Active transportation: do current traffic safety policies protect non-motorists?

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.

The absence of data on driving under the influence of alcohol in road traffic studies: a scoping review of non-randomized studies with vote counting based on the direction of effects of alcohol policies

BACKGROUND

Data on driving under the influence of alcohol (DUIA) are not always available, accurate, or reliable, making it difficult to study the effects of alcohol policies on road traffic outcomes. The objectives of our study were twofold: 1) to describe how road traffic outcomes of alcohol policies are assessed when DUIA data are missing, and 2) to explore the effects of alcohol policies when DUIA data are missing.

METHODS

We conducted a scoping review of non-randomized studies that assessed the road traffic outcomes of alcohol policies when DUIA data are missing. Until November 2021, we searched studies published between 2000 and 2021, in English or French, via MEDLINE, APA PsycInfo, CINAHL, and SocINDEX. We assessed the risk of bias in the included studies with the Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group. The selection process, data extraction, and the risk of bias assessment were conducted independently and in duplicate. We used vote counting based on the direction of the effects of alcohol policies as a synthesis method. The protocol for this review was published in PROSPERO under record number CRD42021266744.

RESULTS

Twenty-four eligible studies were included. Regarding objective 1, most studies used uncontrolled interrupted time series designs to assess road traffic fatalities resulting from night-time crashes. The reasons for missing DUIA data were generally not reported. Regarding objective 2, we found evidence for an association between alcohol policies and decreased road traffic fatalities. Subgroup analyses found no evidence for an association between methodological modifiers and positive effect directions for road traffic fatalities.

CONCLUSION

Caution is needed when interpreting road traffic outcomes associated with alcohol policies when DUIA data are missing. Greater efforts should be made to improve the reporting of outcomes assessments. Future studies must address several methodological issues (e.g., more granular data, well-defined intervention and implementation, and controlled designs). Our results should be compared to those from others reviews where DUIA data were available to confirm or recalibrate the associations found in studies where DUIA data were missing.

Pedestrians' unsafe road-crossing behaviors in Iran: An observational-based study in West Azerbaijan

OBJECTIVE

Pedestrians are one of the most vulnerable users in road traffic injuries (RTIs). The rate of pedestrians' fatality is high in Iran. It is worthwhile to investigate how pedestrians behave. This observational study aimed to investigate pedestrians' unsafe behaviors while crossing.

METHODS

This cross-sectional study examined the behavior of 1095 pedestrians (69.7% men) using videotaping when they crossed at two intersections and three non-intersections on a weekend and two working days in the morning, at noon, and in the evening. The information obtained was classified into 5 domains including adherence to traffic rule, violation, environmental barriers, visibility, and distraction. Data were analyzed using Stata version 17.

RESULTS

About 60% of the pedestrians ignored the crosswalk and crossed the street wherever they wanted. More than 30% ignored the vehicles passing and crossed the street inattentively. About 60% of the pedestrians committed violations. More than half of pedestrians crossed unsafe crossings diagonally or in a hurry. More than 35% wore dark clothing and had low visibility, and nearly 30% were distracted. Adolescent pedestrians did not adhere traffic rules about 6 times more than the young adult pedestrians. Pedestrians who did not adhere to traffic rules in the morning were significantly more than in the evening. Men committed a violation 1.47 times more than women. The results showed that the pedestrians committed a violation in the morning significantly more than in the evening.

CONCLUSION

The occurrence of pedestrians' unsafe behaviors in Maku was high. Unsafe behaviors were high among men and young adult pedestrians. Therefore, it's essential to implement educational interventions via different media as well as environmental interventions by different organizations to improve safe behavior among pedestrians.

Characteristics of Fatal, Pedestrian-Involved, Motor Vehicle Crashes in West Virginia: A Cross-Sectional and Spatial Analysis

Fatal, pedestrian-involved, motor vehicle collisions are increasing in the United States yet remain lower in rural states such as West Virginia. This study's purpose was to investigate the overall risk factors of pedestrian fatalities by rurality and sex in West Virginia. Data were obtained from the Fatality Analysis Reporting System. The fatality had to occur within West Virginia between 1 January 2009 and 31 December 2019. Risk factors of rural vs. urban and male vs. female crashes were determined using multivariable logistic regression models. Clustering of crash locations was analyzed using kernel density estimation and Ripley's K. Among the 254 fatalities, most victims were male (70%). Most crashes occurred at night (76%), on highways (73%), on level (71%), non-curved (84%), dry (82%) roads during fair weather conditions (82%). Nearly 34% of the victims tested positive for alcohol. Men were 2.5 times as likely to be hit in a rural area (OR = 2.5; 95% CI 1.2, 5.4), on curved roads, and 57% less likely (OR = 0.43; 95% CI 0.2, 0.9) to test positive for drugs compared to women. Crash characteristics, including location, were similar between the sexes. As many risk factors were modifiable behaviors, public health interventions to ensure pedestrian safety may be necessary.

