Disability related to road traffic crashes among adults in Spain

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Monography

Disability related to road traffic crashes among adults in Spain

Rocío Palmera-Suárez

^a,c,∗

, Teresa López-Cuadrado

^a,d

, Javier Almazán-Isla

^b

, Rafael Fernández-Cuenca

^a,c

, Enrique Alcalde-Cabero

^b

, I ˜naki Galán

^b,d

aAreaofepidemiologicalanalysisandhealthsituation,NationalCentreforEpidemiology,InstitutodeSaludCarlosIII,Madrid,Spain

bAreaofappliedepidemiology,NationalCentreforEpidemiology,InstitutodeSaludCarlosIII,Madrid,Spain

cResearchCentreNetworkforEpidemiologyandPublicHealth(CIBERESP),NationalCentreforEpidemiology,InstitutodeSaludCarlosIIIMadrid,Spain

dDepartmentofPreventiveMedicineandPublicHealth,SchoolofMedicine,UniversidadAutónomadeMadrid/IdiPAZ,Madrid,Spain

a r t i c l e i n f o

Articlehistory:

Received4August2014 Accepted19January2015 Availableonline2September2015

Keywords:

Disabilityevaluation TrafficAccidents Injuries Inequalities Socioeconomicfactors

a b s t r a c t

Background: Roadtrafficaccidentscausesubstantialmorbidityanddiseaseburden;fewstudieshave examinedtheirimpactondisability.

Objective:Toestimatethemagnitudeanddistributionofdisabilityduetoroadtrafficaccidentsaccording tosocio-demographicvariables,anditsmainsocioeconomicandhealthdeterminants.

Methods:Across-sectionalstudywasconductedincommunity-dwellingparticipantsinthe“2008Span- ishNationalDisabilitySurvey”,arepresentativesampleof91,846householdswith20,425disabled personsolderthan15years;443haddisabilityduetoroadtrafficaccidents.

Results: Theprevalencewas2.1per1000inhabitants(95%CI:1.8-2.3),withnodifferencesbysex.Risk washighestamongpersonsaged31to64years,andonsetofdisabilityshowedasharpinflectionpoint atage16yearsinbothsexes.Oddsratios(ORs)werehigher(OR=1.3;95%CI:1.1-1.7)forparticipants withsecondaryeducationthanforthosewiththelowesteducationallevelsandwerelower(OR:0.5;

95%CI:0.3-0.8)forparticipantswiththehighesthouseholdincomelevelsthanforthosewithlowest.Only 24%ofdisabledparticipantsweregainfullyemployed.Ascomparedtoothersourcesofdisability,traffic crashescausedgreaterdisabilityintermsofmobility(OR=3.1;p<0.001),agreaterneedforhealth/social services(OR=1.5;p=0.003),andmoreproblemswithprivatetransportation(OR=1.6;p<0.001),moving aroundoutsidethehome(OR=1.6;p<0.001)andchangesineconomicactivity(OR=2.4;p<0.001).

Conclusions: TheprevalenceofdisabilityduetoroadtrafficaccidentsinSpainislowerthaninother developedcountries,withmiddle-agedandsocio-economicallyunderprivilegedpersonsbeingthemost affected.Disabilityduetoroadtrafficaccidentsisrelatedtoagreaterdemandforsocial/healthcare support,problemsofaccessibility/commuting,andmajorchangesineconomicactivity.

Discapacidadporaccidentesdetráficoenlapoblacionadultaespa ˜nola

Palabrasclave:

EvaluacióndelaDiscapacidad Accidentesdetráfico Lesionesexternas Inequidades

Factoressocio-económicos

r e s um e n

Antecedentes:Losaccidentesdetráficocausanimportantemorbilidadycargadeenfermedad;suimpacto sobreladiscapacidadhasidopocoestudiado.

Objetivo:Estimarlamagnitudydistribucióndeladiscapacidadporaccidentesdetráficosegúnvariables socio-demográficas,ysusprincipalescondicionantessocio-sanitariosyeconómicos.

