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Why is public health missing from the road safety debate?

In the wake of widespread concern about carnage on the roads, Croakey recently put out a plea to readers: what are some evidence-based suggestions for improving road safety and reducing the toll? And are these being adequately and effectively implemented across the various jurisdictions?

Margo Saunders, a public health policy consultant in Canberra, took up the challenge.

First, she reframed my questions into: what can road safety learn from public health?

And then she provided plenty of answers, as you will discover below:

Not many crashes occur because someone has turned the car on its side deliberately.”
– Asst Commission John Hartley, NSW Police (‘Police shocked by poor driving’, Canberra Times 5/1/10)

That police are frustrated to the point of making comments like this to the media is an indication of the point that has been reached in the road safety debate.

A week after Croakey asked, ‘What more can we do to reduce the road toll?, Federal Transport Minister Anthony Albanese joined the frustration chorus and called for a wider debate about Australia’s ‘road toll’ (an unhelpful phrase which suggests that devastating and avoidable injury is a normal price that we have to pay for using the roads).

The Minister called for the debate to involve parents, communities, and sporting clubs – but there was no mention of public health experts.  Why would there be, when road safety is siloed well away from health portfolios?

The national agreement which established the National Road Safety Council notes that the Council is to be comprised of members drawn from a range of sectors who bring expertise in key areas including road use behaviour, public health and social marketing.  Yet public health or social marketing experts are not much in evidence among the 7-member Council responsible for advising on the next 10-year National Road Safety Strategy.

Not everything that kills and injures people is necessarily a public health problem.  However, according to the National Road Safety Action Plan, ‘Crash data, analysis and research clearly identify road crashes as a significant public health risk.’  Leaving aside the question of whether ‘road crashes’ are a ‘risk’ or the end product of risks, what is clear is that an activity viewed as a normal part of daily life for millions of Australians led to the death of more than 1 500 Australians last year and, according to annual data for recent years, led to the serious injury of more than 52 000 people, of whom more than half were under the age of 30 and more than a quarter were aged 15-24.

Police frustration is evident, with police across the country admitting that they don’t know why the ‘road toll’ is as high as it is and people continue to be seemingly unresponsive to warnings (‘Police shocked by poor driving’, Canberra Times 5/1/10).  Newspaper headlines such as, ‘Road toll climbs despite police appeals’ are common.

But would this frustration on the part of politicians and the police take the same form, and be allowed to continue down dead-ends, if it were any other public health problem?

Public health problems such as obesity and alcohol abuse are also complex, involving a host of behavioural, economic, and environmental factors.  In public health, we need to do more qualitative research, but we know this.  With road safety, finding out what drivers think, why they do what they do, and how they respond to various initiatives (and why) does not seem to be happening in a big way, or necessarily in the right way.

I was encouraged when I read that a senior Victorian police official said that police need to ‘go back to the drawing board’ and consider research – but he meant research that might show that some people are ‘predisposed’ to being involved in crashes (Traffic chief flags banning licenses’, Can.Times 19/1/10, quoting Deputy Commissioner Ken Lay).  This may be a productive line of research, but then I can think of a number of others that might be worthwhile.

My own discussions with young P-plate drivers have reminded me that it’s not just about the messages being right, either.  These young people were dismissive of recent anti-texting-and-driving and anti-drinking-and-driving television ads on the grounds that they would reject ‘anything that the Government wants me to do’.

They want messages that they consider credible, which doesn’t include the Government, the police, or even health groups, all of whom young people see as running their own self-serving agendas.  Interestingly, I had heard about the emphasis that young people place on ‘authenticity’ before – from incredibly knowledgeable advertising and marketing companies that specialize in youth marketing.  We should be listening to them, asking questions, and doing real public health research.

I am aware of little Australian research into why people drive when they have been drinking, for example, and what it would take to reduce this (there’s currently a debate about whether the greatest benefits come from trying to change the driving behaviour or the drinking behaviour).  The reasons may be simple and obvious: didn’t plan on drinking that much, didn’t want to leave the car there, promised so-and-so I’d give him a lift home, there weren’t any buses, taxi queue was too long, and didn’t think I’d had that much.