Effect of transit-oriented design on pedestrian and cyclist safety using bivariate spatial models

INTRODUCTION

Walking and cycling for transportation provide immense benefits (e.g., health, environmental, social). However, pedestrians and bicyclists are the most vulnerable segment of the traveling public due to the lack of protective structure and difference in body mass compared with motorized vehicles. Numerous studies are dedicated to enhancing active transportation modes, but very few studies are devoted to the safety analysis of the transit stops, which serve as the important modal interface for pedestrians and bicyclists.

METHOD

This study bridges the gap by developing joint models based on the multivariate conditional autoregressive (MCAR) priors with distance-oriented neighboring weight matrix. For this purpose, transit-oriented design (TOD) related data in Los Angeles County were used for model development. Feature selection relying on both random forest (RF) and correlation analysis was employed, which leads to different covariates inputs to each of the two joint models, resulting in increased model flexibility. An integrated nested Laplace approximation (INLA) algorithm was adopted due to its fast, yet robust, analysis. For a comprehensive comparison of the predictive accuracy of models, different evaluation criteria were utilized.

RESULTS

The results demonstrate that models with correlation effect perform much better than the models without a correlation of pedestrians and bicyclists. The joint models also aid in the identification of the significant covariates contributing to the safety of each of the two active transportation modes. The findings show that population density, employment density, and bus stop density positively influence bicyclist-involved crashes, suggesting that an increase in population, employment, or the number of bus stops leads to more active modes involved collisions.

PRACTICAL APPLICATIONS

The findings of this study may prove helpful in the development and implementation of the safety management process to improve the roadway environment for the active modes in the long run.

The guilty, the unlucky, or the unaware? Assessing self-reported behavioral contributors and attributions on pedestrian crashes through structural equation modeling and mixed methods

INTRODUCTION

Recent literature suggests that the causation of pedestrians' crashes and the contribution of safety-related behaviors within them may substantially differ compared to other road users. This study aimed to test the effect of individual factors and safety-related road behaviors on the self-reported walking crashes suffered by pedestrians and, complementarily, to analyze the causes that pedestrians attributed to the crashes they suffered as pedestrians during the previous five years.

METHOD

For this cross-sectional research performed in Spain, data from a nationwide sample of 2,499 pedestrians from the 17 regions of the country were collected. Participants had a mean age of 31 years. They responded to a questionnaire on demographics, safety-related walking behaviors, and self-reported pedestrian crashes and the causes attributed to them.

RESULTS

Utilizing Structural Equation Models (SEM), it was found that self-reported walking crashes can be predicted through unintentional risky behaviors (errors). However, violations and positive behaviors remain non-significant predictors, allowing to hypothesize that they might, rather, play a key role in the pedestrian's involvement in pre-crash scenarios (critical situations preceding crashes). Also, categorical analyses allowed to determine that the causes that pedestrians attributed to the walking crashes they had suffered were principally their own errors (44.6%), rather than their own traffic violations (8.5%). Nevertheless, this trend is inverse when they believe the responsibility of the crash weighs on the driver. That is to say, they usually attribute the crash to their traffic violations rather than errors. However, many biases could help explain these attributional findings.

PRACTICAL APPLICATIONS

The results of this study highlight key differences in behavioral features and crash predictors among pedestrians, with potentially relevant applications in the study and improvement of walking safety from behavioral-based approaches.

