METHODS

The study setting was the West African country of Ghana (population 17 000 000) with a per capita gross national product of $325. The study was conducted in the capital, Accra, which has a population of 2 000 000 making it the country's largest city.

In the study area, the majority of motorized transport is provided by publicly used vehicles, including taxis, minibuses, and buses. Most taxis and minibuses are privately owned and rented to individual commercial drivers. This is also the case for some buses, many of which are owned by larger companies or government agencies.

To answer the research questions, information was collected through a series of focus group discussions. These were conducted at five separate “lorry [truck] parks” in Accra. These lorry parks are areas where people go to obtain publicly available transportation provided by taxis, minibuses, and buses. They consist of substations, grouped by transport mode (taxi, bus) and destination.

We sought drivers who indicated that they had driven within two hours of consuming alcohol at least once in the past year. We also varied the types of drivers (short distance/intracity compared with long distance/intercity) and stations at which the focus group discussions were held.

An in-depth discussion guide, adapted from similar work carried out in the United States,²¹ was developed for the target groups to capture information and trends related to values, risk perceptions, leisure time activities and experiences, and attitudes on alcohol impaired driving. The guide included open ended questions about the following topics:

• Demographic information.

• Drinking patterns, including the social and physical settings in which most drinking and driving occurs for the target group.

• Driving patterns.

• Leisure activities.

• Decision making processes regarding drinking and driving.

• Perceptions about impaired driving.

• Recommendations for counter measures that would be most acceptable to the target group.

• The appropriate content and vocabulary for countermeasure messages for the target group.

During the focus group discussions it was emphasized that the moderator was not asking the participants to talk publicly about themselves, but rather was asking them their opinions about what other drivers do, think, and feel concerning the problem of drinking and driving.

All focus group discussions were conducted by the coauthors (GA, JB). Depending on the languages understood by the drivers, they were conducted in either English or one of two local vernacular languages (Twi or Ewe). Driver involvement in the focus group discussions was voluntary and anonymous. The study was approved by the Ministry of Health of Ghana and the Ghana Police Force.

RESULTS

Characteristics of participants

Five focus groups discussions were held involving a total of 43 participants; they were conducted in groups of 7–10 participants. All participants were men. (Female commercial drivers are rare in Ghana.) The mean (SD) age was 38.8 (13.7) years and they had a mean of 8.3 (6.8) years of driving experience.

A significant percentage had no formal schooling (16%) and most had only a basic primary education (60%). Only 23% had attended or completed secondary school.

The participants consisted of 26 intercity/long distance drivers and 17 intracity/short distance drivers. All were drivers of either minibuses or large buses.

General issues and drinking and driving

Participants in the focus group discussions were unanimous in admitting that by the nature of their work, they were at risk of motor vehicle crashes. Causes of crashes that were brought up by the groups included:

• Reckless driving, such as wrong overtaking on the part of drivers.

• Bad road surfaces/poor roads.

• Non-maintenance of motor vehicles.

• Alteration of conditions of motor vehicles such as conversion of goods vans into passenger vehicles without the use of the appropriate construction materials.

• The excessive use of fog lights.

• Speeding in general.

• Demands for increased returns on the part of transport owners which prompts drivers to over-speed and to work when exhausted.

• Lack of road signs and markings.

• Alcohol and drug use.

Drinking patterns and attitudes

The groups were also unanimous that drinking causes relaxation, releases their inhibitions, and increases their confidence on the road. It helps them to socialise and they enjoy the taste. However, every group listed more problems associated with alcohol than good points, usually beginning with “hangovers”, addiction, “accidents”, and deaths.

The general practice was that commercial drivers concentrate their alcohol intake to early mornings, before the start of work, and late in the evenings, after the close of work, usually before the heavy evening meal. The most favored drinks were hard liquor.

When asked what they think about the relative levels of risks associated with drinking and driving, most recognized the dangers:

• “Drinking gives the driver false courage”.

