Effectiveness of graduated driver licensing in reducing motor vehicle crashes

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

Effects of interventions for preventing road traffic crashes: an overview of systematic reviews

BACKGROUND

Road traffic crashes (RTCs) are among the eight-leading causes of death globally. Strategies and policies have been put in place by many countries to reduce RTCs and to prevent RTCs and related injuries/deaths.

METHODS

In this review, we searched the following databases Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Epistemonikos, Web of Science, and LILACS for reviews matching our inclusion criteria between periods January 1950 and March 2020. We did not apply language or publication restrictions in the searches. We, however, excluded reviews that focused primarily on injury prevention and reviews that looked at crashes not involving a motor vehicle.

RESULTS

We identified 35 systematic reviews matching our inclusion criteria and most of the reviews (33/35) included studies strictly from high-income countries. Most reviews were published before 2015, with only 5 published between 2015 and 2020. Methodological quality varied between reviews. Most reviews focused on enforcement intervention. There was strong evidence that random breath testing, selective breath testing, and sobriety checkpoints were effective in reducing alcohol-related crashes and associated fatal and nonfatal injuries. Other reviews found that sobriety checkpoints reduced the number of crashes by 17% [CI: (- 20, - 14)]. Road safety campaigns were found to reduce the numbers of RTCs by 9% [CI: (- 11, - 8%)]. Mass media campaigns indicated some median decrease in crashes across all studies and all levels of crash severity was 10% (IQR: 6 to 14%). Converting intersections to roundabouts was associated with a reduction of 30 to 50% in the number of RTCs resulting in injury and property damage. Electronic stability control measure was found to reduce single-vehicle crashes by - 49% [95% CI: (- 55, - 42%)]. No evidence was found to indicate that post-license driver education is effective in preventing road traffic injuries or crashes.

CONCLUSION

There were many systematic reviews of varying quality available which included studies that were conducted in high-income settings. The overview has found that behavioural based interventions are very effective in reducing RTCs.

Factors Contributing to Delay in Driving Licensure Among U.S. High School Students and Young Adults

PURPOSE

More teens delay in driving licensure (DDL). It is conceivable they miss Graduated Driver Licensing (GDL) safety benefits. We assessed prevalence, disparities, and factors associated with DDL among emerging adults.

METHODS

Data used were from all seven waves (W1-7) of the NEXT Generation Health Study (W1 in 10th grade [2009-2010]). The outcome variable was DDL (long-DDL [delayed >2 years], intermediate-DDL [delayed 1-2 years] versus no-DDL), defined as participants receiving driver licensure ≥1 year after initial eligibility. Independent variables included sex, urbanicity, race/ethnicity, family structure, parental education, family affluence, parental monitoring knowledge, parent perceived importance of alcohol nonuse, and social media use. Logistic regressions were conducted.

RESULTS

Of 2,525 participants eligible for licensure, 887 (38.9%) reported intermediate-DDL and 1,078 (30.1%) long-DDL. Latinos (adjusted odds ratio [AOR] = 2.5 vs. whites) and those with lower affluence (AOR = 2.5 vs. high) had higher odds of intermediate-DDL. Latinos (AOR = 4.5 vs. whites), blacks (AOR = 2.3 vs. whites), those with single parent (AOR = 1.7 vs. both biological parents), whose parents' education was high school or less (AOR = 3.7 vs. bachelor+) and some college (AOR = 2.0 vs. bachelor+) levels, and those with lower affluence (AOR = 4.4 vs. high) had higher odds of long-DDL. Higher mother's monitoring knowledge (AOR = .6) was associated with lower odds of long-DDL, but not intermediate-DDL.

CONCLUSIONS

Some teens that DDL "age out" of protections afforded to them by GDL driver restrictions. Minority race/ethnicity, socioeconomic status, urbanicity, and parenting factors contribute to DDL. Further study of these factors and their individual/collective contributions to DDL is needed to understand potential unintended consequences of GDL, particularly in more vulnerable youth.

The impact of the 2007 graduated driver licensing law in Massachusetts on the rate of citations and licensing in teenage drivers

OBJECTIVE

We recently demonstrated that the 2007 Massachusetts Graduated Driving Licensing (GDL) law decreased the rate of motor vehicle crashes in teenage drivers. To better understand this decrease, we sought to examine the law's impact on the issuance of driving licenses and traffic citations to teenage drivers.

