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1.  A Statewide Observational Assessment of the Pedestrian and Bicycling Environment in Hawaii, 2010 
Walking and bicycling are important but underused modes of transportation in the United States. Road design influences how much walking and bicycling takes place along streets and roads. Currently, numerous national policy initiatives, including Safe Routes to School and Complete Streets, are attempting to improve pedestrian and bicycling infrastructure and "friendliness." However, no state has completed a systematic assessment of its streets to determine how amenable they are to walking and bicycling. Our statewide study was undertaken to assess how accessible and friendly Hawaii roads are to these 2 activities.
We randomly selected street segments in Hawaii's 4 counties and then completed objective assessments using the Pedestrian Environmental Data Scan. We audited 321 segments, and interrater reliability was adequate across all measures. Streets were coded as high (42.4%) or low capacity (57.6%) depending on how much vehicular traffic the street was designed to accommodate. Outcome measures included street accommodations (ie, sidewalks and crossing aids) and pedestrian and bicyclist use.
Most high-capacity streets had sidewalks (66%). These sidewalks were usually in good condition, contiguous, and had traffic control devices and pedestrian signals. Most low-capacity roads did not have sidewalks (63.4%). Bicycling facilities were limited (<10%) on both types of roads. Pedestrian and bicycle traffic was related to mixed use, including both residential and retail space, and to pedestrian and bicycling infrastructure.
Road segments in Hawaii with more infrastructure and types of use, including single-family houses, apartment complexes, restaurants, office buildings, and industrial buildings, are used more by pedestrians and bicyclists.
PMCID: PMC3277384  PMID: 22172181
2.  The association between sidewalk length and walking for different purposes in established neighborhoods 
Walking in neighborhood environments is undertaken for different purposes including for transportation and leisure. We examined whether sidewalk availability was associated with participation in, and minutes of neighborhood-based walking for transportation (NWT) and recreation (NWR) after controlling for neighborhood self-selection.
Baseline survey data from respondents (n = 1813) who participated in the RESIDential Environment (RESIDE) project (Perth, Western Australia) were used. Respondents were recruited based on their plans to move to another neighborhood in the following year. Usual weekly neighborhood-based walking, residential preferences, walking attitudes, and demographics were measured. Characteristics of the respondent’s baseline neighborhood were measured including transportation-related walkability and sidewalk length. A Heckman two-stage modeling approach (multivariate Probit regression for walking participation, followed by a sample selection-bias corrected OLS regression for walking minutes) estimated the relative contribution of sidewalk length to NWT and NWR.
After adjustment, neighborhood sidewalk length and walkability were positively associated with a 2.97 and 2.16 percentage point increase in the probability of NWT participation, respectively. For each 10 km increase in sidewalk length, NWT increased by 5.38 min/wk and overall neighborhood-based walking increased by 5.26 min/wk. Neighborhood walkability was not associated with NWT or NWR minutes. Moreover, sidewalk length was not associated with NWR minutes.
Sidewalk availability in established neighborhoods may be differentially associated with walking for different purposes. Our findings suggest that large investments in sidewalk construction alone would yield small increases in walking.
PMCID: PMC3479072  PMID: 22853008
Pedestrian; Urban form; Walkability; Exercise; Sidewalks
3.  Active Transportation Safety Features around Schools in Canada 
The purpose of this study was to describe the presence and quality of active transportation safety features in Canadian school environments that relate to pedestrian and bicycle safety. Variations in these features and associated traffic concerns as perceived by school administrators were examined by geographic status and school type. The study was based on schools that participated in 2009/2010 Health Behaviour in School-aged Children (HBSC) survey. ArcGIS software version 10 and Google Earth were used to assess the presence and quality of ten different active transportation safety features. Findings suggest that there are crosswalks and good sidewalk coverage in the environments surrounding most Canadian schools, but a dearth of bicycle lanes and other traffic calming measures (e.g., speed bumps, traffic chokers). Significant urban/rural inequities exist with a greater prevalence of sidewalk coverage, crosswalks, traffic medians, and speed bumps in urban areas. With the exception of bicycle lanes, the active transportation safety features that were present were generally rated as high quality. Traffic was more of a concern to administrators in urban areas. This study provides novel information about active transportation safety features in Canadian school environments. This information could help guide public health efforts aimed at increasing active transportation levels while simultaneously decreasing active transportation injuries.
PMCID: PMC3863867  PMID: 24185844
cyclist; environment; injury; pedestrian; policy; road; safety; schools; traffic
4.  Road Trauma in Teenage Male Youth with Childhood Disruptive Behavior Disorders: A Population Based Analysis 
PLoS Medicine  2010;7(11):e1000369.
Donald Redelmeier and colleagues conducted a population-based case-control study of 16-19-year-old males hospitalized for road trauma or appendicitis and showed that disruptive behavior disorders explained a significant amount of road trauma in this group.
