Community-level infrastructure risk factors for motor vehicle injuries of car occupants and pedestrians: results from the PURE study

Disproportionately more of the world's fatalities and injuries on the roads occur in low- and middle-income countries, despite these countries having approximately only 60% of the world's vehicles. Injury rates due to motor-vehicles are related to a complex multidimensional array of risk factors, embedded in the social and economic infrastructure of a country or region. Whether environmental infrastructure factors differ in determining the risk of an injury for motor vehicle occupants compared to pedestrians and other vulnerable road users has not been extensively studied. We explored the role of environmental infrastructure factors on motor-vehicle-related non-fatal injury using the Prospective Urban and Rural Epidemiology (PURE) cohort study of 162,793 adults from 23 high-, middle- and low-income countries. As expected, low-income countries had slightly higher motor vehicle injury rates, with pedestrians tending to have higher injury rates in these countries. There was considerable variation in motor vehicle injury rates within country-income-categories, while there were similarities in motor vehicle injury rates despite large differences in motorization of countries. There was a meaningful community effect on motor vehicle injury rates. We found that community-level infrastructure risk factors for motor vehicle injuries differed for car occupants and for pedestrians, with road quality and alcohol use being the main factors associated with an injury for car occupants, while poor roadside infrastructure (streetlights, sidewalks) and alcohol use were the main risk factors for an injury as a pedestrian. Active transport, such as walking and bicycling, are being promoted as leading to healthy lifestyle habits and reduced pollution. These require improved walkability for pedestrians, but also separation from motorized vehicles, which leads to recommending that low-and middle-income countries devote more funds for roadway quality and streetlight infrastructure. Policies to reduce motor vehicle injuries should be supported at the national level, but should be specific at the community level, since they must be focused on the specific local infrastructure. Countermeasures for reducing road transport injuries for pedestrians have different risk factors than for reducing injuries for car occupants.