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Table of Contents
REVIEW ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 46-56

Factors affecting the severity of pedestrian traffic crashes


1 Occupational Health and Safety Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
2 Clinical Research Development Unit of Besat Hospital, Hamadan University of Medical Sciences, Hamadan, Iran
3 Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
4 Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
5 Community Based Participatory Research Center, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
6 Department of Environmental Health Engineering, Student Research Committee, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
7 Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran
8 Department of Public Health, School of Public Health, Social Determinants of Health Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
9 Department of Clinical Psychology, School of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran

Date of Submission29-Jan-2019
Date of Acceptance04-May-2019
Date of Web Publication07-Oct-2019

Correspondence Address:
Mr. Yadolah Fakhri
Ph.D Candidate, Department of Environmental Health Engineering, Student Research Committee, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/atr.atr_6_19

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  Abstract 

Background: Considering the importance of pedestrian traffic crashes and the role of environmental and demographic factors in the severity of these crashes, this article aimed to review the published evidence and synthesize the results of related studies to determine any associations between demographic and environmental factors and the severity of pedestrian-vehicle crashes. Methods: All epidemiological studies published from 1970 to 2019 were searched in international electronic databases (PubMed [Medline], Scopus, Web of Science, Embase, ScienceDirect, and Ovid) and reference lists of the identified articles were also searched. Studies were included if they investigated the severity of pedestrian-vehicle crashes as outcome, measured any environmental and demographic factors for pedestrian-vehicular crashes as exposure, designed observational, and if they were written in all languages. Quality of included studies was evaluated using the strengthening the reporting of observational studies in epidemiology checklist for observational studies. Results: We found 3126 references among which 24 studies were included in this review. All retrieved studies were conducted between 1990 and 2019 and had a cross-sectional design. In most of these studies, the associations between environmental and demographic variables such as vehicle speed or speed limits, pedestrian age, lighting, type of road, type of vehicle, and alcohol intake with the severity of pedestrian traffic crashes were examined. Conclusion: This study showed that few studies were conducted in this area; in fact, most of the studies were carried out in metropolises of developed countries. As a result, studies which provide strong causal inferences by focusing on high-risk groups and a higher level of evidence such as cohort and case-control ones are needed in developing countries.

Keywords: Pedestrian, review, severity of traffic crash


How to cite this article:
Moradi A, Ameri P, Rahmni K, Najafi M, Jamshidi E, Fakhri Y, Khazaei S, Moeini B, Amjadian M. Factors affecting the severity of pedestrian traffic crashes. Arch Trauma Res 2019;8:46-56

How to cite this URL:
Moradi A, Ameri P, Rahmni K, Najafi M, Jamshidi E, Fakhri Y, Khazaei S, Moeini B, Amjadian M. Factors affecting the severity of pedestrian traffic crashes. Arch Trauma Res [serial online] 2019 [cited 2019 Oct 17];8:46-56. Available from: http://www.archtrauma.com/text.asp?2019/8/2/46/268663


  Introduction Top


Deaths and injuries of pedestrians caused by traffic crashes have been growing in recent years in the world.[1] Globally, pedestrians constituted 22% of those killed on the world's roads. Each year, about 270,000 pedestrians lost their lives due to traffic crashes.[2] Pedestrians also accounted for the highest rate of traffic fatalities in the world's most populated cities. For example, in the cities of Mumbai and New Delhi, deaths of pedestrians constituted 78% and 53% of the traffic fatalities, respectively.[3]

Moreover, world statistics showed that there was a difference in the ratio of pedestrian deaths to the whole traffic fatalities in different countries. This proportion is much higher in developing countries than in developed ones. For example, 86% and 68% of traffic deaths were because of pedestrian traffic crashes in Peru and Mozambique, respectively, while they were 13% and 26% for the United States of America and Canada, respectively.[4],[5]

In addition, injuries in pedestrian – vehicle crashes were usually more severe in low- and middle-income countries than in developed ones. However, the proportion of deaths and injuries and the number of cars did not fit. For example, 80% of the cars are in North America, Western Europe, and Japan which only included 15% of the population, whereas 85% of traffic deaths and 90% of disabilities resulting from pedestrian traffic crashes occurred in low- and middle-income countries.[6],[7],[8],[9],[10]

Furthermore, a significant number of victims in traffic crashes were child and teenager pedestrians. According to the World Health Organization (WHO), approximately 21% of traffic crash fatalities were related to child pedestrians, and about 720 child pedestrians lost their lives daily in road crashes.[11]

Given the importance of this issue and lack of a review on existing relevant studies to determine the role of demographic and environmental factors in the severity of pedestrian-vehicle traffic crashes, this review aimed to find, evaluate, and synthesize the results of relevant studies to determine environmental and demographic factors, which were associated with the severity of pedestrian-vehicle crashes.