METHODS

Citation and license data were obtained from the Massachusetts Department of Transportation. Census data were obtained from the Census Data Center. Two study periods were defined: pre-GDL (2002-2006) and post-GDL (2007-2012). Two populations were defined: the study population (aged 16-17) and the control population (aged 25-29). The rates of licenses per population were compared pre- vs. post-GDL for the study group. The numbers of total, state, and local citations per population were compared pre- vs. post-GDL for both populations. A sensitivity analysis was performed for the rates of citations using licenses issued as a denominator.

RESULTS

While licenses per population obtained by the study group decreased over the entire period, there was no change in the rate of decrease per year pre- vs. post-GDL (2.0% vs. 1.4%; p=0.6392). In the study population, total, state, and local citations decreased post-GDL (17.8% vs. 8.1%, p<0.0001; 3.7% vs. 2.2%, p<0.0001; 14.1% vs. 5.8%, p<0.0001, respectively). In the control group, total and state citations did not change (26.7% vs. 23.9%, p=0.3606; 9.2% vs. 10.2%, p=0.3404, respectively), and local citations decreased (17.5% vs. 13.7%, p=0.0389). The rates of decrease per year for total, state, and local citations were significantly greater in the study population compared with control (p<0.0001, p=0.0002, p<0.0001, respectively).

CONCLUSIONS

The 2007 GDL law in Massachusetts was associated with fewer traffic citations without a change in the rate of licenses issued to teenagers. These findings suggest that 2007 GDL may be improving driving habits as opposed to motivating teenagers to delay the issuing of licenses.

An evaluation of the effect of Ohio's graduated driver licensing law on motor vehicle crashes and crash outcomes involving drivers 16 to 20 years of age

OBJECTIVE

Nationally, motor vehicle crashes are the leading cause of death among youth ages 16 to 20 years. Graduated driver licensing (GDL) laws have been implemented to reduce motor vehicle crashes among teen drivers. Studies have shown decreases in teen crash rates and crash-related fatality rates following enactment of GDL laws. However, GDL laws typically apply to teens only until their 18th birthday; therefore, the effect, if any, that GDL laws have on youth drivers ages 18 to 20 years and whether these programs should be extended to include these older youth warrant further study. The objective of this study was to evaluate the effects of Ohio's 2007 revised GDL law on motor vehicle crashes and crash-related injuries for crashes involving teen drivers ages 16 to 20 years, with a focus on the effects on crashes involving drivers ages 18 to 20 years.

METHODS

Cross-sectional analysis of motor vehicle crashes involving drivers ages 16 to 20 years in Ohio in the pre-GDL (2004-2006) and post-GDL (2008-2010) periods was performed. Descriptive statistics and population-based crash rates for drivers and occupants ages 16 to 20 years were calculated, as well as rate ratios and 95% confidence intervals (CIs) comparing crashes in the pre-GDL and post-GDL periods.

RESULTS

Compared with the pre-GDL period, the post-GDL period was associated with lower crash rates for drivers age 16 years (relative risk [RR] = 0.94; 95% CI, 0.90-0.98), age 17 years (RR = 0.90; 95% CI, 0.88-0.93), age 18 years (RR = 0.95; 95% CI, 0.92-0.97), and ages 16-17 years combined (RR = 0.92; 95% CI, 0.90-0.95). Crash rate was higher for the post-GDL period for drivers age 19 years (RR = 1.04; 95% CI, 1.01-1.07), age 20 years (RR = 1.09; 95% CI, 1.05-1.13), and ages 18-20 years combined (RR = 1.02; 95% CI, 1.00-1.03).

CONCLUSIONS

Unlike previous studies, this investigation used linked data to evaluate the outcomes of all occupants in crashes involving drivers ages 16-20 years. The post-GDL period was associated with lower crash, injury crash, and fatal crash involvement among drivers and occupants ages 16-17 years but higher overall crash involvement for drivers and occupants ages 19 years, 20 years, and 18-20 years combined. These findings support extending GDL restrictions to novice drivers ages 18 through 20 years to reduce crashes in that group.

