What can we learn from road safety and injury prevention professionals about health equity and the built environment?

By Emily McCullogh, Alison Macpherson, Brent Hagel, Audrey Giles, Pamela Fuselli, Ian Pike, Juan Torres, and Sarah A. Richmond

Emily McCullogh: Dr. Emily McCullogh is a postdoctoral fellow at York University in the Faculty of Kinesiology and Health Science working under the supervision of Dr. Alison Macpherson (York University) and Dr. Sarah Richmond (Public Health Ontario). Her doctoral work was conducted in the fields of sociology and philosophical ethics and examined care and caring within coach-athlete relationships in youth competitive sport; however, her research scope has expanded to include injury prevention, road safety, and implementation science. Upon completing her Ph.D. she joined a pan-Canadian research team dedicated to reducing road-related injuries and deaths, as well as promoting active transportation. Her ongoing work focuses on accessibility, equity, and the built environment, as well as system-based approaches to safe mobility in Canada. 

Alison Macpherson: Dr. Alison Macpherson is a Professor in the School of Kinesiology and Health Science at York University and an adjunct senior scientist at IC/ES.  Her research is related to keeping kids active, healthy, and safe, and focuses on the prevention of childhood injuries primarily through policies and laws designed to reduce injuries.  

Brent Hagel: Dr. Brent Hagel is a Professor in the Departments of Paediatrics and Community Health Sciences in the Cumming School of Medicine and Adjunct Professor in Kinesiology at the University of Calgary. He is Director of the Healthy Children, Families and Communities Program of the Alberta Children’s Hospital Research Institute and a member of the O’Brien Institute for Public Health. His key research interest area is child and adolescent injury prevention currently focused on the determinants of child and youth bicycle, pedestrian, ski-snowboard, and ice hockey injuries.

Audrey Giles: Dr. Audrey Giles is a Full Professor in the School of Human Kinetics at the University of Ottawa. Through her research, she studies the intersections of culture, gender, and place, and how they influence injury prevention efforts.

Pamela Fuselli: Pamela Fuselli, MSc is the President and CEO at Parachute and one of the four co-founders who successfully led a process of national consultation and visioning, resulting in the formation of Parachute, Canada’s national charity dedicated to injury prevention. Pamela leads Parachute’s mission to turn evidence of what works into action, building strong relationships with stakeholders across Canada to achieve this mission. Over 20 years in the health care and injury prevention field, her work has focused on influencing public policy and harnessing the strength of those seeking similar outcomes to achieve social change. Pamela has led publications including two Cost of Injury in Canada reports, the Evidence Summary on the Prevention of Poisoning in Canada, as well as the Canadian Injury Prevention Resource and the Canadian Guideline on Concussion in Sport, both first such resources in Canada.

Ian Pike: Dr. Ian Pike is a Professor of Pediatrics at The University of British Columbia; Investigator and Co-Director of the Evidence to Innovation Research Theme at the BC Children’s Hospital Research Institute; Director of the BC Injury Research and Prevention Unit, and Co-Executive Director and Spokesperson for The Community Against Preventable Injuries – a not-for-profit injury prevention social marketing organization. His current research is focused on the determinants of injury, including deprivation and risky play; linkages between unintentional and inflicted injury including firearm injuries; child passenger safety; fire-related injury prevention; the relationship of COVID-19 policies and injury; and the efficacy of a social marketing campaign to reduce serious injury and death.

Juan Torres: Dr. Juan Torres is a certified urban planner (Quebec, Canada) and Professor at the School of Urban Planning and Landscape Architecture at the Faculty of Environmental Design, University of Montreal. He was born in Mexico and graduated in architecture (2000), in urban planning (M.Urb 2003), and environmental design (Ph.D. 2008). Specialized in urban design, his research focuses on children’s mobility, the production of child-friendly urban spaces and the participation of children and youth in urban planning and design. Since 2009, he has been collaborating with EspaceMuni as a member of the advisory committee of the UNICEF’s Child-Friendly Cities program in Québec. A list of his publications is available here: https://amenagement.umontreal.ca/professeurs/fiche/in/in15446/sg/Juan%20Torres/

Sarah A. Richmond: Dr. Sarah Richmond is the injury prevention lead at Public Health Ontario as well as an Assistant Professor in the Division of Epidemiology, Dalla Lana School of Public Health at the University of Toronto. Sarah has a multidisciplinary Ph.D. in Epidemiology and Exercise Physiology and 15 years of experience in injury epidemiology, implementation science, and knowledge translation. At Public Health Ontario, Sarah provides both scientific and technical guidance for injury prevention to the Ministry of Health and public health practitioners across Ontario.