Métodos: EstudiotransversalenparticipantesdelaEncuestaNacionaldeDiscapacidad,Autonomía Personal y Situaciones de Dependencia 2008; muestra representativa de 91.846 hogares con 20,425discapacitadosmayoresde15a ˜nos,443causadosporaccidentesdetráfico.

Resultados:Laprevalenciafuede2,1por1000(IC95%:1,8-2,3),sindiferenciasporsexoymayorriesgo entre31-64a ˜nos.Ladiscapacidadtuvoinicioabruptoalos16a ˜nos(ambossexos).Aquellosconeducación secundariatuvieronunmayoroddsratioOR(OR=1,3;IC95%:1,1-1,7)queaquellosconmenornivel educativo;losdiscapacitadosconmayoresingresostuvieronmenorOR(OR=0,5;IC95%:0,3-0,8)que aquellosconingresosmásbajos.Sóloun24%teníanempleoremunerado.Comparadoconotrascausas dediscapacidad,losaccidentedetráficogeneraronmayordiscapacidadenmovilidad(OR=3,1;p<0,001)

∗ Correspondingauthorat:Areaofepidemiologicalanalysisandhealthsituation,NationalCentreforEpidemiology.InstitutodeSaludCarlosIII.CalleMonfortedeLemos, 5Pabellón12,PC28029Madrid,Spain,Tel.:+34918149706/652375155;fax:+34913877815/16.

E-mailaddresses:prociodel[email protected],[email protected](R.Palmera-Suárez).

http://dx.doi.org/10.1016/j.gaceta.2015.01.009

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ynecesidaddeasistenciasocio-sanitaria(OR=1,5;p=0,003);mayoresproblemasconeltransportepri- vado(OR=1,6;p<0,001),losdesplazamientosfueradecasa(OR=1,6;p<0,001)ycambiosenlaactividad económica(OR=2,4;p<0,001).

Conclusiones: LaprevalenciaenEspa ˜naesbajacomparadaconotrospaísesdesarrollados.Lapoblación demedianaedadycondesventajassocio-económicasfuelamásafectada.Ladiscapacidadportráfico serelacionaconmayordemandadeserviciossocio-sanitarios,problemasdeaccesibilidadymovilidade importantescambiosenlaactividadeconómica.

Introduction

Injuries caused by road traffic crashes (RTCs) have a major impactonmorbidity,mortalityandprematuredisability.Accord- ingtotheWorldHealthOrganisation(WHO),everyyearthereare over1.2milliondeathsduetothiscausearoundtheworld,20to 50millionpersonssustaininjuries,andmorethan5millionremain disabledforlife.¹RTCscausedisabilityintheshortandlongterm, arethe9^thleadingcauseintheworldofdisability-adjustedlife years(DALYs)andgenerate41.2millionyearsofhealthylifelost, thusaccountingfor2.7%ofthetotalworldwide.^2–5Itisestimated that there are 3.8 milliondisabled persons in Spain. Accidents arethe3^rdleadingcauseofdisabilityandaccountfor9%ofalldis- ability;withinthiscategory,RTCsranksecondafteroccupational accidents.⁶

Despite the appreciable reduction in traffic accident figures observedinthiscountryfrom2000onwards,⁷theresultinginjuries continue generating a substantial disease burden, witha great impactonthecountry’ssocialandeconomicspheres.RTCsgen- erate prematuremortality,⁸ continue tobethe leadingspecific causeofdeathinthe15-34yearagegroup,andaretheleading (inmen)and2^ndleadingcause(inwomen)ofyearsofpotentiallife lost.⁹