A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective

This paper reviews the evidence for the effectiveness and cost-effectiveness of policies to reduce alcohol-related harm. Policies focus on price, marketing, availability, information and education, the drinking environment, drink-driving, and brief interventions and treatment. Although there is variability in research design and measured outcomes, evidence supports the effectiveness and cost-effectiveness of policies that address affordability and marketing. An adequate reduction in temporal availability, particularly late night on-sale availability, is effective and cost-effective. Individually-directed interventions delivered to at-risk drinkers and enforced legislative measures are also effective. Providing information and education increases awareness, but is not sufficient to produce long-lasting changes in behaviour. At best, interventions enacted in and around the drinking environment lead to small reductions in acute alcohol-related harm. Overall, there is a rich evidence base to support the decisions of policy makers in implementing the most effective and cost-effective policies to reduce alcohol-related harm.

Has the great recession and its aftermath reduced traffic fatalities?

An analysis of state-level data from 1984 to 2014 provides evidence on the relationship between economic recessions and US traffic fatalities. While there are large reductions associated with decreases in household median income, other policy variables tend to have additional and in some cases, larger effects. An increase in the inequality of the income distribution, measured by the Gini index, has reduced traffic fatalities. Graduated licensing policies, cell phone laws, and motorcycle helmet requirements are all associated with reductions in fatalities. Other factors include a proxy for medical technology, and access to emergency medical services (based on the percent of vehicle miles traveled in rural areas); reductions in the latter accounted for a substantial reduction in fatalities and is likely another indicator of reduced economic activity. Changes in the road network, mainly increases in the percent of collector roads has increased fatalities. Population growth is associated with increased traffic fatalities and changes in age cohorts has a small negative effect. Overall, results suggest that there has been a beneficial impact on traffic fatalities from reduced economic activity, but various policies adopted by the states have also reduced traffic fatalities.

The association between graduated driver licensing laws and travel behaviors among adolescents: an analysis of US National Household Travel Surveys

Background

Young novice drivers have crash rates higher than any other age group. To address this problem, graduated driver licensing (GDL) laws have been implemented in the United States to require an extended learner permit phase, and create night time driving or passenger restrictions for adolescent drivers. GDL allows adolescents to gain experience driving under low-risk conditions with the aim of reducing crashes. The restricted driving might increase riding with parents or on buses, which might be safer, or walking or biking, which might be more dangerous. We examined whether GDL increases non-driver travels, and whether it reduces total travels combining drivers and non-drivers.

Methods

We used data from the US National Household Travel Survey for the years 1995–1996, 2001–2002, and 2008–2009 to estimate the adjusted ratio for the number of trips and trip kilometers made by persons exposed to a GDL law, compared with those not exposed.

Results

Adolescents aged 16 years had fewer trips and kilometers as drivers when exposed to a GDL law: ratio 0.84 (95 % confidence interval (CI) 0.71, 1.00) for trips; 0.79 (0.63, 0.98) for kilometers. For adolescents aged 17 years, the trip ratio was 0.94 (0.83, 1.07) and the kilometers ratio 0.80 (0.63, 1.03). There was little association between GDL laws and trips or kilometers traveled by other methods: ratio 1.03 for trips and 1.00 for kilometers for age 16 years, 0.94 for trips and 1.07 for kilometers for age 17.

Conclusions

If these associations are causal, GDL laws reduced driving kilometers by about 20 % for 16 and 17 year olds, and reduced the number of driving trips by 16 % among 16 year olds. GDL laws showed little relationship with trips by other methods.

Understanding the social context of fatal road traffic collisions among young people: a qualitative analysis of narrative text in coroners' records

BACKGROUND

Deaths and injuries on the road remain a major cause of premature death among young people across the world. Routinely collected data usually focuses on the mechanism of road traffic collisions and basic demographic data of those involved. This study aimed to supplement these routine sources with a thematic analysis of narrative text contained in coroners' records, to explore the wider social context in which collisions occur.

METHODS

Thematic analysis of narrative text from Coroners' records, retrieved from thirty-four fatalities among young people (16-24 year olds) occurring as a result of thirty road traffic collisions in a rural county in the south of England over the period 2005-2010.

