic injury in Turkey, 2010

Data source Strengths Weaknesses Opportunities Threats

Death statistics A well-established annual reportthat assembles anddisaggregates data regardingdeaths and causes of deatha

The definition of road traffic deathdoes include 30-day follow-up

Raw data for this report areprocured from hospitals,clinics, death certificates, andprosecutors

Only includes informationregarding provincial anddistrict centersa

Extend beyond the district andprovincial areas to encompass widerpopulation

Risk of RTIs beingencompassed intoinjuries category

Police data Well-established system ofreporting as police aremandated by Highway TrafficLaw No. 2918 to complete roadtraffic accident reports afterevery crash and to compilethese information monthly forthe Turkish Statistical Instituted

The definition of road traffic deathdoes not include 30-dayfollow-upb,c

Misreporting or underreportingOnly enforcement informationare available

Standardize data collection with otherministries to allow for 30-dayfollow-up

Tighten reporting of crashesCollect more systematic risk factordata

Collection of too much datawill detract from policework

Reporting may have widerimplications to thegeneral population interms of insurance costs

Pre-hospitaland hospitaldata

Advanced 24-h reporting systemthat covers all 81 provinces andfollows emergency vehiclesusing GPS

The definition of road traffic deathdoes not include 30-dayfollow-up

Risk factor information is notcollected

Modify surveillance to include 30-dayfollow-up

Collect more disaggregated data on RTIsand risk factors

Must ensure thatsurveillance system doesnot become tootime-consuming

Will require training of datacollectors

Traffic accidentstatisticsreport

Well-established annual reportthat assembles anddisaggregates data related toroad traffic crashesd

Raw data for this report areprocured from GDS,gendarmerie, and insurance.Therefore, limitations fromthese data sources apply (seeabove for GDS)

Hold organizations responsible for datacollection; e.g., GDS, Ministry ofHealth accountable for quality of dataImpose quality indicators and timeconstraints to ensure validity andtimeliness of data

Risk of not being given thedata with politicalchangeovers

aTurkStat (2008).bBilgic and Karacasu.cSweRoad (2001).dTurkStat (2008b).

Information regarding the extent of injuries and deaths thathave occurred during transport to medical care and at the hospitalare not included (Bilgic and Karacasu; SweRoad 2001). Onlyfatalities that occur at the scene are reported—those that occurwithin the official 30-day post-RTI definition of a road trafficfatality are currently not reported. However, this gap in the datacollection process has been identified and TurkStat is currentlyworking with the GDS (Turkish police) to bring their reportingstrategies in line with international standards.

Data from the aforementioned secondary sources focused oncrashes, injuries, and fatalities. There was limited national dataon risk factors surrounding road safety in Turkey. Using theTurkish Statistical Institute’s population figures and number ofregistered motor vehicles, the country’s crash, injury, and deathrates were calculated and are described below.

Road Traffic CrashesAccording to the 2008 traffic accidents statistics report, therewere over 71 million individuals residing in Turkey and morethan 13 million registered motor vehicles. A total of 950,120road traffic crashes were reported during this year, of which898,451 and 51,669 were from the responsibility areas of thetraffic police and the gendarmerie, respectively. Using the totalpopulation presented in this report, the annual crash rate for 2008was calculated to be 1328.5 per 100,000 population (Figure 3a),

which exceeded the rate of the previous year (1169.6 per 100,000population) and nearly doubled that of 1999 (702.8 per 100,000population). Using the number of registered motor vehicles asthe denominator, the crash rate per vehicle revealed that thenumber of crashes grew at approximately the same rate as thenumber of vehicles: 6005.2 per 100,000 vehicles in 1999 and6902.2 per 100,000 vehicles in 2008 (TurkStat 2008b).

The road traffic crash rate of drivers in 2008 was 343.2 per100,000 population for males and 17.8 per 100,000 populationfor females. Individuals between 25 and 64 years shared theheaviest burden compared to those in the 15 to 24 and 65+ cate-gories (TurkStat 2008b; Figure 4a). Disaggregating road trafficcrashes by regions, the highest road traffic crash rates withinthe traffic police responsibility area occurred in Istanbul, WestAnatolia, Aegean, and East Marmara. Together, West Anatoliaand Aegean accounted for 249,624 or about 27 percent of allroad traffic crashes (TurkStat 2008b).

Road Traffic InjuriesAccording to the traffic accident statistics report, in 2008,184,468 individuals were injured in road traffic crashes, of which145,163 were in the responsibility area of traffic police and39,305 were in the responsibility area of the gendarmerie at thetime of the crash. This translates to a rate of 257.9 per 100,000population. As illustrated in Figure 3b, the injury rate decreased

Dow

nloa

ded

by [

73.1

72.1

4.22

8] a

t 22:

09 3

0 Se

ptem

ber

2014

68 PUVANACHANDRA ET AL.

Figure 2 Primary and secondary data sources in Turkey.

to 169.6 per 100,000 population in 2001, steadily increasing to267.8 per 100,000 population in 2007. This was followed by aslight drop in 2008 (TurkStat 2008b).