The health and wellness of road users living in Canada is a growing concern and modifying the built environment (BE) has been established as an effective way to reduce road-related injury and death. Road safety and injury prevention professionals working across sectors, such as transport and public health, have valuable insights into the BE change process within their respective municipalities. This article frames their important contributions within the context of health equity (HE). Road users, broadly, do not experience the same levels of vulnerability, and it is imperative that BE changes are made to enhance the health and wellness of road users made vulnerable by the current BE. The qualitative data presented in this article were collected via interviews and virtual focus groups for a larger pan-Canadian study examining safe and active travel, as well as barriers and facilitators to BE change. Results showed that participants were not only aware of HE concerns in their BE change work, but they also had suggestions for more inclusive BE consultation processes to ensure that vulnerable road users (VRUs) are served by BE changes in their neighbourhoods. Our aim is for these results to inform future BE change processes and work in municipalities across Canada and that rates of road-related injury and death are reduced as a result. 

The following article summarizes results from a published study looking at links between health equity (HE) and the built environment (BE) (1). The health and wellness of road users living in Canada has become a priority of many Canadian road safety professionals in recent years. As key actors working across sectors such as public health and transport, road safety and injury prevention professionals occupy a unique role within their organizations as they witness, first-hand, specific contextual factors that inform and constrain their work. The following article highlights some key findings from a pan-Canadian study examining the BE and its influence on the health and wellness of road users living in Canada (2). This study was unique in design as it prioritized the voices and perspectives of road safety and injury prevention professionals about barriers and facilitators to BE change (3). The results showed the importance of embedding HE principles into their work, as well as the challenges experienced with implementing desired changes. Our aim in this article is to provide an overview of these findings with the intention of informing current and future road safety and injury prevention work in Canada. 

Road Safety and Health Equity in the Canadian Context

Canadians’ health and wellness is influenced by the conditions in which they live (4,5), which includes the design of the BE. As defined by the Canadian Institute of Planners (CIP), the BE refers to, “the human-made surroundings that provide the setting for all human activity, including those places where people live, work, learn, rest, and play” (6), while transportation and mobility infrastructure “form the connective tissue that links these places together and represents an integral part of the built environment” (7). In other words, the BE is considered a determinant of health, one that is modifiable (6) and influences people’s health by shaping their transportation choices and habits. 

Given the prioritization of HE in recent road safety and injury prevention work (8-10), an important consideration is the health and wellness of vulnerable road users (VRUs): “pedestrians, motorcyclists, and bicyclists are considered to be vulnerable road users since they do not have the protective shell of a vehicle in case of a collision” (11). The risk of road-related injuries and deaths is significantly higher for VRU groups (12), which highlights the impacts of health inequities exacerbated by the current BE design. However, it is important to note that road users are not inherently vulnerable; they are made vulnerable by the current design of road systems (1,3). Thus, VRUs are equity-deserving (12), and significant changes to our systems of roads are required to enhance their health and safety. 

The BE can be changed or modified to reduce injury and enhance VRU safety (14) by reducing motor vehicle collisions (15) and reducing the speed of motorists (9). An example of such changes are traffic calming interventions that have been shown to reduce road traffic injury rates (16,17). Further, the design of the BE can encourage active travel choices (18,19). Overall, people’s health is significantly influenced by the design of the BE (6,17,20), which draws attention to the distribution of resources for BE changes and begs the question as to why some neighbourhoods experience changes faster than others (21).  

According to the World Health Organization (WHO), HE is defined as “the absence of unfair avoidable or remedial differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically by other dimensions of inequality (e.g., sex, gender, ethnicity, disability, or sexual orientation)” (22). In other words, health is a fundamental human right that is inextricably linked to the environments in which we live, work, and play (6), and any combination of the factors listed above can contribute to health inequities. Implementing HE principles into any health-related work requires, “removing obstacles to health – such as poverty and discrimination and their consequences, which include powerlessness and lack of access to good jobs with fair pay; quality education, housing, and health care; and safe environments” (23). Thus, an HE approach to BE change requires the creation of safe environments to support health and reduce injury rates (24) for the most vulnerable (11) and equity-deserving populations (13). 

