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Content analysis of reported activities of the United Nations Road Safety Collaboration Members during the Decade of Action for Road Safety 2011–2020

Objective Several activities were planned for the Decade of Action (DOA) for Road Safety 2011–2020, covering key policies and interventions on road safety. Knowledge of the activities implemented by key actors is currently lacking in the literature. This study answers the question: what activities were implemented during the DOA by the United Nations Road Safety Collaboration (UNRSC) members? Design The study used content analysis techniques to extract and analyse information from five United Nations Secretary General’s reports, which summarise the activities reported by UNRSC members. Setting The primary setting for this study are 116 countries in which activities supporting the DOA were conducted. Outcome measures Frequency of themes and subthemes that emerged from reported activities are identified and cross-tabulated by year of report, country level of income, geographical region and organisation type. Results Over the entire DOA, establishment of institutions and lead agencies as well as the development of national strategies featured prominently under the theme of management. This theme was steadily reported across regions, country income level and organisation type. Workshops, training and major events regarding road safety increased in frequency of reporting throughout the decade as did developing and promoting the basic road and vehicle systems supportive of road safety. It is further noted that other key activities like infrastructure and behaviour change that are required for a balanced approach to road safety policy were also attended to by various organisations. Activities related to road safety enforcement and post-crash response as well as activities in low-income countries appeared to be less reported. Conclusion The wide range of activities reported by UNRSC members over the entire DOA need to be sustained and evaluated in years to come if they are to have a significant impact on reducing road traffic deaths and injuries at national and international levels.


INTRODUCTION
What did United Nations Road Safety Collaboration (UNRSC) members do during the Decade of Action (DOA) for Road Safety 2011-2020? During the DOA, several activities were implemented under a global plan of action aimed at stabilising and reducing the global trend in road traffic deaths and injuries. 1 They were organised under five groups or pillars related to road safety management, infrastructure, road users, vehicle safety and post-crash response, and were implemented by governments, non-governmental organisations, companies, foundations and international organisations. Additionally, several governments prepared action plans. Given that this was the first decade targeted at road safety, knowledge of the activities implemented, and their outcomes would be beneficial to future road safety policy.
Several editorials and journal articles describing the objectives and scope of the DOA were published at the beginning of the DOA. 2 3 A few articles were also published during the DOA, pointing out its importance and providing an overview of progress being made during and prior to its inception. [4][5][6][7][8][9][10][11] What is not known, however, are the activities that were implemented by governments, Strengths and limitations of this study ► To date, there is no comprehensive assessment of the activities implemented during Decade of Action (DOA) for Road Safety 2011-2020. ► Use of content analysis technique and Nvivo software provided a rigorous approach. ► The findings of the study are critical for the recently announced new DOA. ► A limitation of this study is that activities of United Nations Road Safety Collaboration members do not represent the full spectrum of DOA activities. ► Another limitation is that an in-depth investigation of selected activities by the authors was not possible, pointing to a future research topic.
Open access non-governmental organisations (NGOs), international organisations and road safety coalitions like UNRSC as well as where these activities took place. Although some more regionally focused assessments of activities have been published, 12 to date, there is no comprehensive analysis of the activities of these groups conducted from a global context. Though a comprehensive database of these activities and plans from around the world is not available, there is a track of the activities that were reported by members of UNRSC. Examining the activities that were described by this group helps to shed light on the scope of work that was done. The objective of this study is to examine activities that various actors across the organisational spectrum including international agencies, NGOs, foundations, governments, academia and the private sector reported throughout the DOA. This study analyses the content of five progress reports on DOA that were submitted by the United Nations Secretary General to the United Nations General Assembly. [13][14][15][16][17] These reports are comprised of valuable information on various actions undertaken and reported by different members of UNRSC. The analysis in this study focuses on the patterns in themes of reported activities covered in these reports.

Study design
This study used content analysis techniques [18][19][20][21][22][23] to extract and analyse information on the activities of international agencies, non-governmental organisations, foundations, governments, members of academia and the private sector affiliated with the UNRSC. Thematic content analysis was chosen because the focus of the study was on showing the patterns in the themes of activities reported by UNRSC members. We were also interested in conducting textual and discourse analysis which was ultimately omitted because the text presenting activities demonstrates a basic 'standard' statement indicating organisation, activity conducted and venue of activity.

