ORIGINAL ARTICLE
doi: 10.36311/jhgd.v32.12614

 

Factors associated with incidence and mortality by road accidents involving motorcyclists and pedestrians: a rapid systematic review

 

 

Francisco Naildo Cardoso Leitão^{I, II, III, IV}; Ítalla Maria Pinheiro Bezerra^V; Renata Martins Macedo Pimentel^II; Gabrielle do Amaral Virgínio Pereira^II; Adilson Monteiro^{II, VI}; Alan Patricio da Silva^II; Beatriz Cecilio Bebiano^II; Andrés Ricardo Perez Riera^II

^IPhD candidate student in Health Sciences at Centro Universitário FMABC (FMABC) - Santo André, São Paulo, Brazil
^IIStudy Design and Scientific Writing Laboratory (LaDEEC/FMABC) - Santo André, São Paulo, Brazil
^IIILaboratório Multidisciplinar de Estudos e Escrita Científica em Ciência da Saúde (LaDEECCS/UFAC) - Rio Branco, Acre, Brazil
^IVUniversidade Federal do Acre (UFAC) - Rio Branco, Acre, Brazil
^VEscola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM) - Vitória, Espírito Santo, Brazil
^VIUniversidade Federal de Rondonópolis (UFR/MT) - Rondonópolis, Mato Grosso, Brazil

Correspondence

 

 

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ABSTRACT

INTRODUCTION: traffic accidents are the third leading cause of death in the world. Vulnerable road users do not benefit from a high level of protection. As such, they face devastating consequences when involved in accidents
OBJECTIVE: to analyze the incidence and mortality, and associated factors in traffic accidents among motorcyclists and pedestrians
METHODS: rapid Systematic review of articles from the National Library of Medicine (PubMed), Virtual Health Library (VHL), and Web of Science databases using the descriptors Mortality, Accidents, traffic, Motorcyclists and Pedestrians. Inclusion criteria were: (1) studies involving pedestrians and motorcyclists; (2) the object of study is traffic accidents; (3) articles that studied mortality; and (4) articles published in the last ten years (2010-2019
RESULTS: of the 206 articles found, 19 met the inclusion criteria. Factors such as increased sales of motorcycles, darkness on the roads, older pedestrians, lack of safety equipment for motorcyclists, and drug and alcohol intake contribute to the increase of the mortality rate of these individuals
CONCLUSION: mortality due to traffic accidents involving pedestrians and motorcyclists has increased during the analyzed period, especially among men

Keywords: mortality, accidents, traffic, motorcycles, pedestrians.

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Authors summary

Why was this study done?

This study was carried out to analyze the mortality, incidence, and associated factors in traffic accidents among motorcyclists and pedestrians. Thus, contributing to public health policies.

What did the researchers do and find?

The authors actively searched for studies published in the most robust scientific literature to analyze traffic accidents involving pedestrians and motorcyclists. The 19 articles filtered showed an increase in older pedestrians. Our findings revealed drugs and alcohol consumption, which contributes to the rise in the mortality rate of these individuals.

What do these findings mean?

It is one of the most problematic topics for public health in the world. It is essential to understand the behavior of people involved in traffic accidents related to pedestrians and motorcyclists, the most vulnerable population in traffic accidents in Brazil.

 

INTRODUCTION

Traffic accidents are a public health problem globally. Every day, hundreds of people lose their lives or suffer severe sequelae from traffic accidents.

The United Nations (UN) recognizes that these accidents are associated with behavioral factors, vehicle safety, and the precariousness of urban space due to the high rate of morbidity and mortality. This scenario is becoming worse due to the growing number of vehicles, lifestyle changes, and risk behaviors in the general population^1,2.

The World Health Organization (WHO) published the first global report on the prevention of road traffic injuries in 2004 and, for the first time, World Health Day focused on road safety. These causalities are the third leading cause of death in the world. Injuries mainly occur in people aged 15 to 20 years. About 90% of deaths and injuries occur in developing countries^3,4. Moreover, the WHO estimates a 40% increase in worldwide mortality from this group of causes by 2030 if effective preventive measures are not adopted⁵.

The advances of the automobile industries in Brazil generated multiplying effects of urban and social transformations⁶. The growth of the motorcycle fleet is expressive, with a 61% increase between 2002 and 2006. This growth was supported by federal policies that favored manufacturing, low cost, and financing facilitated by credit expansion, contributing to the increase of deaths from motorcycles in Brazil⁷.