Consistent with global and regional trends, males accountedfor more of the RTIs than females. The RTI rate for males inthe traffic police jurisdiction was 288.9 per 100,000 popula-

Figure 3a Annual road traffic crash rate per 100,000 population (1999–2008)in Turkey. Source: TurkStat (2008b).

tion, considerably higher than the corresponding female RTIrate of 116.4 per 100,000 population (TurkStat 2008b). In-dividuals between 25 and 64 years shared a disproportion-ate burden, with an injury rate of 245 per 100,000 popu-lation compared to the under 25 and over 65 groups (Fig-ure 4b). The majority of the victims were passengers (49%),

Figure 3b Annual road traffic injury rate per 100,000 (1999–2008) in Turkey.Source: TurkStat (2008b).

Dow

nloa

ded

by [

73.1

72.1

4.22

8] a

t 22:

09 3

0 Se

ptem

ber

2014

BURDEN OF ROAD TRAFFIC INJURIES IN TURKEY 69

Figure 3c Annual road traffic fatality rate per 100,000 population (1999–2008) in Turkey. Source: TurkStat (2008a).

followed by drivers (39%) and pedestrians (12%; TurkStat2008b).

Road Traffic DeathsData from the 2008 traffic accident statistics report showed thatthe number and rate of traffic fatalities at the scene of the crashhave generally decreased (Figure 3c). In 1999, for example,there were 5713 RTI-related deaths in both traffic police andgendarmerie responsibility areas, whereas in 2008 there were4236. The corresponding road traffic fatality rate per 100,000population was 8.6 in 1999 and 5.9 in 2008. The majority offatalities occurred in the Aegean region, suffering 15 percentof the total RTI-related deaths in 2008. The second highestnumber of fatalities occurred in the Mediterranean region ofTurkey (12%), followed by East Marmara (12%), West BlackSea (11%), and West Antolia (9%; TurkStat 2008b).

Similar to road traffic crashes and injuries, males accountedfor more of the deaths compared to females in 2008. The ratesof road traffic deaths per 100,000 population were 6.3 and 1.9,respectively (TurkStat 2008b). When disaggregating road trafficdeaths by age group, the majority of the victims were 65 yearsand above. These individuals experienced a death rate of 6.4per 100,000 population. The second highest rate of road trafficdeaths occurred in the 25 to 64 age range (5.5 per 100,000

Figure 4a Road traffic crash rate of drivers in 2008 by age and gender (trafficpolice jurisdiction only). Source: TurkStat (2008b).

Figure 4b Road traffic injury rate per 100,000 population in 2008 by age(traffic police jurisdiction only). Source: TurkStat (2008b).

population) and the lowest in the 25 and under group (1.9 per100,000 population; TurkStat 2008b).

Similar to RTIs, when disaggregating by road user type, themajority of the fatal road traffic crash victims were passen-gers. This group experienced 1245 lives lost or 42 percent ofthe total deaths in 2008 within the traffic police jurisdictiononly. Drivers and pedestrians accounted for 1149 (39%) and554 (19%) deaths, respectively (TurkStat 2008b).

The literature review yielded a total of 70 studies with pub-lication years ranging from 1988 to 2010: cost studies (n = 3),hospital-based (n = 21), medicolegal (n = 8), modeling (n =3), population-based (n = 3), secondary analysis (n = 6), so-ciobehavioral (n = 20), spatial analysis (n = 4), and others (n= 2; Table II). Although various study designs exist, the major-ity were hospital-based or qualitative sociobehavioral studies.Together, the 2 categories accounted for 58.57 percent of theidentified literature. Very few studies, on the other hand, took apopulation-based approach. A full summary of selected studiesis presented in Table II.

Results from the literature review showed that the major-ity of victims were male, consistent with global and regionaltrends (Akgungor 2007; Alicioglu et al. 2008; Aygencel et al.2008; Cekin et al. 2005; Demircan et al. 2008; Durak et al.2008; Esiyok et al. 2005; Fedakar et al. 2005; Hilal et al. 2010;

Figure 4c Percentage of road traffic deaths in 2008 by road user type (trafficpolice jurisdiction only). Source: TurkStat (2008b).

Dow

nloa

ded

by [

73.1

72.1

4.22

8] a

t 22:

09 3

0 Se

ptem

ber

2014

70 PUVANACHANDRA ET AL.

Table II Summary of selected studies on road traffic injuries in Turkey literature review

Author (date) Type of study Location Study population RTI-related results

Cost studiesGurses et al. (2003) Prospective Denizli 91 Patients under

16 years of age45% of the injuries were the result of motor vehicle crashesCosts due to motor vehicle crash-induced pediatric trauma was estimated tobe US$500

Naci et al. (2008) Secondary Turkey N/A 360,571 years of potential life were lost as a result of road traffic fatalities142,696 potentially productive years of life were lost as a result of roadtraffic fatalities

Sut et al. (2010) Retrospective Edirne 126 Patients The daily cost of road traffic crash victims is estimated to be US$582The cost per life saved was US$8,578 and the cost per life-year saved wasUS$272.5

Hospital-based studiesAksoy et al. (2002) Retrospective Ankara 553 Patients Most common cause of maxillofacial fracture was traffic crashes (90.15% or

n = 498)Alicioglu et al.