Will increased enforcement be effective in addressing such issues?  Will other initiatives generate unintended consequences?  Limits on the number of passengers/late-night driving for P-plate drivers have been accepted in some US States, but remain controversial here, with young people arguing that this would have a negative impact on designated driver arrangements.

There have been suggestions about required refresher courses for drivers who have had their licenses for some time – as anyone who drives the Monaro, Kings or Princes Highway will attest, young people don’t have a monopoly on bad driving.  I regularly see male drivers from 18 to 55 possessed by assertiveness and the ideological need to overtake anything in front of them.

In many respects, the more you find out about road safety, the more difficult it gets. I have tended to believe that part of the problem is that the driver training that my sons received a few years ago did not differ in any real respect from the training I was given 30 years ago: neither placed an emphasis on issues that now seem to be important, such as attitude, patience, or how to overtake, drive safely around motorcycles or near large trucks.

I always thought that initiatives involving driving simulators sounded useful (are these programs being evaluated?), but just try to get cocky young drivers to attend anything voluntarily.  Insurer AAMI runs a sensible-sounding program for young drivers, but these are easily dismissed as an uncool ‘waste of time’.  Are the young drivers right?  There is appears to be no real consensus about where to place our efforts.

The Australian Automobile Association says that more effort to needs to go into changing driver behaviour (‘Safety strategy fails as driver behaviour remains unchanged’, SMH, 10/11/09).

Road safety experts who have conducted detailed examinations of the literature advise that this may not be worth doing, at least not in conventional ways, with road safety education and training found to be ‘largely ineffective’, and media advertising only effective in conjunction with legislative and enforcement programs (Ron Christie, ‘Road Safety Education and Training from a Public Health Perspective’, National Research, Education and Policing Conference, keynote address, 2002).

Even programs that focus on teaching advanced vehicle control skills as a way to help notice drivers get out of risky situations ‘are unlikely to have positive road safety benefits because the successful application of a new skill relies on the repetitive practice of that skill in it context over a long timer period’ and such training ‘cannot be expected to influence behavioural responses to risky situations in the real world’(Ron Christie and Warren Harrison, Driver Training and Education Programs of the Future, Royal Automobile Club of Victoria Ltd, October 2003, at:  ).

On the other hand, it would be useful to pay more attention to findings about ‘associative learning’ in relation to actions and consequences and to research on motivation, which has a direct bearing on behaviour (Christie and Harrison 2003).

While there would probably be little disagreement that determined, sustained and targeted enforcement is needed to underscore advertising and promotion to discourage speeding and drink-driving, many public health experts would probably feel professionally challenged by assertions that education, training, and the provision of information do not save lives on the roads.

The calls for evidence-based policy, however, will strike a familiar chord and there would be little disagreement that, ‘Continuing to squander time, money and effort on measures that don’t deliver road safety or public health benefits makes little sense from an economic, moral or evidence-based perspective’ (Ron Christie, 2002).

Road safety experts have also noted the lack of evidence for a ‘best practice’ model of driver development (Ron Christie and Warren Harrison, Driver Training and Education Programs of the Future, Royal Automobile Club of Victoria Ltd, October 2003), a problem familiar to public health practitioners working on cutting-edge policies and programs.

A public health approach says that you’ve got to give some things a try in order to get the evidence.

In public health, we do not tend to say, ‘What’s wrong with these people? They aren’t getting the message!’  Although they may think it, most respectable public health professionals would not consider it helpful to be publicly quoted – even when frustrated and upset – saying, as a senior police officer did: ‘You can’t get through to some young people today, you can’t get through their thick skulls!’.

If it is obvious that the initiative is not having the desired effect, the usual approach is to change the initiative, not berate the target group for being stupid. In the case of ‘campaigns’, this could mean changing the message or the messenger – but you have to do the research to find out.

With road safety, it will be interesting to consider what has gone wrong, or at least what people think has gone wrong.