Data collection and processing
We started off by reading the five reports to gain an overall sense of the content and themes covered. We discovered that the activities were reported according to a standard format, which made it possible to compare them across the years. The text was then broken down into identified activities. Using a manual open coding process, 24 we labelled each activity mentioned in the five reports as meaning units. Corresponding meaning units were then condensed into codes that were derived using an inductive reasoning approach as they emerged and were suggested by the text. This iterative process allowed us to effectively analyse the information presented.
The original text was re-read alongside identified codes and re-classified. This process was repeated five times to refine the codes to eliminate overlap and misclassification as well as to facilitate analysis and interpretation as required in qualitative research. [25][26][27] As it happens with thematic content analysis, the codes are grouped into several themes, and with further analysis, the thematic groups become fewer. 28 We originally identified 24 overarching themes from manual classification. With NVivo software, we narrowed the themes from 24 to 11 overarching themes, which we narrowed down further to five after we eliminated overlapping categories and calculated the salience (table 1).
In addition to the variety of meaning units and subsequent thematic groups highlighted in our manual open coding process, several cases were identified in the United Nation's Secretary General reports. Cases were defined as primary actors executing or supporting activities or as subjects being acted on during the DOA. Each theme was then connected to one or more defined cases which could represent a country, an organisation or other actor. In this context, 'activities' correspond to one or more cases depending on how many subjects were connected to the said meaning unit in the text. We consider each reported activity to have been executed or supported by at least one reporting agency. Thus, the counts of activities that we present and discuss in this study are not abstract ideas but real activities that these entities indicated to have supported or implemented as part of their efforts to realise the goals of the DOA global plan.
We omitted the introduction, conclusion and recommendations sections of each report during this process as they did not contribute to tangible activities reported or conducted during the DOA. Given the amount of raw text to process, we used a qualitative data analysis software package known as NVivo to aid in creating a database for extraction and analysis of relevant information. 29 30 The total word count for the entire text for the five reports that we coded was 30 865 words.

Data analysis
We determined the degree of salience to establish the proportion of the entire text taken up by each theme as coded text. 31 32 It helps in determining emphasis given to themes or concepts in the document thereby further improving clustering performance. 31 32 Salience statistics were derived based on the percentage of text the thematic codes took up in each of the five documents. A cut-off of 5% was used for exploratory analysis.
We chose country level of income, geographical region and organisation type as markers to examine the data on what was done during the DOA. There continues to be a strong association between the risk of road traffic death and the income level and region of countries. 33 With this in mind, we chose to analyse activities by country level of income and region in order to identity any potential variation in themes that may be contributing to these disparities. Organisation type was chosen in order to explore the different actors involved in the DOA. Analysis of variance (ANOVA) was conducted to determine whether the observed variance within and between groups was statistically significant.

Open access
Patient and public involvement Patients and the public were not involved in the design of this study. As already indicated, the study uses information that already exists.

RESULTS
As shown in Themes by year of reporting The first half of the DOA exhibited a steady rate of overall activity whereas an upward trend in reporting was seen throughout the second half. The identified themes of management and information featured prominently throughout the DOA. It is evident that the frequency of meetings and investment in infrastructure reported in the Secretary General's progress reports trended up.
Programmes to enhance behaviour, information dissemination and managerial oversight seemed to remain steady throughout the DOA with a dip in activity reported in 2015 (table 2). ANOVA revealed that the thematic pattern observed was not statistically significant. General's progress reports by level of income and region can be found in online supplemental appendix 1. Most of the activities performed throughout the DOA were associated with middle-income countries. In fact, over 86% of middle-income nations were involved in the DOA in some way. It is also noted that almost half of the world's low-income countries, whose average rate of 27.5 deaths per 100 000 populations, 33 were included in the DOA. Many of these nations engaged in management activities related to establishing lead agencies, strengthening capacity and preparing national strategy in support of road safety policies. It is evident, however, that more work could be put into building and investing in the infrastructure of these low-income nations as well as data collection and dissemination. ANOVA revealed that the thematic pattern observed was not statistically significant.

Themes by geographical regions
We explored the relationship between reported themes and geographical region in table 4. Extensive work was reported to be done in Asian and the Pacific countries throughout the decade, most notably in the implementation of programmes aimed to improve driver behaviour and increase the safety of vulnerable populations. Furthermore, Asian and Pacific countries made great strides in strengthening management of the DOA. African countries similarly made great advances in activities related to establishing lead agencies, strengthening capacity and preparing national strategy in support of road safety policies as well as improving legislation and enforcement. Conferences, workshops and major events related to road safety seemed to be attended by all regions; whereas, reporting on data collection and dissemination seemed to be lacking in most regions other than high-income western nations. Developing improved driver infrastructure seemed to be limited to high-income western nations as well as in Asia and the Pacific. Observed variation in thematic groups by geographical region were in fact statistically significant as ANOVA of the relationships presented in table 4 revealed a p value of 0.015.

