What are the challenges of pedestrian safety from the viewpoints of trac and transport stakeholders? A qualitative Study


 Background

Pedestrians are among the most vulnerable groups in traffic accidents. Our aim in this study was to explore the challenges associated to pedestrian safety from the perspective of traffic and transport stakeholders.
Methods

In 2018, applying a qualitative approach, twenty-four traffic and transport stakeholders were invited to participate in semi-structured individual interviews in Tabriz, Iran. To analyze data, conventional content analysis approach was used. MAXQDA software version 11 was applied to manage data analysis process.
Findings:

Participants reported a wide range of challenges which were grouped into six categories: "Challenges related to pedestrians", "Challenges related to drivers", "Management system challenges", "Environmental infrastructure challenges", "Educational and media challenges", and "Challenges of legislation and enforcement".
Conclusion

We identified pedestrian safety as a challenging urban traffic and transport issue with specific complexities, particularly in the management system. With a holistic approach to the challenges, as discussed inside, all reported obstacles seem to be overshadowed by one core challenge, namely the lack of a traffic management system with health-oriented approach and enough authority. Using evidence while policy-making and intervention planning, as well as media support is recommended.


Abstract Background
Pedestrians are among the most vulnerable groups in tra c accidents. Our aim in this study was to explore the challenges associated to pedestrian safety from the perspective of tra c and transport stakeholders.

Methods
In 2018, applying a qualitative approach, twenty-four tra c and transport stakeholders were invited to participate in semi-structured individual interviews in Tabriz, Iran. To analyze data, conventional content analysis approach was used. MAXQDA software version 11 was applied to manage data analysis process.

Findings:
Participants reported a wide range of challenges which were grouped into six categories: "Challenges related to pedestrians", "Challenges related to drivers", "Management system challenges", "Environmental infrastructure challenges", "Educational and media challenges", and "Challenges of legislation and enforcement".

Conclusion
We identi ed pedestrian safety as a challenging urban tra c and transport issue with speci c complexities, particularly in the management system. With a holistic approach to the challenges, as discussed inside, all reported obstacles seem to be overshadowed by one core challenge, namely the lack of a tra c management system with health-oriented approach and enough authority. Using evidence while policy-making and intervention planning, as well as media support is recommended.
Background A large number of deaths and injuries occur annually as a result of road crashes among pedestrians, especially in low-income countries. Globally, about 400,000 pedestrians are killed due to road tra c crashes each year (1). Universal statistics show that the proportion of pedestrian deaths to total death caused by tra c accidents is high in developing countries (2,3). In developed countries, however, road accidents are declining due to continued investment in infrastructure and safety programs. Studies on the risk of pedestrian accidents in developing countries (such as Iran) are in their infancy because road safety interventions have just begun and are in full swing. In addition, in such countries, the focus of road safety interventions is more on improving the safety of drivers than pedestrians (4).
Among all road users, pedestrians increase the risk of road accidents because they are so exible and unpredictable (5,6). In many studies, several behavioral factors like talking on the cellphone while crossing the street, neglecting tra c light, crossing a red light and crossing at inappropriate places (crossing dangerous lines) are suggested as pedestrians' unsafe behaviors (7)(8)(9)(10). Furthermore, low perceived risk of unsafe behaviors (11,12), consumption of unauthorized drinks, poor visibility on the roads (13,14) and distraction (9) are also reported as other behavior-associated factors that endanger pedestrian safety.
As evident in literature, a wide range of factors are associated to pedestrian safety. In most cases, unsafe situations for pedestrians are not only related to poor decision making and risky behaviors exhibited during road crossings but also associated to lack of tra c and environmental factors (12,15). As an instance, older people experience a sense of insecurity and unsafe to cross the streets because of lacking pedestrian crossing facilities (16). Based on literature, some factors like failing to give priority to pedestrians by drivers (17), ignoring to use facilities due to normalization (18), lacking a sense of security in using the facilities especially at night, lack of pedestrian escalators, and the presence of vendors along pedestrian bridges (18)(19)(20) are also reported as barriers to pedestrian safety.
Previous studies have emphasized the identi cation of pedestrian safety obstacles and challenges prior to designing any pedestrian safety promotion interventions within societies (21,22). Pedestrian risky behaviors is a context dependent issue affected by a wide ranges of cultural and attitudinal factors (23). In many quantitative studies, the reasons for dangerous behaviors of pedestrians during road crossings have not well been discussed, as the quantitative studies on such risky behaviors alone cannot represent the motives behind the behaviors (24), so the association safety is remained ambiguous. Urban tra c researchers and policy makers can nd a better understanding of pedestrian unsafe behaviors through conducting qualitative studies. In this regard, there is a great need to identify the opinions of both pedestrians themselves and tra c and transport stakeholders, as experts in the eld pedestrian safety.
In 2018, a multi-method study was developed to design and implement a Pedestrian Safety Promotion Program (PSPP) aiming to improve the pedestrian safety in Tabriz, Iran. As the rst phase of study, a qualitative method was applied to identify the challenges and obstacles of pedestrian safety from the perspectives of both pedestrians and urban tra c and transport stakeholders. The ndings of this phase were then considered as the basis to develop the PSPP, as a community-based educational intervention, in the second phase. In a previously published paper (25), the challenges associated to pedestrian safety from the perspective of pedestrians were reported. In the present manuscript, we reported our qualitative ndings on the challenges of pedestrian safety from the perspective of urban tra c and transport stakeholders.

