An evaluation of the general effect of the New Zealand graduated driver licensing system on motorcycle traffic crash hospitalisations

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 role of inexperience in motorcycle crashes among novice and returning motorcycle riders

OBJECTIVES

To examine the crash trends of younger novice and older novice/returning motorcycle riders.

METHODS

We used a linked database of North Carolina crash and licensing data from 1991 through 2018 that included 103,142 younger novice and 98,540 older novice/returning motorcycle riders. We examined the percent of riders who crashed each month after obtaining a motorcycle license.

RESULTS

Crash rates peak for both younger novice and older novice/returning motorcycle riders immediately after licensure. Crash rates decline rapidly, and the rate of decrease resembles a power function. The improvement rate (IR) for younger novice riders is 0.42; that is, the crash rate for younger novices declines by approximately 42% as experience doubles.

CONCLUSION

The crash curve for novice motorcyclists is similar to that of novice car drivers and is consistent with a learning process.

PRACTICAL APPLICATIONS

The crash trends of novice motorcycle riders indicate that current training, licensing, and educational efforts are not adequately preparing new riders. Additional efforts to develop more effective training, and research to inform a well-calibrated graduated licensing process for new riders are needed.

Epidemiology of traffic crash mortality in west of Iran in a 9 year period

PURPOSE

In Iran, the most common cause of injuries and the second leading cause of deaths are traffic accidents, and those problems impose a substantial financial burden on the society. This study aims to determine traffic accident mortality trends and their epidemiologic characteristics in the Kermanshah province, west of Iran.

METHODS

In a cross sectional study, road traffic fatality data from 2004 to 2013 were analyzed to determine the epidemiological pattern of traffic accident mortality. Trend assessment was performed to ascertain the decreasing or increasing status. Chi-square and one-way analysis of variance (ANOVA) tests, as well as Poisson regression were used to determine the significance of the data in time. Data were analyzed using Excel and statistical package of SPSS version 19.

RESULTS

Out of 5110 people that died in traffic accidents, 4024 (78.7%) were males. The state of accidents indicated that 404 (43.8%) female pedestrians died as a result of car crashes, and 1330 (41.4%) males died because of car collisions. 1554 (31.9%) deaths happened to pedestrians and 1556 (32.1%) to vehicle drivers, and the rest belonged to vehicle passengers. Head trauma was the cause of death for as much as 3400 (69.9%) cases. Fatal crashes in which pedestrians were involved mostly occurred between the hours 13:00 to 15:00, while the time for vehicle drivers was between 16:00 to 18:00. 2882 people (59.1%) died before reaching to health care facilities. Traffic crash mortality trend for pedestrians follows a linear pattern with a gentle downward slope, but the trend shows various swings when it comes to vehicle drivers.

CONCLUSION

The number of traffic crash deaths from 2004 to 2013 indicates a decreasing trend in two groups of road users: vehicle drivers and car occupants. This can be due to some interventions such as modification of traffic rules and enhancement of police control which has been implemented in recent years. Moreover, more attention should be paid to promote the optimal health care services to save the lives of the injured from traffic accidents.

Risk factors for injury accidents among moped and motorcycle riders

OBJECTIVE

To study and quantify the effect of factors related to the riders of powered two-wheelers on the risk of injury accident involvement.

METHODOLOGY

Based on national data held by the police from 1996 to 2005, we conducted a case-control study with responsibility for the accident as the event of interest. We estimated the odds ratios for accident responsibility. Making the hypothesis that the non-responsible riders in the study are representative of all the riders on the road, we thus identified risk factors for being responsible for injury accidents. The studied factors are age, gender, helmet wearing, alcohol consumption, validity of the subject's driving licence and for how long it has been held, the trip purpose and the presence of a passenger on the vehicle. Moped and motorcycle riders are analyzed separately, adjusting for the main characteristics of the accident.

RESULTS

For both moped and motorcycle riders, being male, not wearing a helmet, exceeding the legal limit for alcohol and travelling for leisure purposes increased the risk of accident involvement. The youngest and oldest users had a greater risk of accident involvement. The largest risk factor was alcohol, and we identified a dose-effect relationship between alcohol consumption and accident risk, with an estimated odds ratio of over 10 for motorcycle and moped riders with a BAC of 2 g/l or over. Among motorcycle users, riders without a licence had twice the risk of being involved in an accident than those holding a valid licence. However, the number of years the rider had held a licence reduced the risk of accident involvement. One difference between moped and motorcycle riders involved the presence of a passenger on the vehicle: while carrying a passenger increased the risk of being responsible for the accident among moped riders, it protected against this risk among motorcycle riders.

CONCLUSION

This analysis of responsibility has identified the major factors contributing to excess risk of injury accidents, some of which could be targeted by prevention programmes.