Teenage male drivers contribute to a large number of serious road crashes despite low rates of driving and excellent physical health. We examined the amount of road trauma involving teenage male youth that might be explained by prior disruptive behavior disorders (attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder).
Methods and Findings
We conducted a population-based case-control study of consecutive male youth between age 16 and 19 years hospitalized for road trauma (cases) or appendicitis (controls) in Ontario, Canada over 7 years (April 1, 2002 through March 31, 2009). Using universal health care databases, we identified prior psychiatric diagnoses for each individual during the decade before admission. Overall, a total of 3,421 patients were admitted for road trauma (cases) and 3,812 for appendicitis (controls). A history of disruptive behavior disorders was significantly more frequent among trauma patients than controls (767 of 3,421 versus 664 of 3,812), equal to a one-third increase in the relative risk of road trauma (odds ratio  =  1.37, 95% confidence interval 1.22–1.54, p<0.001). The risk was evident over a range of settings and after adjustment for measured confounders (odds ratio 1.38, 95% confidence interval 1.21–1.56, p<0.001). The risk explained about one-in-20 crashes, was apparent years before the event, extended to those who died, and persisted among those involved as pedestrians.
Disruptive behavior disorders explain a significant amount of road trauma in teenage male youth. Programs addressing such disorders should be considered to prevent injuries.
Please see later in the article for the Editors' Summary
Editors' Summary
In the latest World Health Organization (WHO) global burden of disease list, road traffic crashes are currently ranked eighth but are predicted to take fourth place by 2030 (by which time, road traffic deaths are likely to increase by more than 80% in developing countries and to decrease by nearly 30% in industrialized countries.) Every year, road traffic crashes kill an estimated 1.2 million people world-wide and injure or disable a further 20–60 million. Furthermore, the economic consequences of road traffic crashes account for about 2% of the gross national product of the entire global economy.
90% of road traffic deaths occur in developing countries where pedestrians, cyclists, and users of two-wheel vehicles (scooters, motorbikes) are the most vulnerable. In industrialized countries, teenage male drivers are the single most risky demographic group, with an incidence of road traffic crashes of twice that of the population average. Also, male teenagers are sometimes a hazard to other road users and contribute to more fatalities in older pedestrians than older drivers. Furthermore, teenage male drivers involved in serious crashes can have ongoing health care needs but are often resistant to standard road safety advice.
Why Was This Study Done?
Previous studies have suggested that disruptive behavior disorders might contribute to the risk of road traffic crashes in male teenagers but methodological problems with these studies make these results unclear. Given the importance of this topic, authorities have called for more research into the full range of behavioral disorders and relevant populations. This study attempted to avoid the methodological problems of previous studies and to rigorously assess whether disruptive behavior disorders predispose male teenagers to road traffic crashes.
What Did the Researchers Do and Find?
The researchers conducted a 7-year population-based case-control study in Ontario, Canada of consecutive male teenagers aged between 16 and 19 years who were admitted to a hospital due to a road traffic crash, including those who were pedestrians. For the controls, the researchers used consecutive males in the same age range who were admitted to the same hospitals during the same time interval for acute appendicitis (which is common and generally unrelated to traumatic injury). For each participant in the study, the authors used universal health care databases in Canada's single-payer health care system to identify relevant psychiatric diagnoses (attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder) during the decade before admission.
During the study period, 3,421 male teenagers were admitted to hospital as the result of a road traffic crash and 3,812 male teenagers were admitted to hospital for appendicitis. A history of disruptive behavior disorders was significantly more frequent among male teenagers admitted for road traffic crashes than controls (767 of 3,421 versus 664 of 3,812) giving an odds ratio 1.37. This higher risk was still present after the researchers adjusted for possible confounding factors (such as age, social status, and home location) and accounted for about one-in-20 road traffic crashes, including male teenagers who had died and those involved as pedestrians.
What Do These Findings Mean?
The results of this study suggest that disruptive behavior disorders explain a significant amount of road traffic crashes experienced in male teenagers. Overall, attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder are associated with about a one-third increase in the risk of a road traffic crash (which is similar to the relative risk among individuals treated for epilepsy.) As in previous studies in this area, some methodological problems may affect the interpretation of these findings. As this study did not document who was “at fault,” an alternative interpretation might be that behavioral disorders impair a teenager's ability to avoid a mishap initiated by someone else. Most importantly, the observed increase in risk as pedestrians indicates that male teenagers who abstain from driving do not escape the danger of road traffic crashes.
