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Original Article
14 (
4
); 629-636
doi:
10.25259/JNRP_145_2023

Untapped potential of commercial drivers in providing post-crash care to road traffic accident victims: A cross-sectional study from fast urbanizing city of Jodhpur, India

Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences Jodhpur, Jodhpur, Rajasthan, India
Department of Community Medicine, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India
Department of Medical Education, School of Medicine, University of Limerick, Limerick, Ireland
Corresponding author: Neeti Rustagi, Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences Jodhpur, Jodhpur, Rajasthan, India. drneetigoswami@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Rustagi N, Dileepan S, Mittal A, Solanki HK, Kelly D, Raghav P. Untapped potential of commercial drivers in providing post-crash care to road traffic accident victims: A cross-sectional study from fast urbanizing city of Jodhpur, India. J Neurosci Rural Pract 2023;14:629-36.

Abstract

Objectives:

Most road traffic accident (RTA) deaths occur before victim reaches a definitive trauma care facility. The aim of the study was to determine the role of commercial drivers toward providing post-crash care to RTA victims in Jodhpur, Rajasthan.

Materials and Methods:

This cross-sectional study assessed the role of commercial auto-rickshaw and cab drivers for providing post-crash care in urban Jodhpur during 2019–2020. Eligible participants volunteering for the study were included from taxi and auto stands in urban Jodhpur. A pre-tested questionnaire was administered by a trained interviewer. Data analysis was done using SPSS v23.0. Summary measures in terms of frequencies, means, and range are reported. Chi-square test, Fisher’s Exact test, and Multivariate Logistic Regression analysis were done for statistical associations.

Results:

Two hundred male participants completed the study with a mean age of 37.74 (8.96) years having an average work experience as commercial drivers of more than 10 years. Over 70% of participants witnessed RTA in the past year and 52% provided care to victims. The knowledge of post-crash care was most affected by their education level (adjusted odds ratio [aOR]: 1.778, 95% confidence interval [CI]: 0.958, 3.301), whereas the intended post-crash care practices were significantly better among participants with previous training (aOR: 15.376, 95% CI: 2.149, 110.017).

Conclusion:

The current study establishes the role of commercial drivers as first responders at accident sites in the fast urbanizing city of Jodhpur, Rajasthan. Systematic capacity building initiatives of commercial drivers to salvage RTA victims have potential to strengthen pre-hospital trauma care continuum in non-metro districts of India experiencing high burden of accidents.

Keywords

Commercial drivers
Road traffic accidents
Urbanization
Post-crash care
Continuum of care

Key Messages

  • Commercial drivers commonly witness and provide post-crash care to RTA victims irrespective of their poor understanding regarding it.

  • Capacity building of commercial drivers with supportive engagement of legal and health-care authorities is warranted for their effective contribution as first responders at an accident site.

INTRODUCTION

Road traffic accidents (RTAs) kill approximately 1.2 million people worldwide annually.[1] The majority of trauma deaths in low- and middle-income countries occur in pre-hospital period, of which a third may be preventable with treatment typically aimed at airway preservation, promoting oxygenation, and rapid transfer to hospital.[2]

The World Health Organization recommends training of lay people in providing pre-hospital care for RTAs.[3] Systematic review found training of bystanders including commercial drivers is feasible and may reduce mortality rates.[4,5] Studies describing training interventions were mainly reported from African countries, often in urban settings with the recommendation that training be targeted at taxi drivers.[4] In India, though some local training initiatives are previously reported for commercial drivers, there is no national level strategy.[6-8]

This study aims to determine the role of professional drivers as post-crash care providers for RTA victims in fast urbanizing Jodhpur district of Rajasthan and to assess their knowledge and practices in this regard.

MATERIALS AND METHODS

Study design and study area

This cross-sectional study among commercial auto-rickshaw (three-wheeler) and cab drivers in urban Jodhpur, Rajasthan was conducted during the year 2019–2020. The drivers were reached out on different highway and state roads within the boundary of Jodhpur Municipal Co-operation considered urban Jodhpur [Figure 1].

Study participants

Drivers of age more than 18 years, driving commercial cabs and auto rickshaws, in and from Jodhpur through the designated stands for at least past 6 months were included.

Sample size

The required sample size was calculated to be 97 using the predicted prevalence of first aid knowledge among drivers at 50%, precision at 10%, and confidence level at 95%.[9] Using design effect of 1.5 and assuming 20% nonresponse rate, the final sample size of 176 participants was obtained. As per stratified sampling, it was decided to include at least 88 cab and auto-rickshaw drivers each for the study purpose.