OninvestigatingtheeffectsonRTC-injuryvictims,analysisof disabilitycanprovideacomplementaryviewofthiseventandfur- nishthenecessaryinformationforthepreventionandcontrolof RTCs,andsominimisetheriskofprematuredeath,disabilityand sequelae.Roadtrafficdisability(RTD)isanimportantindicatorof theseverityofsuchaccidents,andallowsforassessmentofrelated temporaryorpermanentdisability,lossofautonomy,individual developmentdisorders,familyinvolvementandtheensuingsocial burden.¹⁰

Theaimofthisstudywasthustoprovideafirst-everestimate of themagnitude and distributionof disability caused by RTCs inSpain,and todescribetheRTC-disabled populationby refer- encetobasicsocio-demographicvariables,aswellasthetypesof RTC-relateddisabilityandtheirmainsocio-economicandhealth profiles.

Methods

Studydesignandpopulation

A cross-sectional study was conducted among community- dwellingparticipantsofthe“2008Nationalsurveyofdisability, personal autonomyand situations ofdependency”(EDAD2008).

The survey covered all regions of Spain from November 2007 toFebruary2008, targetingallpersons residingin main family dwellings.¹¹

TheEDAD2008wasbasedonatwo-stage,stratifiedsampling design, withthefirst-stage unitsbeingcensussectionsandthe second-stageunitsbeingmainfamilydwellings.Asamplesizeof 96,075householdswasestablished.Responsewasobtainedfrom 91,846households(overallresponserateof97%),¹²yieldingdata

on213626subjects,including20,425disabledpersonsoverthe ageof15years,443ofwhomhaddisabilityduetotrafficcrashes.

Thedata-collectionmethodusedwasthepersonalinterview.¹¹

Studyvariables

TheEDAD2008partlyfollowstheconceptualframeworkofthe InternationalClassificationofFunctioning,Disability andHealth (ICF),¹³accordingtowhichdisabilityisdefinedas,“asetoflim- itationsonactivitiesofdailylivingandparticipationrestrictions (handicaps),whichhavelastedorareenvisagedtolastformore than oneyear and havetheirorigin insome impairment,even thoughtheymayhavebeenovercomewiththeuseofexternal technical aids or with the aid or supervision of another per- son.“Forstudypurposes,RTDwasdefinedas,“anytypedisability caused by a road traffic accident”, and analysed using thefol- lowingindependentvariables:sex;age(fourgroups);educational level (no formal education/primary; secondary/intermediate;

higher/university); marital status (single; married; widowed;

divorced/separated);nationality(Spanish;foreign/dual);occupa- tion (employed; unemployed; receiving any type of pension;

unfit for work; other non-remunerated activity); net monthly household income (<D500; D500-<D1,500; D1,500-<D3,000;

>=D3,000); type of disability (vision; hearing; communication;

learning, application of knowledge and performance of tasks;

mobility; self-care; domestic life; interpersonal interactions/

relationships);ageatdisabilityonset(exactage);healthandsocial conditions(healthstatus;needofconsultation/health/socialservices;type of helpreceived; financialbenefit orcompensation;

problemswithtransport andcommuting); economicconditions (primaryhouseholdearner;changeineconomicactivity;reasonfor leavingwork;expenditureintheprecedingyear;andmainitems ofexpenditure).

Statisticalanalysis

We calculated the crude prevalence and its 95% confidence interval(CI),usingthetotalnumberofpersonssurveyedoverthe ageof15years(n=213626)asthereferencepopulation.Thedistri- butionaccordingtosocio-demographicvariableswassummarised withoddsratios(ORs)obtainedfromlogisticregressionmodels, controllingforallsocio-demographicvariablessimultaneously.We calculatedtheproportionoftherespectivetypesofdisabilityand themainhealth,social andeconomicconditions intwogroups, i.e., RTDand othercausesof disability(OCD). Differences were adjusted forsex, agegroupand educationallevel usinglogistic regression,withstatisticalsignificance beingsetatp<0.05.The complexsamplingdesignwasconsideredduringanalysis,which accountsforweighting,clustering,andstratification,byusingthe

“SurveyData”moduleoftheStatav.12.0forWindowscomputer softwareprogramme (StataCorp.2011.StataStatisticalSoftware:

Release12.CollegeStation,TX:StataCorpLP).Standarderrorswere computedbyusingthelinearizedvarianceestimatorbasedona first-order Taylorseries.First-orderinteractionswereevaluated betweensexandotherssociodemographicvariables.

