Background Under-reporting of road crashes and associated fatalities and injuries is a significant problem. The WHO estimates that levels of under-reporting can be as high as 50% in developing countries. The reasons for this are many and complex. It is critical to properly understand the true extent of road trauma so that appropriate resources can be allocated to crash and injury prevention.

Purpose To explore the role of fatalistic beliefs in risky road use in Pakistan to better understand the issues of under- and non-reporting of road crashes and related road trauma.

Methods In-depth interviews were conducted with 30 participants in Islamabad, Rawalpindi and Lahore. Participants were professional drivers, car drivers, police officers, policy makers and religious orators.

Results A strong link between fatalism and risky road use emerged as well as between fatalistic beliefs and non-reporting of crashes. Those killed or injured can go unreported in some cases because the tragedy of a road crash is considered predestined and beyond personal control. Fate was also described as related to drivers reconciling after a crash without police involvement and the seeking and granting of pardon for a road death, both of which can result in non-reporting of crashes and deaths.

Significance This is the first instance of fatalistic beliefs being directly linked to non-reporting of crashes and fatalities. In a country such as Pakistan where fatalism is linked to Islamic faith, properly recording and addressing road crashes and associated trauma is an immense challenge requiring urgent attention.