Sampling technique

Investigator approached the taxi and auto stands for the inclusion of the study participants. The drivers who volunteered for the study were included one after another till the required sample size was reached [Figure 1]. The time given for data collection was 2 h/day, 5 days a week. Interviewing no more than 10–12 drivers in a single day was the predetermined cap.

Figure 1:
Density of three-wheeler and four-wheeler passenger vehicles in the Jodhpur city, Rajasthan.

Data collection

Recruitment of participants and administration of questionnaire were done during July to September 2019 at all the possible driver posts which were located in the area of high road-crash density as identified by data on RTAs. Identified stops were visited between 10.00 h and 17:00 h on 5 days of the week. Enough distance from other drivers was maintained during the administration of survey to ensure the privacy of the respondents.

The use of Geographic Information System (GIS) mapping was done to study the geographic dispersion of commercial drivers and road accident hotspots in the past 2 years as per Jodhpur traffic Commissioner ate records. Furthermore, GIS maps were made for the presence of health facilities and ambulance locations in Jodhpur city.

A trained interviewer administered pre-tested questionnaire in local language Hindi for data collection. The questionnaire explored sociodemographic details, experience of motor vehicle crashes, providing assistance to victims of crash in past, type of the assistance, and knowledge, attitude, and behavioral practices toward providing care to road traffic crash victim.

Following operational definitions were used in the study: [6]

Commercial driver

A person who drives a commercial four wheeler taxi or auto rickshaw (three wheeler) on a regular basis (defined as at least 4 days in a week) for at least 6 months preceding the data collection.

Post-crash care

All kind of helping behavior (includes making call to police, ambulance, or family members of the victim; and transporting the RTA victim to the health facility or police post) and initial care provided for an RTA injury to the victim.

RTA

Any injury due to crashes originating from the collision of vehicles with other vehicles, pedestrians, or any other stationary obstacles. For inclusion as RTA in our study, at least one of the vehicles should have been in motion at the time of the crash.

For assessing the knowledge and intended practices of the participants, the questionnaire consisted of road accident scenarios with related questions [Appendix 1]. The responses to practice questions were considered along with knowledge questions to strengthen the internal validity of questionnaire to validate participants intended practices at the site of accident in the background of knowledge they have regarding managing such scenarios.

Statistical analysis

Data were analyzed using IBM SPSS Statistics (Version 23). Background characteristics and post-crash care knowledge and practices score were separately analyzed for auto-rickshaw and cab drivers. The variables were analyzed using descriptive statistics to calculate frequencies, mean, range, etc. The predictors of knowledge of post-crash care and intended practices were determined with the help of bivariate statistical tests and multivariate logistic regression. Knowledge scores were changed to dichotomous variable using median score, and intended practice was classified as better practice if all three assessed intended practices were present. All tests were applied at 95% confidence level.

Ethical consideration

The study was conducted following approval of Institutional Ethical Committee (AIIMS/IEC/2018/1188, dated 02.05.2018). Informed written consent was obtained from all the participants before administering the questionnaire. Confidentiality of data and anonymity of participant was ensured in the study.

RESULTS

A total of 200 professional drivers (100 each auto and cab drivers) were interviewed for the study. GIS map shows that the auto-rickshaw and cab driver waiting posts are overlapping with accident hotspots as per traffic police records of the past 2 years [Figures 1 and 2a]. Widespread presence of health facilities and ambulance can be appreciated in same geographic area [Figure 2b].

Figure 2:
(a) Accident hotspots areas in the Jodhpur city (blue dots). (b) Health facilities (red signs) and ambulance location in urban Jodhpur.

All the drivers were male participants; their mean age was 37.74 ± 8.96 year and ranged between 18 and 68 years. The majority (65.0%) of participants had education of at least 8th standard or more. Out of 200 participants, only few (3.5%) reported attending a training course on post-crash care of accident victims. The majority of the participants were sufficiently experienced – working for more than 10 years as drivers. Mean age and professional work experience were significantly higher among cab drivers (P < 0.05).

Exposure and involvement in crashes

Significantly higher number of auto-rickshaw drivers reported witnessing any road accident (88.0%), providing care to RTA victim ever (93.7%) or in the past 1 year (77%). About one-fifth (21.0%) of auto-rickshaw drivers reported providing care to road accident victims for more than 5 times. Significantly higher proportion of auto-rickshaw drivers reportedly experienced problems while providing post-crash care as compared to cab drivers (P < 0.05). Poor cooperation by police personnel/hospital staff/ambulance personnel was the most common issue reported by auto-rickshaw drivers [Table 1].

