The impact and sustainability of the graduated driver licensing program in preventing motor vehicle crashes in Massachusetts

Day to Day Advocacy by Pediatric Health Care Providers

This manuscript highlights the impressive advocacy work that members of the American Academy of Pediatrics have achieved and serves to inspire pediatric health care providers of all specialties to pursue such efforts beyond the acute physical need of the child. This article represents one of the Symposia presented at the 2023 American Academy of Pediatrics Section on Surgery.

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.

A systematic review of the evidence for effectiveness of interventions to address transport and other unintentional injuries among adolescents

INTRODUCTION

Globally, injuries are a leading cause of mortality and morbidity for adolescents, which disproportionately affect the disadvantaged. To build an investment case for adolescent injury prevention, evidence is needed as to effective interventions.

METHODS

A systematic review of peer-reviewed original research published between 2010-2022 was conducted. CINAHL, Cochrane Central, Embase, Medline and PsycINFO databases were searched for studies reporting the effectiveness of unintentional injury prevention interventions for adolescents (10-24 years), with assessment of study quality and equity (e.g., age, gender, ethnicity, socio-economic status).

RESULTS

Sixty-two studies were included; 59 (95.2%) from high-income countries (HIC). Thirty-eight studies (61.3%) reported no aspect of equity. Thirty-six studies (58.1%) reported prevention of sports injuries (commonly neuromuscular training often focused on soccer-related injuries, rule changes and protective equipment). Twenty-one studies (33.9%) reported prevention of road traffic injury, with legislative approaches, commonly graduated driver licensing schemes, found to be effective in reducing fatal and nonfatal road traffic injury. Seven studies reported interventions for other unintentional injuries (e.g., falls).

DISCUSSION

Interventions were strongly biased towards HIC, which does not reflect the global distribution of adolescent injury burden. Low consideration of equity in included studies indicates current evidence largely excludes adolescent populations at increased risk of injury. A large proportion of studies evaluated interventions to prevent sports injury, a prevalent yet low severity injury mechanism. Findings highlight the importance of education and enforcement alongside legislative approaches for preventing adolescent transport injuries. Despite drowning being a leading cause of injury-related harm among adolescents, no interventions were identified.

CONCLUSION

This review provides evidence to support investment in effective adolescent injury prevention interventions. Further evidence of effectiveness is needed, especially for low- and middle-income countries, populations at increased risk of injury who would benefit from greater consideration of equity and for high lethality injury mechanisms like drowning.

Estimating the avoidable burden and population attributable fraction of human risk factors of road traffic injuries in iran: application of penalization, bias reduction and sparse data analysis

The aim of this study was to prioritize human risk factors for preventive interventions by estimating the avoidable burden and population attributable fraction (PAF) of each risk factor using penalization and data augmentation method. To avoid the sparse data bias, Bayesian logistic regression via data augmentation methods, were used for multivariable analysis. Informative normal priors adopted from the studies were used for the studied human risk factors. Weakly informative log-f was used for the covariates. The population attributable fraction was calculated based on direct method. The comparative risk assessment methodology of the WHO was used to estimate the potential impact fraction for each risk factor. The most important human factors influencing the traffic-related deaths were overspeeding (OR = 9.6, 95% CI: 2.45-37.7), reckless overtaking (OR = 8.6, 95% CI: 1.82-40.7), and fatigue and drowsiness (OR = 6.7, 95% CI: 1.79-25). The total PAF for the all studied risk factors was about 56% (PAF = 0.567, 95% CI: 0.37-0.7). The greatest avoidable burden was related to fatigue and drowsiness, overspeeding, and not fastening seatbelt. By considering the high contribution of human risk factors in occurrence of fatal traffic injuries appropriate legislation and prevention programs for these risk factors would decrease half of such deaths.

Trends in potentially preventable trauma deaths between 2005-2006 and 2012-2013

BACKGROUND

Most studies of trauma deaths include non-preventable deaths, potentially limiting successful intervention efforts. In this study we aimed to compare the potentially preventable trauma deaths between 2 time periods at our institution.

METHODS

Trauma patients who died in our hospital in 2005-2006 or 2012-2013 were included, non-preventable deaths were excluded from analysis. The Mann-Whitney and chi square test were used to compare variables between both time periods.

RESULTS

80% of deaths were non-preventable. Between the study time periods there was a decrease in potentially preventable deaths, from 29% to 12%, p < 0.001. Head injury deaths significantly decreased (40.6%-24.6%, p = 0.03), while hemorrhage deaths were stable during both time periods (47.6%-43.1%, p = 0.55).

CONCLUSION

Potentially preventable trauma deaths decreased during the study period. Hemorrhage remains constant as the leading cause of potentially preventable deaths. Continued research to improve survival from hemorrhage is warranted.

Graduated driver licensing (GDL) in the United States in 2016: A literature review and commentary

This is the sixth in a series of reviews of research on graduated driver licensing (GDL) published in the Journal of Safety Research, the present review covering the period mid-2012 through 2016. In the two decades since GDL programs began to be introduced on a widespread basis in the United States, a vast amount of research has been published. The current review discusses recent research and the present state of knowledge on the following topics: characteristics of the novice driver population; effects of GDL on crashes for ages 16-19; the learner and intermediate periods; night and passenger restrictions; cellphone laws; GDL for older novices; enforcement of GDL rules; and programs attempting to influence GDL compliance and safe driving practices in general. GDL stands out as a successful policy for reducing teen driver crashes and is worth building on to extend its benefits. Strengthening existing GDL programs has the most potential for producing further crash reductions.

