Alcohol-impaired Walking in 16 Countries: A Theory-Based Investigation

Highlights

• Alcohol-impaired walking is a frequent behaviour internationally.

• International groups of pedestrians were identified based on their psychosocial characteristics.

• Perceived risk predicted intentions of alcohol-impaired walking across 16 countries.

• Japanese pedestrians' intention of alcohol-impaired walking was not predicted using classical TPB variables.

Abstract

Alcohol is a global risk factor for road trauma. Although drink driving has received most of the scholarly attention, there is growing evidence of the risks of alcohol-impaired walking. Alcohol-impaired pedestrians are over-represented in fatal crashes compared to non-impaired pedestrians. Additionally, empirical evidence shows that alcohol intoxication impairs road-crossing judgements. Besides some limited early research, much is unknown about the global prevalence and determinants of alcohol-impaired walking. Understanding alcohol-impaired walking will support health promotion initiatives and injury prevention. The present investigation has three aims: (1) compare the prevalence of alcohol-impaired walking across countries; (2) identify international groups of pedestrians based on psychosocial factors (i.e., Theory of Planned Behaviour (TPB) and perceptions of risk); and (3) investigate how segments of pedestrians form their intention for alcohol-impaired walking using the extended TPB (i.e. subjective norm, attitudes, perceived control, and perceived risk). A cross-sectional design was applied. The target behaviour question was “have you been a pedestrian when your thinking or physical ability (balance/strength) is affected by alcohol?” to ensure comparability across countries. Cluster analysis based on the extended TPB was used to identify groups of countries. Finally, regressions were used to predict pedestrians’ intentions per group. A total of 6,166 respondents (Age M(SD) = 29.4 (14.2); Males = 39.2%) completed the questionnaire, ranging from 12.6% from Russia to 2.2% from Finland. The proportion of participants who reported never engaging in alcohol-impaired walking in the last three months ranged from 30.1% (Spain) to 83.1% (Turkey). Four groups of countries were identified: group-1 (Czech Republic, Spain, and Australia), group-2 (Russia and Finland), group-3 (Japan), and group-4 (final ten countries including Colombia, China, and Romania). Pedestrian intentions to engage in alcohol- impaired walking are predicted by perceptions of risk and TPB-psychosocial factors in group-1 and group-4. Favourable TPB-beliefs and low perceived risk increased alcohol-impaired walking intentions. Conversely, subjective norms were not significant in group-2 and only perceived risk predicted intention in group-3. The willingness of pedestrians to walk when alcohol-impaired differs significantly across the countries in this study. Perceived risk was the only common predictor among the 16 countries.

Introduction

Pedestrians are the most vulnerable road users and are at risk of injury, disability, and death due to road crashes (Hashemiparast et al., 2017; Rod et al., 2021). According to the World Health Organization, global deaths from traffic crashes are around 1.35 million per year and more than half of these people are not travelling in a car (World Health Organization (WHO), 2018). Globally, pedestrians and cyclists account for 26% and motorcycle riders and passengers account for 28% of all road traffic deaths (World Health Organization (WHO), 2019). While eighty percent of road traffic deaths occur in low-to-middle-income countries, one factor affecting all countries’ road transport systems is human behaviour (McIlroy et al., 2020a; World Health Organization (WHO), 2018). To date very limited research (e.g. McIlroy et al., 2020b) has attempted to study pedestrian behaviour using a multi-country perspective, including the influence of alcohol consumption and intoxication on pedestrian behaviour and associated decision-making processes.

Alcohol is an important risk factor influencing both the risk of a road crash occurring, as well as the increase in severity of the injuries that result from crashes (Pawłowski et al., 2019). Much of the attention of alcohol as a risk factor for road crashes has been given to its effects on driver behaviour. Alcohol is responsible for traffic accidents due to its pharmacological action on the central nervous system, affecting driver’s vision, awareness, perception, reaction time and the ability to concentrate (Behnood & Mannering, 2017). Alcohol consumption also results in a decreased ability to estimate space and distance, increased levels of self-confidence, and a generally impaired ability to safely operate a vehicle (Chen et al., 2016). Drivers who have been drinking have a higher risk of involvement in crashes than those not intoxicated (World Health Organization (WHO), 2018).