Objectives

This article aimed to review the published evidence and synthesize the results of related studies to determine any associations between demographic and environmental factors and the severity of pedestrian-vehicle crashes.


  Methods Top


This study sought to identify all observational studies which investigated the association between environmental and demographic factors and the severity of pedestrian-vehicle crashes from 1970 to 2019. The question addressed in this review was: which environmental and demographic factors were significantly associated with severity of pedestrian-vehicle crashes as an outcome?

PubMed (Medline), Scopus, Web of Science, Embase, ScienceDirect, and Ovid databases were searched for published articles and reports. Reference lists of identified articles and proceedings of relevant conferences were also hand-searched. The search was done as follows: (pedestrian) AND (crashes OR vehicle collisions OR injury OR casualties OR hazard OR risk factor OR safety OR security OR environmental attributes OR demographic attributes OR environmental characteristics OR built environment OR vehicle speed OR road segments OR traffic OR transportation OR alcohol intake).

In fact, studies were included if they investigated the severity of pedestrian-vehicle crashes as outcome, measured any environmental and demographic factors for pedestrian-vehicular crashes as exposure, designed observational, and if they were written in all languages. Moreover, assessment of the quality of the studies was done as follows: Published articles in indexed and peer review journals were considered to be the indication for the quality of these articles. In addition, quality of articles published in nonindexed journals, reports, and books published by UN agencies (WHO, UNESCO, UNICEF) and the World Bank, and the proceedings of conferences and seminars were assessed by experts in epidemiology and traffic crashes using the strengthening the reporting of observational studies in epidemiology checklist.

In fact, titles and abstracts of the studies were reviewed by two separate Ph. D. candidates of Epidemiology. Articles and reports that were deemed irrelevant by these two reviewers were excluded from the study list. The number of excluded articles and their titles were recorded. Then, the full text of articles and reports were retrieved and referred to two independent teams of reviewers. Each team separately extracted the answers to the research question from the contents of the paper and took the necessary notes. In case of any discrepancy, the original text of the article was evaluated by the project supervisor and decisions were made.


  Results Top


The reviewers scanned 3126 studies; 3088 titles were irrelevant to the objectives of this review and they were excluded from the study. Full texts of the remaining 38 studies were retrieved and screened, among which, 24 studies met the inclusion criteria. [Figure 1] shows the selection process of enrolled studies. All retrieved studies were conducted from 1990 to 2019 and used a cross-sectional design. Characteristics of the studies, including the country, study population, data source, sample size, study period, main results, and the statistical model used in the study, are summarized in [Table 1].
Figure 1: Selection process of the studies

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Table 1: Characteristics of studies included in the review

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The results of the studies which investigated the associations between demographic and environmental variables (independent variables) such as vehicle speed/speed limit, pedestrian age, lighting (light condition), types of road, alcohol intake, and vehicle type with the severity of traffic crashes (dependent variable) were as follows:

Vehicle speed or speed limit

In 14 of the 24 reviewed studies, the associations between the severity of pedestrian-related traffic crashes and vehicle speed or speed limit were statistically significant.[12],[14],[15],[17],[18],[19],[21],[22],[23],[25],[26],[27],[28],[34] These studies used various indicators including speed limit, vehicle speed, speeding, impact speed, unsafe speed and speed. The speed was measured in miles per hour (mph) in a number of studies and kilometers per hour (km/h) in the others. The significance level ranged from P < 0.05 to P < 0.00001. In a study conducted by Mohamed et al., the significance level was P < 0.00001 which was higher than that in other studies. In this study, the statistical population was the total population, and pedestrian death was used as an outcome variable.[23] The correlation was positive in the majority of studies. In other words, studies showed that with the increase of vehicle speed or speed limit, the severity of pedestrian crashes also increased.

