Road safety issues in China: Understanding key risk factors to improve public health and safety Dr Judy Fleiter Postdoctoral Research Fellow Topic: Road safety issues in China: Understanding key risk factors to improve public health and safety   This year, 2015, marks the middle of the United Nations Decade of Action for Road Safety (2011-2020). The World Health Organization identifies road trauma as a major public health issue in all countries, though most notably among low-to-middle income countries, and particularly those experiencing rapid motorization, such as China. As China transitions from a nation of bicycle riders and pedestrians to one where car ownership is increasingly desired, it is important to consider the impact of the large road trauma burden and act to promote safer road use for all. Unfortunately, the road trauma burden is carried disproportionately among the population. In highly motorised countries, such as Australia, the majority of road user fatalities occur among drivers and passengers. However, in China, vulnerable road users (pedestrians, cyclists, and motorcyclists) are of primary concern because they are most frequently killed in road crashes, representing approximately 70% of all Chinese road-related fatalities. Road fatalities are reportedly the leading cause of injury deaths in China, ahead of all natural disasters, including fire, earthquake, and flood (Ma, Li, Zhou, Duan, & Bishai, 2012). Figures published by the World Health Organization (2013), as identified from Chinese police records, indicate that 65, 225 people were killed in road crashes in 2010, with males representing three quarters (76%) of all fatalities. However, some researchers have suggested that the figure may be up to five times higher when hospital data is used as an indicator of road trauma (Qiu et al, 2015). Data quality is an important issue in monitoring the road trauma situation and prioritizing areas of most need for intervention efforts. It is possible that a better understanding of road safety issues can be gained from examining multiple data sets (e.g., hospital, police) in China. There are many challenges associated with the pace of change linked to rapidly increased motorization. These challenges include: managing vehicle-related pollution and traffic congestion; safety management systems and communication between components of the road transportation system; provision of adequate and safe infrastructure to meet competing road user demands; provision of adequate road rules and related enforcement of existing legislation; limited post-crash emergency response and care; increasing needs for driver education and training in the face of large numbers of novice drivers; the need to promote understanding of key risk factors among the general population; and the economic and social consequences of human trauma experienced from road crashes. CARRS-Q has conducted behaviour-focused research in China (Guangzhou, Beijing, Hangzhou and Yinchuan) over the past 8 years, focusing primarily on speeding and drink driving. These two risky behaviours are key challenges for China, Australia, and many other countries. Our research has demonstrated limited knowledge of the risks associated with them among road users, non-compliance with traffic regulations relating to these behaviours, limitations in police enforcement activities and legislation which can lead to non-compliance, the need for greater awareness among drivers and traffic police of the legal blood alcohol concentration (BAC) levels, the need for greater enforcement resources, and the need to consider culturally specific issues when introducing road safety countermeasures. Overall, our research indicates that much can be done to improve road safety in China in order to promote safer road use and reduce the road trauma burden. Australia China Centre for Public Health, SYSU visit, May 11, 2015

Overview Global road safety Road safety in China Behavioural research conducted by CARRS-Q in China Future research priorities

Acknowledgements Partner Institutions: Colleagues: Institute of Psychology, Chinese Academy of Science, Beijing (5 months) Zhejiang Police College, Hangzhou, China (2 years) Guangdong Institute of Public Health, Guangdong Province Centre for Disease Control and Prevention (4 months) Yinchuan City Centre for Disease Control and Prevention (4 months) Colleagues: Dr Barry Watson, Dr Mark King, Emeritus Professor Mary Sheehan, Dr George Jia, Dr Alexia Lennon - CARRS-Q (QUT) Professor Shi Kan, - Chinese Academy of Sciences Professor Guan Manquan, Ding Jingyan, Xu Cheng – Zhejiang Police College Professor Ma Wenjun – Guangdong Institute of Public Health Dr Jing Lei - Yinchuan City Centre for Disease Control and Prevention

Acknowledgements Funding Australia’s National Health & Medical Research Council Postdoctoral Research Fellowship (Australia-China Exchange) Promote Australia-China road safety research & capacity building (2011-2015) Endeavour Australia Awards Cheung Kong Postgraduate Award – 2008 (Fleiter) Prime Minister’s Australia Asia Postgraduate Award – 2012 (Jia)