(2008)Retrospective Edirne 212 Patients Most patients were male (n = 204 or 96.2%) with mean patient age of 36

yearsAras et al (2004) Cross-sectional Ankara 40 Patients Most common cause was traffic crashes (62.5%)Atilgan et al. (2010) Retrospective Diyarbakir 532 Patients Most common causes were falls (n = 248 or 46%) and road traffic crashes

(n = 153 or 28%)Aygencel et al. (2008) Cross-sectional Ankara 262 Patients 3% of all patients who visited the emergency department during the study

period were road traffic crash victims19 Patients had alcohol levels above the legal limit and 244 (93.1%) did notuse seat belts

Demirhan (2009) Retrospective Istanbul 4205 Patients Most common cause of blunt injury was road traffic crashes (n = 1998 or47.5%)

Durak et al. (2008) Retrospective Bursa 1307 Patients Most of the victims were male (n = 889 or 68%) and motor vehicleoccupants (n = 941 or 72.2%)The mean age was 34.8 years and the majority of the victims were between15 and 59 (n = 1035 or 81.5%)

Erhan et al. (2005) Retrospective Istanbul 106 Pediatricpatients

Most common cause was motor vehicle crashes (41%)The majority of the motor vehicle crash victims were in the 12 to 17 agegroup

Erol et al. (2004) Retrospective Diyarbakir 2901 Patients Most common cause was road traffic crashes (n = 1104 or 38%)Erturer et al. (2005) Retrospective Istanbul 372 Patients Most common causes were falls (n = 211 or 56.7%) and motor vehicle

crashes (n = 145 or 39%)Gur et al. (2005) Retrospective Anatolia 539 Patients Most common cause was road traffic crashes (n = 200 or 37.1%)Guven (1988) Retrospective Central and

easternAnatolia

302 Patients Most common causes were road traffic crashes (n = 91 or 47.89% in EastAnatolia; n = 94 or 44.34% in central Anatolia)

Karacan (2000) Retrospective Turkey 581 Patients Most common cause was road traffic crashes (48.8%)Victims of road traffic crashes were generally in their middle ages

Karamehmetoglu etal. (1997)

Retrospective SoutheastTurkey

75 Patients Most common causes of spinal cord injury were falls (37.3%), gunshotwounds (29.3%), and road traffic crashes (25.3%)

Ozkaya et al. (2009) Retrospective Istanbul 216 Patients Most common cause of maxillofacial trauma was road traffic crashes(67.1%)

Simsek et al. (2007) Retrospective Turkey andUnitedStates

210 Patients Road traffic crashes was the most common cause of mandibular fractures inTurkey (36.2%) and the second leading cause (28.1%) in the United States

Soylu et al. (1998) Retrospective Adana 242 Children Traffic crashes accounted for 9.1% of injuries and were the leading cause ofperforations with glass

Squyer et al. (2008) Retrospective Turkey andUnitedStates

506 Cases fromTurkey

Most common cause of injury was road traffic crashes in Turkey (40.32%)and the United States (45.23%)

Uzun et al. (2006) Retrospective Istanbul 802 Patients Road traffic crashes were the third most common cause of nerve injury inchildren (n = 27 or 15.7%) and adults (n = 150 or 23.77%)

Yagmur et al. (1999) Retrospective Diyarbakir 329 Cases Males accounted for more road traffic-related deaths than femalesChildren 10 and under were at the highest risk for traumatic deaths related toroad traffic crashes

Yetiser et al. (2008) Retrospective Ankara 35 Patients Most common cause for temporal bone fractures was road traffic crashes(n = 19 or 54%)

(Continued on the next page)

Dow

nloa

ded

by [

73.1

72.1

4.22

8] a

t 22:

09 3

0 Se

ptem

ber

2014

BURDEN OF ROAD TRAFFIC INJURIES IN TURKEY 71

Table II Summary of selected studies on road traffic injuries in Turkey literature review (Continued.)

Author (date) Type of study Location Study population RTI-related results

Medicolegal studiesBirgen et al. (1999) Retrospective Turkey 112 Cases Most common causes of dental injuries were assaults (n = 61 or 54.5%) and

road traffic crashes (n = 43 or 38.4%)Asirdizer et al. (2004) Retrospective Turkey 372 Cases Most common causes included cutting and stabbing objects (n = 160 or

43%), gunshots (n = 136 or 36.6%), and traffic crashes (n = 52 or 14%)Cekin et al. (2005) Retrospective Adana 1110 Cases Road traffic crash victims constituted 441 of the cases

Most of victims of road traffic crashes were pedestrians (n = 207 or 47%),male (n = 296 or 67.1%), and in the 0 and 6 age group (n = 207 or 46.9%)

Demircan et al.(2008)