RESULTS

Six key themes emerged: social driving, driving experience, interest in motor vehicles, driving behaviour, perception of driving ability, and emotional distress. Social driving (defined as a group of related behaviours including: driving as a social event in itself (i.e. without a pre-specified destination); driving to or from a social event; driving with accompanying passengers; driving late at night; driving where alcohol or drugs were a feature of the journey) was identified as a common feature across cases.

CONCLUSIONS

Analysis of the wider social context in which road traffic collisions occur in young people can provide important information for understanding why collisions happen and developing targeted interventions to prevent them. It can complement routinely collected data, which often focuses on events immediately preceding a collision. Qualitative analysis of narrative text in coroner's records may provide a way of providing this type of information. These findings provide additional support for the case for Graduated Driver Licensing programmes to reduce collisions involving young people, and also suggest that road safety interventions need to take a more community development approach, recognising the importance of social context and focusing on social networks of young people.

Graduated driver licensing for new drivers: effects of three states' policies on crash rates among teenagers

BACKGROUND

Evidence is mixed on the effects of graduated driver licensing (GDL) on motor vehicle crashes involving drivers aged 18 years.

PURPOSE

This study examined the effects of GDL on crashes involving drivers aged 18 years in three states: Maryland, where GDL applies to novice drivers of all ages, and Florida and Michigan, where GDL applies only to new drivers aged <18 years. In addition, this study sought to confirm positive effects of GDL among drivers aged 16 and 17 years.

METHODS

Monthly rates for three levels of crash severity (fatal/disabling injury, nondisabling injury, and possible injury/property damage only [PDO]) for drivers aged 16, 17, and 18 years were calculated using crash records and census data. Data for Maryland spanned 1998 to 2009, for Florida 1990 to 2009, and Michigan 1992 to 2009. GDL's effects on teen driver crashes by age were estimated using time-series analyses, conducted in 2012.

RESULTS

Crash rates for drivers aged 16 and 17 years declined in all three states following implementation or revision of GDL. For drivers aged 18 years, revision of an existing GDL law in Maryland was followed by a 6.9% decrease in possible-injury/PDO crashes; in Michigan, GDL implementation was followed by a 3.6% increase in possible-injury/PDO crashes; and in Florida, GDL had no effect.

CONCLUSIONS

GDL led to expected declines in crash rates for drivers aged 16 and 17 years. However, the findings suggest that when GDL applies only to novice drivers aged <18 years, rather than to all novice drivers, crash rates among drivers aged 18 years may increase. In order to potentially extend the safety benefits of GDL, the age at which GDL for new drivers should be applied requires further attention.

Graduated driver licensing for reducing motor vehicle crashes among young drivers

BACKGROUND

Graduated driver licensing (GDL) has been proposed as a means of reducing crash rates among novice drivers by gradually introducing them to higher risk driving situations.

OBJECTIVES

To examine the effectiveness of GDL in reducing crash rates among young drivers.

SEARCH STRATEGY

Studies were identified through searching MEDLINE, EMBASE, CINAHL, Healthstar, Web of Science, NTIS Bibliographic Database, TRIS Online, SIGLE, the World Wide Web, conference proceedings, consultation with experts and reference lists in relevant published literature. The searches were conducted from the time of inception to May 2009, and the Cochrane Injuries Group conducted an updated search of the TRANSPORT database in September 2009.

SELECTION CRITERIA

Studies were included if: 1) they compared outcomes pre- and post-implementation of a GDL program within the same jurisdiction, 2) comparisons were made between jurisdictions with and without GDL, or 3) both. Studies had to report at least one objective, quantified outcome.

DATA COLLECTION AND ANALYSIS

Results were not pooled due to substantial heterogeneity. Percentage change was calculated for each year after the intervention, using one year prior to the intervention as baseline. Results were adjusted by internal controls. Analyses were stratified by denominators (population, licensed drivers). Results were calculated for the different crash types and presented for 16 year-olds alone as well as all teenage drivers.