United Nations Decade of Action for Road Safety (2011-2020) Every year, globally, road crashes: kill 1.3 million people injure 20 – 50 million people Aim to reduce road-related trauma save 5 million lives in 10 years by sharing experiences, and introducing effective legislation, enforcement and education World Health Organization, 2009; 2013

United Nations Decade of Action for Road Safety (2011-2020) Globally, Road traffic injuries 8th leading cause of death Leading cause of death of young people 15-29 90% of road deaths & injuries occur in low- & middle-income countries 46% of global road deaths are ‘vulnerable road users’ pedestrians, cyclists, motorcyclists First United Nations Global Road Safety Week 2007 Youth and Road Safety The Second UN Global Road Safety Week to be held 6-12 May 2013 is dedicated to pedestrian safety The Third UN Global Road Safety Week - #SaveKidsLives - seeks to highlight the plight of children on the world’s roads and generate action to better ensure their safety World Health Organization, 2013

In China Scale of road trauma problem difficult to determine: Unlinked reporting systems (police, hospital datasets) Reporting mechanisms vary (e.g., death within 7 days of crash in police records, doesn’t follow ICD10 classification) Under-reporting likely Police records indicate ~70,000 fatalities/year with sharp decrease since 2002 Examination of 210 military hospitals shows slow increase since 2002 Analysis of city level data indicates 3 times as many fatalities and up to 5 times as many injuries as reported in official data (Qui et al., 2015) These data similar to WHO estimates Alcorn, 2011; Hu et al, 2012; Qiu et al, 2015; WHO, 2103; Zhang et al., 2008 Police records. Defined as died within 7 days of crash. Does not follow ICD10 Classification. 70 134 The records from 210 military hospitals show a slow increase in deaths and injuries after 2002, in stark contrast to the sharp declines in the released police-reported data. The city study found 3 times asmany fatalities and 5 times asmany injuries in original data as finally released. The present findings confirm the conclusion in earlier publications that fatal injuries did not decline and that actual deaths and injuries are more than twice as many as reported

In China Road fatalities = leading cause of injury deaths ahead of all natural disasters (including fire, earthquake, and flood) (Ma, et al;, 2012). 25% of total productive years lost from all injuries (Zhou et al., 2003) Road fatalities Males = 76% Majority of road traffic injuries (RTI) occur among young males RTI = one of the top 3 causes of death in people aged 60+ (Zhou et al., 2014) Vulnerable road users = 70 % Road fatalities are reportedly the leading cause of injury deaths in China, ahead of all natural disasters, including fire, earthquake, and flood (Ma, Li, Zhou, Duan, & Bishai, 2012). Figures published by the World Health Organization (2013), as identified from Chinese police records, indicate that 65, 225 people were killed in road crashes in 2010, with males representing three quarters (76%) of all fatalities. However, some researchers have suggested that the figure may be up to five times higher when hospital data is used as an indicator of road trauma (Qiu et al, 2015). Data quality is an important issue in monitoring the road trauma situation and prioritizing areas of most need for intervention efforts. It is possible that a better understanding of road safety issues can be gained from examining multiple data sets (e.g., hospital, police) in China.

Vulnerable Road Users, China 70% Road fatalities are reportedly the leading cause of injury deaths in China, ahead of all natural disasters, including fire, earthquake, and flood (Ma, Li, Zhou, Duan, & Bishai, 2012). Figures published by the World Health Organization (2013), as identified from Chinese police records, indicate that 65, 225 people were killed in road crashes in 2010, with males representing three quarters (76%) of all fatalities. However, some researchers have suggested that the figure may be up to five times higher when hospital data is used as an indicator of road trauma (Qiu et al, 2015). Data quality is an important issue in monitoring the road trauma situation and prioritizing areas of most need for intervention efforts. It is possible that a better understanding of road safety issues can be gained from examining multiple data sets (e.g., hospital, police) in China. Source: 2010 PRC Road Traffic Accident Annual Statistic Report, Traffic Management Bureau of Ministry of Public Security, cited in WHO, 2103 Global Road Safety Status Report.