Retrospective Ankara 13,823 Cases A total of 165 motor vehicle trauma cases died in the emergency departmentand 15 died outside of the emergency department

Esiyok et al. (2005) Retrospective Ankara 563 Cases Most of the cases were male (n = 364 or 64.7%)Most of the injuries took place in the lower extremities (n = 347)

Fedakar et al. (2007) Retrospective Bursa 160 Cases Most common cause of blunt heart wound was traffic crashes (n = 9 or5.6%)All victims of blunt heart wounds caused by traffic crashes were male

Hilal et al. (2010) Retrospective Adana 726 Cases 65 yearsor older

Most common cause for unnatural death was road traffic crashes (n = 119 or16.4%)Males were at higher risk compared to females (n = 86 and n = 33,respectively)

Secondary data analysisAkgungor (2007) Secondary data

analysisTurkey N/A Although the number of motor vehicles has increased significantly, highway

networks only expanded by 8700 km between 1955 and 2005The number of road traffic crashes and injuries both rose between 1990 and2004Males accounted for more deaths and injuries (76.99% and 71.69%,respectively) in 2004Passengers were at the highest risks accounting for 48.79% of injuries and40.18% of deaths in 2004

Caglayan et al.(2010)

Secondary dataanalysis

D-100 thatpassesthroughIzmir City

N/A The risk of road traffic death is 2 times higher on D-100 than on other roadswithin Izmir CityThe total number of road traffic crashes between 2000 and 2004 decreasedfrom 2119 to 1336. Likewise, injuries decreased from 448 to 339 and deathsfrom 16 to 5

Ergor et al. (2003) Secondary dataanalysis

Aegean region N/A Motor vehicle crashes constituted 10.8% or n = 183 of the accidents in theAegean regionOf all fatal accidents, 26.3% were due to motor vehicle crashes

Tansel (1989) Secondary dataanalysis

Turkey N/A The relationships between vehicle kilometers as well as young drivers ontraffic crash rate were positive

Tansel (1988) Secondary dataanalysis

Ankara,Istanbul, andIzmir

N/A Road traffic crashes were found to be more prevalent in built-up areas (90%)Istanbul had the highest number of road traffic crashes and deaths butAnkara had the most severe crashes80% of the crashes were due to driver error such as speeding

Tansel (1988) Secondary dataanalysis

Turkey N/A Most of the road traffic crashes involving pedestrians were found to be inbuilt-up areasPedestrians under the age of 18 and 65 years and above were at the highestrisk

Social behavioral studiesOksuz and Malhan

(2005)Cross-sectional Ankara 650 Students More men than women drove under the influence of alcohol

Parental education and living away from family were associated with notwearing seat belts

Ozkan et al. (2006) Cross-sectional Ankara 217 Students High perceptual-motor skills were associated with being male and havinghigh masculinity scores, whereas high safety skills were associated withhaving high femininity scores

Ozkan et al. (2005) Cross-sectional Ankara 306 Turkish drivers Positive drivers committed fewer errors and violations. Moreover, theytended to be older in age and had more driving experience

Ozkan et al. (2005) Cross-sectional Ankara 354 Students The relationship between high masculinity scores and risky driving (i.e.,aggression, violations, and offenses) was positively associated

(Continued on the next page)

Dow

nloa

ded

by [

73.1

72.1

4.22

8] a

t 22:

09 3

0 Se

ptem

ber

2014

72 PUVANACHANDRA ET AL.

Table II Summary of selected studies on road traffic injuries in Turkey literature review (Continued.)

Author (date) Type of study Location Study population RTI-related results

Rasanen et al.(2007)

Cross-sectional Ankara 408 Pedestrians Pedestrian bridge usage varied from 6% to 63%Pedestrian bridges with escalators had the highest percentage of usage andpedestrian bridges with traffic signals below had the lowest percentage of usage

Sevketoglu etal.(2009)

Cross-sectional Istanbul 532 Mothers 28% of mothers did not know what a car seat was; 52% knew but never used it;20% knew and used it

Simsekoglu (2008) Cross-sectional Ankara 277 Students Seat belt use was associated with attitude and subjective normsSimsekoglu et al.

(2008)Cross-sectional Turkey 221 People Mean response showed that seat belts were used more often outside the city and

during bad weather. Seat belts were least likely to be used within the cityReasons for using seat belts included travel conditions, safety, habit, and toavoid fines

Simsekoglu (2005) Multi-methods Ankara N/A The proportion of seat belt use by drivers was 49% on city roads, 45% oninter-city roads, and 46% on bothThe proportion of seat belt use by front seat passengers was 51.3% for cityroads, 55.5% for inter-city roads, and 54.2% for all roads

Sumer et al. (2006) Cross-sectional Turkey 785 Drivers Low safety skills and heavy dependence on driving skills may lead drivers tounderestimate risks

Turkum (2006) Cross-sectional Eskisehir 398 People Self-protecting behavior was affected by personal and social network’sexperiences with road crashes

Warner et al.(2009)