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Table1

Disabilitybyroadtrafficcrashesaccordingtosocio-demographicvariablesamong individualsaged16andover.Spain,2008.

n Prevalence/1000 AdjustedOR^a

(95%CI) (95%CI)

Total 443 2.1(1.8-2.3)

Sex

Men 239 2.3(2.0-2.7) Ref

Women 204 1.9(1.6-2.2) 0.9(0.8-1.2)

Agegroups

16to30ages 44 0.8(0.6-1.3) Ref

31to45ages 129 2.0(1.6-2.6) 2.8(1.7-4.6) 46to64ages 167 2.9(2.4-3.4) 2.1(1.2-3.7)

≥65ages 103 2.5(2.0-3.0) 0.6(0.3-1.1) Educationallevel

Notstudy/primarystudy 230 2.6(2.3-3.0) Ref Sec-

ondary/bachelor/Intermediate vocational

166 2.1(1.7-2.6) 1.3(1.1-1.7)

Higher

vocational/University

47 1.0(0.7-1.4) 0.8(0.5-1.1)

Maritalstatus

Single 144 2.0(1.7-2.5) Ref

Married 214 1.8(1.5-2.2) 0.6(0.5-0.8)

Widowed 46 2.8(2.1-3.8) 0.5(0.3-0.8)

Divorced/Separated 39 4.3(3.1-6.0) 1.1(0.7-1.7) Nationality

Spanish 419 2.2(1.9-2.4) Ref

Foreign/Dualnationality 24 1.3(0.5-2.9) 0.8(0.4-1.9) Occupationinprecedingweek

Gainfullyemployed 106 0.9(0.7-1.2) Ref Unemployed 30 2.2(1.4–3.4) 2.0(1.1-3.5) Receivingpensionsby

retirement,permanently disabilityandothers

240 5.5(4.7-6.3) 12.7(8.6-18.7)

Unfitforwork(without anytypeofpension)

22 19.8(12.5–31.2) 19.5(11.3-33.7)

Othernon-remunerated activities

45 1.1(0.7-1.5) 1.5(1.0-2.4)

Netmonthlyhouseholdincome

UnderD500 41 5.6(4.0-7.9) Ref

D500to<D1,500 237 2.9(2.4-3.4) 0.7(0.5-1.1) D1,500to<D3,000 114 1.4(1.2-1.7) 0.5(0.3-0.8)

≥D3,001 26 1.3(0.8-2.2) 0.6(0.3-1.1)

Noanswer/No information

25 1.0(0.6-1.7) 0.3(0.2-0.7)

a:Oddsratiossimultaneouslyadjustedbyallvariablesofthetable

Results

In2008,theprevalenceofRTDinSpainwas2.1per1000inhabi- tants;injurieswerethefourthcauseofdisabilityandwithinthese, trafficaccidentsrankedsecond.

Table1showsthedistributionofRTDbysocio-demographic variables.Incomparisonwithpersonsaged16to30years,theodds ratio(OR)ofhavingRTDwashigherinthe31-64yearagegroupand particularlyamongthoseaged31to45years,withanORof2.8(95%

CI:1.7-4.6).Therewerenostatisticallysignificantdifferencesbysex ornationality.SubjectswithasecondaryeducationhadahigherOR thandidthosewithaprimaryeducationorlower(OR=1.3;95%CI:

