Child pedestrian deaths: sensitivity to traffic volume--evidence from the USA

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.

Road-Crossing Behavior in Complex Traffic Situations: A Comparison of Children With and Without ADHD

All children are vulnerable to pedestrian injuries, but previous research suggests children diagnosed with ADHD may have elevated risk. Child pedestrian injury risk also increases with increasing traffic volume and speed. The current study examined three hypotheses: (a) Pedestrian behavior of children with ADHD is riskier than that of typically-developing children; (b) Children's pedestrian behavior is riskier with increased traffic complexity; and (c) Pedestrian behavior of children with ADHD is influenced more by complex traffic situations than behavior of typically-developing children. A sample of 38 children ages 8-12 years, 45% diagnosed with ADHD, completed 21 virtual street-crossings, 7 in each of three levels of traffic complexity. Outcome measures included unsafe crossings, ratio of looking at traffic by time, start-delay to enter the road, time to contact with oncoming vehicles, and time waiting to cross. A repeated measure MANOVA and follow-up tests showed that all children had more unsafe crossings, shorter start-delays and shorter TTCs when exposed to increased traffic complexity compared to lighter traffic. Children with ADHD had more unsafe crossings than typically-developing children. Further, compared to typically-developing children, ADHD children had comparatively more unsafe crossings, lower time to contact and longer wait-time in more complex traffic environments. Executive function deficits among children with ADHD likely influence their behavior in complex traffic environments. Implications of the results for policy-making and preventive strategies are discussed.

Factors related to road system organisation and its association with mortality due to motor vehicle-pedestrian collisions in Guadalajara Metropolitan Area

Introduction

Traffic events are one of the five leading causes of mortality in Mexico. Pedestrians are one of the main road users involved in such incidents and have the highest mortality rate, which is regularly analysed in relation to vehicles and pedestrians, but not the built environment. The purpose of this study was to analyse the elements of the road system organisation that influences the mortality rate of pedestrians hit by motor vehicles in the Guadalajara Metropolitan Area.

Method

We designed a case and control study in which the cases were sites where a pedestrian died during 2012. The controls were sites close to where the death occurred, as well as those with road infrastructure characteristics similar to those where the events took place. We obtained the pedestrian data from the death certificates and assessed some of the environmental elements of the road sites. A logistic regression analysis was used to estimate OR; 95% CI.

Results

Road system factors related with pedestrian mortality in close locations were: the presence of bus stops on intersections in one street or both, and road system features, such as the presence of traffic islands, vehicle flow and pedestrian flow.

Conclusions

According to the urban network theory and multiple theory, the final elements resulted as risk factors due to a fault in connectivity between the nodes. A temporal analysis of urban features will help urban planners make decisions regarding the safety of pedestrians and other road users.

Time trend analyses of child pedestrian morbidity in Japan

OBJECTIVES

Road traffic injuries, particularly pedestrian injuries, are a major health issue among children worldwide. The present study quantitatively analyzed the time trends of child pedestrian injuries in Japan from 1975 to 2013 by age.

STUDY DESIGN

Time trend analysis of nationally aggregated data.

METHODS

We analyzed police data on pedestrian injuries requiring medical treatment among children aged 0-15 years occurring between 1975 and 2013. To quantify the time trends of pedestrian injury morbidity rates and to identify change-points in the trends, joinpoint regression analysis was applied by age group. Children were categorized into the age groups of 0-3, 4-6, 7-9, 10-12, and 13-15 years old.

RESULTS

Preschool children aged 0-6 years old showed continuous declining trends throughout the study period; these declining trends accelerated in the 2000s. School-age children aged 7-15 years old showed minimal changes from the early 1970s to the 1990s; of this age group, children aged 7-12 years old showed slight but significant declining trends in the first half and increasing trends in the latter half of this period. Children aged 7-15 years old showed declining trends in the 2000s. Despite the consistent declining trends among all age groups in the 2000s, the younger age groups showed steeper declines during this period.

CONCLUSIONS

The declining trends in all age groups in the 2000s may reflect the improved traffic environments in Japan although the environmental approaches are not yet sufficiently adopted yielding modest effects. The continuing contrast between preschool and school-age children may reflect different behaviour changes by age such as more restricted outdoor activities among young children.

Do school crossing guards make crossing roads safer? A quasi-experimental study of pedestrian-motor vehicle collisions in Toronto, Canada

Background

The presence of school crossing guards has been associated with more walking and more pedestrian-motor vehicle collisions (PMVCs) in area-level cross-sectional analyses. The objectives of the study were to (1) Determine the effect on PMVC rates of newly implemented crossing guards in Toronto, Canada (2) Determine where collisions were located in relation to crossing guards throughout the city, and whether they occurred during school travel times.

Methods

School crossing guards with 50 m buffers were mapped along with police-reported child PMVCs from 2000–2011. (1) A quasi-experimental study identified all age collision counts near newly implemented guards before and after implementation, modeled using repeated measures Poisson regression adjusted for season and built environment variables. (2) A retrospective cohort study of all child PMVCS throughout the city to determine the proportions of child PMVCs which occurred during school travel times and at guard locations.

