Accident Analysis and Prevention 36 (2004) 399–404

Evaluation of effectiveness of safety seatbelt legislation

in the United Arab Emirates
Mohammed El-Sadig a,∗ , Mohammed Sarfraz Alam b , Anne O. Carter a , Khalid Fares b ,
Hashel Obaid Salem Al-Taneuiji b , Peter Romilly c , J. Nelson Norman a , Owen Lloyd a
a Department of Community Medicine, Faculty of Medicine and Health Sciences, UAE University, P.O. Box 17666, Al-Ain, United Arab Emirates
b Al-Ain Hospital, Al-Ain Medical District, Ministry of Health of United Arab Emirates, P.O. Box 1006, Al-Ain, United Arab Emirates
c Division of Economics, School of Social and Health Sciences, University of Abertay Dundee, 158 Marketgait, Dundee DD1 1NJ, Scotland, UK

Received 4 December 2002; received in revised form 29 January 2003; accepted 30 January 2003

Abstract
Seatbelt legalisation was implemented in the United Arab Emirates (UAE) in January 1999. This provided the opportunity to evaluate
the effectiveness of the legislation in the Eastern District of Abu Dhabi Emirate in the UAE by establishing levels of injury severity from
motor vehicle crashes (MVC) before and after the legislation and the rate of compliance with the legislation. Data were obtained from a
major hospital in the Eastern District of Abu Dhabi Emirate, UAE. Subjects were a systematic sample of MVC victims who arrived alive
at hospital in either the pre-implementation period (January–June 1998) or the post-implementation period (February–August 2000). The
main measures of outcome were injury severity codes, numbers of hospital bed days and rates of admission and discharge at hospital. The
analysis of injury severity from MVCs, from the pre- to the post-implementation period, revealed a significant declining trend (χ2 = 77.68,
P < 0.001). While the proportion of minor injuries increased from 42% (95% CI: 36–48%) in the pre-implementation period to 77% (95%
CI: 71–83%) in the post-implementation period, the proportion of ‘moderate to fatal injuries’ declined from 54% (95% CI: 48–60%) to
17% (P = 0.001) and the median number of hospital bed days declined from 5 days (25% = 2; 75% = 8) to 3 days (25% = 1; 75% = 4)
(P = 0.028). The rate of seatbelt compliance reported by occupants involved in MVCs in the post-implementation period was 59% (95%
CI: 52–67%). The implementation of the seatbelt legislation in the Eastern District of Abu Dhabi Emirate was associated with statistically
significant reduction in morbidity in those arriving alive at hospital following MVC, including reduced severity of injury, admission rate
to hospital and the duration of hospital stay. More active implementation of seatbelt law would most likely further reduce severity of MVC
injuries and fatalities in the Eastern District of Abu Dhabi Emirate, UAE.
© 2003 Elsevier Ltd. All rights reserved.
Keywords: Seatbelts; MVC injuries; Injury severity; UAE; Traffic accidents

1. Introduction biomechanics specialists to target post-crash injury (i.e. sec-

Programmes for motor vehicle crash (MVC) and injury
prevention are growing in size and depth and involve a
growing number of agencies in most countries in the world.
After World War II, the number of motor vehicles rose dra-
matically, as consequently did the numbers and severity of
injuries from MVC (Haight, 1994; El-Sadig et al., 2002).
These increases, together with the increasing cost of medical
care and rehabilitation of victims of those injuries, brought
the realisation that more efforts should be made to prevent
injuries (Haight, 1994; Miller et al., 1998). In particular,
traumatologists combined efforts with safety engineers and
∗ Corresponding author. Tel.: +971-3-7039463; fax: +971-3-7672022.
E-mail addresses: msadig@uaeu.ac.ae, Msadig40@hotmail.com
(M. El-Sadig).
ondary) prevention in addition to crash (i.e. primary) preven-
tion. That effort culminated in establishing the effectiveness
of safety seatbelts, airbags, crash helmets and collapsible
steering columns before the 1970s (NOMESCO, 1997).
Safety seatbelts are effective in reducing the risk of in-
jury in motor vehicle crashes (Kaplan and Cowley, 1991;
Viano, 1995; Rivara et al., 2000). Effectiveness is defined
as the percentage reduction in injuries and deaths for peo-
ple with the device compared to those without it when the
crash occurred. It is well established that safety seatbelts
and other restraints are very effective in reducing morbidity
and mortality from MVCs in addition to medical treatment
costs of victims (Nelson et al., 1993; Marine et al., 1994;
Miller et al., 1998).
In the United Arab Emirates (UAE), seatbelt legislation
was implemented in January 1999 (El-Sadig, 2002). It