Setting and participants
This qualitative study was conducted in Iran applying conventional content analysis approach from March 2018 to March 2019. Interviews were carried out either at the health centers or the work o ce of stakeholders, according to the agreement between the interviewer and participants. Twenty-four key stakeholders in the area of urban tra c and transport were selected based on purposive sampling with maximum variation in characteristics such as age, gender, specialty, the number of years worked as an urban tra c and transport specialist and education level. Participants' characteristics are presented in Table 1. Semi-structured individual interviews were conducted to collect data. Inclusion criteria for this study were living in Tabriz and to be consent to participate in the study.

Data Collection
To collect data, individual semi-structured interviews were carried out. In this study, an interview guide (Table 2) was prepared prior to the interviews, based on Krueger & Casey 2014 standard protocol (26,27). This guide included participants' views on pedestrian safety and the barriers and challenges associated with the issue. Consequently, the interviews began with the following question "How is your opinion about the barriers and challenges related to pedestrian's safety in Tabriz?" Some probing questions such as "can you explain more" were used to extract more information and to advance the interview. After 21 individual interviews, we rarely identi ed new codes or categories in transcripts. However, we continued to conduct interviews, and in the interview number 24 no new code or category emerged. So, we concluded the theoretical saturation of data and terminated the interviews. The average length of time taken to complete the interviews was 45 minutes. What role do you think the authorities can play in protecting pedestrians?
Why do you think pedestrians don't use the safe passages?
What role do you think drivers play in pedestrian safety?
What is your idea about the management system of urban traffic and transport for pedestrian safety in the country? Can you explain more?
What do you think about the rules for pedestrian safety?
How do you think about the causes of unsafe behaviors of pedestrians?
Explain the role of social media such as radio and television in the safety of pedestrians?
What do you think about the education available in the community for the safe behavior of pedestrians?

Data analysis
Data analysis was performed during the data collection process. Conventional qualitative content analysis technique was initiated from the rst interview in parallel with interviews. Initially, the recorded interviews were written and each interview was reviewed two to four times to ensure that the transcripts were correct. Then, the rst researcher coded the transcripts of the interviews. The codes were read for several times, and the conceptually similar codes were then grouped into one category. With the progress of analysis process and reiterated reading of the texts, extracted codes and categories, the similarities and differences between the categories were identi ed and the themes were distinguished in terms of features and dimensions. The management of data was performed using MAXQDA 11 software.
To increase data validity and transferability, four criteria including credibility, conformability, transferability and dependability were considered (28). The validity of the current study was provided through careful selection of eligible participants, long-term and consistent participation of volunteers during the analysis of information, and applying experts' opinion at different stages of study. The con rmation of study was obtained after preserving documentation at all stages of the research, and there was possibility for others to examine the process through clarifying methodological decisions. The transferability of ndings was evaluated using a complete and detailed description of the situation, participants and data analysis methods. To increase reliability of the research, all data were presented to a researcher who had no connection with the research study so that determine if he/she had a similar understanding of the data.