Themes by organisation type
Further investigation into activities reported as having been implemented by different organisation genres Open access throughout the DOA was conducted to identify any thematic patterns among organisational actors (table 5). A significant fraction of the DOA Secretary General's Reports described the works of international agencies and United Nations affiliates. NGOs reported most activities on improving driver behaviour primarily through advocacy and public awareness campaigns as well as introducing programmes to promote child safety and protection. Nationally run organisations particularly reported mainly hosting workshops and trainings aimed at improving road safety. Funding was largely dominated by United Nation's affiliates and the private sector. However, the private sector appeared to be less involved in other aspects of the decade compared with other organisation types. ANOVA revealed that the thematic pattern observed was not statistically significant.

DISCUSSION
This study has identified patterns in reported activities by UNRSC members consisting of international agencies, non-governmental organisations, foundations, governments, members of academia and the private sector during DOA. Achieving global and national road safety goals and targets requires appropriate management capacity and is essential to implementing effective, system-wide interventions. 1 35 Consequently, the theme of management had the highest number of overall activities related to creating multisectoral partnerships, launching programmes, establishing lead agencies, strengthening capacity and preparing national strategies. This theme was reported frequently in all five Secretary General reports published during the DOA. The decline in managerial support reported in 2015 appears to be secondary to a temporary decrease in establishment of national strategies, lead agencies and institutions. Furthermore, this theme seemed to be a highly engaged activity across national income levels, regions and organisation type. As lowincome nations report an average rate of 27.5 deaths per 100 000 populations, 33 it is reassuring to see the increasing establishment of lead agencies and national strategies in these countries. Furthermore, the rates of motor vehicle deaths are highest in the African (26.6/100 000 people)

Open access
and southeast Asia (20.7/100 000 people) which reflects an increasing focus on institutional management within these regions. 33 Funding incorporated 26% of this heavily reported theme and suggests that the decade encouraged increased sustainable funding to road safety or there were additional donors who showed interest in road safety. In fact, according to the Global status report on road safety 2018, 132 countries reported having a national strategy for road safety fully funded while 129 countries have lead agencies funded. 33 The extent of this funding has yet to be assessed; however, our research shows that international funding was focused on low-income and middle-income countries in the African and Asian regions. Furthermore, we show that the private sector played a major role in financing the activities carried out throughout the DOA, particularly automotive companies, oil industry and tyre manufacturers. Information and meetings had the second and third highest number of activities, respectively. Although the collection and dissemination of information through technical reports, guidelines, scientific articles, conducting research and sharing experiences were not heavily reported on in relation to national income level or region, analysis revealed that these activities were driven largely by international organisations and United Nations affiliates. Surprisingly, academic organisations were not widely reported of having conducted significant investigations and studies regarding global road safety which undoubtedly highlights an important partner to target moving forward into the upcoming decade. Under the theme of information, data collection emerged as an important activity conducted by UN affiliates as it comprised just under 50% of this given component with a steady frequency of reporting throughout the decade. It is encouraging to see an expanding global involvement in meetings regarding the DOA. Specifically, regarding this dramatic rise in reporting, workshops and trainings directed at improving road safety at multiple levels increased the most having been reported only once in 2011 and 17 times in 2019. The majority of national and regional workshops held to promote road safety were conducted in the middle-income nations in Africa, Asia and the Pacific. However, only two low-income nations were reported to have been involved in these workshops, highlighting a significant need in these more at risk countries.
The theme of behavioural change was consistently reported throughout the DOA with a small dip in 2017. Advocacy campaigns and public relations proved to be one of the most reported activities of the decade and were exceptionally prevalent in middle-and high-income nations as well as Africa, Asia and the Pacific. These activities were critical in elevating the profile of road safety as an important health and development challenge globally, thereby revolutionising public attitudes and opening new avenues for UNRSC interventions. Additionally, enacting and enforcing legislation on key risk factors have been shown to be critical components of an integrated strategy to prevent road traffic deaths and injuries. Local NGOs and foundations led the promotion of programmes and legislation to support child safety and protection. However, most of the legislative progress reported in these biannual reports seem to be centralised around middle-income nations with much work still to be done in low-income nations. With the substantial expansion of lead agencies, national strategies and public relations as well as involvement in workshops and trainings, it is hopeful that greater legislative advances will be seen in low-income nations over the decade to come. Despite the significant progress made in improving behavioural legislation across multiple risk factors, enforcement remains markedly underreported, particularly in low-income and middle-income countries, at the end of the decade.
Investment and promotion of improved infrastructure started off slowly but appreciably increased throughout the decade. This rise in infrastructure reported was significantly driven by improved road planning and systematic road risk mapping as well as improvement in safety features of vehicles and harmonising safety standards of vehicles. Road safety inspections and the star rating of roads provide mechanisms to identify failings in infrastructure which can affect a crash likelihood and severity. The International Road Assessment Programme set out to achieve this in all regions of the world but appeared to work primarily with middle-income nations according to our analysis. Eastern Europe was under-reported in road Open access safety improvement reporting and vehicle safety progress. Meanwhile many activities regarding the advancement of harmonising vehicle safety standards and making safer vehicles more accessible were reported as having been implemented in Latin America and the Caribbean. Lastly, post-crash care and promoting improved rapid road traffic injury response and universal trauma systems saw a slow increase in reports throughout the decade but still seemed to be significantly under-represented given the fact that they compose a major pillar of the DOA. A broad and integrated approach to post-crash care and emergency response can save millions of lives and mitigate acute and chronic sequelae of motor vehicle collisions. 36 37 Therefore, it is critical for UNRSC members to address this challenge and endorse more activities in this field over the decade to come.