Alcohol intoxication is not only a risk factor among users of motor vehicles, but is also significant and meaningful among pedestrians (Lang et al., 2003; Törő et al., 2005). Alcohol-impaired pedestrians are more likely to display behaviours that are unsafe such as crossing the street when the signal is red or crossing roads where there is no pedestrian crossing (Dultz & Frangos, 2013) as well as sitting or lying on the road (Hutchison et al., 2010). Impairments resulting from alcohol intoxication among pedestrians contribute to decreased cognitive functioning and potentially poor decision making (Eichelberger et al., 2018). Alcohol was associated with 58% of fatalities among pedestrians in South Africa and 48% of pedestrian fatalities in the United Kingdom (World Health Organization (WHO), 2018). Another study using data from 2014 to 2016 in the US reported that 75% of all pedestrian fatalities involved alcohol (Thomas et al., 2019). Additionally, Lasota et al (2019) found the presence of alcohol in the blood, muscle and vitreous body in 72% of a sample of pedestrian fatalities in Warsaw. In another Polish study, victims of road crashes who were under the influence of alcohol were predominantly young males (Pawłowski et al., 2019). Another study found that fatally injured pedestrians who had positive alcohol screens had a higher incidence of severe abdominal injuries (Demetriades et al., 2004). This suggests that alcohol is not only a clear contributor to traffic crashes but also presents a risk factor leading to a higher level of severe outcomes in pedestrian road traffic incidents as well as a generally higher incidence of injury severity (Živković et al., 2016).

The limited number of theory-based studies examining alcohol-impaired walking has hindered the development of interventions worldwide. Although interventions have been established to address general pedestrian crash risk; interventions for alcohol-impaired walking are virtually non-existent (Gannon et al., 2014; Haque et al., 2012; McGhie et al., 2012). The lack of evidence-based interventions presents a clear gap in literature and practice, and to find suitable interventions we need to evaluate the suitability of theories in cross-cultural contexts. Investigating the cross-cultural differences in intentions to walk when alcohol-impaired could lead to better theoretical basis for countermeasures which are more globally useful. Given the increase in interest in global health initiatives (Adams et al., 2016), increasing understanding of cultural differences in intention to walk when alcohol-impaired is an important addition to the literature.

Human behaviours are difficult to predict, and evidence-based theories are required for a holistic understanding of decision-making processes, particularly in relation to risk behaviours, where it has been demonstrated that knowledge of negative consequences itself is commonly not sufficient to cease or change behaviours (Egger et al., 2013). The TPB (Ajzen, 1991), an extension of the Theory of Reasoned Action (Fishbein and Ajzen., 1975), has become one of the most frequently cited and influential models explaining the determinants of human social behaviour in social psychology and consumer decision making (Ajzen, 2011). According to the TPB, the proximal determinant of behaviour is the intention to engage in a particular behaviour. Behavioural intentions are assumed to be a function of an (1) attitude (i.e., favourable or unfavourable beliefs), (2) subjective norms (i.e., perceptions that important others would approve of), and (3) perceived behavioural control (PBC) (i.e., ease or difficulty of performing that behaviour) (Ajzen, 1991; Kaye et al., 2020; Oviedo-Trespalacios et al., 2020). Thus, the model consists of the three previous standard constructs, the strength of which determine the strength of one’s intentions toward engaging in the behaviour, which are then regarded as proxies for whether people will actually engage in the behaviour (Ajzen, 1991, 2011). In this research, the TPB was selected to seek a greater insight into the factors influencing, and motivations underpinning, pedestrian alcohol- impaired walking at an international level. Intentions are used as dependent variables as they show how likely a pedestrian is to engage or continue engaging in alcohol-impaired walking. The TPB is a well- validated decision-making model, which has been used in recent road-safety studies to explain or predict risky behaviours on the roads such as distraction, speeding, and seat belt non-use (Lennon et al., 2017; Oviedo-Trespalacios et al., 2019).