Creating Built Environments That Expand Active Transportation and Active Living Across the United States: A Policy Statement From the American Heart Association

Physical activity is vital for the health and well-being of youth and adults, although the prevalence of physical activity continues to be low. Promoting active transportation or human-powered transportation through policy, systems, and environmental change is one of the leading evidence-based strategies to increase physical activity regardless of age, income, racial/ethnic background, ability, or disability. Initiatives often require coordination across federal, state, and local agencies. To maximize the effectiveness of all types of interventions, it is imperative to establish strong and broad partnerships across professional disciplines, community members, and advocacy groups. Health organizations can play important roles in facilitating these partnerships. This policy statement provides recommendations and resources that can improve transportation systems, enhance land use design, and provide education to support policies and environments to promote active travel. The American Heart Association supports safe, equitable active transportation policies in communities across the country that incorporate consistent implementation evaluation. Ultimately, to promote large increases in active transportation, policies need to be created, enforced, and funded across multiple sectors in a coordinated and equitable fashion. Active transportation policies should operate at 3 levels: the macroscale of land use, the mesoscale of pedestrian and bicycle networks and infrastructure such as Complete Streets policies and Safe Routes to School initiatives, and the microscale of design interventions and placemaking such as building orientation and access, street furnishings, and safety and traffic calming measures. Health professionals and organizations are encouraged to become involved in advocating for active transportation policies at all levels of government.

Evaluating the impact of penalising the use of mobile phones while driving on road traffic fatalities, serious injuries and mobile phone use: a systematic review

BACKGROUND

A vast literature has demonstrated that using mobile phones while driving increases the risk of road traffic crashes. In response, policy-makers have introduced bans and harsher penalties on using mobile phones while driving. Even though emerging evidence suggests that such measures may reduce mobile phone use and crashes, the literature has not been systematically reviewed and synthesised.

OBJECTIVE

To evaluate the impact of penalising mobile phone use while driving on road traffic fatalities, serious injuries and the prevalence of mobile phone use while driving.

METHODS

We employed a comprehensive search strategy using electronic databases, websites, handsearching and other sources to locate studies evaluating legislation on mobile phone use while driving. Randomised controlled trials, interrupted time series', controlled before-after studies with control(s) not exposed to harsher sanctions and panel data designs were included if they measured the outcomes of fatalities, serious injuries or the prevalence of mobile phone use while driving. Eligible studies were critically appraised. Due to substantial heterogeneity, the results were synthesised narratively. The synthesis structured studies according to the type of legislation and outcome measure.

RESULTS

Of the 7420 studies retrieved, 32 were included. The evidence on the effects of penalising mobile phone use while driving was weak, and somewhat inconsistent, but pointed to a potential decrease in the prevalence of mobile phone use and fatalities for all-driver primary enforcement hand-held bans and texting bans.

CONCLUSIONS

Preventing fatalities from risky driving practices may be helped by implementing harsher laws that penalise mobile phone use while driving.

Distracted Pedestrian Behavior on two Urban College Campuses

Pedestrian injuries injure about 180,000 individuals and kill 6000 each year in the United States, and pedestrian injury rates have increased each of the last several years. Distracted pedestrian behavior may play a role in the trend of increasing risk for pedestrian injury. Using in vivo behavioral coding over the course of  two weeks on two urban college campuses, this study aimed to (1) understand the type and rate of distractions engaged in by pedestrians on urban college campuses, and (2) investigate the impact of distraction on street-crossing safety and behavior. A total of 10,543 pedestrians were observed, 90% of them young adults. Over one-third of those pedestrians were distracted while actively crossing roadways. Headphones were the most common distraction (19% of all pedestrians), followed by text-messaging (8%) and talking on the phone (5%). Women were more likely to text and talk on the phone than men, and men were more likely to be wearing headphones. Distracted pedestrians were somewhat less likely to look for traffic when they entered roadways. As handheld device usage continues to increase, behavioral interventions should be developed and implemented. Changes to policy concerning distracted pedestrian behavior, including improvement of the built environment to reduce pedestrian risk, should be considered in busy pedestrian areas like urban college campuses.

Epidemiology of Pedestrian-Motor Vehicle Fatalities and Injuries, 2006-2015

INTRODUCTION

Pedestrian road safety remains a public health priority. The objective of this study is to describe trends in fatalities and injuries after pedestrian-motor vehicle collisions in the U.S. and identify associated risk factors for pedestrian fatalities.