Large population, unprecedented economic growth, rapid motorisation, large number of novice drivers Mixed traffic fleet: pedestrians, non-motorised vehicles, increase in e-bikes (banned in some places), heavy vehicles Large rural > urban migration = unfamiliarity with traffic and traffic rules Key risk factors = drink driving, speeding, vehicle overloading, road conditions, night time driving, non-compliance with traffic & licensing regulations; e-bikes/motorbikes

In Transition

Enforcement & Education Road safety legislation relatively new (2004) and still in formative stage Traffic police not well respected & responsible for public education with limited resources Varying levels of traffic law enforcement Traffic laws not well understood by general community Road safety awareness relatively low Non-compliance with traffic laws evident Fleiter et al., 2009; 2011; 2013a,b,c; Jia et al., 2013; Senserrick et al., 2011

Behavioural factors Illegal/risky on-road behaviours common & appear normalised Non-use of helmets & seat belts Phone use while driving/riding Over-crowded & overloaded vehicles Drink driving Speeding (main reported cause of crashes in China - estimates of between 50-90% of all crashes Speeding is main reported cause of crashes in China (estimates 50-90%) (Wang et al, 2003; Wang & Jiang, 2002; WHO, 2004) Du et al., 2013; Fleiter et al., 2009; Fleiter et al., 2013a,b,c; Jia et al., 2013a,b; Routley et al., 2008

Behavioural factors Illegal/risky on-road behaviours common & appear normalised Non-use of helmets & seat belts Phone use while driving/riding Over-crowded & overloaded vehicles Drink driving Speeding 2 risk factors identified by Bloomberg-funded Global Road Safety Program (2010-2014) Dalian & Suzhou Bloomberg Initiative for Global Road Safety (BIGRS) 2015-2019 Shanghai, legislative focus Bloomberg Initiative for Global Road Safety (BIGRS) 2015-2019 Speeding is main reported cause of crashes in China (estimates 50-90%) (Wang et al, 2003; Wang & Jiang, 2002; WHO, 2004) Du et al., 2013; Fleiter et al., 2009; Fleiter et al., 2013a,b,c; Jia et al., 2013a,b; Routley et al., 2008

CARRS-Q Behavioural Research Speeding CRICOS No. 00213J

Beijing & Hangzhou Speeding Qualitative & quantitative research with car drivers: Speeding viewed as common, normal, necessary, safe Self-reported ‘usual’ speeds up to 50% above posted speed limits (link to enforcement tolerance in legislation) ‘Safe speeds’ reported as up to 20 km/h above posted speed limits ‘Preferred speeds’ significantly faster than ‘safe speeds’ Penalties not certain and can be avoided (use of ‘guanxi’/networks; arguing with police, convincing police not to issue infringement) Experiences of avoiding detection & punishment encourage future offending Participants were asked what speeds they preferred to travel at in two different speed zones (40 and 100 km/hour). The results indicated that mean speeds equated to speeds above both the posted speed limits, with the mean of 54.2 km/hour in the 40 km/hour speed zone most outstanding (compared to the mean of 106 in the 100 km/hour speed zone) in that it was 14.2 km/hour above the posted limit. These results are not surprising, given the previously reported nature of speeding in China as commonplace, attitudes that are supportive of speeds above posted limits (Fleiter, Watson, & Lennon, 2013; Fleiter, Watson, et al., 2009), and the admission of a low rating (4/10) of speed enforcement in the last Global Status Report (World Health Organization, 2013). Additionally, in light of those issues, the results relating to the items asking participants to describe what they perceived as a safe driving speed in these 2 speed zones were also not surprising. Results indicated that one quarter of the sample reported speeds that were 20 km/hour or higher above the posted limits. (Wang et al, 2003; Wang & Jiang, 2002; WHO, 2004) Fleiter et al., 2009; Fleiter et al., 2013a,b,c; Fleiter & Watson, 2015