The researchers stress that any increased risk of road traffic crashes associated with disruptive behavior disorders in male teenagers does not justify withholding a driver's license, especially as many such disorders can be effectively treated or, indeed, because it does not address the issue of the increased risk for those teenagers who were pedestrians. Instead, they suggest that disruptive behavior disorders could be considered as contributors to road traffic crashes—analogous to seizure disorders and some other medical diseases. Therefore, greater attention by primary care physicians, psychiatrists, and community health workers might be helpful since interventions can perhaps reduce the risk including medical treatments and avoidance of distractions.
Additional Information
Please access these Web sites via the online version of this summary at
The World Health Organization has information on road traffic crashes
The US National Institutes of Health has information about behavior disorders in children as well as UK-based Kids Development
The Ontarion Ministry of Transportation has information on annual roadway collisions in Ontario
PMCID: PMC2981585  PMID: 21125017
5.  Comparing objective measures of environmental supports for pedestrian travel in adults 
Evidence is growing that the built environment has the potential to influence walking--both positively and negatively. However, uncertainty remains on the best approaches to representing the pedestrian environment in order to discern associations between walking and the environment. Research into the relationship between environment and walking is complex; challenges include choice of measures (objective and subjective), quality and availability of data, and methods for managing quantitative data through aggregation and weighting. In particular, little research has examined how to aggregate built environment data to best represent the neighborhood environments expected to influence residents' behavior. This study examined associations between walking and local pedestrian supports (as measured with an environmental audit), comparing the results of models using three different methods to aggregate and weight pedestrian features.
Using data collected in 2005-2006 for a sample of 251 adult residents of Montgomery County, MD, we examined associations between pedestrian facilities and walking behaviors (pedestrian trips and average daily steps). Adjusted negative binomial and ordinary least-squares regression models were used to compare three different data aggregation techniques (raw averages, length weighting, distance weighting) for measures of pedestrian facilities that included presence, condition, width and connectivity of sidewalks, and presence of crossing aids and crosswalks.
Participants averaged 8.9 walk trips during the week; daily step counts averaged 7042. The three aggregation techniques revealed different associations between walk trips and the various pedestrian facilities. Crossing aids and good sidewalk conditions were associated with walk trips more than were other pedestrian facilities, while sidewalk facilities and features showed associations with steps not observed for crossing aids and crosswalks.
Among three methods of aggregation examined, the method that accounted for distance from participant's home to the pedestrian facility (distance weighting) is promising; at the same time, it requires the most time and effort to calculate. This finding is consistent with the behavioral assumption that travelers may respond to environmental features closer to their residence more strongly than to more distant environmental qualities.
PMCID: PMC2789060  PMID: 19925658
6.  Parental safety concerns and active school commute: correlates across multiple domains in the home-to-school journey 
Empirical evidence of the relationship between safety concerns and walking to school (WTS) is growing. However, current research offers limited understanding of the multiple domains of parental safety concerns and the specific mechanisms through which parents articulate safety concerns about WTS. A more detailed understanding is needed to inform environmental and policy interventions. This study examined the relationships between both traffic safety and personal safety concerns and WTS in the U.S.
This cross-sectional analysis examined data from the Texas Childhood Obesity Prevention Policy Evaluation (T-COPPE) project, an evaluation of state-wide obesity prevention policy interventions. All study data were from the survey (n = 830) of parents with 4th grade students attending 81 elementary schools across Texas, and living within two miles from their children's schools. Traffic safety and personal safety concerns were captured for the home neighborhood, en-route to school, and school environments. Binary logistic regression analysis was used to assess the odds of WTS controlling for significant covariates.
Overall, 18% of parents reported that their child walked to school on most days of the week. For traffic safety, students were more likely to walk to school if their parent reported favorable perceptions about the following items in the home neighborhood environment: higher sidewalk availability, well maintained sidewalks and safe road crossings. For the route to school, the odds of WTS were higher for those who reported "no problem" with each one of the following: traffic speed, amount of traffic, sidewalks/pathways, intersection/crossing safety, and crossing guards, when compared to those that reported "always a problem". For personal safety in the en-route to school environment, the odds of WTS were lower when parents reported concerns about: stray or dangerous animals and availability of others with whom to walk.
Findings offered insights into the specific issues that drive safety concerns for elementary school children’s WTS behaviors. The observed associations between more favorable perceptions of safety and WTS provide further justification for practical intervention strategies to reduce WTS barriers that can potentially bring long-term physical activity and health benefits to school-aged children.
PMCID: PMC3975836  PMID: 24602213
Active commuting to school; Walking to school; Child pedestrian; Traffic safety; Personal safety; Crime safety; Pedestrian safety; Physical activity; Environmental perception; Safe routes to school
7.  Risk perception, road behavior, and pedestrian injury among adolescent students in Kathmandu, Nepal 
Injury Prevention  2007;13(4):258-263.