Modern cars have advanced safety features for protection in the event of a collision. The occupants have seat belts, airbags, and crumple zones. Pedestrians, cyclists, and motorcyclists face devastating consequences when involved in accidents; they are vulnerable road users and do not benefit from this level of protection⁸.

Studies on traffic accidents in Brazil are scarce. Prevention and control actions are just beginning, and little is known about the behavior of motorcyclists and pedestrians, the safety conditions of roads and vehicles, traffic engineering, the human and environmental costs of the use of motor vehicles, and the traumatic consequences resulting from these accidents⁹.

Therefore, this study aimed to identify the trend and incidence of mortality and associated factors in traffic accidents among motorcyclists and pedestrians.

 

METHODS

A rapid systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)¹⁰. It was guided by the structured question: "What is the trend of mortality, incidence and associated factors in accidents involving motorcyclists and pedestrians?". The PICOS strategy was the base to build the research question (P) - motorcyclists and pedestrians; intervention (I) - traffic accidents; comparator (C) - not applicable; outcome (O) - death; and study (S): studies that follow the eligibility criteria. The findings and discussion of this study are presented with a descriptive and narrative approach.

In July 2020, it was registered in the PROSPERO Systematic Review Protocol Database to avoid unintentional duplication and reduce the risk of bias in selective reporting of the outcome. The registration identification is no. 199358, and, on August 16 of the same year, the definitive official registration code was no. CRD42020199358.

Research strategy

The search was focused on peer review articles published in the National Library of Medicine (Pubmed), Virtual Health Library (VHL), and Web of Science databases by keywords obtained by the VHL Descriptors in Health Sciences (DeCS).

In Pubmed, the identification of potential articles was performed through the descriptors: Mortality AND Accidents, Traffic AND Motorcycles AND Pedestrians in "All fields." In the Web of Science platform, "Topic" and document types (article) used the same descriptors. In the VHL, the search was by title, abstract, and subject, all with the same descriptors.

Selection strategy

The selection was made as follows: (I) search for articles in the databases; (II) reading of titles and abstracts, with analysis according to the eligibility criteria and; (III) full-text analysis of the works, being included in the systematic review only those that met all the inclusion criteria^11,12.

Inclusion criteria

Published studies were eligible when meeting the following criteria: (1) studies envolving pedestrians and motorcyclists; (2) the study object is a traffic accident; (3) focused on mortality; and (4) articles published in the last ten years (2009-2019). There were no restrictions on sample size and foreign language.

Exclusion criteria

Articles were excluded if: (1) they used secondary databases (for example, books, theoretical works, or literature reviews); (2) studied samples that do not include motorcyclists and pedestrians; (3) duplicates; (4) studied a specific age (only elderly, children or adults); (5) had no direct relationship with traffic accidents; (6) do not differentiate the vehicles involved in traffic accidents and; (7) focuses on different subjects such as injury patterns, medical screenings, autopsies, mass transport.

Data extraction and study quality

The data retrieved were compiled in Microsoft Excel 2019. The form consisted of fields filled in by a reviewer in the following order: (1) identification of the study (name of the first author, year, and country); (2) Methods; (3) aspects of the target population (age and sex); (4) aspects of the intervention performed (sample size, presence of supervision, frequency, session duration, and follow-up); (5) presence and (6) loss of follow-up; and (7) results studied.

To increase confidence in selecting articles, all search and selection steps were independently reviewed by two researchers who, after reading all the papers, agreed to establish which ones met the inclusion criteria.

 

RESULTS

Searches were performed in Pubmed, Virtual Health Library (VHL), and Web of Science databases, resulting in 206 articles; 81 articles were excluded due to duplicity. The main reason for exclusion in filtering by title was the focus on other subjects (clinical diagnosis, autopsies, medical screenings, types of injuries, head trauma, educational inequality, neurological trauma, among others). The flowchart below shows each step of the selection strategy (figure 1).

After filtering by reading the titles, the next step was to read the abstract of 76 articles. At this stage, articles were excluded mainly because they did not focus on accidents involving motorcycles and pedestrians (n=46), did not differentiate the vehicles involved in the accident (n=4), there were no pedestrians in the sample (n=3), did not have a focus on mortality and incidence of these accidents (n=2), review articles or special review edition (n=2), and specific studies on roads (n=1). Finally, 19 articles were thoroughly read.

Study characteristics

Table 1 summarizes the 19 studies included for the synthesis: eight were descriptive^7,8,13-17, two longitudinal^18,19, two retrospective analyzes^20,21, three cross-sectional^22-24, two prospective^25,26, one quantitative²⁷ and one retrospective descriptive study²⁸.