Pathways linking car transport for young adults and the public health in Northern Ireland: a qualitative study to inform the evaluation of graduated driver licensing

Background

Novice drivers are at relatively high risk of road traffic injury. There is good evidence that Graduated Driving Licensing (GDL) schemes reduce collisions rates, by reducing exposure to risk and by extending learning periods. Legislation for a proposed scheme in Northern Ireland was passed in 2016, providing an opportunity for future evaluation of the full public health impacts of a scheme in a European context within a natural experiment. This qualitative study was designed to inform the logic model for such an evaluation, and provide baseline qualitative data on the role of private cars in health and wellbeing.

Methods

Nine group interviews with young people aged 16–23 (N = 43) and two group interviews with parents of young people (N = 8) were conducted in a range of settings in Northern Ireland in 2015. Data were analysed using thematic content analysis.

Results

Informal car-pooling within and beyond households led to routine expectations of lift provision and uptake. Experiences of risky driving situations were widespread. In rural areas, extensive use of farm vehicles for transport needs meant many learner drivers had both early driving experience and expectations that legislation may have to be locally adapted to meet social needs. Cars were used as a site for socialising, as well as essential means of transport. Alternative modes (public transport, walking and cycling) were held in low esteem, even where available. Recall of other transport-related public health messages and parents’ existing use of GDL-type restrictions suggested GDL schemes were acceptable in principle. There was growing awareness and use of in-car technologies (telematics) used by insurance companies to reward good driving.

Conclusions

Key issues to consider in evaluating the broader public health impact of GDL will include: changes in injury rates for licensed car occupants and other populations and modes; changes in exposure to risk in the licensed and general population; and impact on transport exclusion. We suggest an important pathway will be change in social norms around offering and accepting lifts and to risk-taking. The growing adoption of in-car telematics will have implications for future GDL programmes and for evaluation.

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.

Description of Various Factors Contributing to Traffic Accidents in Youth and Measures Proposed to Alleviate Recurrence

Traffic accidents are the leading cause of hospitalization in adolescence, with the 18-24-year-old age group accounting for 23% of deaths by traffic accidents. Recurrence rate is also high. One in four teenagers will have a relapse within the year following the first accident. Cognitive impairments known in adolescence could cause risky behaviors, defined as repetitive engagement in dangerous situations such as road accidents. Two categories of factors seem to be associated with traffic accidents: (1) factors specific to the traffic environment and (2) "human" factors, which seem to be the most influential. Moreover, the establishment of a stronger relation to high speed driving increases traffic accident risks and can also be intensified by sensation seeking. Other factors such as substance use (alcohol, drugs, and "binge drinking") are also identified as risk factors. Furthermore, cell phone use while driving and attention deficit disorder with or without hyperactivity also seem to be important risk factors for car accidents. The family environment strongly influences a young person's driving behavior. Some interventional driving strategies and preventive measures have reduced the risk of traffic accidents among young people, such as the graduated driver licensing program and advertising campaigns. So far, few therapeutic approaches have been implemented. Reason why, we decided to set up an innovative strategy consisting of a therapeutic postaccident group intervention, entitled the ECARR2 protocol, to prevent recurrence among adolescents and young adults identified at risk, taking into account the multiple risk factors.

Health care utilization and charges following the enactment of the 2007 Graduated Drivers Licensing Law in Massachusetts

BACKGROUND

Graduated Drivers Licensing (GDL) programs phase in driving privileges for teenagers. In 2007, Massachusetts implemented a stricter version of the 1998 GDL law, with increased fines and education. This study evaluated the impact of the law on motor vehicle crash (MVC)-related health care utilization and charges.

METHODS

Massachusetts government and US Census Bureau data were analyzed to compare the rates of MVC-related emergency department (ED) visits and hospital charges before (2002-2006) and after (2007-2011) the 2007 GDL law. Three driver age groups were studied: 16-17 (evaluating the law effect), 18-20 (evaluating the sustainability of the effect), and 25-29 years old (control group).

RESULTS

MVC-related ED visits per population decreased after the law for all three age groups (16-17: 2326 to 713; 18-20: 2110 to 1304; 25-29: 1694 to 1228; per 100,000, p<0.001), but the decrease was greater amongst teenagers (16-17: -69%; 18-20: -38%) compared to the control group (-27%); p<0.001. MVC-related hospital charges per population also decreased for teenagers but increased for the control group (16-17: $2.70 m to $1.45 m; 18-20: $3.52 m to $2.26 m; 25-29: $1.86 m to $1.92 m; per 100,000, p<0.001).

CONCLUSIONS

The 2007 GDL law in Massachusetts was associated with significant decreases in MVC-related health care utilization and hospital charges among teenage drivers.

Injury Prevention as an Integral Part of Health System Reform Efforts: Lessons Learned from Recently Enacted Massachusetts Laws

Abstract-Injury is the leading cause of mortality in people younger than 44 years of age. Injury prevention laws and policies are not only effective in saving lives at a population level but are also remarkably cost-effective compared to most public health interventions. For example, the implementation of a stricter Massachusetts Graduated Driver Licensing Law in 2007 resulted in a very significant and rapid decrease in the rates of motor vehicle crashes of teenager drivers, saved thousands of lives, and resulted in more than $10 million dollars savings in health care costs over 5 years. We therefore suggest that trauma and injury prevention should be made a priority in any attempt at local, regional, or national health system reform.