MAIN RESULTS

We included 34 studies evaluating 21 GDL programs and 2 analyses of >40 US states. GDL programs were implemented in the US (n=16), Canada (n=3), New Zealand (n=1), and Australia (n=1) and varied in their restrictions during the intermediate stage. Based on the Insurance Institute for Highway Safety (IIHS) classification, eleven programs were good, four were fair, five were marginal, one was poor and two could not be assessed. Reductions in crash rates were seen in all jurisdictions and for all crash types. Among 16 year-old drivers, the median decrease in per population adjusted overall crash rates during the first year was 15.5% (range -27 to -8%, five studies). There was a decrease in per population adjusted injury crash rates (median -21%, range -46 to -2%, five studies). Results for all teenage drivers, rates per licensed driver, and rates adjusting for internal controls were generally reduced when comparing within jurisdictions.

AUTHORS' CONCLUSIONS

GDL is effective in reducing crash rates among young drivers, although the magnitude of the effect varies. The conclusions are supported by consistent findings, temporal relationship, and plausibility of the association. Stronger GDL programs (i.e. more restrictions or higher quality based on IIHS classification) appear to result in greater fatality reduction. Future studies should focus on which components and combination of components yield the greatest reductions.

[Evidence-based effectiveness of road safety interventions: a literature review]

INTRODUCTION

Only road safety interventions with scientific evidence supporting their effectiveness should be implemented. The objective of this study was to identify and summarize the available evidence on the effectiveness of road safety interventions in reducing road traffic collisions, injuries and deaths.

METHODOLOGY

All literature reviews published in scientific journals that assessed the effectiveness of one or more road safety interventions and whose outcome measure was road traffic crashes, injuries or fatalities were included. An exhaustive search was performed in scientific literature databases. The interventions were classified according to the evidence of their effectiveness in reducing road traffic injuries (effective interventions, insufficient evidence of effectiveness, ineffective interventions) following the structure of the Haddon matrix.

RESULTS

Fifty-four reviews were included. Effective interventions were found before, during and after the collision, and across all factors: a) the individual: the graduated licensing system (31% road traffic injury reduction); b) the vehicle: electronic stability control system (2 to 41% reduction); c) the infrastructure: area-wide traffic calming (0 to 20%), and d) the social environment: speed cameras (7 to 30%). Certain road safety interventions are ineffective, mostly road safety education, and others require further investigation.

CONCLUSION

The most successful interventions are those that reduce or eliminate the hazard and do not depend on changes in road users' behavior or on their knowledge of road safety issues. Interventions based exclusively on education are ineffective in reducing road traffic injuries.

An evaluation of graduated driver licensing programs in North America using a meta-analytic approach

Most jurisdictions in North America have some version of graduated driver licensing (GDL). A sound body of evidence documenting the effectiveness of GDL programs in reducing collisions, fatalities and injuries among novice drivers is available. However, information about the relative importance of individual components of GDL is lacking. The objectives of this study are to calculate a summary statistic of GDL effectiveness and to identify the most effective components of GDL programs using a meta-analytic approach. Data from 46 American States, the District of Columbia and 11 Canadian jurisdictions are used and were obtained from the Fatality Analysis Reporting System (FARS) for the U.S. and from Transport Canada's Traffic Accident Information Database (TRAID) for Canada. The timeframe of this evaluation is 1992 through 2006, inclusive. Relative fatality risks and their 95% confidence intervals were calculated using fatality counts and population data for target and comparison groups, both in a pre-implementation and post-implementation period in each jurisdiction. The target groups were 16-, 17-, 18- and 19-year-old drivers. The comparison group was 25-54-year-old drivers. The relative fatality risks of all jurisdictions were summarized using the random effects DerSimonian and Laird model. Meta-regression using Restricted Maximum Likelihood (REML) and Markov Chain Monte Carlo (MCMC) Gibbs sampling was also conducted. Strong evidence in support of GDL was found. GDL had a positive and significant impact on the relative fatality risk of 16-year-old drivers (reduction of 19.1%). Significant effects were found for meta-regression models with 16-, 18- and 19-year-old drivers. These effects include length of night restriction in the learner stage, country, driver education in the learner stage and in the intermediate stage, whether night restrictions are lifted in the intermediate stage for work purposes, passenger restriction in the intermediate stage, whether passenger restrictions in the intermediate stage are lifted if passengers are family members, and whether there is an exit test in the intermediate stage. In conclusion, several GDL program components have an important effect on the relative fatality risk of novice drivers. These results help understand how such effects are achieved.

