[Download detailed results tables: Spain-WebTables] ]
Last Updated: Sept 27 2009
Important: Please note that the results presented here are preliminary. Additional adjustments will be necessary as the results are made consistent with the ongoing Global Burden of Disease (GBD-2005) project, for which the results presented here are an input. Final estimates of the GBD-2005 study will be released in late 2010.
Reliable statistics of road injuries are an essential input for describing the public health burden of injuries, evaluating the impact of safety policies, and benchmarking achievements. While injury surveillance systems are common in high income countries, most low and middle income countries are unlikely to have such capacity for several decades. In the interim, estimates should be derived by harmonizing injury statistics from the wide array of data sources that may be available in a country or region.
This report summarizes our findings for the incidence of deaths and non-fatal injuries from road crashes in Spain. It is one of a series of national road injury assessments that we are producing during the course of this project. The intended audience of these reports includes the global donor community, the international research community, and national health and transport policy makers. We are committed to keeping this project open-source and collaborative in nature. All readers are encouraged to provide feedback to help improve methods, incorporate other sources of information, and suggest more effective methods for communicating these results.
In 2005, road crashes resulted in 5,374 deaths in Spain representing an annual injury rate of 12.4 deaths per 100,000 people. In addition, over 1.3 million people were victims of non-fatal injuries due to road crashes. While the road injury death rate in Spain is typical of many other countries (Figure 1), it is over twice the death rate in countries with the best road safety performance (Sweden, UK, and Netherlands).
Injuries as a whole, including from unintentional and intentional causes, resulted in 16,902 deaths or 4.4% of all deaths in Spain in 2005.
Road injuries are the leading cause of injury deaths in Spain, substantially in excess of deaths from suicides (Table 1), the second leading cause of injury deaths. In 2005, road injuries account for nearly one-third of all injury deaths in Spain.
Our general methodology for estimating deaths and non-fatal injuries involves piecing together data from a wide array of sources that typically include death registers, hospital records, funeral records, health surveys, and police reports. This requires filling information gaps, mapping from varying case definitions, deriving population based incidence estimates from sources that may not track denominator populations, and appropriately reapportioning cases assigned to poorly specified causes. For a general description of the broad methodology, please visit the Methods-overview section of our website.
The following sections describe the specific data sources used, the estimation methods, and the key results for our estimates of road injuries in Spain. The analytical adjustments to the data introduce uncertainty in the estimates. Thus, wherever possible, we have outlined the effects of the adjustments on the estimates.
We estimated the incidence and distribution of road injury deaths in Spain using national death registration data obtained from the WHO Mortality Database. We estimated the incidence and distribution of non-fatal injury deaths using the results of the 2002/2003 World Health Surveys.
publicly available WHO Mortality Database. These data are tabulations of deaths recorded by national civil registration systems. Typically these systems record age, sex, and causes of death coded using principles of the International Statistical Classification of Diseases (ICD).
A total of 57 years of data were available, most recently for the year 2005. We only analyzed data for the most recent seven years available (1997-2005), which had causes of death coded to ICD-10 categories. Data from prior years was not analyzed because it is not reported at a level of detail that allows us to use our analytical estimation methods. In particular, 19 years of data from the ICD-9 coding era has not been analyzed because the data was reported in the WHO Mortality Database using a condensed tabulation list (ICD-9 BTL).
Reclassification to GBD-2005 definitions: We reclassified age into 38 age-sex groups. The age definitions match those used by the GBD-2005 project and are available on the GBD-Injury expert group website. Click here to go directly to the age definitions. We reclassified the ICD coded deaths to the definitions of road injuries (and other injuries) as recommended by the GBD-Injury expert group. The definitions are available on the expert group's website (click here). These definitions map all ICD codes for external causes of injury to 48 fully-specified cause categories and 21 partially-specified and undetermined cause categories. The fully-specified cause categories include nine road-user categories:
In addition, there are two partially-specified sub-categories of road injuries:
We assessed the quality of the death registration data based on the distribution of the number of deaths in the partially specified categories. As shown in Table 2, over one-fourth (27.1%) of the deaths that are specified as being from road injuries do not have a road-user specified. Also, 14.0% of the injury deaths specified as being from unintentional injuries do not have an injury mechanism specified. While this is not unusual for a death registration system, our analysis of global data has found that this category can exceed 20% in many countries. It is nevertheless a large number that can lead to biases in the estimates.