1.1-1.7);andmarried(OR=0.6;95%CI:0.5-0.8)andwidowedper- sons(OR=0.5;95%CI:0.3-0.8)hadasignificantlylowerORthandid singletons.Nevertheless,therewasaninteractionbetweensexand maritalstatusstatisticallysignificant:thecomparisonofmarried menversussingleshowedanORof0.4(CI:0.2-0.5)whilewomen hadanORof1.7(1.4-2.8).Abreakdownbyoccupationshowedthat personswithRTDweremorelikelytobe“unfitforwork,without anytypeofallowance”(OR=19.5;95%CI:11.3-33.7)or“receiv- ingdifferenttypesofpensions”(OR=12.7;95%CI:8.6-18.7);only 24%weregainfullyemployed.Personswithhouseholdincomesof

D1,500to<D3,000permonthhadanOR=0.5(95%CI:0.3-0.8) ascomparedtothosewithmonthlyfamilyincomesbelowD500.

Apartfromsexandmaritalstatuswedidnotfindotherstatisti- callysignificantinteractionsbetweensexandsociodemographic variables.

Figure1depictsageatdisabilityonset.Sevenoutoftenper- sonsaffectedbyRTDreportedonsetofdisabilitybeforetheageof 45years.Thedisabilityonsetcurveshowedaninflectionpointat age16yearsinbothsexes,withonsetofdisabilityoccurringbefore theageof28 years inhalfofallmenand beforetheageof40 yearsinwomen.Thisdifferenceofapproximately10yearsinRTD onsetbetweenmenandwomenremainedinevidenceuptoage 65years.

Table2describesthetypeofdisability.Mobility,domesticlife andself-carewerethemostfrequenttypesofdisabilityinalldis- abled persons,andweresignificantlyhigher inthecase ofRTD regardingtoothercausesofdisability(mobilityOR=3.1;p<0.001;

domesticlifeOR=1.8;p<0.001;self-careOR=1.3;p=0.046).Hear- ing(p<0.001),communication(p<0.040),learning(p<0.005)and interaction/interpersonal relationship(p<0.008) disability,were meaningfullylowerintheRTD-persons.

Table 3 shows health and social conditions withrespect to disability.Although68.8%ofRTD-sufferersperceivedtheirhealth statusasfairorpoor,thispercentagewasnotsignificantincompar- isonwiththeOCDcategory.SubjectswithRTDhadagreaterneedof health/socialservices(OR=1.5;p=0.003),requiredmoretechnical aids(OR=1.4;p=0.014),andexperiencedmoreproblemswithpri- vatetransportation(OR=1.6;p<0.001)andmovingaroundoutside thehome(OR=1.6;p<0.001).

Intermsofeconomicconditions(Table4),closeon50%ofall disabledpersonsweretheprimaryhouseholdearners,withnodif- ferencebetweentheRTDandOCDcategories.RTDcausedmajor changes in economic activitydue totheonset or worseningof disabilityamongpersonswhoweregainfullyemployed(OR=2.4;

p<0.001).Healthreasonswerethemostfrequentcauseforleav- ing work;disability-related earlyretirementwashigheramong personsintheRTDthanamongthose intheOCDcategory,but thisdifferencewasnotsignificant.Nodifferenceswereobserved intermsofdisability-relatedexpenditureandthemainitemsto whichsuchexpenditurewasallocated.

Discussion

InSpain,RTCsgeneratetwodisabledpersonsper1,000pop- ulation over theage of15 years. Thisprevalencerate is lower whencomparedtodatapublishedbyotherdevelopedcountries

10,14–16buthigherinrelationtorecentChinesestudies,^17,18despite thefactthatsuchinformationdisplaysimportantdifferencesin methods,data-sourcesandtypeofpopulationanalysed.Thislower prevalencecouldberelatedtothedecreaseinRTCswithvictims, andtheensuingdecreaseinseriousinjuries(-43%)intheperiod 1998-2007.^7,9

Although statistics and previously published studies agree on the fact that the greatest number of road accident- relateddeaths,injuriesanddisabilitiesaffectyoung/middle-aged men,1,3,5,9,17–19theprofileoftheRTD-suffererin Spaincoincides onlyintermsofagebecauseourstudyfailedtofoundanysignificant differencesbysex.