Results
According to the experts' perspective, the challenges related to pedestrian's safety were classi ed under six categories including "Challenges related to pedestrians", "Challenges related to drivers", "Management system challenges", "Environmental infrastructure challenges", "Educational and media challenges" and "Challenges of legislation and enforcement" (Table 3).  implemented. If we consider this issue, our problems in public education, vehicle safety, and road safety will be resolved". Challenges related to pedestrians As our participants believed, a wide range of pedestrian safety challenges is related to pedestrians themselves: One area that a majority of participants mentioned was lack of demand from community members to resolve pedestrian safety issues. A contributor stated that: "A part of the budget has to be paid for the development of urban infrastructure, but it doesn't happen in a reasonable amount unless the public demands of the community are effective. The people have to be demanding" (P18)

3-Becoming accustomed to perform unsafe behaviors
The habit of engaging in risky behaviors was one of the areas that most participants mentioned: "Pedestrians have become accustomed to risky behaviors; that is, people have become accustomed to a previous wrong culture. They think that they can get in car at the crossroads or making transverse passage where they want". (P3)

4-Lack of knowledge, awareness, and literacy about tra c rules
Poor tra c literacy, lack of knowledge and awareness about tra c were some of the areas that many participants mentioned in various ways: "Most people are not aware of the tra c principles since they were not trained. They do not have the required knowledge. ". (P23)

-Poor perceived risk
Lack of risk perception was also mentioned as a challenge for the pedestrians' safety.
"In occupational safety issues, perceived risk is much more important than knowing about the risk. In other words, being aware of a risk does not guarantee performing safe behaviors. Individuals have to perceive the tra c risk, properly". (P11)

6-Adherence to people's unsafe behaviors
In most cases, participants noted that the pedestrians usually follow the people's unsafe behaviors as they see.
"The other point is that when you see that no one is following the tra c rules, you say why should not I do it?" (P10)

7-Parents as poor role models
A majority of participants believed that children emulate parental behaviors, including their unsafe tra c behaviors.
"For example, father or mother in a family usually crosses the street without paying attention to road signs and symptoms, ignoring that their children are looking at them. You now, parents play as role models for their children". (P12) Challenges related to drivers

1-Drivers' poor perceived risk
Most participants reported the drivers' poor risk perception as one of the challenges and obstacles to the safety of pedestrians.
"The drivers have not yet perceived how much the risk of increasing speed from 60 to 80 km/h is in causing a deadly accident with a pedestrian. They do not understand that pedestrians are really vulnerable ". (P14)

2-Tra c rule violations by drivers
Tra c rule violations and unsafe behaviors of drivers, such as disregarding to pedestrians' right-of-way, crossing the green light, high speed, stopping on the pedestrian crossing, parking cars on the sidewalks, and motorcycling on the sidewalks were also mentioned by our participants as challenges to pedestrians' safety.
"Sometimes, drivers perform high-risk behaviors, like high-speed, which cause fear and confusion to pedestrians ". (P13)

3-Distracting driving behaviors
A majority of participants reported behaviors like sending short messages, talking on a cell phone, talking to a passenger, and watching a monitor while driving as the challenges that endanger pedestrians' safety: "Most drivers either talk on their cell phones or send SMS, and they still don't follow the rules!" (P23) Environmental infrastructure challenges 1-Inappropriate or lack of safe pedestrian lanes lack of pedestrian bridges and underpasses, non-mechanized pedestrian bridges, unsuitable pedestrian bridges for older adults and the disabled persons, as well as having potholes on the sidewalks, multiple disconnections in the sidewalks along a route, rugged and/or narrow sidewalks, the presence of stairs on sidewalks, trees planted in improper places of sidewalks and even absence of sidewalks on some streets were among the pedestrian lane challenges reported by participants: "Many of our streets don't even have sidewalks, and you know that all the streets must have sidewalks." (P9)

2-Inappropriate/poor tra c signs and equipment
As participants reported, inappropriate or lack of tra c and transport signs and equipment including out of service red lights, absence of pedestrian crossings in some routes, inappropriate location of pedestrian crossings, lack of lighting in the sidewalks, and mismatch between pedestrian crossings and tra c lights caused problems to pedestrian safety: "In the developed countries, there are pedestrian lights, but practically there are few numbers of such things in our country. At a majority of intersections, there are pedestrian crossings, but no pedestrian lights". (P10)

