1 Safety education of pedestrian a systematic review O. Duperrex, F. Bunn, I. Roberts Sources of support: Institut de médecine sociale et préventive, Geneva, Switzerland Cochrane Injuries Grant, UK Medical Research Council, UK

2 Road Deaths World 1,391,000

3 Global problem: vulnerable pedestrians over 1 million road deaths per year fatality rate per billion passenger km: –pedestrians: 78 –car passengers: 5 pedestrian deaths per year: –280,000 children –210,000 elderly

4 Pedestrian injuries disabilities deaths Pedestrian attitude knowledge behaviour Driver Law enforcement Environnement Education Pedestrian crashes

5 This Cochrane systematic review is the result of a comprehensive search –in 10 transportation, educational and medical electronic databases –in 7 languages –contacts with authors & experts in the field included only randomised controlled trials aimed at modifying pedestrian behaviour

6 Results Total hits Elligible 674 (5%) Excluded – cohort study 1 – controlled non randomised35 – RCT 5 Included 15

7 Methodological quality - generally poor (number of included RCTs = 15) adequate allocation concealment: 3 RCTs blinding of outcome assessment: 8 RCTs small study population (<200): 10 RCTs large losses to follow up in many studies

8 Included studies (number of included RCTs) conducted between 1976 to 1997 Australia, Japan, Germany, UK, USA, Canada => none in low & middle income countries participants 14 children (3y to 13y) 1 adults (institutionalised) 0 elderly

9 Interventions (number of included RCTs) 8 direct education 7 indirect education - parents or teachers variety of settings: home - classroom - traffic situation variety of media: verbal - printed material - film - multi-media kit table-top model - mock intersection concert

10 Outcomes main outcomes: none crashes - deaths - injuries - disabilities surrogate outcomes 6 behaviour - 5 attitude - 6 knowledge big diversity –in the tools used to measure outcomes –in the conditions under which they were used –in the delays for post-test measurements (<1 to 8 mo) => no meta-analysis

11 Effect of pedestrian education on behaviour - selection (5-9y) Stop & look at the line of vision RR 1.79 (1.18 to 2.72) Stop at the line of vision when crossing between parked cars RR 1.73 (1.39 to 2.14) ’Safe behaviour' RR 2.13 (1.01 to 4.47) Post-test Transfer Score SMD 0.83 (0.31 to 1.35)

12 Behaviour (observed) of 5 to 7 yr olds - post-test at 1 to 3 monthsIndirect education versus No education Favours intervention Favours control RR (95%CI random) Stop & look at line of vision distraction (competition) no distraction

13 The effect of the intervention was lower in the later follow up period 18 of the 24 behavioural outcomes, 2 of the 4 attitude outcomes and the 2 knowledge outcome measures. (6 RCTs)

14 Pedestrian injuries disabilities deaths Pedestrian attitude knowledge behaviour Driver Law enforcement Environnement Education Pedestrian crashes Education of children ?? Left out: elderly LMIC

15 limitations combined strategies overlooked publication & other selection biases minimised but not excluded poor quality of included trials no trial from LMIC outcomes of interest not usually measured variety of interventions and outcomes: difficult to summarise

16 challenges identification of relevant studies - indexes access to databases search too sensitive obtaining papers variety of interventions and outcomes: difficult to summarise time management - keep motivation for a marathon

17 Thanks to Frances Bunn and Ian Roberts for their support and participation as co-reviewers, to authors who kindly replied to my requests, to Reinhard Wentz and Irene Kwan for help with database searching and obtaining papers, to Angela Huertas, Maaike Kruseman, Valdo Pezzoli and Finn Johnsen for help with translation, to Marjan Loep from the Dutch Cochrane Centre for help with the Dutch titles, to Toshihiko Yanagawa for help with translation and contacting Japanese experts.

18 Published as: Duperrex O, Roberts I, Bunn F. Safety education of pedestrians for injury prevention (Cochrane Review). In: The Cochrane Library, Issue 2, Oxford: Update Software. Duperrex O., Bunn F. and Roberts I. Safety education of pedestrians for injury prevention: a systematic review of randomised controlled trials. BMJ May 11; 324(7346):1129.