Ultimately, we call upon policy and decision-makers to make equitable changes to the BE to enhance road safety across Canada because structural determinants, such as political leadership, financial commitment, and public engagement (25), significantly impact the distribution of capacity and resources. It is an unfortunate reality that BE changes are more often implemented in neighbourhoods characterized by high socioeconomic status (SES) (26). The fact that the design of BEs prioritizes the needs of some users over others (21,24), such as transportation efficiency for motor vehicle users (3), is of great concern for VRUs living in Canada.

 Prioritizing the Voices of Road Safety and Injury Prevention Professionals

In order to prioritize the voices of road safety and injury professionals, we conducted interviews and focus groups in five Canadian municipalities: Vancouver, Calgary, Peel Region, Toronto, and Montréal. Participants were recruited from multiple sectors involved in BE changes in their municipality: policy/decision-making; transportation; public health; police services; non-profit; university research; community organizations; and private. These data were collected for a larger study funded by the Canadian Institutes of Health Research (CIHR) titled, The Built Environment and Active Transportation Safety in Children and Youth (hereafter, the CHASE Study), a pan-Canadian research project that examined collision and active transportation (AT) rates in Canada (2). An objective of this study was to further our understanding of the barriers and facilitators to BE change, and the results of that work have been published elsewhere (3). In addition, results from this study highlighted significant concerns about how HE is accounted for in BE change work (or not). While the scope of the broader project did not specifically include HE, our analysis highlighted significant findings about the importance of embedding HE principles in BE change work. 

How Did Road Safety and Injury Prevention Professionals Discuss Health Equity?

Road safety and injury prevention professionals discussed HE in several ways. Most importantly, VRUs who experience marginalization were considered a priority and the lack of BE infrastructure to support their mobility needs was concerning to participants. Participants also identified inequities in the BE change process that limits access for equity-deserving road user groups who experience marginalization, as well as strategies for inclusion. These results provide valuable insight into how HE is considered and practiced in BE change work from the perspectives of these road safety and injury prevention professionals. The following section summarizes data and results from the published study and does not include any raw data. A more detailed account of the data and results are available and openly accessible (1).

In their reflections about the BEs within their municipality, participants identified equity and accessibility concerns. Participants were cognisant that vulnerable populations, such as children, older adults, and people living in low SES neighbourhoods, experience disproportionate injury risks. In addition, participants recognized that changing the BE to support these groups would reduce health inequities. Participants also identified the various health and safety privileges associated with motor vehicle travel and ownership and demonstrated an awareness of the intersecting vulnerabilities that exacerbate health and safety concerns, as well as injury rates.  

While many participants discussed road user vulnerabilities, broadly, some participants also identified particular road user groups and their specific mobility needs. For example, people with low SES and new Canadians were identified as groups that experience marginalization, especially due to the fact that low SES neighbourhoods are often underserved when it comes to BE changes for road safety. For instance, these neighbourhoods do not receive the same prevalence of traffic calming interventions, nor do they have the same number and/or quality of sidewalks and crosswalks. 

Older adults and children pedestrians were also identified as road user groups who experience disproportionate risk and vulnerability. For example, participants discussed concerns with inadequately designed and maintained BEs contributing to social isolation among older adults. According to participants, if the BE is not safe or accessible, older adults will not engage in AT and given older adults’ increased fragility, a BE that does not support their mobility needs is concerning. Children also experience disproportionate collision risks and require a BE that supports their safe travel needs (e.g., to and from school, active play outdoors, etc.). Overall, participants demonstrated an awareness of the increased vulnerability of older adults and children, and they also acknowledged that low SES can further exacerbate vulnerabilities among these road user groups. 