• “Drinking affects one's sense of judgment”.

• “The drunk driver is always prone to over-speeding and accidents”.

• “The drunk driver does not exercise restraint at dangerous portions of the road”.

• “The drunk driver overtakes other vehicles unnecessarily”.

• “The drunk driver is a potential killer on the road”.

However, there was also an under-appreciation of the extent of drunk driving. All the focus group discussions thought alcohol use was minimal because they belonged to unionised groups or cooperatives and hence were constantly being monitored by their executives. However, it was generally agreed that some drivers may beat the executives' vigilance.

Reasons for drinking

Pressure from friends to drink seemed to be persuasive. In some cases, pressure was the result of social practices, such as funerals, baby “out-doorings”, and other social gatherings. Participants described norms that exist in these social settings that require that all of the members of a social group be “on the same level” of intoxication. At their eating places, some drivers take alcohol as appetizers.

Other reasons assigned why commercial drivers drink and drive included:

• For medicinal purposes.

“We use the local spirit ‘akpeteshie’ to prepare the herbal concoctions `bitters' which is often taken twice daily. The bitters restore our appetite for food and also help in curing so many diseases such as hernia, sight problems etc.”

• Others just have the urge to drink alcohol because they have become addicted to it.

“Some drivers do not feel okay in the absence of alcohol”.

“Drinking makes some of us alert behind the steering wheel”.

Alcohol use seems to play a significant part in the life of most commercial drivers and many focus group participants conceded that most drivers consume some form of alcoholic beverage. The one exception to this was the lorry park where many of the drivers were Muslim.

Drivers' suggestions as to ways to address drunk driving

All groups indicated that road safety as an issue is frequently discussed by the drivers.

• “We periodically organise welfare meetings where issues about road traffic accident prevention feature very prominently. We often invite personnel from the police to educate our drivers on defensive driving techniques and road safety principles”.

All agreed that drivers know that avoidance of alcohol can reduce their risk of involvement in a crash.

• “We know the harmful effects of alcohol and the role it plays in causing accidents; therefore avoiding alcohol especially while driving will reduce our involvement in road traffic accidents”.

The groups also indicated a variety of ways to decrease the problem of drunk driving by commercial drivers. In these, there was a sense that it was the very drunk drivers that were the problem and that these should be controlled. It appeared that most of the participants did not think of themselves in this sense.

• “The police should increase their patrols on all major roads especially during all public holidays so as to arrest and get rid of all drunken and other reckless drivers”.

• “Passengers must also report drivers who drink alcohol while driving to policemen who man barriers along their routes”.

• “Our executives should be firm and sanction drivers who drink and drive and also prevent the sale of alcohol at the vehicle terminals”.

Most participants think the performance of the police has not been satisfactory. While a few said that they had been tested for drunk driving by the police only once, the majority said that they had only heard of the breathalyser from other drivers or seen it demonstrated by the police. Moreover, there was a general lack of understanding of the concept of blood alcohol concentration.

• “We occasionally see policemen on the road with a machine which has a tube and we're made to blow air into the tube. The machine records certain values and the policeman tells you that you've taken alcohol. We don't know the limits to which one may take alcohol and we also do not know what the law stipulates with regards to drunk driving.”

To ensure that drivers do not drink while on the road, the following suggestions were put forward:

• All barriers leading to the city should have breathalysers; so that all drivers can be tested and those who have been found to be drunk would be prevented from continuing their journey.

• Increase enforcement procedures through frequent police patrols so that the fear of potential arrest would cause them (drivers) to alter their drinking and driving patterns.

• Drivers who are certified drunk should have their licences withdrawn and should be jailed for a period of up to three months.

• Alcohol related accidents should be treated as murder/manslaughter.

