CHILDHOOD PEDESTRIAN MORTALITY: EPIDEMIOLOGY AND RISK FACTORS

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TOWARDS A CHILDHOOD TRAFFIC INJURY SYSTEMS FRAMEWORK

Road traffic collisions are a consequence of a dynamic combination of the elements linked to the constituents of the system comprising roads, road users, vehicles and the environment, and their mechanism of interaction. Certain elements contribute to the collision happening, and are therefore part of accident causation, while other elements magnify the effects of the collision and its impact on trauma severity. Some elements may be indirectly connected to road traffic injuries, the causes of which may be either immediate or accentuated by medium-term and long-term structural causes. Identifying the risk factors that contribute to road traffic crashes may help in the development of interventions that may decrease the risks associated with such factors (WHO, 2006).
Various analytical frameworks may be applied to detect risk factors that are germane to road traffic injuries and deaths, and provide contextual information that is correlated to the broader injury prevention framework. A theoretical framework is defined as a ‘conceptual model of how one theorises or makes logical sense of the relationships among several factors that have been identified as important to the problem’ (Sakaran, 2003, p. 19). The approaches that underpin the aetiology of fatal childhood pedestrian injuries are discussed below:
•Public Health Approach
•Systems Approach

Public Health Approach

The public health approach is a generic analytical framework that may be useful for identifying many health-related issues including injuries and violence (Krug, Sharma, & Lozano, 2000; Mercy, Rosenberg, Powell, Broome, & Roper, 1993). This approach may be helpful in guiding the entire injury process, from identifying the problem (surveillance), to analysing the causes (risk factors), and developing, implementing, and evaluating interventions (What works?). In view of the fact that the analysis of risk factors is one of the steps involved in this approach, it is relevant to include its application to road traffic injuries. The public health approach involves four interconnected pathways (refer Figure 4).

Systems Approach

The systems approach (in terms of which the interactions between various components are taken into account) was built on Haddon’s insights, and was aimed at untangling and correcting the elements that may have contributed to the key sources of the errors, or design flaws that may have resulted in fatal injuries, crashes or severe trauma, as well as contributed to fatal crashes or crashes that resulted in severe injury, or helped to moderate the intensity and consequences of injury. The essence of the systems approach involves taking account the interplay of multifaceted elements, including the role of different agencies and actors in prevention efforts.
Road traffic injuries are a multidimensional problem that requires a comprehensive lens when the determinants, consequences and outcomes are examined. Road traffic systems are highly complex, and may be hazardous to human health. Elements of the system include motor vehicles, roads, and road users together with their physical, social and economic environments. Thus, making a road traffic system less hazardous requires a systems approach. This is made possible by understanding the system holistically, including the interplay between the elements of the system, and identifying the potential for intervention. This approach takes into account both the shortcomings of human beings, and also the vulnerability of the human body to trauma. According to Peden (2004), a safe road traffic system is one that accommodates and compensates for human vulnerability and fallibility.
The adapted road transport system is depicted in Figure 5. The road transport system illustrates the interplay and interlinking of various elements of the system that either produced a desired and or undesired outcome of injury. The main principle is that a road traffic crash or collision is the outcome of the interaction among a number of factors and subsystems. It is therefore essential to consider all aspects of causation in the system and its subsystems when planning interventions aimed at decreasing the likelihood of collisions and mortalities. Some of the elements identified in research, and that influence the exposure to the risk of RTIs include, the level of economic development and social deprivation; demographics (age and sex); land-use planning practices which influence the lengths of road trips and modes of travel; a combination of high-speed motorised traffic and vulnerable road users, and insufficient attention to the integration of road functions as regards decisions about speed limits, road layout and design. In view of the fact that the elements of an accident include human and social factors, as well as the physical and technical components of the road and transport system, the shift from adopting an approach of simplistic injury causation to a multidisciplinary approach, afforded the opportunity to design appropriate measures that may prevent injury, and promote safety in road transport systems.
Muhlrad and Lassarre (2005) posited that a systems approach attempts to identify and rectify the major sources of the error or design weaknesses that contribute either to fatal crashes or to crashes that result in severe injury, as well as to mitigate the severity and consequences of injury. The elements of the system include motor vehicles, roads, and road users together with their physical, social and economic environments. Muhlrad and Lassarre (2005) also highlighted that the essence of using the systems approach is to consider not only the underlying factors in respect of road traffic crashes, but also the role of various agencies and actors in the causes and impacts of such crashes, as well as in intervention measures aimed at preventing these crashes.
This study adapted the existing road and transport system framework developed by Muhlrad and Lassare (2005), and reconfigured it into a systems approach to the child risk factors in relation to child pedestrian injuries (see Figure 5). A systems approach to child risk factors encompasses an eco-systemic multidimensional perspective on the interplay of the identifiable individual and familial risk factors associated with the road user (child pedestrian), as well as various contextual drivers and crash factors (human, vehicle, road and environment), that both contribute to and mitigate the consequences of motor vehicle crashes, and that either result in desired outputs (safe mobility), and or undesired outputs (fatal crashes and / or pedestrian deaths), and also other outcomes.
The individual risk factors associated with the road user (pedestrian) include age, level of development, sex, physical stature, behaviour etc. and also familial factors (caregiver supervision, knowledge, capacity, beliefs and practices), while the crash factors are associated with human factors (speed, alcohol, fatigue, knowledge, skill and experience, etc.), vehicle factors (maintenance, design etc.), road features (design, lighting, signage etc.), environmental factors (physical – recreational spaces, separation of mixed traffic, traffic calming, etc.), social factors (single parent, low maternal education, social capital, community cohesion, etc.) and societal factors (poverty, urbanisation, and motorisation). Both the risk and moderating influences of all these factors on child pedestrian injuries and deaths are explicated in this study.

