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Systematic review
Walking and child pedestrian injury: a systematic review of built environment correlates of safe walking Linda Rothman,1,2 Ron Buliung,3 Colin Macarthur,1,4,5 Teresa To,1,2,5,6 Andrew Howard1,5,7,8 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ injuryprev-2012-040701). 1
Department of Child Health Evaluative Science, The Hospital for Sick Children, Toronto, Ontario, Canada 2 Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada 3 Department of Geography, University of Toronto, Mississauga, Ontario, Canada 4 Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada 5 Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada 6 Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada 7 Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada 8 Department of Surgery, University of Toronto, Toronto, Ontario, Canada Correspondence to Linda Rothman, Child Health Evaluative Science, Hospital for Sick Children, 555 University Ave., Toronto, Ontario, Canada M5G 1X8;
[email protected] Received 12 November 2012 Revised 4 April 2013 Accepted 17 April 2013 Published Online First 24 May 2013
To cite: Rothman L, Buliung R, Macarthur C, et al. Inj Prev 2014;20: 41–49.
ABSTRACT Background The child active transportation literature has focused on walking, with little attention to risk associated with increased traffic exposure. This paper reviews the literature related to built environment correlates of walking and pedestrian injury in children together, to broaden the current conceptualization of walkability to include injury prevention. Methods Two independent searches were conducted focused on walking in children and child pedestrian injury within nine electronic databases until March, 2012. Studies were included which: 1) were quantitative 2) set in motorized countries 3) were either urban or suburban 4) investigated specific built environment risk factors 5) had outcomes of either walking in children and/or child pedestrian roadway collisions (ages 0-12). Built environment features were categorized according to those related to density, land use diversity or roadway design. Results were cross-tabulated to identify how built environment features associate with walking and injury. Results Fifty walking and 35 child pedestrian injury studies were identified. Only traffic calming and presence of playgrounds/recreation areas were consistently associated with more walking and less pedestrian injury. Several built environment features were associated with more walking, but with increased injury. Many features had inconsistent results or had not been investigated for either outcome. Conclusions The findings emphasise the importance of incorporating safety into the conversation about creating more walkable cities.
INTRODUCTION Child pedestrian injuries are a leading cause of injury-related death for Canadian children younger than 14 years.1 In children of ages 5–9 years, pedestrian collisions are tied with motor vehicle collisions as the primary cause of unintentional injury death (18%).1 Every year, approximately 56 child pedestrians die and 780 are hospitalised with serious injuries in Canada.1 While the burden of child pedestrian injuries and fatalities is high, there has been a decline of over 50% in Canadian hospitalisation and deaths from 1994 to 2003.1 2 Declining trends are also evident in the USA, Europe and New Zealand.3–7 This reduction may not be due to safer traffic environments, but rather because children are walking less often, thus reducing the exposure to risk of injury from collision with a motor vehicle.4 6 8 While children’s walking trips to all destinations have fallen, this decline is most apparent for school trips. From 1986 to 2006, active school transportation (ie, walking,
Rothman L, et al. Inj Prev 2014;20:41–49. doi:10.1136/injuryprev-2012-040701
biking) declined from 53% to 43% in Canadian children of ages 11–13 years.9 Declines have also been noted in the USA, Great Britain and Australia.8 10 11 Initiatives to increase walking in children have been developed to promote healthy active living and are focused primarily on school trips.12–14 The Safe Routes to School (SRTS) concept began in Denmark in the 1970s, with programmes developed in Europe, Australia, New Zealand, Canada and the USA.15 In the USA, a national SRTS program was passed in 2005 as part of the US federal surface transportation bill with 11 000 schools funded by 2011.13 15 16 In Canada, SRTS programs are conducted at a grassroots/activist level with some pilot funding from a provincial government agency.17 When planning interventions to increase walking to school, the potential effects of increased walking exposure on pedestrian injury rates should be considered. Gropp et al18 recently found a dose– response relationship between longer school travel distances and injury related to active school transportation in a Canadian national survey. In Toronto, Canada, almost 50% of child pedestrian collisions were found to occur during school transportation times and the highest density of collisions occurred within 150 m of a school.19 Since the 1970s, research from the transportation and urban planning fields has investigated the ‘walkability’ of the environment. More recently, public health researchers have become interested in the effects of the built environment and walkability on physical activity and obesity. The definition of walkability is problematic as it varies by discipline and there is no standard set of factors describing a walkable environment. Walkability has been defined as ‘the extent to which the built environment supports and encourages walking by providing for pedestrian comfort and safety…’.20 This conceptual recognition of safety in walking has not been well addressed in the built environment active travel literature. Focus has been on what can be done to increase walking with little attention paid to the risks associated with increased traffic exposure. Others have also acknowledged the importance of linking road safety indicators to active school commuting.21–23 Reviews related to walkability and children have investigated the correlates of walking, which encompass many characteristics of the household, behaviours and material and social environments.16 22–26 There are few systematic reviews, however, that link features of the built environment to child pedestrian injury. Wazana et al27 found that risk factors for child pedestrian injury were 41
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Systematic review related to the physical environment. Their review was limited to Medline articles from 1985 to 1995. Built environment roadway characteristics have been statistically linked with child pedestrian injury risk (OR=2.5); however, the effects of specific built environment features have not been examined.28 The purpose of this review is to use the published literature to develop an understanding of how specific features of the built environment relate to both walking in elementary school children and child pedestrian injury to direct further research. As this review incorporated a variety of papers drawn from a wide array of disciplines that use different reporting standards, traditional systematic review was challenging. However, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were adhered to as closely as possible.29
METHODS The search strategy was developed in consultation with a research librarian at the Hospital for Sick Children, Toronto, Canada. As the research question crossed many disciplines, nine
electronic databases were searched until 1 March 2012: Medline (1980–2012), Embase (1980–2012), Transport (1980– 2012), Dissertations and Theses (1980–2012), Web of Science (1980–2012), Scopus (2004–2012), PyscInfo (1980–2012), CINAHL (1985–2012) and SafetyLit (1995–2012). Search strategies were broad, given the variety of discipline-specific terminologies (see online supplementary appendix A). Two sets of searches were conducted on each database, one for child pedestrian injury and another for walking in children. Search results are illustrated using a PRISMA flow diagram (figure 1).29 Hand searches were done for references from systematic reviews and select journals between the years 2006 and 2011: Accident Analysis & Prevention, Injury Prevention, Traffic Injury Prevention, Transportation Research Part D: Transport and the Environment, and Health and Place. Google searches were used to identify articles/reports/grey literature from websites using the search terms: pedestrian, child pedestrian, built environment and pedestrian injury, walkability, active school transportation and active transportation.
Figure 1 The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. 42
Rothman L, et al. Inj Prev 2014;20:41–49. doi:10.1136/injuryprev-2012-040701
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Systematic review Eligibility Two reviewers from the research team independently reviewed titles and abstracts initially and then assessed full-text versions using standardised checklists. There were no language restrictions. Only literature from highly motorised countries (ie, Australia, Japan, New Zealand, North America and Western Europe) was considered. This classification of high motorised countries (HMCs) versus low motorised countries (LMCs) was developed by the Transport Research Laboratory and used by WHO to describe road fatality trends.30 31 Motorisation level is measured by the number of motor vehicles/1000 population and LMCs have typically much less motorisation levels (