3-Poor aesthetic pedestrian lanes
Poorly aesthetic design of pedestrian lanes and crossings was another infrastructure challenge mentioned by a majority of the participants: "Most overpasses are made from steel with no fascinating design, which do not attract pedestrians. I think the designers have not done a good practice in urban beauty". (P4)

4-Obstruction of sidewalks
A majority of participants reported the obstruction of sidewalks due to vendors, shopkeepers' stands, and leaving construction materials. As they believed, such obstructions impede the pedestrians to cross over the sidewalks, and thus they inevitably walk on the street. Participants also pointed out to the lack of training students about tra c rules and pedestrian safety at schools. They believed that there is a gap in the academic courses of all grades, from elementary to high school.
"There is a training gap in this eld at schools. We do not have any educational course or book in this regards. Pedestrian safety should be embedded in the educational programs of the schools". (P7)

3-Lack of mass media in acculturalization of tra c behaviors and pedestrian safety
Participants believed that mass media (e.g. television and radio) in the country lacks in developing the culture of tra c and pedestrian safety throughout the society. As an instance, they pointed out to the poor role modeling of actors in the movies: "When an actor is talking on a cell phone while driving, crossing a street while talking either on a cell phone or with a friend, you know, people especially teenagers and young adults perceive such unsafe behaviors as the true way of crossing." (P6) challenges related to tra c and transport management system 1-Improper urban planning management related to tra c and transport In terms of poor urban planning associated to pedestrian safety, participants reported a wide range of challenges, including ignoring pedestrian rights in designing urban furniture, lack of safety at a number of sidewalks for pedestrians (e.g. the presence of addicts, drug dealers and bag-rubbers, particularly at nights), poor inter-sectoral collaboration for pedestrian safety, and not employing the true specialists in the eld of tra c and transport.
"In my opinion, the issues of 'pedestrians' are neglected in urban furniture design. This subject has received less attention in our country." (P20) As they believed, the origin of these problems is the lack of a unique tra c and transport management system within the country, which has resulted in aggravating the urban tra c and transport issues: "A way to reduce tra c accidents is to create a leading organization. A leading organization headed by urban transport experts and policy makers could manage many aspects of the issue". (P8)

2-Lack of contact channels between people and o cials
According to participants, lack of communication channels for people to contact urban tra c and transport o cials was an important challenge for pedestrian safety.
"People do not know where to go to complain about pedestrian safety and if they do, will they be effective?" (P15) 3-Poor policy making while planning pedestrian safety programs As reported by participants, poor tra c and transport policy making, non-reliance on evidence to promote pedestrian safety, lack of comprehensive need assessments, non-compliance with pedestrian safety standards, poor budget allocation, and not employing private sector in implementing the programs were example of poor policy making related issues in planning pedestrian safety programs.
"Decision-making based on scienti c evidence is necessary to promote pedestrian safety. But, a majority of our stakeholders do not pay attention to it ". (P8) 4-Lack of health-oriented perspective in the tra c and transport management system Absence of health-oriented perspective on urban transportation was one of the major management challenges addressed by a majority of participants.
"In the developed countries, tra c issues and pedestrian safety are considered from the aspect of health promotion, but this is a recent subject in our country." (P14)

5-Lack of proper vehicle manufacturing
A majority of participants pointed out to the improper design of domestic vehicles, which is associated to pedestrian safety while accidents. Poor brake system, early depreciation and non-adaptation with pedestrian safety were the mainly reported issues by participants that endanger pedestrian health.
"Another measure that can be taken to protect pedestrians is related to vehicles. Cars manufactured in the country are poorly designed". (P4) Challenges of legislation and enforcement 1-Poor tra c and transport legislation As most participants believed, lack of legal boundaries contributed to the pedestrian and drivers' behaviors as well as lack of a penal/incentive system for pedestrian behaviors were among the challenges of pedestrian safety.
"We have nes for tra c violations of car drivers, but unfortunately we have no ne for pedestrians". (P16)