0001-4575/$ – see front matter © 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0001-4575(03)00033-2
400 M. El-Sadig et al. / Accident Analysis and Prevention 36 (2004) 399–404
required only front seat passengers to wear seatbelts. The
implementation of the legislation provided the opportunity
to evaluate the compliance of the population in the East-
ern District of Abu Dhabi Emirate, UAE, with the law, to
establish levels of MVC injury severity and lengths of hos-
pital stay before and after its implementation, and, thereby
to determine the potential benefits of the safety seatbelt
legislation in the District.
2. Methods
Data on injury outcomes from review of medical records
of individuals injured in MVCs and taken to Al-Ain Hospi-
tal (before and after the implementation of the seatbelt leg-
islation in the UAE) were abstracted. Al-Ain Hospital is one
of two major hospitals in the Eastern District of Abu Dhabi
Emirate, UAE. The hospital receives annually about 70% of
the total of MVC casualties in the district (MoH, 1999).
The severity of injury was coded for all victims according
to the AIS codes, using the AIS90 manual (AAAM, 1990).
For the case series sample of MVC victims injured before the
legislation, the study recruited subjects from 18 January to
30 June 1998 (the pre-implementation period). For the case
series sample of victims injured after the enactment of seat-
belt legislation, the study recruited subjects from 2 February
to 3 August 2000 (the post-implementation period).
For the pre- and post-implementation periods, the study
used data abstraction forms to collect data on MVC victims
brought alive to Al-Ain Hospital in the UAE. The first form
was used to retrieve data for the ’pre-implementation’ pe-
riod from patients’ medical records. Inclusion criteria were
all persons who presented alive to the Accident and Emer-
gency Room (ER) of the hospital as a result of involvement
in MVCs during the time periods specified. Using the ER
registry, which identifies MVC victims, every fifth patient
brought alive to the hospital was selected. Information on
the patient’s demographics was abstracted. Then a panel of
orthopaedic and trauma surgeons and nurses retrieved rel-
evant data on injury diagnoses and inpatient hospital treat-
ment. The second form, which was composed of two parts,
was used to collect data for the post-implementation period.
Research assistants at the ER of Al-Ain Hospital completed
descriptive details for every fifth person meeting the inclu-
sion criteria during the time period at the time of presen-
tation to the ER. These details included the mechanism of
injury, the seating position of the occupant and the use of
safety belts. The data were gathered from various sources:
the patient, his relatives or friends and the police. After that,
the form was set aside until the patient was discharged from
the ER or the hospital. Then, using the patient’s medical
record, orthopaedic and trauma surgeons completed its sec-
ond part, containing details of injury diagnoses and inpatient
hospital treatment.
In the absence of any routine injury coding system in
the UAE, the study used trauma and orthopaedic specialists
to estimate injury severity, from MVC patients’ records
for both data forms, using the Abbreviated Injury Severity
Scale (AIS) (AAAM, 1990). This was done through con-
verting injury diagnosis and text descriptions of injuries
into AIS90 codes (AAAM, 1990). The AIS categorises
each injury by body region (head or neck, chest, abdominal
or pelvic contents, extremities or pelvic girdle and general)
and by severity (0: no injury; 1: minor; 2: moderate; 3:
serious, not life-threatening; 4: severe, life-threatening—
survivable; 5: critical, survivable—uncertain; 6: fatal—
unsurvivable) (Baker et al., 1974; Bull, 1978; Yates, 1990;
Durbin et al., 2001). The AIS ranking order of severity
is based on the criterion of ’threat to life’, determined by
clinicians. Accordingly, all patients’ injuries in the pre- and
post-implementation periods were assigned AIS severity
codes. For multiple injuries, affecting more than one body
region, the codes were assigned on the basis of the injury
with the highest severity. The days of hospitalisation per pa-
tient were calculated by counting the difference between the
date of admission and the date of discharge from hospital.
Overall, the following outcomes were measured identi-
cally from both time periods: location as driver or non-driver
in the vehicle, severity of injury using the AIS90 and the
number of days of hospitalisation.
Data variables were coded and analysed, using the sta-
tistical software package SPSS Version 10. The χ2 -test was
used to test the statistical significance of differences in cat-
egorical variables between the two evaluation periods (P ≤
0.05 was considered as the cut-off value for significance).
The numbers of days spent in hospital were compared using
the two-sample Wilcoxon’s rank-sum (Mann–Whitney) test.
3. Results
In the pre-implementation period (January–June 1998) a
sample of 247 cases was enrolled. Overall, 85% were male,
most were aged 19–44 years while 20% were below 18 years
and 14% above 45 years; over one quarter were UAE citizens
while the others were expatriates (Table 1). Of all victims,
36% were drivers, 22% were passengers while 42% were un-
specified road-users. Forty-two percent sustained minor in-
juries, 18% moderate injuries, 24% serious injuries and 8%
severe injuries; 43% were admitted to the hospital (Table 2).
Of those admitted to hospital, 89% were discharged without
complications, and 11% were transferred to specialist hos-
pitals for further treatment (Table 2); drivers spent a median
period of 5 hospital bed days (Table 3).
In the post-implementation period (February–August
2002) a sample of 173 was enrolled. Overall, 82% were
male, over three quarters were aged 19–44 years while 16%
were below 18 years and 8% above 45 years (Table 1).
Thirty-one percent were UAE citizens while the others were
expatriates (Table 1). Of the total victims, 29% were back
seat passengers, 26% front seat passengers, 24% drivers and
21% non-specified road-users; 59% were using seatbelts
 M. El-Sadig et al. / Accident Analysis and Prevention 36 (2004) 399–404 401