CARRS-Q Behavioural Research Speeding Drivers attending re-training program after losing licence Significantly more crashes among newly licensed drivers Mean of 4.6 infringements in previous year (range 2-18, SD=3.8) 62% drink driving offence; 48% speeding offence Identification of ‘most dangerous’ on-road behaviours by drivers Drink driving ... Phone use while driving, fatigue, non-use of seat belts nominated by very few Reflects enforcement practices by police? Participants were asked what speeds they preferred to travel at in two different speed zones (40 and 100 km/hour). The results indicated that mean speeds equated to speeds above both the posted speed limits, with the mean of 54.2 km/hour in the 40 km/hour speed zone most outstanding (compared to the mean of 106 in the 100 km/hour speed zone) in that it was 14.2 km/hour above the posted limit. These results are not surprising, given the previously reported nature of speeding in China as commonplace, attitudes that are supportive of speeds above posted limits (Fleiter, Watson, & Lennon, 2013; Fleiter, Watson, et al., 2009), and the admission of a low rating (4/10) of speed enforcement in the last Global Status Report (World Health Organization, 2013). Additionally, in light of those issues, the results relating to the items asking participants to describe what they perceived as a safe driving speed in these 2 speed zones were also not surprising. Results indicated that one quarter of the sample reported speeds that were 20 km/hour or higher above the posted limits. (Wang et al, 2003; Wang & Jiang, 2002; WHO, 2004) Fleiter & Watson, 2015

CARRS-Q Behavioural Research Drink Driving

Guangzhou & Yinchuan Drink Driving Legislative change in May 2011, Drunk driving criminalised 2 legal blood alcohol concentration limits Drink driving = 20mg-80mg/100 ml Drunk driving = >80mg/100ml Qualitative & quantitative research General drivers Convicted drunk driving offenders in detention Traffic police Jia, 2015; Jia et al., 2013a,b, c

CARRS-Q Behavioural Research Drink Driving High awareness in both cities that Drunk driving now a criminal offence Low awareness of legal BAC levels in all samples Only 16 – 40% reported correct knowledge of legal BACs Knowledge of how to keep BAC below legal limit was extremely low for all, including traffic police Participants were asked what speeds they preferred to travel at in two different speed zones (40 and 100 km/hour). The results indicated that mean speeds equated to speeds above both the posted speed limits, with the mean of 54.2 km/hour in the 40 km/hour speed zone most outstanding (compared to the mean of 106 in the 100 km/hour speed zone) in that it was 14.2 km/hour above the posted limit. These results are not surprising, given the previously reported nature of speeding in China as commonplace, attitudes that are supportive of speeds above posted limits (Fleiter, Watson, & Lennon, 2013; Fleiter, Watson, et al., 2009), and the admission of a low rating (4/10) of speed enforcement in the last Global Status Report (World Health Organization, 2013). Additionally, in light of those issues, the results relating to the items asking participants to describe what they perceived as a safe driving speed in these 2 speed zones were also not surprising. Results indicated that one quarter of the sample reported speeds that were 20 km/hour or higher above the posted limits. (Wang et al, 2003; Wang & Jiang, 2002; WHO, 2004) Jia, 2015; Jia et al., 2013a,b, c

CARRS-Q Behavioural Research Drink Driving Evidence of limited police roadside testing and lack of adequate police resourcing Drivers use many strategies to avoid detection, some endangering police safety AUDIT scores used to assess problematic drinking Higher level of alcohol misuse among convicted drunk driving offenders (both cities). Higher among Yinchuan than Guangzhou offenders 1st time vs Repeat offenders: significant difference in AUDIT scores in both cities. 1st time offenders had a significant lower AUDIT scores than recidivists. Indicates problematic alcohol use levels among repeat drink drivers Jia, 2015; Jia et al., 2013a,b, c

Future Research Legislation in formative stage penalties not necessarily a deterrent low levels of awareness (e.g. BAC levels) low levels of perceived risk associated with high risk behaviours (e.g. speeding, phone use while driving) Evidence needed to reduce harm Enhance data quality Inform policy development Inform public education campaigns Raise awareness about high risk behaviours Consider culturally-specific issues when introducing countermeasures

Thank you for your attention today. j.fleiter@qut.edu.au

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