Analysis of factors that increase motorcycle rider risk compared to car driver risk

As in other parts of the Western world, there is concern in New Zealand about increasing popularity of motorcycles because of potential increases in road trauma. This study sought to identify important factors associated with increased risk for motorcyclists to inform potential policy approaches to reduce motorcyclist injury, such as changes to motorcyclist licensing, training and education. Using data extracted from a register of all New Zealand licensed motor vehicles that were matched to crash data, statistical models were fitted to examine patterns of motorcycle risk in comparison with small cars. These showed generally elevated risks for motorcyclists compared to cars, but particularly elevated risks for motorcycle owners aged in their 20s or who lived in more urbanised settings. In crashes, motorcyclists have little protection from injury, putting the motorcyclist at high risk of injury. When comparing new motorcycles with new cars, the odds of fatal or serious injury to a motorcycle rider involved in an injury crash were almost eight times the odds for a car driver.

Road injuries and relaxed licensing requirements for driving light motorcycles in Spain: a time-series analysis

OBJECTIVE

To assess differences between the risk of injury for motorcycle riders before and after the passing of a law allowing licenced car drivers to drive light motorcycles without having to take a special motorcycle driving test.

METHODS

We carried out a quasi-experimental study involving comparison groups, and a time-series analysis from 1 January 2002 to 30 April 2008. The study group was composed of people injured while driving or riding a light motorcycle (engine capacity 51-125 cubic centimetres), while the comparison groups consisted of riders of heavy motorcycles (engine capacity > 125 cc), mopeds (engine capacity <or= 50 cc) or cars who were injured in a collision within the city limits. The 'intervention' was a law passed in October 2004 allowing car drivers to drive light motorcycles without taking a special driving test. To detect and quantify changes over time we used Poisson regression, with adjustments for trend and seasonality in road injuries and the existence of a driver's licence penalty point system.

FINDINGS

The risk of injury among light motorcycle riders was greater after the law than before (relative risk, RR = 1.46; 95% confidence interval, CI: 1.34-1.60). Although less markedly, after the law the risk of injury also increased among heavy motorcycle drivers (RR = 1.15; 95% CI: 1.02-1.29) but remained unchanged among riders of mopeds (RR = 0.92; 95% CI: 0.83-1.01) and cars (RR = 1.06; 95% CI: 0.97-1.16).

CONCLUSION

Allowing car drivers to drive motorcycles without passing a special test increases the number of road injuries from motorcycle accidents.

A review of risk factors and patterns of motorcycle injuries

Per vehicle mile traveled, motorcycle riders have a 34-fold higher risk of death in a crash than people driving other types of motor vehicles. While lower-extremity injuries most commonly occur in all motorcycle crashes, head injuries are most frequent in fatal crashes. Helmets and helmet use laws have been shown to be effective in reducing head injuries and deaths from motorcycle crashes. Alcohol is the major contributing factor to fatal crashes. Enforcement of legal limits on the blood alcohol concentration is effective in reducing motorcycle deaths, while some alcohol-related interventions such as a minimal legal drinking age, increased alcohol excise taxes, and responsible beverage service specifically for motorcycle riders have not been examined. Other modifiable protective or risk factors comprise inexperience and driver training, conspicuity and daytime headlight laws, motorcycle licensure and ownership, riding speed, and risk-taking behaviors. Features of motorcycle use and potentially effective prevention programs for motorcycle crash injuries in developing countries are discussed. Finally, recommendations for future motorcycle-injury research are made.

Power computations in time series analyses for traffic safety interventions

The evaluation of traffic safety interventions or other policies that can affect road safety often requires the collection of administrative time series data, such as monthly motor vehicle collision data that may be difficult and/or expensive to collect. Furthermore, since policy decisions may be based on the results found from the intervention analysis of the policy, it is important to ensure that the statistical tests have enough power, that is, that we have collected enough time series data both before and after the intervention so that a meaningful change in the series will likely be detected. In this short paper, we present a simple methodology for doing this. It is expected that the methodology presented will be useful for sample size determination in a wide variety of traffic safety intervention analysis applications. Our method is illustrated with a proposed traffic safety study that was funded by NIH.

Persuasion and licensure: a randomized controlled intervention trial to increase licensure rates among Maryland motorcycle owners

OBJECTIVE

This study aimed to determine whether a persuasive educational intervention could increase licensure among motorcycle owners. Unlicensed motorcycle operators appear to be disproportionately involved in police-reported motorcycle crashes in Maryland, accounting for about 27% of motorcycle operators in police-reported crashes, although unlicensed owners comprise 17% of primary motorcycle owners.