LIMITATIONS OF THE STUDY
This study has four main limitations. The first is that there is an 8000-word limit for the Secretary General reports. This limit puts restriction on the number and scope of activities that the partners could report on. The partners are expected to provide a very brief text of activities they have conducted at global and regional levels, which is then edited by a focal point. What is then ultimately included in the final report is a negotiated text between the UNRSC members, the focal point and members of the secretariat who review and approve the drafts. Given this process of inclusion, it is possible that reported activities may be underestimated. The second limitation is that activities analysed are not representative of all DOA initiatives. Further, activities are not representative of all organisations, regions and countries. Activities coded and analysed are limited to those reported by members of the United Nations Road Safety Collaboration. Whereas these members execute and support activities in different parts of the world, they cannot be assumed to be able to report on activities implemented by those who are not affiliated with this network. There are very few activities reported by governments in the coded text. Hence, a comprehensive picture and a database of activities implemented during the DOA cannot be provided.
The third is that verification and a follow-up on a few key activities has not been conducted. Background documents against which to verify the reported activities were not available. Furthermore, there was not enough time for these authors to follow-up with individual UNRSC members to get details on a few key activities that they felt could have been tracked over the years to assess implementation reality and outcomes at national and subnational levels. This limitation represents an aspect that requires consideration in future research on this or the new DOA for Road Safety 2021-2030 that has recently been announced.
Lastly, an important issue in research is attribution. 38 While we have been able to summarise and even count the number of activities reported by UNRSC members, we have not been able to ascertain from the Secretary General's progress reports which of these activities were going on before the decade and which ones started during the decade. We cannot rule out that several activities were implemented during the decade but at the same time, we must point out that assessing and interpreting the decade through patterns in activities that have occurred during the decade period should be done with care, recognising that these changes may not solely be due to the Decade itself but might have only happened at the same time.

CONCLUSION
This study set out to examine the reported activities implemented by UNRSC members throughout the DOA. Since the launch of the DOA, the establishment of institutions and lead agencies as well as the development of national strategies has been consistently implemented and supported as shown by the strong representation of management reporting in all five of the reports. Additionally, this activity has been steadily reported across regions, income level and organisation type. Advocacy, workshops, training and major events regarding road safety increased in frequency of reporting throughout the decade as did developing and promoting the basic road and vehicle systems supportive of road safety. However, road traffic enforcement and post-crash care have low frequencies. Furthermore, activities conducted in low-income countries appeared to be fewer. Monitoring the activities that were conducted and reported throughout the DOA is important as it will help guide improvements in road safety policy over the upcoming decade.
Contributors MK conceptualised the study, SF extracted and analysed data and both MK and SF jointly wrote the text through a consultative approach with each refining the text as it took shape.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.

Patient consent for publication Not required.
Ethics approval Being a component of DOA evaluation, ethical approval for this study was obtained from George Washington University and University of Oxford, the home institutions for the principal investigators, Professor Adnan Hyder and Dr Margie Peden, respectively.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. All relevant data have been included in the article. ORCID iDMeleckidzedeck Khayesi: 0000-0002-2335-4077Sean Flannigan: 0000-0002-5042-7526 Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content