Table 1: Characteristics of the study participants: (n=200).
Sociodemographic and driver characteristics Auto-rickshaw driver (n=100) Cab driver (n=100) P-value
Education (years of education)
    >8 68 62 0.374
    <8 32 38
Age in years (Mean±SD) 36±6.9 39.4±10.4 0.006*
Professional experience as driver in years (Mean±SD) 12.01±6.8 16.5±8.3 0.001*
Ever trained in managing RTA victims 2 5 0.248
Ever acted as care provider for any RTA victims
    Yes 93 55 <0.001*
    No 7 45
Frequency of ever acting as care provider for RTA victims
    1–2 times 34 26 <0.001*
    3–4 times 38 20
    ≥5 times 21 09
    Never 07 45
Witnessed any RTA in past 1 year 88 53 <0.001*
Acted as care provider for any RTA victims in past 1 year 77 27 <0.001*
Problems experienced while helping RTA victim
    No problem faced 49 36 0.055a
    Problem faced 14 03
    By relatives or family members of victim 01 01
    Issues with bystanders 02 00
    Issues with police/hospital staff/ambulance personnel 11 02
    No response 37 61
Significant at 95% CI, aChi-square test is applied between type of vehicle driven and problem faced/no problem faced. Types of problems and no responses are not included in analysis. RTA: Road traffic accident, SD: Standard deviation

A total of 103 (51.5%) drivers responded regarding the nature of care given to RTA victims. The most participants reported victim’s transportation to healthcare facility or arranging transport for them and providing care (48.0%) to injured victims. One third of participants (33.3%) did not get involved in providing care to crash victims because of the fear of causing inconvenience to the passengers riding in their vehicles.

Attitude toward providing post-crash care

All participants reported a positive attitude toward providing primary care to accident victims, role of bystanders in providing primary care, and their own readiness in providing primary care. All except one cab driver agreed that post-crash primary care would increase the probability of survival of victim.

Post-crash care knowledge

Majority of drivers (65.5%) correctly determined victim to be prioritized at the scene of accident. Only a few participants (3.0%) were aware of recovery position/lying on side as preferred position for RTA victim. No significant difference was present among auto-rickshaw and cab drivers’ post-crash care knowledge and practices except for correctly determining priority victim and ensuring personal safety while providing post-crash care. Only one participant (1 cab driver) was able to convey chin lift and jaw thrust maneuver for relieving airway in case of suspected airway obstruction [Table 2].

Table 2: Distribution of study participants for knowledge and intended behaviors about post-crash care administered to RTA victim (n=200).
Knowledge and intended behavior Auto-rickshaw driver (n=100) Cab driver (n=100) Total (n=200) P-value
OR
(95% CI)
Knowledge of post-crash care of victims
    At accident site, priority should be given to victim with bleeding heavily 73 58 131 0.026*
1.96
(1.08, 3.55)
    Chin lift and head tilt should be performed to open obstructed airway of the victim 0 1 1 -
    Laying on the side is a recommended position for RTA victim at the scene 02 04 06 0.683
0.49
(0.09, 2.74)
    Effective way to manage bleeding in RTA victim is applying direct pressure to the wound 33 30 63 0.683
1.15
(0.63, 2.09)
    Initial care for suspected fracture is to immobilize fracture by applying splint 40 48 88 0.254
0.72
(0.41, 1.27)
Intended behaviors in providing post-crash care to victims
    Prevention of cross infection#
    (Use of glove/plastic or cloth/disinfection)
93 78 171 0.004*
3.75
(1.52, 9.24)
    Initial care of bone fracture
    (Applying traction/splinting)
2 12 14 0.015
0.15
(0.03, 0.69)
    Managing blood loss from fracture
    (Tying cloth or bandage)
92 86 178 0.180
1.87
(0.75, 4.68)
Significant at 95% CI, #Use of cloth or plastic for covering their hands/use of gloves/use of disinfectant for cleaning hands. RTA: Road traffic accident, CI: Confidence interval, OR: Odds ratio

Intended behavior for post-crash victim care

For cross-infection prevention practices during post-crash care of victim, the majority of participants reported the use of cloth or plastic for covering their hands (63.5%), followed by use of gloves (16.0%) and the use of disinfectant for cleaning hands (6.0%), whereas 7.0% participants prioritized shifting of accident victims to hospital over infection prevention and 7.5% drivers did not respond. The initial care of fractured bone was not reported by 45.0% of the participants. About one-fourth of the participants (24.0%) reported moving victim or limb to check condition, 7.5% reported the use of cloth or bandage for tying limb, and 16.5% prioritized shifting to hospital. Only 5.5% of participants reported using traction and 1.5% conveyed splinting of fractured bone. The majority (89.0%) of participants intended to use cloth or bandage for managing blood loss from fractured limb, 1.5% prioritized hospitalization, 2% intended to put ash on wound and bandage, and 7.5% did not know or respond.