Several studies have used TPB constructs, or extended versions of it, to explain alcohol- impaired behaviours. For instance, Conner et al. (1999) examined the predictive power of the TPB explaining alcohol consumption in three prospective samples of students. The results showed that attitude, subjective norms and perceived behavioural control explain between 12 and 50% of the variability in intentions. The researchers also found that past engagement in alcohol consumption was a significant, positive predictor of intentions and subsequent drinking behaviour (Conner et al., 1999). In a more recent study, Moan & Rise (2011) determined to what extent the theory of planned behaviour (TPB) extended with moral norms and descriptive norms were able to predict intentions not to drink and drive. The results showed that the extended TPB model accounted for a small amount of the variance in intentions in the sample as a whole. However, the model was better suited to predict intentions not to drink and drive among men and drivers aged 35 years and younger than women and drivers aged above 35 years (Moan & Rise, 2011). Haydon, Obst, & Lewis (2018) applied an extended TPB, including self-identity, to examine women’s intentions to consume alcohol. The results showed the importance of the standard TPB constructs in influencing women’s intentions to drink frequently or binge drink. Specifically, attitude and perceived behavioural control were significantly associated with intentions to binge and drink frequently for women of all age cohorts (Haydon et al., 2018).

The TPB and extended version of the TPB have been implemented to understand the determinants of alcohol-impaired walking intentions. For example, McGhie et al. (2012) examined the influence of psychosocial factors upon individuals’ intentions to walk when alcohol-impaired, indicating that an individuals’ intentions are stronger when an individual was walking with others than when alone. Haque et al. (2012) offered some support for the utility of the Theory of Planned Behaviour (TPB) framework in explaining young peoples (aged 17–25 years) intentions to drink alcohol and walk. Another study (Gannon, et al., 2014) explored the role of TPB, normative influences and perceived risk in predicting young people’s self-reported intentions to walk after alcohol consumption. The results found that males, when compared with females, had higher intentions to drink and walk and lower perceptions of risk regarding walking after alcohol consumption. Especially younger males have consistently been found to be less risk averse than females and more likely to take part in risky activities (Byrnes et al., 1999), particularly under the influence of alcohol and other drugs (Kim & Kim, 2012). In the context of alcohol-impaired walking, it could be expected that a person who anticipates risky behaviour or feelings of regret for their behaviour would be less likely to walk when alcohol-impaired. For instance, Haque et al. (2012) showed perceived behavioural control, anticipated regret, and past behaviour were predictors of young pedestrians’ (aged 17–25 years) intentions to walk after alcohol consumption (Haque et al., 2012). Previous research has also found that the construct of perceived risk is a significant predictor of road users’ intentions as well as alcohol related behaviours (Lang et al., 2003). Thus, it is expected that psychosocial factors as defined in the TPB extended with perceived risk could be used to predict intentions to walk when alcohol-impaired across countries. However, what underlies the differences in intentions to walk when alcohol-impaired across countries needs significant further research. The extended TPB has not been extensively tested among diverse groups of pedestrians with diverse socio-cultural perceptions of risk and alcohol use.

Understanding the prevalence, intentions and perceptions of walking when alcohol-impaired is an under researched global road safety issue. The limited body of research on alcohol-impaired walking does not provide a strong enough evidence base to create health behaviour messaging and little is known about how these frameworks perform at an international level across different socio-cultural perceptions of risk and alcohol use (most of the psychosocial research on alcohol-impaired walking has been conducted in Australia). To address this gap, the present investigation has three aims:

(1) compare the prevalence of alcohol-impaired walking across 16 countries;

(2) identify international groups of pedestrians based on psychosocial factors (i.e., Theory of Planned Behaviour (TPB) and perceptions of risk); and

(3) investigate how segments of pedestrians form their intention for alcohol-impaired walking using the extended TPB (social norm, attitudes, perceived control, and perceived risk).

To enable a cross-cultural comparison between such diverse countries and cultures in this study, alcohol-impaired walking was described to participants as walk or cross the road “when your thinking or physical ability (balance, strength) was affected by alcohol”. This definition was agreed upon as one that is cross-culturally understandable after a systematic discussion amongst experienced alcohol related harm researchers at the Centre for Accident Research and Road Safety-Queensland (CARRS-Q). Previous research in alcohol-impaired walking has asked about walking following a given number of standard drinks or having a blood alcohol concentration (BAC) above 0.05 mg/ml (McGhie et al., 2012). However, types of alcohol, knowledge of BAC, and alcohol content of particular drinks is not globally uniform, and a more human-centred approach was needed to measure alcohol-impaired walking behaviour in such a diverse group of countries. Additionally, some countries such as Colombia have a strong culture of artisanal/homemade alcoholic beverages which are not standardised which made the use of the number of alcoholic drinks or BAC less desirable for this research. Furthermore, such a binary approach may limit recall bias that more complex measurements may be more prone to, particularly across different cultures.