DISCUSSION

In developed countries, social marketing strategies against drunk driving, in and of themselves, have had mixed results. Many individual campaigns have not shown significant effects.^22,24 This is especially the case with those that only promote general awareness of the drunk driving problem. However, campaigns that target individual behavior change and promote an alternative behavior have been more successful such as campaigns promoting the use of designated drivers.²² Moreover, effects of such educational work tend to be noticeable only over longer periods and with repetition.²⁵

Educational campaigns are more effective when combined with other antidrunk driving interventions. The complementary nature of law enforcement and education is especially notable. Publicity about new, more stringent laws, about the increased likelihood of being caught or punished, and about the rationale for such laws are often associated with increased compliance.^21,22,26 Educational campaigns have been found to be especially effective when they are part of a comprehensive, multistrategy, community based approach. For example, the “Saving Lives Program” in Massachusetts reported a 42% decrease in fatal crashes involving alcohol in participating communities.²⁶

Probably the greatest effect of educational campaigns comes in the long term and results from changing societal norms. Such changes in developed countries have been especially useful in allowing more stringent antidrunk driving laws to be passed.^22,23

Limitations

Drivers were selected for interview using a convenience sampling method. Those available at their lorry park stations while their vehicles were loading and who were willing to participate were selected but may not be representative of all commercial drivers in Ghana. This possibility is suggested by the drivers' education levels which tended to be greater than men in the general population.²⁷ There were also better educated than the randomly selected drivers studied in the aforementioned random roadside breathalyzer study,¹⁶ among whom 30% had no formal education, compared with 16% in the current study.

Second, although the focus group discussions were anonymous, participants are likely to have given socially desirable answers. Hence, the extent of the problem of drunk driving would be under-estimated.

Third, the focus group discussions concentrated on bus drivers whereas the earlier study showed impaired driving to be even higher among taxi drivers and truck drivers. For the present, however, given the numbers of lives at stake in buses, concentrating on these drivers first is reasonable.

IMPLICATIONS FOR PREVENTION

Despite these limitations, the data from the focus group discussions provide useful insights into the attitudes of commercial drivers about drunk driving on which we can build.

Most of the drivers recognized drunk driving as a danger and a risk factor for crashes. Hence, there are existing motivations and values to start with—that is, most of the drivers do not need to be convinced that drunk driving is bad. Moreover, there seemed to widespread support for greater police enforcement in an environment where police are generally not trusted.

However, some drivers had misperceptions that need to be corrected, as reflected in statements such as that about drinking making one alert behind the wheel. To develop good social marketing strategies, more background research would be needed to better understand these misperceptions. Although a minority of drivers expressed such views, these drivers may be more likely to engage in drunk driving and hence they may be particularly important to target.

Probably the greatest misconception that needs to be addressed in educational campaigns is the under-estimation of the extent of the problem. Two problems existed in this regard. First, the drivers voiced the opinion that only a few drivers drove while intoxicated. This is clearly at odds with the results of the prior roadside breathalyzer survey.¹⁶ Second, there was widespread lack of appreciation of how much alcohol it takes to become an unsafe driver. Although the participants were all people who had consumed alcohol before driving at some time in the past year, they did not appear to recognize this as a problem. Rather, it was other drivers who were felt to be the problem. There appeared to be a sense that a driver was dangerous only if he were extremely drunk. Along the same lines, it is noteworthy that several drivers brought up the topic of breathalyzers. They indicated that they did not understand the implications of what was being measured—the amount of alcohol that could be safely or legally consumed.

A major focus for subsequent development in social marketing campaigns will be to provide specific information on the concept of blood alcohol concentration and its effect at varying levels. Such information will provide a basis for understanding that even small amounts of alcohol can increase the risk of crashes and injury, that is, that it is not just the severely intoxicated drivers who are the problem. It will also promote understanding the legal limits and the rationale behind them. These messages will need to be developed and delivered taking account of the local culture as well as the educational level, background, and the mindset of commercial drivers in Ghana.