2-Weakness in law enforcement
The most participants stated the lack of penalties for drivers who disregard the rights of pedestrians, failure in enforcing the existing laws for pedestrian safety, improper enforcement of urban tra c laws, and poor inspection of tra c law enforcement.
"The laws allow the police to ne offending pedestrians, but its mechanism and manner are not clear. I mean, this law is not applicable and the most of discussions are focused on drivers." (P12) Discussion: Our aim in the present qualitative study was to explore the viewpoints of urban tra c and transport stakeholders on the challenges and barriers of pedestrian safety in Tabriz, Iran. Participants, as the experts of urban tra c and transportation, reported several challenges ranged from those associated to pedestrians themselves and inner-city drivers to the obstacles related to environment, society and culture, education, legislation and management. In agreement with those reported by Haghighi et al., (25) pedestrian safety seems to be a multi-factorial issue affected by a wide range of factors.
Besides emphasizing some common factors in developing countries, participants stressed some pedestrian factors that are not reported so high in the literature. Not caring about one's safety in the streets, lack of demand for resolving pedestrian safety issues in the community, poor perceived risk, and lack of tra c safety literacy were pedestrian associated factors that needs to be paid attention in future studies. Poor level of tra c literacy, for example, is a common problem among individuals in developing countries. Although we can improve knowledge and road crossing behaviors through implementing educational programs (29), tra c and road safety literacy is something more than having knowledge about tra c safety, and incorporates a series of abilities and skills to access, understand and apply pedestrian safety behaviors (30). In many cases, pedestrians are unaware of their tra c-associated highrisk behaviors, road hazards and the consequences of their behaviors (4,31). Thus, promoting pedestrians' awareness of road hazards is also an important factor in adopting safe behaviors (32). Of course, to enable pedestrians in performing pedestrian safe behaviors, planning educational programs is not enough, and instead multifaceted interventions including public health campaigns, community mobilization, as well as advocacy and social marketing efforts are necessary. So, policymakers and tra c stakeholders should improve pedestrian safety in the community through developing multifaceted tra c safety promotion programs.
Similar to those reported in previous studies (25,33,34), drivers' poor perceived risk, tra c rules violations and distracting behaviors were challenges associated to pedestrian safety reported by participants in the present study. According to a previous study, risky behaviors in drivers are factors that can lead to pedestrians' overruns (35). Findings from another study similarly showed that most pedestrians did not feel safe while crossing the road due to disregarding to pedestrians' right-of-way by drivers (17). Drivers-related factors noted in the present study were expected, as previously reported in several studies (36,37). In a current study in Ghana, many drivers were reported to not pay attention to pedestrian crossings and approach them very quickly. Also, Permissible speed was not observed in residential areas, and pedestrian safety was at risk, especially for children who are playing (38).
Another hindrance of pedestrian safety, as participants reported, was environmental infrastructures of urban tra c and transport. Lack of safe pedestrian lanes, particularly for older adults and disabled persons, inappropriate/poor tra c signs and equipment and obstruction of sidewalks were frequently reported by participants. In a community with such common infrastructural problems, it is not unusual for pedestrians to violate tra c rules. For instance, "If I want to use pedestrian overpasses, I have to walk 50-100 meters further down the street, go up the stairs about 50 steps, and then come down; so, I de nitely do not use the overpass and cross the street!". So, the consequence is that more than one third of road tra c injuries happen while walking on the roads (39). Similar to our ndings, non-mechanized pedestrian bridges with high number of steps in uenced the rate of bridge use by pedestrian (20). As our participants stated, pedestrians are indifferent to the bridges located in inappropriate places or have di cult accessibility, so they prefer to cross the street, as noted in a previous study (40). According to the literature, pedestrians give higher priority to convenience and time-saving compared to safety (18,41). So, in the planning to promote infrastructures of urban tra c and transport, the policy makers and stakeholders should pay a great attention to these factors. Osama and Sayed (42) showed that the continuity of sidewalks and their appropriate slope had a positive relationship with less accident's occurrence. Factors like uneven surfaces, crowded intersections and stairs, and slippery surfaces, as the environmental issues commonly reported by participants in our study, play important roles in the rate of pedestrian falls (43). According to our ndings, the mismatch of facilities with older pedestrians and disabled individuals was another barrier of pedestrian safety. Addressing the issues of older adults in the design of urban spaces is so important that the WHO urged the needs for constructing the cities, in terms of the distribution of public services and facilities, based on the needs of the older population (44).
Weakness in legislative performance and poor law enforcement were identi ed as other important barriers to pedestrian safety, in our study. The illegal crossings on the roads in some developing countries has been well studied, and in many cases, they have emphasized the high rate of pedestrian accidents associated to this behavior (45,46). A study in Chile found that pedestrians have a positive attitude toward illegal crossings (47). Of course, in some cases, due to the lack of facilities, illegal crossing is the only way to cross the road. It seems that in addition to promote safety culture and educational interventions, the adoption of appropriate laws and regulations for pedestrians as well as inspection on law enforcement can be good options to improve the safe behaviors of pedestrians.
Moving further, poor tra c management system was an important theme emerged from the data. A majority of participants pointed out to poor urban design with no consideration on pedestrian safety, a systemic approach and a leading organization in the eld of urban tra c. A consequence of these managerial issues is a great lack in inter-sectoral collaboration, as there is no unique management system to mediate between different sectors associated to urban tra c and transport. For example, "Things need to be more cohesive; all relevant organizations should be actively involved in tra c and transport issues". In countries with successful experience in reducing the number of tra c accidents, there is usually an organization with su cient authority and stewardship for managing urban tra c and transport system, and other organizations are responsible for a high level of collaboration and cooperation with (43,48). According to the WHO reports, tra c accidents prevention and tra c safety promotion may not be achieved without cooperation among different organizations (49). Similar ndings were reported in previous Iranian studies (50,51). Lack of proper design in Iranian-manufactured cars in terms of pedestrian safety was another issue mentioned by stakeholders. Compliance with vehicle safety standards has a signi cant impact on pedestrian safety (4), and have to be considered as the rules to be obeyed by car manufactures in developing countries. Because proper design of vehicles plays an important role in maintaining the safety of pedestrians and injure them less in accidents (52).
Lacks of tra c safety trainings from elementary schools to the universities, as well as lack of media support and advocacy for tra c and transport safety emerged as another obstacle to pedestrian safety.
Previous studies have shown that public education alone may not reduce deaths or injuries resulting from accident (53,54). Our participants believed that beside public education and awareness raising, there is great needs for media advocacy, supportive legislations and law enforcement, as recommended in previous research (55). These challenges altogether bear in mind the lack of a tra c management system with health-oriented approach and enough authority in Iran, as a developing country. Such a system with the characteristics noted can manage and mediate the tra c and transport initiatives among different organizations in a comprehensive manner. In Iran, like a majority of developing countries, although limited trainings on tra c principles such as Police Aid Program (PAP) are conducted at schools (56), there is almost no credible and formal training program on tra c safety at schools and universities. Limitations of this study were di cult access to participants and gain their con dence to participate in the study. Despite efforts to build trust through self-introduction and study objectives, a small number of professionals still declined to be interviewed.