Ascomparedtothegeneralpopulation,RTD-sufferersinSpain havealowsocio-economicstatus(worseeducationallevel;lower proportion engaged in gainful employment; high percentage receivingpermanentdisabilityretirementorotherpensions,unfit for work, and living in the lowest-income households).⁶ This situation makes them a vulnerable population, with important disadvantages in social aspects: indeed, the socio-economic

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1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 89

Percentage

Men

Women

Age at disability onset

Figure1. Ageatonsetofdisabilitycausedbyroadtrafficcrashesamongindividualsaged16andover.Spain,2008..Cumulativepercentagebysex.

Table2

TypesofDisabilitiescausedbyroadtrafficcrashesandothercausesamongindividualsaged16andover.Spain,2008..

Roadtrafficcrashes Othercausesofdisability AdjustedOR^a pvalue

n=443 n=20,425

n(%) n(%)

Typeofdisabilities

VisionDisability 81(18.3) 5,370(26.3) 0.8 0.087

HearingDisability 67(15.1) 5,856(28.7) 0.6 <0.001

CommunicationDisability 60(13.6) 3,824(18.7) 0.7 0.040

LearningDisability 45(10.1) 3,258(16.0) 0.6 0.005

MobilityDisability 362(81.7) 13,803(67.6) 3.1 <0.001

Self-CareDisability 193(43.5) 9,937(48.7) 1.3 0.046

DomesticLifeDisability 267(60.2) 11,454(56.1) 1.8 <0.001

InteractionandinterpersonalrelationshipDisability 58(13.1) 3,305(16.2) 0.6 0.008

a:Oddsratiosofroadtrafficdisabilityregardingtoothercausesofdisabilitysimultaneouslyadjustedbysex,ageandeducationallevel

Table3

Healthandsocialconditionsofdisabilitycausedbyroadtrafficcrashesandotherscausesamongindividualsaged16andover.Spain,2008..

n=443 n=20,425

n(%) n(%)

Perceivedhealthstatus^b

Verygood/Good 138(31.2) 5,170(25.4) Ref —

Fair/Poor/Verypoor 305(68.8) 15,200(74.6) 1.2 0.156

Lastmonthconsultationbyhealthproblemsorillness^b 230(52.4) 9,302(50.0) 1.1 0.251

Needofhealth/socialservicesandmedicalconsultinthelastyear 290(65.4) 11,834(57.9) 1.5 0.003

Typeofhelpsreceivedbydisability

Technicalaids 159(35.8) 7,567(37.1) 1.4 0.014

Personalassistance 222(50.1) 11,258(55.1) 1.2 0.137

Financialbenefitorcompensationlast12months^b 68(15.4) 1,879(9.2) 1.1 0.694

Problemswiththetransportandcommuting

Publictransportation 103(23.2) 4,598(22.5) 1.1 0.533

Privatetransportation 141(31.8) 6,622(32.4) 1.6 <0.001

Problemsformovingonthestreet 226(51.1) 10,059(49.3) 1.6 <0.001

a:Oddsratiosofroadtrafficdisabilityregardingtoothercausesofdisabilitysimultaneouslyadjustedbysex,ageandeducationallevel

b:Category“noanswer”excluded

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Table4

Economicconditionsofdisabilitycausedbyroadtrafficcrashesandotherscausesamongindividuals16yearsandolder,Spain2008.

n=443 n=20,425

n(%) n(%)

Primaryhouseholdearner:Disabledperson 225(50.8) 9,735(47.7) 1.2 0.117

Changeineconomicactivityduetoonsetorworseningofdisability (agerange16-64years)