Pedestrian age

In 16 out of the 24 studies, the associations between the severity of pedestrian crashes and pedestrian age were statistically significant.[13],[15],[17],[18],[19],[20],[22],[23],[26],[27],[33] In all 10 studies, by increasing the age of pedestrians, the severity of pedestrian traffic crashes also increased and hence that, the severity of injuries was reported to be higher in the elderly people over 60 years old. The significance level ranged from P < 0.05 to P < 0.000001. The significance level, in the study of Zajac and Ivan, was higher than that in other studies (P< 0.000001). In this study, the statistical population was the total population, and the severity of injury was used as an outcome variable.[13]

Light condition

In 13 out of 24 studies, the associations between the severity of pedestrian crashes and lighting were statistically significant.[14],[15],[18],[20].[21],[22],[23],[24],[26],[27],[28],[29],[30] These studies used various indicators including lighting, daylight, and light conditions. The significance level ranged from P < 0.05 to P < 0.0001. In a study conducted by Mohamed et al., the significance level was reported to be higher than that in other studies (P< 0.0001). In this study, the statistical population was the total population, and pedestrian death was used as an outcome variable.[23] The correlation was positive in the majority of the studies. In other words, these studies demonstrated that when darkness increased (with light decreasing), the severity of pedestrian crashes also increased.

Type of road

Twelve of 24 reviewed studies showed statistically significant associations between the severity of pedestrian crashes and type of the road.[5],[17],[19],[21],[23],[25],[26],[27],[29],[30],[32] In most of these studies, the number of traffic lanes in the carriageway was used to divide roads in the area, and in few studies, roads were divided into national and state, urban and rural or main, and side roads. The significance level ranged from P < 0.05 to P < 0.001. In the study of Zhao et al., the significance level was higher than that in other studies (P< 0.001). In this study, the statistical population was over 18 years, and the pedestrian death was used as an outcome variable.[25]

Alcohol intake

In 10 of 24 studies, the associations between the severity of pedestrian crashes and alcohol intake by drivers or pedestrians were statistically significant.[13],[14],[15],[19],[20],[21],[22],[23],[26],[34] All of these studies showed that when alcohol intake level increased, the severity of pedestrian crashes also increased. The significance level ranged from P < 0.05 to P < 0.0001. In studies by Zhang et al., MacLeod et al., and Mohamed et al., the significance level was higher than that in other studies (P< 0.0001).[22],[23],[26] The statistical population in all three studies was the total population, and pedestrian death was used as an outcome variable.

Type of vehicle

In this study, 12 of the 24 studies showed that there was a significant association between the severity of pedestrian crashes and type of vehicle.[13],[14],[20],[21],[23],[24],[26],[27],[28],[29],[30],[32] In these studies, the severity of pedestrian injuries caused by heavy vehicles crashes such as trucks and buses was compared to those caused by light-motor vehicles. These studies showed that in heavy vehicle-related crashes, severity of pedestrian injuries was much higher. The significance level ranged from P < 0.01 to P < 0.05. In studies by Zhang et al., the significance level was higher than that in other studies (P< 0.01). The statistical population was the total population, and the pedestrian fatality and serious injury were used as outcome variables.[26]

There was also a significant association between variables such as time of day, weather, traffic control, pedestrian action (crossing roads or junctions), location of pedestrian crossing, commercial and industrial land use, population density, mixed-use (this word is often used to indicate a mix of housing types, for example, detached houses and apartments.[35]) pedestrian sex, pedestrian clothing, weekday, driver sex, driver job, average income, season, traffic attributes in terms of presence of signal control, number of road lanes, driver skills, transit access, and pedestrian negligence with the severity of pedestrian-related crashes in, at least, one of the reviewed studies.


  Discussion Top


This review article summarized the results of related studies conducted worldwide to assess the role of demographic and environmental factors in the severity of pedestrian-vehicular traffic crashes. In the reviewed studies, a relatively wide range of demographic and environmental factors affecting the severity of pedestrian crashes was investigated. Most of these studies were carried out in the United States and in most cases, the binary or multinomial logistic regression and ordered probit models were used to measure the association between dependent and independent variables. Furthermore, in most studies, the statistical population consisted of the total population of the area, and in a number of studies, the statistical population consisted of people over 18 years old.[19],[21],[25] Except for the study by Pitt et al., in which the study population reported to be people <20 years old.[12]

The results of the reviewed studies showed that the excessive speeding of vehicles, passages with higher speed limits, especially freeways and highways, the darkness of streets, alcohol intake by the drivers or pedestrians, older pedestrians, and heavy vehicles increased the severity of pedestrian crashes.

It is noteworthy that 11, 3, 2, and 1 out of 24 reviewed studies here were conducted in the United States, China, Canada, and Switzerland, respectively. Although various studies showed that most of the pedestrians' injuries and deaths in traffic crashes occurred in developing countries,[2], 4, [36],[37],[38] this study showed that, except for the Chinese studies, none of the reviewed studies was conducted in such countries. Therefore, it is necessary to conduct researches on risk factors affecting the severity of pedestrian-vehicle crashes in developing countries too.