Cross-sectional Sweden andTurkey

252 Turkish driversand 219 Swedishdrivers

Positive attitude, positive subjective norm, and perceived behavioral control interms of obeying speed limit were found to be more prevalent among Swedishdrivers compared to Turkish drivers after adjusting for age and gender

Yasak et al. (2009) Cross-sectional Turkey 200 Drivers Some factors such as driving experience and academic level were found to beassociated with driving anger

Yildirim andLajunen

Cross-sectional Ankara N/A Average speed was found to be above the speed limit of 50 km/h at all timesthroughout the study. The percentage of vehicles exceeding the speed limit was97.1%Speed was higher during the evenings as well as during Ramadan20.2% of the observed participants wore seat belts

Yilmaz et al.(2004)

Cross-sectional Eskisehir 600 Drivers Most participants did not pay adequate attention to roads and believed that roadtraffic crashes were the result of fate

Yagmur et al. 1999). This difference was explored by socialand behavioral studies, which found that high perceptual-motorskills were associated with being male and having high mas-culinity scores, whereas high safety skills were associated withhaving high femininity scores (Ozkan and Lajunen 2006). Simi-larly, the relationship between high masculinity scores and riskydriving such as aggression and committing violations were pos-itively associated (Ozkan and Lajunen 2005). Most studies alsorevealed that vehicle occupants were at higher risk for RTIs andfatalities compared to other road user types (Akgungor 2007;Aygencel et al. 2008; Donmez and Gokkoca 2003; Durak et al.2008). However, risk factors were only examined by a handfulof studies, particularly those in the social and behavioral fields(Oksuz and Malhan 2005; Ozkan and Lajunen 2006; Sevketogluet al. 2009; Simsekoglu 2005; Sumer 2003).

Overall, the findings suggested that seat belt and child re-straint usage were low and the speed of vehicles tended tobe above the legal limit. Hospital-based studies, for example,showed that 93.1 to 98.2 percent of injured victims did not wearseat belts (Aygencel et al. 2008; Durak et al. 2008). Other studiesrevealed that the proportion of drivers wearing seat belts rangedfrom 17.1 to 52.1 percent (Oksuz and Malhan 2005; Porter et al.2010; Simsekoglu 2005; Yildirim and Lajunen 2009). In termsof child restraint use, studies have found that only 10 percent ofmothers reported the use of this safety device correctly, and 24.5percent of vehicles with children had child seats (Porter et al.

2010; Sevketoglu et al. 2009). Moreover, about 97 percent of ve-hicles examined exceeded the speed limit in a study conductedin Ankara (Yildirim and Lajunen 2009). Recommendations re-volved around education, enforcement, and engineering.

DISCUSSION

This article, for the first time, puts together a systemic reviewof the literature surrounding RTIs as well as secondary data inorder to provide a more accurate description of the burden ofRTIs in the Republic of Turkey.

The findings presented in this article highlight the significantburden that RTIs pose on the health of the Turkish population.Though the systematic review revealed that there were a num-ber of studies emanating from Turkey that focused on RTIs, themajority of them were small-scale facility or city-based stud-ies. There is therefore a strong push for academic researchersin Turkey to move forward with population-based and moresystematic studies.

Available secondary data revealed the dramatic rise in roadtraffic crash and injury rates since 1999. Given that studieshave demonstrated that economic growth and rate of motor-ization can lead to significant increases in the number of roadtraffic injuries, these trends are expected and have importantimplications for Turkey. Proper interventions are needed in or-der to prevent the likely increase of RTI over the next few years.

Dow

nloa

ded

by [

73.1

72.1

4.22

8] a

t 22:

09 3

0 Se

ptem

ber

2014

BURDEN OF ROAD TRAFFIC INJURIES IN TURKEY 73

The decreasing road traffic fatality trends, particularly in lightof increasing crash and injury rates, must be observed with cau-tion. Changes in reporting systems to simplify forms and cutdown time spent on paperwork and underreporting (due to thelack of 30-day follow-up of road traffic victims) are just some ofthe reasons why this apparent decrease in rate may be observed.Recent improvements in postcrash care, vehicle inspections, androadside auditing could also explain this drop. Clearly, althoughdeaths due to RTIs are tragic and preventable, the greater im-pact of RTIs is the morbidity and disability that accompaniesnonfatal injuries. In addition, the greater impact that crashes arehaving on the economically productive male age groups is amajor cause for concern (Ministry of Health of Turkey, RefikSaydam Hygiene Center Presidency School of Public Health;TurkStat 2008b; WHO 2010). Though cost data from Turkeyare limited, in 2003, TurkStat estimated that road traffic crashescost US$334,024,894—a significant financial burden for Turkey(Esiyok et al. 2005).

As Turkey’s economy grows, and investments are made bothwithin the health sector and the transport sector, there has beena visible improvement in both the nature and quality of roadtraffic data (TurkStat 2008a, 2008b). The central reporting ofall road traffic data to TurkStat is, in many respects, a valuablemodel enabling intersectoral data to be brought together andpresented in the public domain. The annual 2008 traffic accidentstatistics report formed a strong basis for this analysis and,though limitations with the various available data sets, includingtime lag and accessibility, prevented a thorough comparisonbetween these sources, we were able to secure some additionalcurrent figures from these additional sources to incorporate intothe article. The TurkStat model is valuable because it providesa good opportunity for data quality control, consistency checks,and a platform for intersectoral collaboration.