Although systematic reviews of randomized clinical trials are frequent, there is evidence of a growing number of literature assessments based on observational research, such as cohort, case-control, cross-sectional, series, and case reports²⁹. For these reasons, there was no restriction by the type of study.

All the studies had, as a sample, accidents involving pedestrians and motorcyclists. Four of them^8,11,16,28 specifically address pedestrians, motorcyclists, and cyclists.

In 15 of them, the mortality was higher among men, whether pedestrians or drivers, and in only one, the difference between the sexes was not significant. Some studies did not present values by sex^12,15,17.

Only three^8,13,27 of the 19 studies included were carried out in developed countries.

Countries where the studies were performed

Four from Brazil^7,17,18,20; four from Iran^14,17,19,22; two in Nigeria^19,26; one in Montenegro¹²; one in Canada⁸; one in France¹³; one in Sri Lanka⁹; one in Tanzania²³; one in Saint Lucia²⁵; one in Ghana²¹; one in the United States²⁷; and one in Argentina¹⁶.

 

DISCUSSION

Some studies showed geographic restriction when analyzing data from only one city or state, making generalization impossible.

Four articles were produced in Iran. Iranian women are free to drive; however, married women must have their husbands' permission²⁹. It can be interpreted as a kind of prejudice in the country.

The safety for pedestrians and motorcyclists is lower compared with the drivers of other types of vehicles¹². The evicence of this review shows that the highest mortality occurs among men. In addition, most of the studies included were carried out in underdeveloped or developing countries.

Data on the safety of vulnerable road users, who are not protected in traffic accidents, such as pedestrians, cyclists, motorcyclists, and mopeds, were analyzed in Montenegro and the European Union. The exposure of this group is higher in low and middle terrirtories¹².

For groups of vulnerable road users in Montenegro and the European Union, between 2000 and 2016, pedestrian mortality rates were the highest, followed by motorcyclists and cyclists. The risk of pedestrian mortality in road traffic is significantly higher in Montenegro than in the European Union¹².

In a fourteen-year time series in Brazil, there were 48,879 admissions for being run over pedestrians in São Paulo city. Pedestrian collisions occurred mainly by automobiles (21.0%), motorcycles (10.1%), buses (4.0%) and bicycles (1.5%). During the years analyzed, there was an increase in pedestrians being run over, 70.1% in males. Lower limb injuries are the most frequent, as they have initial contact with the vehicle. The prevention of traffic accidents is essential because of the morbidity and mortality and the costs they represent. It is necessary to discuss the problem involving the public authorities, transit organs, communities, drivers, and pedestrians¹⁸.

An analysis of the protocols of blunt trauma victims was performed. Motorcyclists were the victims most frequently attended to in the emergency, surpassing in absolute numbers the victims of being run over, falls, car accidents, and physical aggression. Motorcyclists had lower frequency and severity of head injuries and higher frequency and severity of limb injuries. In Brazil, accidents involving motorcyclists are frequent and severe; they need to be targeted by specific actions related to prevention and improvement of care²⁰.

In Iran, the fatality rate from pedestrian traffic accidents is very high. That's why their safety is one of the most crucial problems in the healthcare system. Data on all pedestrian-related traffic accidents were investigated from two databases. Some risk factors that increase pedestrian fatality in urban traffic accidents are not considered risk factors in suburban accidents, such as age, gender, lighting condition, day of the week, holidays, vehicle type, and pedestrian position. The only common factor is the type of road²².

The number of deaths at night was higher, probably due to lack of street lighting, lack of lights in vehicles, fatigue, and drivers' drowsiness. The increase in pedestrian movement and the frequency of road accidents involving a pedestrian are significantly increased²².

Motorbikes are low-cost means of transport, seen as a good option at a time of economic crisis, in addition to allowing their users to avoid traffic jumps, as observed in France. A study with secondary data shows that the risks for motorized two-wheel users are incredibly high compared to other types of road users, mainly due to the combination of speed and lack of protection (except for helmets). Regardless of the exposure unit considered, these users have much higher fatality rates than other types of road users, having 20 to 32 times the chance of death¹³.

A study of fatal road accidents was carried out in a province in Iran. The male/female ratio is 3.41, even higher among motorcyclists. The ratio between injuries to the head and other body parts (trunk and lower body) was 2.51; pedestrians had the highest head injuries (38.2%). Women are more vulnerable at the scene of the accident, according to the study. Pedestrians aged 21-30 years, motorcyclists aged 41-50 years, and motor vehicle occupants aged 31-40 years have the highest mortality rate¹⁴.