On the other hand, given that most of the studies in this review were conducted in metropolises of developed countries, especially in the United States and Canada, the results cannot be generalized to all urban areas, especially cities with the different demographic and environmental context in low- and middle-income countries.

Moreover, the results showed that most of the reviewed studies were conducted in the metropolitan areas of the United States and Canada, the study area was a city or part of a city, and only inter-urban traffic crashes in the metropolises were investigated. Furthermore, they did not pay attention enough to the severity of crashes and contributing factors in the outer ring and suburban roads, highways, and freeways.

In addition, this review showed that in studies in which the independent variables of population density, land use, and the weather situation were included in the final models, there was a significant association between these variables and the severity of pedestrian crashes as the dependent variable. In order to reduce the severity of injury in pedestrians, it is necessary to implement interventions targeting these factors.

However, only one study investigated the association between household income and the severity of pedestrian crashes.[23] In recent years, most of the studies that investigated the inequity in traffic crashes revealed that the severity of crashes was higher in poor areas.[39],[40],[41],[42],[43],[44],[45] Therefore, further studies should be designed to investigate the association between socioeconomic status and the severity of pedestrian-vehicle crashes, especially in metropolises of developing countries to help adopt appropriate strategies to reduce these types of crashes and their consequences.

Furthermore, 12 of 24 studies included in this review revealed a statistically significant association between overspeeding and the severity of pedestrian crashes.[12],[14],[15],[17],[18],[19],[21],[22],[23],[25],[26],[27] Furthermore, several other studies showed that overspeeding was one of the most important risk factors associated with the increased severity of pedestrian crashes.[21],[24],[27],[46],[47],[48],[49],[50] However, they did not pay attention enough to the role of urban and suburban roadway safety facilities in the severity of pedestrian crashes, such as pedestrian bridges, lining of pedestrians crossing and warning signs. In fact, the association of traffic signs and the severity of pedestrian traffic crashes were investigated only in the studies by Eluru, et al., Mohamed, et al., and Aziz, et al.[18],[23],[24] Considering the fact that these safety facilities are of those environmental factors which can be associated with the severity of pedestrian crashes, it is necessary to include them in the future as well as underway studies.

On the other hand, all studies that met the inclusion criteria of this review were designed as cross-sectional. In fact, lack of studies, especially cohort and case-control methodology, on causal inferences which could provide higher levels of evidence for identifying demographic and environmental risk factors affecting the severity of pedestrian-vehicle crashes was obvious. Therefore, organizations and institutions which are involved in the research and prevention of traffic crashes programs should pay enough attention to these factors, and investigate the risk factors affecting the severity of traffic crashes by conducting studies which provide stronger causal inferences.

Moreover, in most studies (13 of 24), the statistical population was the total population. However, according to the WHO, approximately 21% of deaths of pedestrian traffic crashes occurred in children for which only 1 study, conducted for pedestrians under 18 years old, met the criteria to be included in our study.[11] Because children, especially school-aged children, are one of the most vulnerable groups for such crashes,[51],[52],[53] it seems necessary to focus on this group when studying the risk factors associated with the severity of pedestrian traffic crashes.

Finally, no study addressed the role of taxi stations, bus stops, and public parking lots in the severity of pedestrian crashes. Because there is almost a large number of pedestrians in the streets around the bus stops, taxi stations, and public parking lots, the study of the distribution and severity of the pedestrian crashes using the methods such as spatial analysis and regression models can clarify the role of these environmental factors in the severity of pedestrian traffic crashes. Furthermore, the studies showed that the number of bus stops[54],[55] and the area of parking lots[16] had an important role in the severity of pedestrian traffic crashes.


  Conclusion Top


The results showed that few studies were conducted on the association between demographic and environmental factors and the severity of pedestrian traffic crashes. Furthermore, the majority of studies were carried out in developed countries, especially in the metropolises of the United States. In these studies, some environmental factors that played an important role in the severity of pedestrian traffic crashes, such as pedestrian safety facilities, were ignored. Strong causal inference schemes were not used, and sufficient attention was not also paid to high-risk groups. Therefore, it is necessary to conduct more research at national and regional levels in cooperation with international organizations which are active in the field of traffic crashes in various parts of the world such as the WHO, especially in developing countries, because a large number of pedestrian crashes occur in these countries. Preventive programs, to reduce the severity of these crashes and their burden, should be developed and implemented in such countries.

Acknowledgments

We are honestly grateful to all people who contributed us in this study, especially those who were involved in the data collection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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  In this article
Abstract
Introduction
Methods
Results
Discussion
Conclusion
References
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