The effect of a trauma center-based intervention program on recidivism among adolescent driving offenders

BACKGROUND

Motor vehicle crashes remain a major cause of morbidity and mortality. Adolescents are disproportionately represented among victims. Several risk-reduction programs for teenage driving offenders have consequently been introduced. The efficacy of these interventions on subsequent driving behavior is unknown. We assessed the effectiveness of drive alive (DA), a 10-hour trauma center-based interactive program designed to reduce traffic violations in adolescents.

METHODS

All subjects court-ordered to attend DA over a 2-year period were tracked. A random selection of teenagers with similar offenses in corresponding time periods served as controls. Driving records of both groups were obtained from the Bureau of Motor Vehicles. Comparisons were made at 6 months, 12 months, 18 months, 24 months, and 30 months intervals using Fisher's exact test with 0.05 for statistical significance.

RESULTS

Of 183 participants, records were available for 176 (128 male, 48 females). There were 233 controls. Six months after DA completion, 50 of 176 (28%) participants had at least one repeat offense versus 97 of 233 (42%) in controls (p = 0.0068). No differences were observed at 12 months, 18 months, 24 months, and 30 months. Similar 6 month reductions were seen in participants referred for moving violations (28.6% vs. 42%, p = 0.0205) and substance abuse-related violations (15.4% vs. 33%, p = 0.0325). Similarly, no difference in new offenses was seen at 12 months and beyond.

CONCLUSIONS

Participation in the DA program resulted in a lower rate of traffic violations in teenagers for a period lasting up till at least 6 months when compared with a control group. This effect is also seen in individuals referred for moving violations and alcohol-related offenses. Further research on educational intervention programs in interactive settings such as trauma centers is needed.

"Banned from the streets I have paid to use": an analysis of Australian print media coverage of proposals for passenger and night driving restrictions for young drivers

OBJECTIVE

To catalogue arguments that can be anticipated in public debate when passenger and night driving restrictions are being advocated.

DESIGN AND SETTING

Frame analysis of all relevant coverage of these topics in Australian print media during the three month period between June and September 2004 when intensive debate on the topic occurred.

MAIN OUTCOME MEASURES

Debating frames used in reports and commentary on passenger and night driving restrictions.

RESULTS

There were 52 relevant articles published containing seven distinct frames supporting the restrictions and six opposing them. Overall, more instances of frames supporting the restrictions were published; these mostly focused on the potential for saving lives. Opposition to the restrictions focused largely on their inappropriateness as a road safety measure as well as on the importance of young people's autonomy and freedom.

CONCLUSIONS

Advocates of passenger and night driving restrictions have a number of arguments available to advance their case; however, it is important to anticipate and address possible counter arguments. Future research should address the saliency of different arguments to the public and key decision makers in government.

Attendance at a hospital emergency department by drivers involved in automobile accidents in Italy

OBJECTIVE

This study investigated the profile of drivers involved in automobile accidents attending a hospital emergency department (ED) in Catanzaro (Italy).

METHODS

Car drivers involved in automobile accidents who were registered for emergency care between May 2003 and February 2004 were included in the study. Demographics and details of the accident were collected immediately after admittance, before examination by the medical staff. For each patient, the medical staff completed a form including diagnostic investigations and medical/surgical examination in the ED.

RESULTS

Of a total of 424 drivers included in the study 27.4% had conditions that were definitely non-urgent problems. Multiple logistic regression analysis indicated that the use of the ED as a source of non-urgent care was significantly higher among patients who were driving at a lower speed when the accident occurred, among those who presented to the ED before the implementation of the new Italian traffic code, and among those who underwent fewer diagnostic investigations and medical/surgical examinations in the ED. Most of the automobile related lesions occurred in the neck (43.9%) followed by multiple body regions (12.5%) and the upper extremities (10.4%). According to the nature of the injury a third were contusions (34%), followed by pain without physical signs and symptoms (28.8%), and dislocation, sprains, and strains (22.9%).