Table 1
Socio-demographic factors of MVC casualties arriving alive at Al-Ain Hospital in Al-Ain, UAE, before and after the implementation of seatbelt legislation
1998 and 2000
Characteristics Proportions in the Proportions in the P-valueb
pre-implementation (%) post-implementation (%)
(N = 247) (95% CIa ) (N = 173) (95% CIa )
Sex n.s.
Male 84.6 (80.1–89.1) 82 (76.3–87.7)
Female 14 (9.8–18.6) 18 (12.3–23.7)
Age (years) n.s.
<18 20 (14.9–25.1) 16 (10.5–21.5)
18–24 17 (12.2–21.8) 25 (18.5–31.5)
25–34 27 (21.3–32.7) 31 (24.0–38.0)
35–44 22 (16.7–27.3) 20 14.0–26.0)
>44 14 (9.6–18.4) 8 (3.9–12.1)
Nationality n.s.
UAE 28 (22.4–33.6) 31 (24.1–37.9)
Other Arabs 29 (23.3–34.7) 24 (17.6–30.4)
Asians and others 43 (35.8–49.2) 45 (37.6–52.4)
Road-user n.s.
Driver 36 (27.9–44.1) 25 (18.3–31.7)
Passenger 22 (15.0–29.0) 54 (46.3–61.7)
Others 42 (33.7–50.3) 21 (14.7–27.3)
Seatbelt-use
All occupants – 59 (50.2–67.6)
Drivers – 86 (74.1–97.3)
Front seat passengers – 88 (77.3–97.7)
Back seat passengers – 11 (2.0–20.0)
Unknown – 60 (17.0–100)
a 95% confidence interval.
b By χ2 two-tailed test.