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CHAPTER ONE BACKGROUND, RATIONALE AND SCOPE
1. INTRODUCTION
2. SOUTH AFRICAN PERSPECTIVE
3. RESEARCH FOCUS AND AIMS
4. STRUCTURE AND ORGANISATION OF THE THESIS
CHAPTER TWO CHILDHOOD PEDESTRIAN MORTALITY: EPIDEMIOLOGY AND RISK FACTORS
1. INDIVIDUAL FACTORS
2. FAMILIAL AND RELATIONSHIP DYNAMICS
3. COMMUNITY AS SOCIAL AND PHYSICAL ENVIRONMENTS
4. POVERTY
5. URBANISATION AND MOTORISATION
CHAPTER THREE THEORETICAL PERSPECTIVES ON THE DISTRIBUTION AND AETIOLOGY OF CHILD PEDESTRIAN INJURY
1. DEFINITION OF CHILDHOOD..
2. THEORETICAL FRAMEWORK FOR CHILDHOOD INJURY CAUSATION
3. TOWARDS A CHILDHOOD TRAFFIC INJURY SYSTEMS FRAMEWORK
CHAPTER FOUR RESEARCH DESIGN
1. STUDY POPULATION
2. DATA SOURCES
3. SETTING
4. STUDY DESIGN, DATA SOURCES AND ANALYSIS
5. ETHICAL APPROVAL
CHAPTER FIVE RESULTS
1. OVERALL INCIDENCE OF SELECTED CHILD INJURY MORTALITY .
2. AGE-SPECIFIC MORTALITY RATES FOR CHILD PEDESTRIANS
3. SEX-SPECIFIC MORTALITY RATES FOR CHILD PEDESTRIANS
4. POPULATION-SPECIFIC RATES FOR CHILD PEDESTRIANS
5. CIRCUMSTANCES OF CHILD PEDESTRIAN MORTALITY: OCCURRENCE BY TIME OF DAY, DAY OF THE WEEK AND MONTH
6. DEMOGRAPHIC AND CIRCUMSTANTIAL RISKS: CHILDHOOD PEDESTRIAN VERSUS MOTOR VEHICLE PASSENGER MORTALITY
7. DEMOGRAPHIC AND CIRCUMSTANTIAL RISKS: CHILDHOOD PEDESTRIAN VERSUS BURNS AND DROWNING MORTALITY
8. NEIGHBOURHOOD-LEVEL PREDICTORS OF CHILDHOOD PEDESTRIAN MORTALITY
9. INTEGRATED SUMMARY OF RESULTS
CHAPTER SIX DISCUSSION
1. OVERALL INCIDENCE OF SELECTED CHILD INJURY MORTALITY
2. AGE CONCENTRATION
3. THE VULNERABILITY OF BOYS
4. POPULATION GROUPING
5. TEMPORAL INFLUENCES
6. NEIGHBOURHOOD PREDICTORS
CHAPTER SEVEN SUMMARY AND CONCLUSION
1. LIMITATIONS OF THE STUDY
2. RECOMMENDATIONS FOR FUTURE RESEARCH AND ACTION
3. IMPLICATIONS FOR PREVENTION
4. CONTRIBUTION TO RESEARCH
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CHILDHOOD PEDESTRIAN MORTALITY IN JOHANNESBURG, SOUTH AFRICA: MAGNITUDE, DETERMINANTS AND NEIGHBOURHOOD CHARACTERISTICS

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