Results

There were 27,827 PMVCs, with 260 PMVCs at the locations of 58 newly implemented guards. Repeated measures adjusted Poisson regression found PMVCs rates remained unchanged at guard locations after implementation (IRR 1.02, 95 % CI 0.74, 1.39). There were 568 guards citywide with 1850 child PMVCs that occurred at guard locations. The majority of child PMVCs occurred outside school travel times (n = 1155, 62 %) and of those that occurred during school travel times, only 95 (13.7 %) were at a guard location.

Conclusions

School crossing guards are a simple roadway modification to increase walking to school without apparent detrimental safety effects. Other more permanent interventions are necessary to address the frequency of child PMVCs occurring away from the location of crossing guards, and outside of school travel times.

Nationwide study of injury-related deaths among children aged 1-4 years in China, 2000-2008

AIMS

The aims of this study are to investigate injury mortality in children aged 1-4 years, to analyse prevalent mortality rates of childhood injury and to identify the leading causes of child injury deaths in China from 2000 to 2008.

METHODS

The data were obtained from a nationwide mortality surveillance system for children under 5 years of age in China. The injury mortality rates of children aged 1-4 years were compared between rural and urban areas, boys and girls and among five major injury types between 2000 and 2008.

RESULTS

During the 9-year study period, the injury mortality rates for children aged 1-4 years declined significantly by an average of 5.4% each year (P < 0.001; 95% confidence interval (CI): 3.6-7.0%) overall in China, with a decrease of 4.8% (P < 0.001; 95% CI: 2.5-7.1%) and 9.9% (P < 0.001; 95% CI: 4.9-14.7%) in rural and urban areas, respectively. The proportion of injury-related deaths to total mortality rates dropped from 32.9% in 2000 to 18.8% in 2008 in urban areas but increased from 45.6% to 56.9% in rural areas. The injury mortality rates in both boys and girls decreased significantly by an average of 5.4% each year (P < 0.001; 95% CI: 2.6-8.0%) and 6.1% (P < 0.001; 95% CI: 2.7-9.4%), respectively. Drowning and traffic accidents were the most prevalent causes of injury-related deaths in children aged 1-4 years.

CONCLUSION

Childhood injury is still the leading cause of death in children aged 1-4 years in China. Drowning and traffic accidents were the most prevalent causes of childhood deaths in this study. Boys living in rural areas are at a higher risk and therefore require increased attention to help control and prevent childhood injury.

A geographic analysis of collisions involving child pedestrians in a large Southern California county

OBJECTIVES

The goal of this study is to explore the relationship between child pedestrian injuries and socioeconomic characteristics of neighborhoods in the context of local traffic volume.

METHODS

Child pedestrian collisions were identified in the data of the California Statewide Integrated Traffic Records System (SWITRS). Nine hundred sixty crashes over a 5-year period were identified, geocoded, and mapped to Orange County census tracts. Census data from 2000 were used to identify tracts, population, and population characteristics in the county of approximately 3,000,000 individuals. Pedestrian collision maps were merged with census characteristics and analyzed using STATA (Version 10.1, Stata Corp, College Station, IX) to determine correlations between socioeconomic factors and collision rates within census tracts.

RESULTS

The percentage of the population living in households with low income (less than 185% of the federal poverty level) was the strongest predictor of pedestrian injuries. One fourth of census tracts had less than 9 percent of residents with low income and averaged 6 per 100,000 child pedestrian crashes annually. One fourth of the census tracts had more than 32 percent of residents with low income and an average of 56 child pedestrian crashes per 100,000 annually. These data indicate an 8.8-fold increase in collision frequency in the lowest income quartile over the highest income quartile. Other socioeconomic correlates strongly associated with increased child collisions include population density, proportion of population speaking English less than very well, lack of high school education, number of multifamily residences, and Latino ethnicity.

CONCLUSIONS

Our study showed that child pedestrian collisions are nearly 9 times more frequent in the poorest quartile of neighborhoods than in the richest quartile. Other factors associated with increased pediatric collision risk include increased neighborhood crowding, low levels of education and English speaking ability, and Latino ethnicity.

Road traffic injuries in the People's Republic of China, 1951-2008

OBJECTIVE

Road traffic injuries (RTIs) have become the leading cause of injury deaths in China. This article analyzed the trends in all crashes, nonfatal injuries, and fatalities from road traffic crashes from 1951 to 2008 and compared the crash frequency, crash severity, and crash patterns by provinces, types of road, and injured road users.

METHODS

Road traffic crash data were obtained from the Bureau of Traffic Management at the Ministry of Public Security and National Bureau of Statistics of China. Descriptive statistical analyses were conducted.