CONCLUSIONS

Development of health promotion and education campaigns is required to prevent the use of the ED as a source of non-urgent care by those involved in automobile accidents.

Probationary and non-probationary drivers' nighttime crashes in Western Australia, 1996-2000

INTRODUCTION

This study was designed to explore the temporal aspects of crashes for probationary and non-probationary drivers.

METHODS

Data from the West Australian Road Injury Database from 1996-2000 were used to calculate age-sex-specific crash rates per 100,000 person-days and to plot proportions of fatal and hospital crashes by time for probationary and non-probationary drivers. The population attributable risk was used to estimate the potential number of lives saved by nighttime driving restriction in the probationary period.

RESULTS

Probationary drivers were seven times more likely to crash than non-probationary drivers. While the highest number of crashes was in the daytime, probationary drivers had a higher proportion of fatal or hospitalization crashes at night than non-probationary drivers.

CONCLUSION

Restrictions on driving at night could form part of graduated driver training. Even if some probationary drivers disobeyed the restriction, a substantial reduction in car occupant fatalities and hospitalizations could result.

Graduated driver licensing for reducing motor vehicle crashes among young drivers

BACKGROUND

Graduated driver licensing (GDL) has been proposed as a means of reducing crash rates among novice drivers by gradually introducing them to higher risk driving situations.

OBJECTIVES

To examine the effectiveness of GDL systems in reducing crash rates of young drivers.

SEARCH STRATEGY

Studies were identified through searches of MEDLINE, EMBASE, CINAHL, Healthstar, Web of Science, NTIS Bibliographic Database, TRIS Online, SIGLE, the World Wide Web, relevant conference proceedings, consultation with experts and authors, and reference lists. The search was not restricted by language or publication status.

SELECTION CRITERIA

Studies were included if: 1) they compared outcomes pre- and post-implementation of a GDL program within the same jurisdiction, 2) comparisons were made between jurisdictions with and without GDL, or 3) both. Studies had to report at least one objective, quantified outcome. Two reviewers independently screened searches and assessed the full text of potentially relevant studies for inclusion using a standard form.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer and checked by a second. Additional data were requested from authors. Results were not pooled due to substantial heterogeneity between studies. Percentage change was calculated for each year after the intervention, using one year prior to the intervention as the baseline rate. Results were adjusted by internal controls. Analyses were stratified by different denominators (population, licensed drivers). Results were calculated for the different crash types (overall, injury, fatal, night-time, alcohol, and those resulting in hospitalization). Results were presented for 16 year-olds alone and all teenage drivers combined.

MAIN RESULTS

We included 13 studies evaluating 12 GDL programs that were implemented between 1979 and 1998 in the US (n=7), Canada (3), New Zealand (1), and Australia (1). Programs varied in their restrictions during the intermediate stage: e.g. night curfews (8); limitations of extra passengers (2); roadway restrictions (1). Based on the Insurance Institute for Highway Safety classification scheme, no programs were good, six were acceptable, five were marginal, and one was poor. Reductions in crash rates were seen in all jurisdictions and for all crash types. Among 16 year-old drivers, the median decrease in per population overall crash rates during the first year was 31% (range 26-41%). Per population injury crash rates were similar (median 28%, range 4-43%). Results for all teenage drivers, rates per licensed driver, and rates adjusting for internal controls were generally reduced when comparing within jurisdictions.

REVIEWERS' CONCLUSIONS

The existing evidence shows that GDL is effective in reducing the crash rates of young drivers, although the magnitude of the effect is unclear. The conclusions are supported by consistent direction of the findings, and the temporal relationship and plausibility of the association. The reviewers have made recommendations for primary research on GDL (e.g. study methods, standardized reporting of outcomes and results, long-term follow-up). The project has also shown what is needed to carry out systematic reviews of observational studies (e.g. quality assessment instruments).

What are the most effective ways of improving population health through transport interventions? Evidence from systematic reviews

STUDY OBJECTIVE

To review systematic review literature that describes the effectiveness of transport interventions in improving population health.

METHODS

Systematic review methodology was used to evaluate published and unpublished systematic reviews in any language that described the measured health effects of any mode of transport intervention.