191(56.2) 2,603(35.7) 2.4 <0.001

Reasonforleavingwork(agerange16-64years)^b

Healthreasons 97(50.8) 1,304(50.1) Ref —

Disability-relatedearlyretirement 46(24.3) 458(17.6) 1.4 0.142

Otherreasons 48(24.9) 841(32.3) 0.8 0.202

Expenditureinprecedingyearperdisability^c

None 285(69.6) 13,129(70.5) Ref —

UnderD3,000 94(23.0) 4,234(22.7) 0.9 0.716

OverD3,000 30(7.4) 1,274(6.8) 1.1 0.623

Mainitemsofexpenditureinprecedingyear^d

Technicalaidsandpersonalcare 54(44.0) 2,545(46.2) 1.2 0.472

Medications/medical,therapeuticorrehabilitationtreatment 59(47.3) 2,448(44.5) 0.9 0.518

Other(adaptations,transportandcommuting,etc.) 77(61.9) 2,951(53.6) 1.5 0.085

a:Oddsratiosofroadtrafficdisabilityregardingtoothercausesofdisabilitysimultaneouslyadjustedbysex,ageandeducationallevel.

b:Dataamongthosewithchangeineconomicactivity;category“noanswer”excluded

c :Category“noanswer”excluded

d:Dataamongthosewithexpendituretheprecedingyear

inequalitiesintrafficinjuriesandfatalitieshavebeenreportedby previousstudies,4,17,18,20–23 wheretheriskofroadtrafficinjuries andfatalitieshasbeenshowntobehigheramongdisadvantaged groups withless education,^24,25 unskilled occupations,²⁶ lower income^27,28 orlower socio-economicstatusin general.^23,28 RTD mightthusbeaggravatingsocio-economicdisadvantagesalready present inthepopulationaffected,owing-among otherthings- toimportant changes in economic activitydue totheonset or worseningofdisability,healthreasonsanddisability-relatedearly retirement.

Trafficcrashescause14%moremobility-relateddisabilitythan do other causes. Thiscould beexplained by thetype of injury suffered,in thatthis mainlygives risetoosteoarticularimpair- ments affecting the lower limbs and spinal cord, in line with previousresultswhichshowthatthemusculoskeletalsupportsys- tem,essentiallythelegsandpelvis,istheregionmostaffectedby RTCs.^29–31AssumingthatRTCscangeneratemajorinjuriesandlim- itationsalmostimmediately,ageatdisabilityonsetwaspresumed tobeclosetothedateoftheaccident,sothatourresultswould suggestthatover halfofalldisabledpersonshadtheiraccident beforetheageof35years;thisfigurereinforcesandmatchespre- viousdata,whichdefinethemostvulnerablepopulationgroupas beingyoungadults.1,3,5,9,19,32.However,thisinformation should beinterpretedinthecontextoftheagedistributionofthesam- ple,wherearound onein twopeoplehaveless thanfifty years old.

Personswithdisabilityhaveaconsiderablymorenegativeself- reportedhealthstatusthanthatofthegeneralpopulation⁶,andthis situationholdstruefordisabilitycausedbyRTCs.Thiscondition, takentogetherwiththeirlowsocio-economicstatus,reinforcesthe ideathatsocio-economiccircumstances,morethanotherknown riskfactors,createmajordifferencesinhealthstatus.³³

AsPeredaetal.pointout,“disabledpersonshavemoreneed ofmedicalconsultationandhealth/socialservicesthandoesthe generalpopulationbecausetheyareagroupwithgreaterhealth problems.“⁶ RTD generates a major need for these types of services/consultationinagroupwithfewtechnicalaidsandper- sonalcare,whichcouldindicatetheirdegreeofinvolvementand dependence.TheRTD-suffererreceivesmorefinancialbenefitsor compensationwhichcouldbeduetotheroleofcompulsorythird- partyinsuranceandindemnitypayabletotrafficaccidentvictims undertheSpanishMotorVehicleCivilLiabilityInsuranceAct.³⁴The

accessibilityandcommutingproblemsofthedisabledinSpainhave beenpreviously described, withthese beingshowntobemore frequentintheolderpopulation(age>65years).⁶ RTD-sufferers have a greater risk of experiencing these,a situation that may exacerbatetheirhighdegreeofmobility-relateddisability,thereby increasingtheirlevelofdependenceandlimitingtheiractivitiesin andoutsidethehome.