RESULTS

Over the past 5 decades, road traffic injuries have increased substantially in China. From 1951 to 2008, the total number of road traffic crashes, nonfatal injuries, and fatalities increased by 43-fold, 58-fold, and 85-fold, respectively. Linear regression suggested a significant decline of 30.1 percent (95% confidence interval [CI]: 24.8-35.3) in the mortality rate per 100,000 people during the period 2002 to 2008. From 2004 to 2008, road traffic crash mortality rate per 100,000 people varied greatly in China from the lowest of 3.0 in Henan in 2008 to the highest of 21.7 in Xizang in 2004. RTIs in China disproportionally affected the following populations: males, persons 21 to 50 years of age, pedestrians, and motorcyclists/bicyclists. Adults aged more than 65 years accounted for approximately 10 percent of total road traffic deaths. Road types and RTIs severity were closely related; highways were associated with greater mortality rates.

CONCLUSION

Road traffic injuries have become a burgeoning public health problem in China. Programs need to be developed to prevent nonfatal injuries and fatalities caused by road traffic crashes in this emerging country.

Policy at the crossroads: climate change and injury control

Climate change policy presents unprecedented opportunities for injury control

Relationships between child, family and neighbourhood characteristics and childhood injury: a cohort study

There has been little research into the role of neighbourhood effects in childhood injury. We report results from a cohort study, comprising 1717 families (2357 children aged 0-7 years) registered at 47 general practices in Nottingham, UK. Multi-level Poisson regression examined relationships between electoral ward (neighbourhood), family and child characteristics and medically attended injury rates. Primary care attendance rates were higher for children in rented accommodation and those aged 2-3 years. An n-shaped relationship was found between geographical access to services and the primary care attendance rate. Accident and Emergency (A&E) department attendance rates were higher amongst boys, children in rented accommodation, with a teenage mother, aged 2-5 years and living in wards with a higher number of parks and play areas. They were lower for children whose families had a smoke alarm. Hospital admission rates were higher amongst children living in more deprived wards and wards with higher violent crime rates. They were lower in children whose families had smoke alarms, stair gates and stored sharp objects safely. Primary care and A&E attendance rates varied significantly between families. Variation between wards in the A&E attendance rate was explained by family characteristics. We conclude that characteristics of wards, families and children are associated with medically attended childhood injury rates. This study did not find a neighbourhood effect for A&E attendances that could not be explained by family level characteristics. Studies with greater power and a measure of injury severity independent of health service utilisation are needed to explore the relationship between neighbourhood effects and more severe injuries. The greater variation in injury rates vary between families than between neighbourhoods suggests reducing inequalities in injury rates may be achieved more effectively by focussing prevention at families rather than neighbourhoods, but in practice interventions at both levels are likely to be necessary.

Mathematical models assuming selective recruitment fitted to data for driver mortality and seat belt use in Japan

Previous research has indicated that unbelted drivers are at higher risk of involvement in fatal crashes than belted drivers, suggesting selective recruitment that high-risk drivers are unlikely to become belt users. However, how the risk of involvement in fatal crashes among unbelted drivers varies according to the level of seat belt use among general drivers has yet to be clearly quantified. We, therefore, developed mathematical models describing the risk of fatal crashes in relation to seat belt use among the general public, and explored how these models fitted to changes in driver mortality and changes in observed seat belt use using Japanese data. Mortality data between 1979 and 1994 were obtained from vital statistics, and mortality data in the daytime and nighttime between 1980 and 2001 and belt use data between 1979 and 2001 were obtained from the National Police Agency. Regardless of the data set analyzed, exponential models, assuming that high-risk drivers would gradually become belt users in order of increasing risk as seat belt use among general motorists reached high levels, showed the best fit. Our models provide an insight into behavioral changes among high-risk drivers and support the selective recruitment hypothesis.

Children's exposure to traffic and risk of pedestrian injury in an urban setting

Pedestrian injuries to children represent a major urban health problem in the United States. Thousands of children each year are struck by moving motor vehicles; such collisions result in numerous hospitalizations and deaths. At particular risk are young school-age children between the ages of 5 and 9 years. Using a survey methodology, we collected data regarding the method by which children in an urban setting travel to and from school, in addition to the number of streets they cross in a typical school day. This information was compared with data from police records on street intersection locations of pedestrian collisions. There is a wide variation in the number of streets children cross in 1 day, calculated as the number of streets crossed in the entire day, not only those crossed to and from school. Children whose parents own a car and home cross an average of 3.7 streets per day, whereas children whose parents do not own both a car and home cross an average of 5.4 streets per day; this difference is highly significant (P < 0.0001). The largest differences in traffic exposure are between families reporting car- and-home ownership (x = 3.70 streets) versus those who do not own both a car and home (x = 5.39 streets) (Mann-Whitney = -5.5, P < 0.0001). There is a significant correlation between the proportion of children driven home from school and the rate of pedestrian injury in different regions of Baltimore. In areas where children are driven home, rates of pedestrian injury are significantly lower, whereas in areas where children walk home, rates of pedestrian injury are high (r = -0.79, P < 0.01). This study underscores the importance of adapting the child's environment to prevent injury. Interventions that alter the nature of the hazard are indicated. Changing the environment may ultimately prove more useful than attempting to change children's behavior.