Unfortunately, considerable gaps and limitations within thedata systems in Turkey need to be addressed in order to pro-vide a more accurate estimation of the burden of RTIs (Table I).Using the WHO (2004) injury surveillance guidelines, currentdata sources do not capture the core data set required for thedevelopment of effective prevention measures. This includesdemographic information, injury event factors, injury-relateddisability, medical care and treatment, post-injury impact, andinjury-related deaths. Death statistics, for example, need to ex-tend beyond the provincial and district centers. The GDS andMinistry of Health should include 30-day follow-up for RTIvictims, risk factors, and a more comprehensive documentationof postcrash outcomes. Similarly, misreporting of road trafficcrashes and injuries by the GDS will also need to be rectified.As these raw data from GDS and Ministry of Health are fedto TurkStat, improvements in these primary data sources willhelp enhance the quality of reports, including the annual trafficaccident statistics.

Collaborative efforts between the ministries of Health andTransport in Turkey could result in an appraisal of the informa-tion services surrounding RTIs. Frameworks such as the Perfor-mance of Routine Information System Management (PRISM;

Aqil et al. 2009) could guide the development of interventionsto strengthen data systems. The establishment of routine in-jury surveillance within hospitals (to include disability, cost,and injury severity data), standardization of definitions revolv-ing around RTIs with international guidelines, and increasedemphasis on the collection of risk factor data will substantiallyenhance the quality of RTI data in Turkey. With this commit-ment to improving data systems in place, it is clear that thesituation with regard to road safety in Turkey will be ripe forinvestments.

The burden of RTIs in Turkey is high for the European re-gion; however, the current approach to data collection throughthe collaborative model of the Turkish Statistical Institute is agreat opportunity for enhancing quality and promoting harmonywith international standards. Incorporation of standardized def-initions, regular data audits, and timely review of collated datawill improve the utility of RTI data and allow it to be used forpolicy influence. This is important for promoting an evidence-based road safety portfolio across all actors in Turkey.

ACKNOWLEDGMENTS

This work was conducted as part of the Road Safety in 10Countries project funded by the Bloomberg Philanthropies. Theauthors would like to thank Dr. Adnan Hyder for his support andguidance in analyzing the data and preparing the manuscript.

REFERENCES

Akgun S, Rao C, Yardim N, et al. Estimating mortality and causesof death in Turkey: methods, results and policy implications. Eur JPublic Health. 2007;17:593–599.

Akgungor AP. Road traffic accidents and safety programme in Turkey.Int J Inj Contr Saf Promot. 2007;14:119–121.

Aksoy E, Aœnl E, Åzensz A. A restrospective study on epidemiologyand treatment of maxillofacial fractures. Journal of CraniofacialSurgery. 2002;13(6):772–775.

Alicioglu B, Yalniz E, Eskin D, Yilmaz B. Injuries associatedwith motorcycle accidents [Turkish]. Acta Orthop Traumatol Turc.2008;42:106–111.

Aqil A, Lippeveld T, Hozumi D. PRISM framework: a paradigm shiftfor designing, strengthening and evaluating routine health informa-tion systems. Health Policy Plan. 2009;24:217–228.

Aras MD, Kaya A, Atakci A, Gakkaya KO. Functional outcome fol-lowing traumatic brain injury: The Turkish experience. InternationalJournal of Rehabilitation Research. 2004;27(4):257–260.

Asirdizer M, Yavuz MS, Buken E, Daglar S, Uzun I. Medicolegalevaluation of vascular injuries of limbs in Turkey. Journal of ClinicalForensic Medicine. 2004;11(2):59–64.

Atilgan S, Erol B, Yaman F, Yilmaz N, Ucan MC. Mandibular fractures:A comparative analysis between young and adult patients in thesoutheast region of Turkey. Journal of Applied Oral Science. 201018(1):17–22.

Aygencel G, Karamercan M, Ergin M, Telatar G. Review of trafficaccident cases presenting to an adult emergency service in Turkey.J Forensic Leg Med. 2008;15:1–6.

Dow

nloa

ded

by [

73.1

72.1

4.22

8] a

t 22:

09 3

0 Se

ptem

ber

2014

74 PUVANACHANDRA ET AL.

Bilgic S, Karacasu M. Uncertainty in the number of traffic acci-dent fatalities in Turkey. Available at: http://www.iasi.cnr.it/ewgt/13conference/36 bilgic.pdf. Accessed September 19, 2010.

Birgen N, Akif Inanici M, Aliustaog Lu S. The forensic evaluation ofdental injuries in Istanbul, Turkey. Forensic Science International.1999;106(1):37–43.

Caglayan C, Hamzaoglu O, Yavuz CI, Yuksel S. Traffic accidents re-sulting in death and injury on an international road passing through acity in Kocaeli, Turkey. Archives of Environmental and OccupationalHealth. 2010;65(2):59–64.