Education level of drivers predicted knowledge scores which was near significant (adjusted odds ratio [aOR]: 1.778; 95% confidence interval [CI]: 0.958, 3.301; P = 0.068), while intended practices were significantly acceptable among drivers reporting previous training related to post-crash care of accident victims (aOR: 15.376; 95% CI: 2.149, 110.017; P = 0.006) [Table 3].

Table 3: Predictors of knowledge and intended post-crash care practices among the study participants (n=200).
Predictor variable High knowledge scorea Better Intended practiceb
aOR (95% CI) P-value aOR (95% CI) P-value
Education 8 standard 1.778 (0.958, 3.301) 0.068 0.391 (0.095, 1.615) 0.194
Work experience>10 years 0.946 (0.517, 1.731) 0.856 1.043 (0.216, 5.030) 0.958
Ever witnessed accident 1.230 (0.552, 2.742) 0.612 0.105 (0.007, 1.573) 0.103
Helped accident victim in past year 0.634 (0.287, 1.401) 0.260 8.452 (0.495, 144.450) 0.141
Type of vehicle: auto-rickshaw driver 0.666 (0.341, 1.302) 0.235 4.819 (0.726, 32.002) 0.104
Ever trained in post-crash care of victim 0.168 (0.019, 1.465) 0.106 15.376 (2.149, 110.017) 0.006*
Knowledge score more than median - - 1.065 (0.249, 4.556) 0.933

aHigh knowledge score is a score more than median knowledge score of 1, bBetter intended practice is defined as presence of all 3 practices (infection control, fracture management and managing blood loss from fracture). *Significant at 95% CI. CI: Confidence interval, aOR: Adjusted odds ratio

DISCUSSION

All respondents in our study were male, which is consistent with our observations of taxi drivers throughout Rajasthan. The wide range of respondents’ age (18–60 years) supports the findings not being limited to a specific age group.

Our study revealed that only a few drivers (3.5%) have ever received any training in providing first aid and knowledge of providing post-crash care to RTA victims was limited in most. Further, the majority of drivers had witnessed (70.5%) road accidents during their professional experience. This is substantial proportion to emphasize the importance of training among commercial drivers in Jodhpur and other fast urbanizing districts of India. Furthermore, reporting of involvement in support to crash victims supports the hypothesis of commercial cab and auto-rickshaw drivers being of assistance to injured RTA victims.

A large number of auto-rickshaw drivers reported contributing as care providers to RTA victims, but ironically, the post-crash care knowledge and practices score for majority of the components was significantly lower among them. Auto-rickshaw drivers are mainly confined to premises of urban municipal cooperation for providing their services in contrast to cab-drivers who provide services both in and outside of urban Jodhpur. Thus, the auto-rickshaw drivers generally travel familiar routes compared to cab drivers who are required to travel long distances and frequently unfamiliar routes. This is an essential area to intervene as auto-rickshaw drivers possibly has a good understanding of health-care facilities in the city limits and may own up the responsibility of providing care to road accident victims in their vicinity in contrast to cab drivers who provide services both in and outside of urban Jodhpur probably resulting in low familiarity regarding health-care facilities in area. Poor scores among auto-rickshaw drivers highlights the neglect of road safety agencies recognizing their role as effective post-crash care providers which needs to be investigated further in future studies from India. To our knowledge, previously no other studies have exclusively investigated the role of auto-rickshaw drivers in scenarios of RTAs.

Shotland and Heinold discussed the type of bystander’s response at the site of accident and reported that indirect help responses (calling for help or an ambulance) were more frequent among untrained bystanders while trained bystanders responded with prescribed method of responses in a simulated situation of arterial bleeding.[10] Our study provides the essential evidence for investing resources in training commercial drivers, especially auto-rickshaw drivers to administer post-crash care in urban areas. Workplaces were previously recognized as most common place of first aid training by Bakke et al.[11] In India, training of commercial drivers especially auto-rickshaw drivers must be coupled with the engagement of legal authority/health facilities/ ambulance personnel and employers of commercial drivers as emphasized by Sangowawa and Owoaje.[12]

Besides, integration of first aid training in schools is previously emphasized and evidence exists that children and adolescents from 5 to 18-years-old are able to learn certain first aid techniques.[13] Mean years of education of commercial drivers in our study is 8 years and drivers with education of 8 years and more years of education had higher scores for post-crash care related knowledge, also observed previously.[14] Implementation of first aid training program in schools in low- and middle-income countries encountering high burden of accidents and injuries can ensure community engagement and maximize participation in providing post-crash care. Further increasing the minimum level of education required for obtaining driver’s permit and strictly enforcing it can help in having cohort of commercial drivers with better knowledge of post-crash care.