Conclusion
Based on the ndings, we concluded that pedestrian safety was a challenging issue in urban tra c and transport systems of developing countries with speci c complexities, particularly in the management system. Tra c safety researchers, tra c policymakers, municipalities and government o cials, particularly in the developing countries, may consider these various range of pedestrian safety challenges while tra c safety policy making and/or designing pedestrian safety promotion programs within urban environments. Using evidence while policy-making and intervention planning, as well as media support is recommended. With a holistic approach to the challenges, we can conclude that all the obstacles reported in the present study are overshadowed by one core challenge, namely the lack of a tra c management system with health-oriented approach and enough authority. Such a system can manage and mediate the tra c and transport initiatives among different organizations and eventually represent the health and safety of pedestrians as the subject of everyday life, as suggested in the Ottawa Charter for health promotion (57). Our ethical considerations were the statement of study purpose to participants, reassuring the participants about con dentiality of all recorded data, obtaining informed written consent from participants, keeping anonymity of data, and participants' right to withdraw at any time during the research process.
Availability of data and materials All data used for the analysis are available from the corresponding author upon request.

Competing interests
The authors declare that they have no competing interests.

Funding
Vice chancellor for research, Road Tra c Injury Research Center, Tabriz University of Medical Sciences.
Authors' contributions MH, HN and FBA are the main investigator and were involved in the study Design. HSB were also involved in the data collection and analysis.