METHODS

A randomized controlled trial was conducted among unlicensed owners. Linking Maryland records of registered motorcycles with license files, 8,499 unlicensed owners who had no licensed co-owners were identified. Half were randomized to receive a persuasive educational mailing in early June 2005 from Maryland Motor Vehicle Administration (MVA). Motorcycle licenses can be attained by passing an accredited motorcycle training class or passing knowledge and skills tests administered by the state driver licensing agency. Licensure rates and motorcycle class enrollment were followed for 6 months post-intervention.

RESULTS

As of December 16, 2005, 280 intervention group owners had obtained Class M motorcycle licenses and 158 had obtained Class R motorcycle learner's permits. The comparison group obtained 209 M licenses and 122 R permits. The overall success rate in the intervention group, defined as obtaining Class M or R, was 10.4% compared with 7.9% in the comparison group (licensure ratio (LR) = 1.33; 95% confidence interval (CI) = 1.16-1.52). The intervention was most successful among men, whose LR for obtaining M licenses was 1.45 (95% CI = 1.21-1.75). LRs were higher among owners ages 40-48 and 49+ receiving the intervention compared with younger groups. Motorcycle training class enrollment rates were higher in the intervention group, particularly among those taking a course for riders with intermediate skills (enrollment ratio = 2.24; 95% CI = 1.41-3.55).

CONCLUSION

The intervention appeared to increase licensure, yet the licensure rate remained low among the intervention group. Potential risks and benefits of increasing the percentage of motorcyclists who are licensed need to be studied.

Identifying best practices states in motorcycle rider education and licensing

PROBLEM

After decreasing to a historic low in 1997, motorcycle crash-related fatalities are increasing. Although causes remain unclear, motorcycle rider education and licensing play key roles in reducing motorcycle crashes and injuries. Yet, little is known about what constitutes effective rider training and licensing. This study develops a model of best practices in motorcycle rider education and licensing and combines primary and secondary data to identify states that most closely adhere to this model. Evidence on the validity of the model is also examined.

METHOD

States were rated along three areas of best practices: (a) program administration; (b) rider education; and (c) licensing based on 2001 data collected for a National Highway Traffic Safety Administration (NHTSA)-sponsored study.

RESULTS

Results indicate wide variation in states' adherence to best practices; several states meet most, others very few. When the areas of best practices are considered separately, a state tends to behave similarly on all three. Initial evidence supports the validity of the model, with high best practices states having the lowest rates of motorcycle fatalities.

IMPACT ON TRAFFIC SAFETY

As motorcycle-related crashes increase and state and federal support for rider education programs diminishes, it is critical that states identify deficiencies in their program and learn from successful states about efficient, cost-effective strategies for increasing best practices in motorcycle rider education and licensing.

The Effect of State Motorcycle Licensing Laws on Motorcycle Driver Mortality Rates

OBJECTIVE

The purpose of this study was to evaluate the association between motorcycle licensing and operation regulations and motorcycle mortality rates in the United States during 1997 through 1999.

METHODS

A population-based ecologic study was used.

RESULTS

Lower mortality rates were observed in states with the following motorcycling requirements: skill test for a motorcycle permit (rate ratio [RR], 0.76; 95% confidence interval [CI], 0.69-0.84), driver training (RR, 0.80; 95% CI, 0.74-0.86), longer duration of learner's permits (95-190 days [RR, 0.86; 95% CI, 0.79-0.95] and >190 days [RR, 0.87; 95% CI, 0.81-0.93], three or more learner's permit restrictions (RR, 0.78; 95% CI, 0.73-0.84), and a full helmet law (RR, 0.76; 95% CI, 0.71-0.81).

CONCLUSION

Specific motorcycle licensure policies appear to be associated with lower mortality rates.

Adolescent injury morbidity in New Zealand, 1987-96

OBJECTIVES

Adolescents are over-represented in injury statistics. New Zealand is privileged in having a hospital discharge database allowing for analysis of non-fatal injury data at a national level. An epidemiological description of adolescent injury morbidity is provided and options for prevention are discussed.

METHOD

People aged 15-19 years admitted to hospital for their injuries in the period 1 987-96 were identified from the New Zealand Health Information Service morbidity data files. The manner, causes, and nature of injury were examined. Injury prevention strategies were reviewed.

RESULTS

The incidence of hospitalised injury was 1,886 per 100,000 person years. The victims were male (70%). The leading causes of injury were road traffic crashes, sports injuries, and self poisoning. The most common injury diagnoses were head injuries (29%) and limb fractures (21%). Road traffic crashes produced the highest proportion of serious injuries.

CONCLUSIONS

Road traffic crashes, sports injuries, and self inflicted poisoning, stood out as areas with the greatest potential for reducing the burden of injury in late adolescence. Graduated driver licensing shows promise as an injury prevention measure but remains inadequately implemented. Policies to reduce self inflicted poisoning are of unknown efficacy, and evidence is awaited on the effectiveness of measures to reduce injury in sport.