MAIN RESULTS

28 systematic reviews were identified. The highest quality reviews indicate that the most effective transport interventions to improve health are health promotion campaigns (to prevent childhood injuries, to increase bicycle and motorcycle helmet use, and to promote children's car seat and seatbelt use), traffic calming, and specific legislation against drink driving. Driver improvement and education courses are associated with increases in crash involvement and violations.

CONCLUSIONS

Systematic reviews are able to provide evidence about effective ways of improving health through transport related interventions and also identify well intentioned but harmful interventions. Valuable additional information may exist in primary studies and systematic reviews have a role in evaluating and synthesising their findings.

Epidemiology and prevention of childhood injuries

Traumatic injury is the leading cause of death in children after infancy. The leading causes of childhood injury deaths are motor vehicle crashes, submersion injury, homicide, suicide, and fires. Injuries are not random events. Factors associated with injuries allow identification of high-risk populations and targeted interventions. Injury research includes development of conceptual models to include preinjury, event, and postevent features that can be modified to prevent or limit injuries. Successful prevention strategies often include multifaceted approaches such as education, incentives for safe human behavior, legislation/enforcement, and environmental changes. Preventive programs must weigh both societal and economic values and costs. Careful evaluation for effectiveness of injury prevention programs to decrease or limit injury continues to be a challenge. Generally, passive measure such as improved engineering are more effective than measures that require modification of human behaviors. Childhood injury prevention programs have reduced deaths from some causes such as motor vehicle crashes, but deaths from gun-related homicide and suicide remain high. Critical care providers can actively engage in both prevention efforts and improved acute care of the severely injured child.

Teen driving risk: the promise of parental influence and public policy

An analysis is presented of adolescent driving risk, the advantages of graduated licensing programs, and the potential for parent-based programs to moderate teen driving risks. Risk factors associated with youthful driving illustrate the potential importance and benefits of limiting the amount and conditions under which teens can drive. State policies, such as graduated driver licensing systems that formalize restrictions on youthful driving. have been shown to be effective. However, teen driving risks remain elevated. Parents are in a prime position to extend the benefits of state restrictions by developing and implementing their own tailored family policies on adolescent driving. Unfortunately, parents of adolescent drivers are often under-aware of the need to do so and fail to impose effective driving restrictions. An ongoing parent-based intervention to increase parental restriction on teen driving is described, and issues involved in implementing and evaluating family-centered approaches to reduce teen driving risk are raised.

A population-based study of crashes involving 16- and 17-year-old drivers: the potential benefit of graduated driver licensing restrictions

OBJECTIVE

To evaluate the potential effectiveness of graduated driver licensing programs using population-based linked data for motor vehicle crashes (MVCs) that involved teenaged drivers (TDs).

METHODS

Utah crash, inpatient hospital discharge, and emergency department databases were analyzed and probabilistically linked. We computed hospital charges and compared violations, contributing factors, seatbelt use, and passengers for TDs (16-17 years old) relative to adult drivers (18-59 years old).

RESULTS

TDs comprised 5.8% of the study population, but were involved in 19.0% of MVCs. TD crashes resulted in $11 million in inpatient hospital charges and 158 fatalities. TD crashes were 1.70 times (95% confidence interval [CI]: 1.34, 2.04) less likely to result in fatal injury to drivers than were crashes that involved adult drivers, but TDs were 2.20 times (95% CI: 1.96, 2.47) more likely to receive citations. The following were findings of the study: 1) 11% of all TD crashes but 19% of fatal TD crashes occurred between 2200 and 0600 hours; 2) TDs used seatbelts less often than did adult drivers (79.1% vs 84.4%) and less often with passengers present (81.9% vs 75.0%; 3) TDs were 1.72 times (95% CI: 1.38, 2.14) more likely to be involved in crashes that resulted in seriously or fatally injured occupants when driving with passengers than when driving alone.

CONCLUSIONS

TDs are overrepresented in MVCs. TD crashes have a higher fatality rate at night, and TDs wear seatbelts less often than do adult drivers. Passengers affect TD crash characteristics. Graduated driver licensing programs that target state-specific characteristics of TDs may decrease morbidity and mortality.