Participants acknowledged that people with (dis)abilities require particular BE features in order to travel safely. For example, people with vision impairments require tactile features to assist in their navigation of the BE. Alternatively, people who wheel require smooth pathways. Some participants discussed the challenges with ensuring that the BE supports the safe travel needs of all VRUs, particularly when the needs conflict (e.g., tactile features versus smooth pathways). Accommodating the variety of road user needs is certainly a challenge; however, participants emphasized the importance of accounting for all VRU needs and ensuring that the BE is designed or modified to support VRUs’ health and safety.  

Participants’ discussions of HE in relation to BE change also included the BE change process. Overall, participants felt it was important for local community members to be involved in the changes being made in their neighbourhoods. Further, participants were critical of existing BE change process mechanisms that favour road users with higher SES and elevated knowledge of their local political system, such as the complaints process and/or open houses. For example, the complaint process to trigger improvements is often complex, time consuming, and requires organisational and political knowledge that may not be accessible to all community members, particularly those with low SES. Further, participants discussed how groups with higher SES experience lower risk and injury rates, and their elevated access to BE change processes exacerbates the existing vulnerabilities of equity-deserving road user groups. 

As noted above, open houses were identified as a problematic mechanism for community inclusion in the BE change process because, more often than not, the same people – typically higher SES, well-educated, and more engaged in their local political processes – are those that attend and influence the local system. The worry is that the attendees do not represent the needs of the community as a whole, which is problematic given the increased risk of injury amongst road user groups who experience marginalization. Door-to-door petitions were described with the same level of criticism because this approach requires residents to be home and have time available to engage in conversations about local BE changes. Overall, according to participants, not accounting for all the needs of community members perpetuates health inequities for road user groups who experience marginalization. However, participants also identified strategies for including community members in BE change consultation processes. Broadly, participants acknowledged that this process may look differently depending on the community and, thus, requires the extra step of engaging in an active dialogue to determine the most appropriate inclusion mechanisms. Some examples included social media campaigns, community events, or public forums. In general, the approach must be grounded in the community and the dialogue must continue throughout the process. 

Lastly, participants discussed meaningful BE changes that are informed by HE principles. Several participants described data collection strategies, such as measuring the walking speed of pedestrians, to ensure the BE is modified to support VRUs (e.g., older adults and children). Participants also identified modifications such as connecting pedestrian pathways, ensuring adequate lighting on pathways, and wider sidewalks as important BE changes that would help address HE concerns.

 A Call-to-Action for Policy and Decision-Makers

Based on our results, it is clear that changes need to be made to BEs in Canada, as well the processes through which BE modifications are made. Our results provide valuable insight from road safety and injury prevention professionals about the importance of embedding HE into BE change processes and work. There is an urgent need to modify the BE change consultation processes to ensure that equity-deserving (13) road users are included in the procedures for modifying their neighborhoods and communities. 

Our results also highlight the need for policy and decision-makers to enact upstream changes that acknowledge VRUs’ dependency on the BE for health and wellness, such as accessing “places to recreate, learn, work, shop, and buy healthier food” (6) safely. The prioritization of motor vehicles is a barrier of great concern (3), given their role in road-related injuries and deaths. As previously noted, VRUs are not inherently vulnerable; they are made vulnerable by the current design of the roads, a design that can (and ought to be) changed (1,3). A Safe System Approach (SSA), such as Vision Zero, is an example of a road safety strategy that prioritizes changes to the BE and the road transportation system, recognizing that human beings make mistakes and the BE should be designed to mitigate human error (26).

We hope that the results of our work catalyze changes at the policy and local levels, particularly with regards to meeting the needs of local road safety practitioners and how BE change consultation processes are conducted. Road users who live in low SES neighbourhoods are inadequately served by BE changes, while they also experience disproportionate risks to road-related injury and death (27). Further, people with disabilities (e.g., people with vision impairments; people who wheel) have different mobility needs (e.g., tactile features vs. smooth pathways), that require careful consideration of unintended consequences, and which ought to be accounted for when modifying BEs to enhance the safety of all road users. Lastly, new Canadians also experience disproportionate risks and “understanding how cultural obstacles are intermingled with economic status is key to achieving greater health equity” (6). If we are truly dedicated to ensuring the “absence of risk of harm to road users in the road transportation system, including sidewalks and pathways” (28) for all road users, the insights offered by the road safety and injury prevention professionals in this study ought to guide future BE change work.


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