Cekin N, Hilal A, Gulmen MK, Kar H, Aslan M, Ozdemir MH. Medi-colegal childhood deaths in Adana, Turkey. Tohoku J Exp Med.2005;206:73–80.

Central Intelligence Agency. The World Factbook: Turkey.Available at: https://www.cia.gov/library/publications/the-world-factbook/geos/tu.html. Accessed January 3, 2011.

Demircan A, Keles A, Gurbuz N, et al. Forensic emergencymedicine—six year experience of 13823 case in a university emer-gency department. Turk J Med Sci. 2008;38:567–575.

Demirhan R, Onan B, Oz K, Halezeroglu S. Comprehensive analysisof 4205 patients with chest trauma: a 10-year experience. InteractCardiovasc Thorac Surg. Sep 2009;9(3):450–453.

Donmez L, Gokkoca Z. Accident profile of older people in AntalyaCity Center, Turkey. Arch Gerontol Geriatr. 2003;37(2):99–108.

Durak D, Fedakar R, Turkmen N, Akgoz S, Baduroglu E. Road trafficcollisions in Bursa, Turkey, during 2003, 2004 and 2005. Injury.2008;39:547–553.

Erhan B, Ulu MO, Gunduz B, Tanriverdi T. Pediatric spine and spinalcord injury in Istanbul: A retrospective analysis of 106 patients.Neurosurgery Quarterly. 2005;15(1):21–24.

Ergor OA, Demiral Y, Piyal YB. A significant outcome of work life:Occupational accidents in a developing country, Turkey. Journal ofOccupational Health. 2003;45(1):74–80.

Erol B, Tanrikulu R, Gorgun B. Maxillofacial fractures. Analy-sis of demographic distribution and treatment in 2901 patients(25-year experience). Journal of Cranio-Maxillofacial Surgery.2004;32(5):308–313.

Erturer E, Tezer M, Ozturk I, Kuzgun U. Evaluation of vertebral frac-tures and associated injuries in adults. Acta orthopaedica et trauma-tologica turcica. 2005;39(5):387–390.

Esiyok B, Korkusuz I, Canturk G, Alkan HA, Karaman AG, HanciIH. Road traffic accidents and disability: a cross-section study fromTurkey. Disabil Rehabil. 2005;27:1333–1338.

Fedakar R, Turkmen N, Durak D, Gundogmus UN. Fatal traumaticheart wounds: review of 160 autopsy cases. Isr Med Assoc J.2005;7(8):498–501.

Gur A, Kemaloglu MS, Cevik R, et al. Characteristics of traumaticspinal cord injuries in south-eastern Anatolia, Turkey: a compar-ative approach to 10 years’ experience. Int J Rehabil Res. Mar2005;28(1):57–62.

Gurses D, Sarioglu-Buke A, Baskan M, Kilic I. Cost factors in pediatrictrauma. Can J Surg. Dec 2003;46(6):441–445.

Guven O. A comparative study on maxillofacial fractures in central andeastern Anatolia. A retrospective study. J Craniomaxillofac Surg.Apr 1988;16(3):126–129.

Hilal A, Akcan R, Eren A, Turhan A, Arslan M. Forensic geri-atric deaths in Adana, Turkey. Arch Gerontol Geriatr. 2010;50(3):e9–e12.

Jacobs G, Aeron-Thomas A, Astrop A. Estimating Global Road Fatal-ities. Crowthorne, England: Transport Research Laboratory; 2000.

Karacan I, Koyuncu H, Pekel A, et al. Traumatic spinal cord in-juries in Turkey: A nation-wide epidemiological study. Spinal Cord.2000;38(11):697–701.

Karamehmetoglu SS, Nas K, Karacan I, et al. Traumatic spinal cordinjuries in Southeast Turkey: An epidemiological study. Spinal Cord.1997;35(8):531–533.

Ministry of Health of Turkey, Refik Saydam Hygiene Center Pres-idency School of Public Health. National Burden of Diseaseand Cost-Effectiveness Project: Burden of Disease Final Re-port 2004. Available at: http://www.tusak.saglik.gov.tr/pdf/nbd/raporlar/burdenofdiseaseENG.pdf. Accessed January 3, 2011.

Naci H, Baker TD. Productivity losses from road traffic deaths inTurkey. International Journal of Injury Control and Safety Promo-tion. Mar 2008;15(1):19–24.

Nantulya V, Reich M. Equity dimensions of road traffic injuries inlow- and middle-income countries. Inj Contr Saf Promot. 2003;10:13–20.

Oksuz E, Malhan S. Socioeconomic factors and health risk behaviorsamong university students in Turkey: questionnaire study. Croat MedJ. 2005;46:66–73.

Ozkan T, Lajunen T. Why are there sex differences in risky driving?The relationship between sex and gender-role on aggressive driving,traffic offences, and accident involvement among young Turkishdrivers. Aggress Behav. 2005;31:547–558.