The study also states that developing nations have insufficient financial resources for road safety, focusing on riskier groups. Adequate facilities for elderly pedestrians, training courses before obtaining a motorcyclist's license, information on the risk of death for road users, and improved management of patients with head injuries may be good options¹⁴.

In Sri Lanka, pedestrian deaths were around 33%, and drivers and cyclists accounted for 44%. Analysis of different pedestrian variables for other types of vulnerable road users shows that older men, road crossing, head injuries, brain injuries, multiple and head injuries were significantly higher in the pedestrian group. There was a difference in the cause of death: head and numerous injuries were statistically significant among pedestrians, compared to other users, which can be explained by the absence of protective equipment such as helmets⁹.

In a study in Tanzania, 37.2% of traffic accidents involve motorcycle users. The average age was 25.7 years. Injuries are among the leading causes of disability and death, and the primary victims are motorcyclists, passengers, and pedestrians in their productive age group. Contrary to the result of another study²², 73.9% of accidents occurred during the day, 23.9% at night, and 2.2%, it was not specified. Young adult men in their reproductive and productive age group are commonly affected²³.

In St. Lucia, a study was carried out in the hospital emergency room with 115 patients who had injuries from motorcycles accidents. Most were weekend accidents, and 52.9% of patients were not wearing a helmet. The main reasons were collision between motorcycles (n=50), with other vehicles (n = 20) and motorcycle crash (n = 21). Alcohol has been identified as a major contributor to the fatal crash²⁵.

The study revealed that men were injured more than women, suggesting that men are more vulnerable to trauma. This proportion can be explained by the fact that the motorcycle is not used for commercial transport. Driving this vehicle is considered a male activity in St. Lucia. The age of patients ranged from 15 to 72 years. An education program on the high risks associated with helmetless motorcycling is recommended, including laws limiting alcohol concentration in the blood²⁵.

Research in an emergency unit from Nigeria of 150 individuals analyzed motorcycle-related injuries' associated factors and outcomes. The male-to-female ratio was 4:1 in patients aged 20 to 29 years. Only 2.7% of patients wore a helmet at the time of the accident, 39.3% of patients arrived at the hospital within 16 hours of the injury, and the mortality rate was 10.7%. The motorcycle collision caused the most significant number of deaths. Therefore, the authors emphasize the need for preventive measures, law enforcement, and behavioral changes among motorcycle users²⁴.

Accidents of pedestrians seeking care at the busiest emergency room in Lagos, Nigeria, were analyzed. The article reported that the highest incidence of pedestrian accidents was due to motorcycles. There is a need to strengthen the health system, especially regarding emergencies, and improve hospitals' capacity to deal with these events²⁶.

Car use is low in Ghana, and public transport is non-existent or associated with unfair fares forcing people to make most of their travel on foot. For this reason, pedestrian injury patterns were examined from a database²¹.

There has been a considerable reduction in pedestrian mortality rates since 2004, corresponding to an increase in traffic calm and a focus on pedestrian safety. Mortality rates during the night were notably higher²². According to the study, steps that can decrease deaths include reducing vehicles' speed in settlements, providing traffic measures, and better lighting²¹. It suggests that the increase in preventive devices has improved pedestrian safety.

A longitudinal study in Iran investigated accidents in two-wheeled vehicles and pedestrians. The majority, 77%, were outpatients, and 22.1% were hospitalized. Of the victims, 26% were pedestrians, 32% were motorcyclists, 4.6% were cyclists, and 37.1% were not motorcyclists. The mortality risk for men was higher. The results emphasize the need for outpatient care in hospitals. Being a vulnerable road user increases the risk of death compared to other types of traffic victims. The risk rate for mortality of victims referred to public teaching hospitals is 5.8 times higher than in other hospitals¹⁹.

A study on the risk of transport injuries in Wisconsin, USA, uses two sources of information on fatal and non-fatal injuries. When traffic-related injuries are represented, the problem mainly affects adults, white drivers, and men. It is essential to differentiate the risk of transport accidents in different modes of travel, transport policies and programs, and public health. The pattern is that the road transport system is not equally safe for everyone. The concerted effort to protect children has been successful, but teens, older drivers, American Indians, and black people are increasing risks²⁷.