We have a National Road Safety Strategy whose emphasis and accompanying rhetoric doesn’t quite match up with – well — anything else.  The intention was to place more responsibility on ‘system designers’ and acknowledge that people, whose are supposed to follow the rules, will make mistakes.  If road users fail to obey the rules due to lack of knowledge, acceptance or ability, or if injuries occur, the system designers are supposed to take necessary further steps to reduce the likelihood of people being killed or seriously injured.

But what has happened is that ‘notoriously unsafe’ stretches of road have not been upgraded, hazards have not been removed, and the human factors have continued to be singled out, with police highlighting alcohol and drug use, fatigue, speed, and failure to wear seatbelts as ‘major fatal crash errors’.  Road safety experts assert that, ‘Driver safety is a behavioural issue,’(Ron Christie and Warren Harrison, Driver Training and Education Programs of the Future, Royal Automobile Club of Victoria Ltd, October 2003), and NSW Police Commissioner Andre Scipione is not exactly talking about a ‘systems approach’ when he says, ‘Until people change their behaviour, this tragedy is going to continue.’(‘NSW police charge 246 with drink-driving’, SMH 16/11/09).

According to road safety authorities, most crashes occur when ordinary people make everyday human mistakes.  Driving is a complex business, and it has been estimated that around 1 in 500 driving decisions can be wrong, involving a mistake, an error of judgment, a missed signal or the like. It has also been suggested that a behavioural decision is made every 30 metres while driving.  Supposedly we also make an estimated 200 food-related decisions every day, and we get some of those wrong, too. With driving mistakes, however, we may not get a second chance, the consequences are immediate and traumatic, often affect bodies other than our own, and are not counterbalanced by any immediate benefit.

The National Road Safety Action Plan 2007-08 notes that the casualty crash risk doubles when driving with an alcohol level just in excess of 0.05 BAC, and the risk of involvement in a fatal crash rises even more sharply.  Novice drivers are over-represented in crash data by a ratio of at least 3 to 1, and driving late at night and during early morning hours and carrying two or more passengers have been found to increase the risk of crashes for young drivers. But try telling a young male P-plate driver about to drive from Canberra to Ulladulla on the Kings and Princes Highways that, in the words of a police officer commenting on the recent death of a young driver near Braidwood, ‘Teenagers with their probationary licenses should remember that they are still learning to drive, and overtaking and long distance traveling is still a high risk activity in this stage of their driver learning’ (‘Promising life ended’, Can.Times 3/1/10, p.5).

Given the repeated use of the word ‘learning’, perhaps what we need is a graduated ‘L’-plate system.  This would reinforce the recommendations of some road safety experts that we should be talking not about driver training but about driver development.

Many tragic collisions, especially those involving young people, appear to be the result of poor judgment in relation to specific driving decisions, with factors such as substance use, speeding, inattention and over-confidence also implicated.  While judgment comes with experience, the reality is that we know that young people who lack the necessary judgment are free to drive themselves and a carload of friends on dodgy roads where their survival depends on luck and their embryonic judgment about speed, overtaking, fatigue, alcohol, and distractions.

I am fortunate: at about the same time that my early attempts at smoking gave me a sore throat and put an end to the prospects of nicotine addiction, I also had a driving instructor who said something like, ‘Never forget that a car is a lethal weapon.’ It’s been a good thing to remember.

The current national road safety plan has failed to meet its target of reducing road fatalities by 40 per cent. The serious thinking about a new plan comes at a time when the Australian Government wants us to believe that they are serious about the prevention of disease and injury.

There does need to be a wider debate, silos need to be broken down, and we need to apply all the expertise we can get – even to the point of formally acknowledging road safety as a public health issue.

When Deputy Commissioner Ken Lay admits, ‘I don’t know what the answer is’ in relation to young driver behaviour and calls on ‘researchers, health professionals, educationalists’ to ‘do the research to help us understand that’ (Traffic chief flags banning licences, Can.Times 19/1/10), that should be an offer that we can’t refuse.”