Table 2
Injury severity of MVC casualties arriving alive at Al-Ain Hospital, UAE, before and after implementation of seatbelt legislation 1998 and 2000
MVC injury severity Proportions in the Proportions in the P-valueb
pre-implementation post-implementation
period (%) (N = 247) period (%) (N = 173)
(95% CIa ) (95% CIa )
Outcomes at ER n.s.
Discharged from ER 57 (50.8–63.2) 64 (56.8–71.2)
Admitted to hospital 42 (35.8–48.2) 35 (27.9–42.1)
Dead 1 1
Outcomes at wards n.s.
Discharged without complications 89 (85.0–93.0) 92 (88.0–96.0)
Transferred to specialist care in another hospital 11 (7.0–15.0) 8 (4.0–12.0)
Injury severity (by AIS) <0.001
None 3 (1.0–5.1) 6.1 (2.4–9.8) –
Minor 42 (35.8–48.2) 77 (70.6–83.4) <0.001
Moderate 18 (13.2–22.8) 7.3 (3.3–11.3) 0.007
Serious 24 (18.6–29.4) 5.5 (2.0–9.0) <0.001
Severe 8 (4.6–11.4) 1.8 (0.0–3.8) 0.006
Critical 3 (1.0–5.1) 0 (0) 0.04
Fatal 1 (0.0–2.3) 1.8 (0.0–3.8) –
a 95% confidence interval.
b By χ2 two-tailed test.
402 M. El-Sadig et al. / Accident Analysis and Prevention 36 (2004) 399–404
Table 3
Number of hospital bed days of MVC casualties arriving alive at Al-Ain Hospital, Al-Ain, UAE, before and after implementation of seatbelt legislation
1998 and 2000
Descriptive statistics (percentiles)
Number of hospital bed days per driver in the pre-implementation period
Number of hospital bed days per driver in the post-implementation period
Mann–Whitney U-testa
Pre-implementation period
Post-implementation period
a Exact significance (one-tailed test) P = 0.028.
at the time of the crash. Most (86%) of drivers and 88%
of front seat passengers were using seatbelts while 11%
only of back seat passengers were using them. Over three
quarters sustained minor injuries, 7% moderate injuries
and 6% serious injuries; 35% were admitted to the hos-
pital (Table 2). Among those admitted to hospital, drivers
spent a median period of 3 hospital bed days (25% = 1;
75% = 4) (Table 3). Ninety-two percent of those admit-
ted were discharged without obvious complications after
completing treatment, and 8% were transferred to specialist
care for further treatment for disability and neurological
complications (Table 2).
The comparative analysis of the pre-/post-implementation
periods revealed statistically significant declines in injury
severity from MVCs in the Eastern District of Abu Dhabi
Emirate, UAE (Table 2). In the assessment of the overall
effect of the legislation, when the proportion of the group
of casualties which sustained ‘moderate to fatal injury’ was
compared in the pre- and post-implementation periods, the
proportion was 16% in the post-implementation period com-
pared to 54% in the pre-implementation period (RR = 3.0).
The individual comparison for each AIS injury category re-
vealed similarly significant declines in injury severity (P <
0.001) in the post-implementation period (Table 2). Equally
importantly, minor injuries increased from 42 to 77%, a pat-
tern that complemented the downward trend of injury sever-
ity in the Eastern District following the implementation of
the seatbelt legislation.
The analysis of hospital admissions among drivers in
the pre- and post-implementation periods, using Wilcoxon’s
rank-sum (Mann–Whitney) test, showed a significant change
in the duration of hospital stay between the two periods
(Table 3): the median duration of hospital bed days declined
from 5 to 3. Drivers were the only passengers who could be
compared between the two databases, as they were the only
occupants comparable in the databases.
4. Discussion
The results demonstrated that the risk of moderate to
fatal injuries in those presenting alive at hospital, following
N Percentile
Minimum 25th 50th 75th Maximum
19 1 2 5 8 36
14 1 1 3 4 6
N Mean rank Sum of ranks
19 19.74 375
14 13.29 186
a MVC declined by three-fold after the implementation
of the legislation. The number of hospital bed days for
MVC casualty drivers also showed a significant reduction.
The reduction in the rate of admission to hospital in the
post-implementation period, though not statistically signif-
icant contributed to the declining trend of injury severity.
These findings together suggest a decline in injury severity
from MVC in the Eastern District of Abu Dhabi Emirate,
following the implementation of the legislation. The find-
ings are consistent with results obtained elsewhere. For
example, Kaplan and Cowley (1991) in a study in the US
showed that seatbelts reduced the total number of injuries
by 34%, major injuries by 57%, minor injuries by 20%
and deaths in the belted group to zero. The unbelted group
had a mean AIS score twice as great as the belted group
and were hospitalised 1.6 times longer and at double the
cost. Viano (1995) estimated the effectiveness of seatbelts
as reaching 42% in preventing fatalities, in addition to
12% effectiveness provided by a driver side airbag. But
Rivara et al. (2000), while showing similar consistent rates
in reducing fatalities found an associated increased risk of
serious injury to the chest and abdomen.
In the post-implementation period, 59% of casualties in-
volved in crashes self-reported the use of seatbelt when the
crash occurred. Although such evidence might overestimate
the actual rate of seatbelt compliance in the Eastern District
of Abu Dhabi Emirate, UAE—bearing in mind the fines