One approach to reducing these disparities would be to focus analysis and prevention on the travel patterns, behaviors, and environments of specific demographic groups, rather than the population, and implement measures to reduce the risk of traveling, especially for those with a relatively greater chance, like motorcyclists, teenagers and cyclists²⁷.

Data on Brazilian traffic fatalities were extracted from a database of deaths of vulnerable road users, such as pedestrians and motorcyclists. Elderly pedestrians are at exceptionally high risk, and motorcycle deaths are increasing rapidly, coinciding with the motorcycle fleet increase. Death rates among bicycle users are the lowest. Road safety interventions should target vulnerable road users¹⁵.

Using three different sources of data, a study conducted in Argentina analyzed the variations in the mortality of motorcycle users. Motorcyclist mortality increased in the second half of the period studied in the central and central-north regions of the country. It was found that higher mortality rates are generally recorded in areas with greater population density. Brazil also showed an increase in motorcycle mortality, which coincides with the rise in the number of motorcycles in circulation¹⁶.

In Campinas, Brazil, a study of secondary data on traffic accidents registered an increase in the means of transport, with the motorization rate going from 39 to 61 vehicles per 100 inhabitants. The increase in the motorcycle fleet was even more expressive, going from three to nine motorcycles per 100 inhabitants in the same period. The percentage of accidents with victims from 19.3% increased to 24.8%. The percentage of pedestrians who were run over, which was 5.6%, decreased to 4.3%. There was a change in the type of fatality: pedestrian deaths decreased and motorcycle deaths increased⁷.

The risk of men dying from traffic accidents in all periods analyzed and the mortality of vehicle occupants was higher among young people aged 15 to 29 years. For every thousand motorcycle accidents, four caused the death of pedestrians, with 6.7 deaths of pedestrians being run over by a motorcycle for each fatal accident by a car. Thus, the research indicates that the groups at most significant risk for traffic accidents are motorcyclists, the male population in general, and, above all, young people⁷.

Accident data in Iran were used in a descriptive analysis of pedestrian incidents. The simultaneous existence of pedestrians over 60 years old and darkness in an accident increases the risk by 2.5. Thus, the study claims that the interaction of lighting and the dark color of pedestrian clothing can increase the risk of death. This problem can be solved by creating electroluminescent or retro-reflective materials attached to clothing, as well as persuading pedestrians to wear colorful clothing to increase their visibility¹⁷.

In Brazil, the mortality of vulnerable road users represents more than half (51%) of all traffic deaths¹⁵. Motorcyclists are generally more vulnerable as most of them may be driving drunk and exceeding the speed limit. Alcohol consumption causes carelessness and loss of concentration and speeding and neglecting the use of safety equipment such as a helmet²⁰.

Study limitations

All studies included in the synthesis of this review were performed with information taken from a database or medical protocols provided by hospitals. These analyses can generate restrictions due to the lack of harmonization among the databases concerning accidents, underreporting, inability to access specific factors, and lack of detailed information on the severity of injuries.

In the specific case of hospital protocols, amnesia of patients, victim family or health professionals who do not have complete facts about the incidents is also a limitation.

Contributions to public health

Mortality, both in pedestrians and motorcyclists, is higher in males. Factors such as increased sales of motorcycles, older pedestrians, lack of safety equipment for motorcyclists, and drug or alcohol intake increase the rate and incidence of death.

Inadequate lighting is also an important environmental factor, which contributes to increasing the risk of this fatality. In addition, most accidents are consequences of human failures and problems on public roads, considering the lack of traffic education on the part of the population.

This systematic review is extremely important for public policy recommendations to managers aiming to reduce fatalities from traffic accidents, especially among motorcyclists and pedestrians. There is a need to strengthen the health system, especially about emergencies, through research audits and injury control, improve the capacity of hospitals, intensify actions to improve crosswalks and handrails along walkways, and build more walkways and, above all, to carry out effective urban planning.

The application of safety measures, as recommended in legislation and health education, and the use of all possible advertising, including pamphlets and posters, are essential. Only in this way will it be possible to reduce these individuals' number of accidents and deaths.

 

CONCLUSION

Mortality due to traffic accidents with pedestrians and motorcyclists has increased in recent years, especially among men.

Acknowledgments

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001. The financial viability of the article is due to the Acre - Health Project in the Western Amazon (multi-institutional agreement process no. 007/2015 SESACRE-UFAC-FMABC).

 

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Correspondence:
Francisco Naildo Cardoso Leitão
nacal@outlook.com

Manuscript received: december 2020
Manuscript accepted: june 2021
Version of record online: january 2022