Comments 8

  1. Jenny Haines says:

    There is certainly the need for some evidence based conclusions here. Moralising police and parents aren’t going to change young persons behaviour, and I am not certain tht moralising about the road toll helps anyone anyway. Everyone knows that an accident is just that, an accident. Why the accident happened may be an interesting source of research. Was the driver tired, speeding, stressed, under the influence of drugs and or alcohol? What was the state of the road? What was the weather like? Was the driver surrounded by other bad drivers? Was the driver being bullied? It is simplistic to try to contribute accidents to just one cause. I believe they are often caused by many, often interacting factors. There is no doubt in my mind that speed plays a big part in many accidents and driving at speed leaves little room to recover from a mistake or misadventure, particularly for an inexperienced driver. To address the road toll, we have to address the many possible often interacting causes.

  2. Frank Campbell says:

    Speed-limit heavy trucks to 80; 100 on freeways. Enforce load, drug and fatigue laws. 2% of vehicles 9big trucks) cause 22% of fatalities.

  3. Jon Hunt says:

    As far as over-representation of young drivers in the statistics goes, one issue is that it is normal for adolescent men to take risks. I am not sure how one can change this. There was talk of not allowing P platers to take passengers, because of the association of groups in cars and accidents, but I couldn’t imagine this happening in a hurry. The other thing is raising the driving age.

    I think that the problem is one of driving being felt as being a right, not a privilege. It doesn’t matter how foolish you might be as a person, or how aggressive you might be on the road, you will get your licence if you behave during the driving test. Not everyone is allowed to fly a passenger airliner, with resultant safety. But anyone can be allowed to drive a car.

    And it is a public safety issue, the statistics do not mention the quadriplegics, the paraplegics, the brain injured, the limbless that are a result of car crashes, nor the burden of this to the community.

  4. PeeBee says:

    Frank Campbell. You didn’t mention enforce the speed limits. Is that because you see fines are revenue raisers for the state government?

  5. Margo S. says:

    The ‘risk is a normal part of growing up’ argument is a common one and was put to me recently by a 30-yr old male colleague in the alcohol and drug sector: “ My one question,” he asked, “ is where are young people supposed to experiment and test boundaries? It seems to me that all this regulation and concern is designed to make people fit a stereotypical straight jacket.”

    Once upon a time (and still in some societies) young men were sent out with bows and arrows to test themselves against the world, and if they overcame the risks and stayed alive then they proved that they were men. Have we advanced beyond that? Is the modern-day version of that sending a 17-yr old P-plater down the Kings Highway (fill in your own local equivalent) with a car full of mates?

    Seems to me that our approach to risks depends entirely on the type and context of the risks and whether they impose risks on others. Some risks carry severe consequences of getting it wrong – hence the ‘but they didn’t deserve to die!’ response when people die of drug overdoses, car crashes, whatever, even when we think that the individual carries a large share of the responsibility.

    There is also the issue of accurate perception of risks – if scientists are right and the human brain is not fully developed until the age of 26, what does that say about the acquisition of critical judgment? The ability to accurately connect actions with consequences is said to be one of the last abilities to develop – and it shows. Maturity isn’t just a matter of accumulating experience: it’s the ability to process, interpret and apply information. In other words, all of the things that contribute to what we call ‘good judgment’. What makes it more difficult is that for many young people, the process of acquiring good judgment is countered by competing factors, such as immediate gratification, the influence of group-think, and the influence of alcohol on the capacity for rational thought.

    There are risks and there are risks, with varying degrees of consequences. Some people love having sex in a public place because of the ‘risk’ of being seen. But that’s different than activities that carry a risk of debilitating physical injury for the individual and others.

    It seems to me that the ‘regulation and concern’ As for ‘experimenting and testing the boundaries’, I’m not convinced that this needs to involve things like substance use or unsafe driving. There’s plenty of boundary-testing in mountain biking or abseiling, but perhaps it’s more about proving that you conform to the social constructs of what’s ‘cool’. It’s not about straightjackets: it’s about helping to ensure that young people survive their traineeship as ‘apprentice adults’.

  6. Margo S. says:

    Sorry, first sentence in last paragraph was meant to read:

    It seems to me that the ‘regulation and concern’ are aimed not a straightjacketing young people but at helping to minimise the likelihood that people will get slaughtered by people (of whatever age) who do not have the maturity, judgment or skill to be in competent control of a motor vehicle.”

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