Althoughtherewerenoimportantdifferencesintheexpendi- turegeneratedbydisability,theitemsofexpenditurerelatingto adaptations, transport,commuting,schoolingand housingwere themostimportantinRTD.Itwould thusseemvitaltoanalyse thesocialcostofdisabilitycausedbyRTCs.

Previousstudieshaveascertainedthatthereisanincreasedrisk ofdisabilityfollowinganRTC,^16,35andourresultscouldbesug- gestingthatthisriskisespeciallyimportantinayoungersegment ofthepopulation.Thisstudywasundertakenusingadifferentdata source,inordertoprovideanewviewoftheproblem,complement theinformationcurrentlyavailableandsupporttherelevanceof RTDasapublichealthproblem.Notwithstandingthis,therecon- tinues tobelittlescientific informationonthesubject,and the researchthathasbeenconductedindicatesalackofhomogene- ityin thedatasourcesand themethodsapplied,whichhinders comparisonsataninternationallevel.

Thisstudyhasseverallimitationsandstrengths.Amongitslim- itations, the EDAD2008is a specific survey of disability,which unfortunatelydoesnotexplorethecausesofdisabilityindetailand sodoesnotallowforthecharacteristicsofroadtrafficcrashesto be known. Using the currently available format, information cannot belinked withotherRTC databases inorder tosupple- ment ourexisting data. Althoughtheanalyseswere performed using a complexsample design, it isneverthelesspossiblethat someof themultiplecomparisons mayhaveproved significant by chance. Among the study’s strengths is the large size and representativeness of theadult population of the countryas a whole.

To conclude, prevalence of RTD in Spain is lower than in other developed countries, with middle-aged and socio- economicallyunderprivilegedpopulationbeingatgreatestrisk.The disadvantages observed in basicsocio-economic characteristics, health/socialconditionsandeconomicactivitymakesuchpersons aparticularlyvulnerablegroup,withhighneedsintermsofsocial andhealth-caresupport.

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Whatisalreadyknownonthissubject

Themorbidityanddiseaseburdencausedbyroadtraffic crashes(RTCs)arebothwelldocumentedbuttheirimpacton disabilityhasbeenlittle studied.Therearefewstudiesthat usespecificdisabilitysurveystodescribetheconsequences ofRTCsintermsofdisability,andmostofthesehavebeen conductedindevelopingcountries.

Whatthisstudyadds

Thisisthefirststudyonroadtrafficdisabilityinasouthern Europeancountrytousepopulation-baseddisability-specific dataandbeconductedundertheInternationalClassificationof Functioning,DisabilityandHealth.Itcomplementsinformation onRTCsandfacilitatesinternationalcomparisons.

Editorresponsibleforthearticle MiguelAngelNegrín

AuthorshipContributions

RPalmera-Suárez,TLópez-Cuadrado,RFernández-Cuencaand IGalánhavecontributedtotheconceptanddesignoftheproject.

JAlmazán-IslaandEAlcalde-Caberohavecontributedtothecol- lection,review,standardizationandappropriatenessofdatabases.

R Palmera-Suárez, T López-Cuadrado and I Galán collaborated ontheanalyses, interpretingtheresultsandwritingthearticle.

RPalmera-Suárez, TLópez-Cuadrado and IGalánhad access to alldataand areresponsiblefor theoverallcontent. Allauthors reviewedandapprovedthefinalversion.

Funding

ThisstudywassupportedbyagrantfromtheMutuaMadrile ˜na Foundation.

Competinginterest Nonedeclared Acknowledgments

WearegratefultoDianaGómez-BarrosoandAliciaLlácerby theirunconditionalhelpandadministrativeandtechnicalsupport.

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