Ozkan T, Lajunen T. What causes the differences in driving betweenyoung men and women? The effects of gender roles and sex on youngdrivers’ driving behaviour and self-assessment of skills. Transp ResPart F Traffic Psychol Behav. 2006;9:269–277.

Ozkaya O, Turgut G, Kayali MU, Ugurlu K, Kuran I, Bas L.A retrospective study on the epidemiology and treatment ofmaxillofacial fractures. Ulusal Travma ve Acil Cerrahi Dergisi.2009;15(3):262–266.

Porter B, Lajunen T, Ozkan T, Will K. A behavioral observation studyof Turkish drivers’ and children’s safety belt use. Procedia Soc BehavSci. 2010;5:1607–1609.

Rasanen M, Lajunen T, Alticafarbay F, Aydin C. Pedestrian self-reportsof factors influencing the use of pedestrian bridges. Accident; anal-ysis and prevention. 2007;39(5):969–973.

Sevketoglu E, Hatipoglu S, Esin G, Oztora S. Knowledge and attitude ofTurkish parents regarding car safety seats for children. Ulus TravmaAcil Cerrahi Derg. 2009;15:482–486.

Simsek S, Simsek B, Abubaker AO, Laskin DM. A compara-tive study of mandibular fractures in the United States andTurkey. International Journal of Oral and Maxillofacial Surgery.2007;36(5):395–397.

Simsekoglu O. Coorelates of Seat Belt Use Among Turkish Front SeatOccupants. Ankara, Turkey: Department of Psychology, Middle EastTechnical University; 2005.

Soylu M, Demircan N, Yalaz M, Isiguzel I. Etiology of pediatric per-forating eye injuries in Southern Turkey. Ophthalmic Epidemiology.1998;5(1):7–12.

Squyer Et, Cherry RA, Lehman E, et al. Comparison of trauma mortal-ity between two hospitals in Turkey to one trauma center in the US.Eur J Emerg Med. Aug 2008;15(4):209–213.

Sumer N. Personality and behavioral predictors of traffic accidents:testing a contextual mediated model. Accid Anal Prev. 2003;35:949–964.

Sut N, Memis D. Intensive care cost and survival analyses of trau-matic brain injury. Ulus Travma Acil Cerrahi Derg. Mar 2008;16(2):149–154.

Dow

nloa

ded

by [

73.1

72.1

4.22

8] a

t 22:

09 3

0 Se

ptem

ber

2014

BURDEN OF ROAD TRAFFIC INJURIES IN TURKEY 75

SweRoad. Traffic Safety Project: Methods and Values for Appraisal ofTraffic Safety Improvements. Solna, Sweden: SweRoad; 2001.

Turkish Ministry of Health, National burden of disease and cost-effectiveness study report. Ankara, 2004.

Turkmen C, Yormaz E. Incidental detection of multiple abdominopelvicsplenosis sites during Tc-99m HMPAO-labeled leukocyte scintigra-phy. Clin Nucl Med. 2006;31(9):572–574.

TurkStat. Death Statistics. Ankara: Turkish Statistical Institute; 2008a.TurkStat. Traffic Accident Statistics Report. Ankara: Turkish Statistical

Institute; 2008b.Uzun N, Tanriverdi T, Savrun FK, et al. Traumatic peripheral nerve in-

juries: Demographic and electrophysiologic findings of 802 patientsfrom a developing country. Journal of Clinical Neuromuscular Dis-ease. 2006;7(3):97–103.

Wallen Warner H, Ozkan T, Lajunen T. Cross-cultural differences indrivers’ speed choice. Accid Anal Prev. Jul 2009;41(4):816–819.

World Bank. Country and Lending Groups. http://data.worldbank.org/about/country-classifications/country-and-lending-groups#Uppermiddle income. Accessed September 19, 2010.

World Health Organization. The Global Burden of Disease: 2004 Up-date. Geneva, Switzerland: World Health Organization; 2004.

World Health Organization. Global Status Report on Road Safety.Geneva, Switzerland: World Health Organization; 2009.

World Health Organization. Injuries and Violences the Facts. Geneva,Switzerland: World Health Organization; 2010.

Yagmur Y, Kiraz M, Kara I. Looking at trauma and deaths: DiyarbakirCity in Turkey. Injury. 1999;30(2):111–114.

Yasak Y, Durak Batigan A. The role of psychological self-report scalesin selection and evaluation of drivers. Anadolu Psikiyatri Dergisi.2010 11(3):235–241.

Yetiser S, Hidir Y, Birkent H, Satar B, Durmaz A. Traumatic ossiculardislocations: etiology and management. Am J Otolaryngol. Jan-Feb2008;29(1):31–36.

Yildirim Z, Lajunen T. Risky Driving during Ramadan: An Observa-tional StudyAnkara: Middle East Technical University; 2009:1–9.

Yilmaz V, Celik HE. A model for risky driving attitudesin turkey. Social Behavior and Personality. 2004;32(8):791–796.

Dow

nloa

ded

by [

73.1

72.1

4.22

8] a

t 22:

09 3

0 Se

ptem

ber

2014