Reallocation of injury deaths coded to partially-specified causes: The deaths classified to partially-specified and undetermined cause categories were redistributed over the fully-specified categories. All redistributions were done in proportion to the number of cases in the fully-specified causes within age-sex groups. The redistribution is done in 21 steps, one for each partially-specified category. This respects the information content in the hierarchical structure of the partially-specified categories. Thus, several of these steps do not affect the road injury estimates. For instance, the category of firearm: undetermined intent was redistributed over the categories for firearm: unintentional, firearm: self-inflicted, and firearm: inter-personal. This redistribution step has no effect on the road injury estimates. Only the redistribution of the following partially-specified categories has an effect on road injury estimates:
Adjustments that have not applied yet: Two key adjustments that are likely to modify the road injury death counts have not been applied yet. First, we have not reallocated deaths coded to unspecified causes outside the ICD injury chapter. This reallocation has not been done yet because research into the causes of deaths coded to this category is currently ongoing. However, it should be noted that in Spain, only a relatively small fraction (1.4%) of deaths are coded to this category and the effect on road injury death counts is thus expected to be small.
Second, we have made no adjustments to account for incomplete death registration because estimates of completeness of global death registration data are currently being developed. However, our preliminary comparison of total all-cause deaths reported in the death registration data analyzed by us with deaths reported by the UN Population Division suggests that death registration in Spain is near complete. It should be noted that both of these adjustments would increase the estimated death counts. Thus, the mortality results presented here likely underestimate the true number of road injury deaths.
Our estimate of road injury deaths in Spain are 21% higher than those reported by official government statistics in the 2009 WHO Global Status Report on Road Safety (Figure 3). These are based on police reports.
Most road deaths occur among adult males (Figure 4a). Over 3/4th (79%) of all road injury deaths were men and most of these men (90%) were adults older than 20 years. Death rates (Figure 4b) among men are almost four times higher that those among women overall. Men have higher death rates for all age groups but the gender differential is smaller among the elderly. Both death counts and death rates rise dramatically in the transition in age from childhood to young adults (see age groups 10-14 years and 15-19 years). Death rates continue to rise with age and are among the highest in the elderly.
Such age and sex patterns in deaths and death rates are consistent with those seen in other countries. For the most part, the gender differentials in death rate are a result of higher exposure to road traffic among men in combination with higher risk-taking behavior. Similarly, the age pattern of death rates partly reflects patterns of exposure and partly case-fatality rates. While exposure to road traffic declines with age among older populations, the bio-mechanical tolerance to injury (i.e. the likelihood of death in the event of a crash) also declines, resulting in increasing death rates with age.
We estimated the incidence of non-fatal road injuries in Spain using the 2002-2003 World Health Surveys (WHS), a nationally represented household survey that included questions on road injury involvement. These surveys, which were conducted by the World Health Organization, provide a unique opportunity for cross-country comparisons of non-fatal injuries because they asked the same set of questions in 53 countries, most of which are low- or middle- income countries. The surveys included the following set of road injury related questions in their household module:
In Spain, 6275 interviews were conducted as part of the WHS, with a response rate of 98% and only 8.1% of the surveys had missing responses for the question on bodily injury in road accidents. In our analysis of the WHS, we replaced the missing values for this question with the predicted value from a logistic regression model fit to the cases with a non-missing response. The model used the response to this question as the dependent variable and the following independent variables: gender, age groups, place of residence, permanent income quintile, country, marital status, education, occupation, self-rated health, visual acuity (seeing and recognizing a person from across road), and alcohol consumption as predictor dummy variables. We used survey (svy) commands in Stata 10 for the analysis of the WHS.
Although road injury incidence is slightly higher among residents of urban areas than residents of rural areas, the difference is not statistically significantly (Figure 6). Similarly, while men have higher rates of non-fatal road injury incidence than women, the difference is not statistically significant (Figure 7). Road injury incidence is statistically higher among young adults (18-44 years) than among the elderly (Figure 8). It should be noted that while the non-fatal injury rate among those older than 65 years is the lowest of the three age groups, the death rate among the elderly (Figure 4b) is the highest, pointing to high case fatality rates among the elderly.