METHODS

This is a cross-sectional study of U.S. pedestrian-motor vehicle collisions from 2006 to 2015 (performed in 2017). Pedestrian fatality and injury data were obtained from the National Highway Traffic Safety Administration's Fatality Analysis Reporting System and National Automotive Sampling System General Estimates System. Frequencies of fatalities, injuries, and associated characteristics were calculated. Multivariable logistic regression was performed for risk of fatality, controlling for demographic and crash-related factors.

RESULTS

There were 47,789 pedestrian fatalities and 674,414 injuries during the 10-year study period. Fatality rates were highest among the elderly aged 85 years and older (2.95/100,000 population), whereas injury rates were highest for those aged 15-19 years (35.23/100,000 population). Predictors associated with increased risk for death include the following: male sex (AOR=1.36, 95% CI=1.15, 1.62), age ≥65 years (AOR=3.44, 95% CI=2.62, 4.50), alcohol involvement (AOR=2.63, 95% CI=1.88, 3.67), collisions after midnight (AOR=5.21, 95% CI=3.20, 8.49), at non-intersections (AOR=2.76, 95% CI=2.21, 3.45), and involving trucks (AOR=2.15, 95% CI=1.16, 3.97) and buses (AOR=5.82, 95% CI=3.67, 9.21).

CONCLUSIONS

Potentially modifiable factors are associated with increased risk of death after pedestrian-motor vehicle collisions. Interventions including elder-friendly intersections and increasing visibility of pedestrians may aid in decreasing pedestrian injuries and deaths.

The traffic climate in China: The mediating effect of traffic safety climate between personality and dangerous driving behavior

Traffic safety climate is defined as road users' attitudes and perceptions of traffic in a specific context at a given point in time. The current study aimed to validate the Chinese version of the Traffic Climate Scale (TCS) and to explore its relation to drivers' personality and dangerous driving behavior. A sample of 413 drivers completed the Big Five Inventory (BFI), the Chinese version of the TCS, the Dula Dangerous Driving Index (DDDI) and a demographic questionnaire. Exploratory factor analysis and confirmatory factor analysis were performed to confirm a three-factor (external affective demands, internal requirements and functionality) solution of the TCS. The reliability and validity of the Chinese version of TCS were verified. More importantly, the results showed that the effect of personality on dangerous driving behavior was mediated by traffic climate. Specifically, the functionality of the TCS mediated the effect of neuroticism on negative cognitive/emotional driving and drunk driving, while openness had an indirect impact on aggressive driving, risky driving and drunk driving based on the internal requirements of the TCS. Additionally, agreeableness had a negative direct impact on four factors of the DDDI, while neuroticism had a positive direct impact on negative cognitive/emotional driving, drunk driving and risky driving. In conclusion, the Chinese version of the TCS will be useful to evaluate drivers' attitudes towards and perceptions of the requirements of traffic environment in which they participate and will also be valuable for comparing traffic cultures and environments in different countries.

The epidemiology of fatal cyclist crashes over a 14-year period in Alberta, Canada

Background

Cycling is a popular recreational activity and a common transportation option; however, cycling-related injuries can be fatal. There are few studies of cycling fatalities in Canada and none in a region as sparsely populated as Alberta.

Methods

A chart review was conducted of cyclists involved in fatal crashes. Charts for deaths that occurred between 1998 and 2011 (inclusive) were identified and abstracted onto standardized forms. Personal characteristics and crash circumstances, including motor vehicle involvement, were collected; mechanisms of fatally injured cyclists across age groups were compared. Census data were used to calculate region-specific and provincial age-specific cycling fatality rates.

Results

Charts from 101 deaths over 14 years were reviewed. Events mainly occurred during the summer. There were more fatalities in urban (64 [63 %]) than in rural settings. Collisions with motor vehicles and cyclist-only crashes accounted for 68 and 15 % of cycling fatalities, respectively. Most (87 %) deceased cyclists were male, and the median age was 47 years (inter-quartile range: 25, 58). The population-based fatality rate over the study period was highest among deceased cyclists older than 65. Helmet use was reported in 26 (26 %) cases and increased with age. Alcohol use was detected in 25 (25 %) cases.

Conclusions

Fatal cycling crashes in Alberta typically involve adults riding on urban roads and collisions with motor vehicles. While helmet legislation has reduced non-fatal cycling head injuries, deaths may be further prevented by physical separation of cyclists and motor vehicles and avoidance of substance use while operating bicycles.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2476-9) contains supplementary material, which is available to authorized users.