The intended practices/behaviors of drivers were found to be significantly affected by the previous training in these skills. This emphasizes the importance of training in post-crash care to have enabled first responders. The implementation of training programs has shown to be tricky due to variable literacy, variability in the availability of first aid supplies, role played by legal authorities (police), and bystanders. Further, these programs are operational in only some districts with most commercial drivers on national level being still untrained.[15,16]

Our study has several limitations such as limited generalizability as all the study participants were representative of single district selected through purposive sampling. Considering the different geographic location s and route s ferried upon by cab and auto drivers, the use of disproportionate sampling in our study led to satisfactory representation of both subgroups. Keeping precision as 10% rather than convention 5% was decided considering the exploratory nature of research, only few published studies in this area from India, and feasibility to reach out required number of study participants. The potential for social desirability bias was reduced by assuring the anonymity of respondents and the administration of questionnaire to individual drivers keeping enough distance from other drivers. The study results might be influenced by self-selection bias as drivers with a strong interest in post-crash care may have been more likely to understand the importance of topic and show interest in being part of this study.

Further studies in India are required to explore the implantation of training in first aid care for commercial drivers. Furthermore, the diffusion of knowledge among drivers from those who ever got trained in first-aid or helped an accident victim is possible and must be explored.

CONCLUSION

The current study establishes the role of commercial drivers as first responder s at accident sites in fast urbanizing city of Jodhpur, Rajasthan. Bridging the existing gaps by investing resources in their training and building an enabling environment by engaging legal and health authorities to salvage RTA victims has potential to strengthen pre-hospital trauma care continuum.

Declaration of patient consent

The authors certify that they have obtained all appropriate consent.

Conflicts of interest

There are no conflicts of interest.

Financial support and sponsorship

ICMR funded (2016–0274).

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Appendix 1: Knowledge, practice, and attitude questions for drivers.

Knowledge towards post-crash care:

Q1. After the accident priority should be given to the

  1. Victim with breathing problems

  2. Victim who is bleeding heavily

  3. Victim with a fracture

  4. Confused victim

Q2. What will you do to open an obstructed airway of the victim

  1. Uncover the victim by removing clothes especially around the chest.

  2. Depopulate the area so the victim can get fresh air

  3. Perform chin lift and head tilt

  4. Fan the patient to increase ventilation.

Q3. Which one is a recommended position for RTA victim at the scene?

  1. Laying on the back

  2. Laying on the stomach

  3. Laying on the side

  4. Upright position.

Q4. The best and effective way to manage bleeding in RTA victim is by:

  1. Put some salt to the wound

  2. Apply ice directly to the wound

  3. Apply direct pressure to the wound

  4. Cover the wound with gauze.

Q5. What initial care you will provide to RTA victim with suspected fracture?

  1. Immobilize fractured bone by applying splint (tying to a rigid object like wooden board, cardboard etc.)

  2. Push the bone back in place

  3. Tie the bone tightly together

  4. Stretch/pull the bone to align.

Intended Practice in post-crash care:

Scenario: A car hit a motorcycle which was crossing the road. The motorcyclist was thrown several meters away from the road into a ditch. Meanwhile the car lost balance and crashed into the light pole but the driver managed to escape. Assume you’re the only person at the scene with the victim who is unresponsive and bleeding profusely from a fractured left leg. From the given scenario: Please write your response in space given in questions 6–8

Q6. How would you prevent cross infection during the process of helping the victim?

..................................................................................................

........................................................................................

Q7. How would stop bleeding from a fractured leg of the victim?

..................................................................................................

........................................................................................

Q8. How would you initially care for a fractured leg?

.................................................................................................. ........................................................................................

Attitude toward post-crash care

Q9. I am of this belief that it is my responsibility to provide primary care to post-crash victim.

Disagree (1) (2) (3) (4) (5) (6) (7) Strongly Agree

Q10. I am of this belief that post-crash victim should be immediately provided primary care by bystanders.

Disagree (1) (2) (3) (4) (5) (6) (7) Strongly Agree

Q11. I am ready to provide primary care to post-crash victim.

Disagree (1) (2) (3) (4) (5) (6) (7) Strongly Agree

Q12. I am of this belief that post-crash victim’s probability of surviving will increase by providing primary care.

Disagree (1) (2) (3) (4) (5) (6) (7) Strongly Agree

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