imposed for violations—it suggests a notable improvement
as opposed to the rates reported by Bener et al. (1994),
which described estimates of not over 11% for frequent use
and 6% for non-frequent use before the implementation of
the seatbelt legislation. The analysis of the association be-
tween seating position and seatbelt-use revealed that 86%
of drivers and 87% of front seat passengers reported using
seatbelts as required by the law. On the other hand, only
11% of back seat passengers reported using seatbelts when
the crash occurred (backseat passengers are not covered in
the current legislation). A more reliable estimate could have
come from a roadside observational study. Compared to
other countries, similar rates of compliance following the
implementation of seatbelts have also been reported. For
example, in the US, Marburger and Friedel (1987) estimated
 M. El-Sadig et al. / Accident Analysis and Prevention 36 (2004) 399–404
the rate of compliance to be within the range of 60–90%,
while Hauswald (1997) estimated the actual rate among
drivers in the US to be 40%. However, these high rates of
compliance for front seat passengers taken in conjunction
with the overall reduction in injury severity for all passen-
gers and the reduction in the number of hospital bed days
for drivers, demonstrated in the post-implementation period,
clearly suggest the effectiveness of the implementation of
the seatbelt legislation in the Eastern District of Abu Dhabi
Emirate.
The descriptive analysis of the socio-demographic data in
the pre- and post-implementation periods revealed that the
sex distribution of MVC casualties remained similar in both
periods. Also, the proportionate distribution of casualties ac-
cording to nationality did not differ in the two comparison
periods. Asians maintained the highest proportions in both
evaluations, reflecting their high proportion in the District’s
population (56%). UAE citizens constituted the second high-
est proportion in both evaluations (28 and 31%, respectively)
despite the fact that they represent approximately 20% of
the total population. The high rate of involvement of UAE
citizens and the concentration of that on young age groups
(19–44 years) is alarming and suggests that safety cam-
paigns should be targeted at them (El-Sadig et al., 2002). A
comparison of the age distribution of casualties between the
periods showed that, in the post-implementation period, a
statistically significantly higher proportion (29%) of MVC
injuries was in the age group 19–24 years compared to the
pre-implementation period while the proportion for the age
group >45 years declined significantly from 14 to 6%. This
declining trend in the occurrence of MVC injury in the older
age cohort and the increasing trend within the younger age
cohorts may suggest the presence of a greater tendency to-
wards non-compliance with seatbelt legislation among the
younger age groups or a higher degree of risk-taking driv-
ing. This dictates that specific prevention strategies should
be directed to these groups, such as driver training and ed-
ucation, legislation and/or monitoring the implementation
of existing laws, especially those planned to enhance the
compliance of the population with seatbelt law. The find-
ings also supported the extension of seatbelt legislation to
include the requirement that back seat passengers also use
seatbelts.
4.1. Limitations
Several limitations should be considered when interpret-
ing the results of this paper. The study is restricted to cases
that arrived alive at the ER department in the hospital. There-
fore, an increase or decrease in the rates of those who died
prior to arriving at ER or who did not require any med-
ical care could bias the results. The data were collected
retrospectively for the pre-implementation period. This re-
sulted in failure to obtain important epidemiological infor-
mation such as the use of restraints among vehicle occupants;
as such information was missing for most of the sample
403
population. During the post-implementation period, the use
of restraints was determined mainly through self-reporting,
which could bias the results due to fear of legal liability. In
both evaluations, some information relating to injury sever-
ity was not available from medical charts, leading to the
possibility of underestimating injury severity for casualties
in both databases. The periods through which the databases
were collected were not identical and did not include the
full year. However, due to the rarity of metrological events
in the UAE, there are no major variations in MVC incidence
and severity (El-Sadig et al., 2002) over time. Finally, only
driver data was fully comparable between the two data col-
lection periods.
Acknowledgements
The authors would like to extend their thanks to the staff
in Al-Ain Hospital for their valuable assistance in producing
this paper. We also wish to extend special thanks to the
staff in the Community Medicine Department, Faculty of
Medicine and Health Sciences of the UAE University for
their help in producing this paper. In particular, we thank
Dr. Peter Barss and Dr. Hafiz Ahmed for their comments on
the manuscript and Mr. S.V. Shinelal for his valuable help
in collecting the data.
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