To examine the relationship between the perceived safety of specified road behaviors, self‐described road behaviors, and pedestrian injury among adolescent students in Kathmandu, Nepal.
A cross‐sectional study was conducted among 1557 adolescents in grades 6–8 across 14 schools in Kathmandu using a self‐administered questionnaire in 2003. A multiple logistic regression analysis was used to analyze the data.
Adolescents were more likely to suffer from pedestrian injury when they did not always “wait for green signals to cross the road”. There were no significant associations between road behaviors such as “looking both ways along the road before crossing” or “playing in the road or sidewalks” and pedestrian injury. Adolescents who “perceived it safe to cross the road from any point” or “did not perceive it to be safer to cross the road at a zebra crossing” were less likely to “look both ways” or “wait for green signals” before crossing the road. Adolescents who “perceived it to be safe to play in the road” were more likely to play in the road or sidewalk. Similarly, this study showed a positive association between road safety education and adolescents' road crossing behaviors.
Adolescents' road behaviors, except for compliance with green signals, were not significantly associated with pedestrian injury. This suggests that a behavioral approach without modification of the traffic environment (such as provision of crossing signals) might not effectively prevent the occurrence of pedestrian injury in developing countries with poor traffic conditions.
PMCID: PMC2598342  PMID: 17686937
traffic; accidents; risk‐taking; risk reduction behavior; school health; developing countries
8.  Using Manipulated Photographs to Identify Features of Streetscapes That May Encourage Older Adults to Walk for Transport 
PLoS ONE  2014;9(11):e112107.
Experimental evidence of environmental features important for physical activity is challenging to procure in real world settings. The current study aimed to investigate the causal effects of environmental modifications on a photographed street's appeal for older adults' walking for transport. Secondly, we examined whether these effects differed according to gender, functional limitations, and current level of walking for transport. Thirdly, we examined whether different environmental modifications interacted with each other. Qualitative responses were also reported to gain deeper insight into the observed quantitative relationships. Two sets of 16 panoramic photographs of a streetscape were created, in which six environmental factors were manipulated (sidewalk evenness, traffic level, general upkeep, vegetation, separation from traffic, and benches). Sixty older adults sorted these photographs on appeal for walking for transport on a 7-point scale and reported qualitative information on the reasons for their rankings. Sidewalk evenness appeared to have the strongest influence on a street's appeal for transport-related walking. The effect of sidewalk evenness was even stronger when the street's overall upkeep was good and when traffic was absent. Absence of traffic, presence of vegetation, and separation from traffic also increased a street's appeal for walking for transport. There were no moderating effects by gender or functional limitations. The presence of benches increased the streetscape's appeal among participants who already walked for transport at least an hour/week. The protocols and methods used in the current study carry the potential to further our understanding of environment-PA relationships. Our findings indicated sidewalk evenness as the most important environmental factor influencing a street's appeal for walking for transport among older adults. However, future research in larger samples and in real-life settings is needed to confirm current findings.
PMCID: PMC4232399  PMID: 25396732
9.  The importance of accurate road data for spatial applications in public health: customizing a road network 
Health researchers have increasingly adopted the use of geographic information systems (GIS) for analyzing environments in which people live and how those environments affect health. One aspect of this research that is often overlooked is the quality and detail of the road data and whether or not it is appropriate for the scale of analysis. Many readily available road datasets, both public domain and commercial, contain positional errors or generalizations that may not be compatible with highly accurate geospatial locations. This study examined the accuracy, completeness, and currency of four readily available public and commercial sources for road data (North Carolina Department of Transportation, StreetMap Pro, TIGER/Line 2000, TIGER/Line 2007) relative to a custom road dataset which we developed and used for comparison.
Methods and Results
A custom road network dataset was developed to examine associations between health behaviors and the environment among pregnant and postpartum women living in central North Carolina in the United States. Three analytical measures were developed to assess the comparative accuracy and utility of four publicly and commercially available road datasets and the custom dataset in relation to participants' residential locations over three time periods. The exclusion of road segments and positional errors in the four comparison road datasets resulted in between 5.9% and 64.4% of respondents lying farther than 15.24 meters from their nearest road, the distance of the threshold set by the project to facilitate spatial analysis. Agreement, using a Pearson's correlation coefficient, between the customized road dataset and the four comparison road datasets ranged from 0.01 to 0.82.
This study demonstrates the importance of examining available road datasets and assessing their completeness, accuracy, and currency for their particular study area. This paper serves as an example for assessing the feasibility of readily available commercial or public road datasets, and outlines the steps by which an improved custom dataset for a study area can be developed.
PMCID: PMC2685779  PMID: 19409088
10.  Pattern of Pedestrian Injuries in the City of Nairobi: Implications for Urban Safety Planning 
Pedestrians are overrepresented in road traffic injuries and deaths in Nairobi, the capital city of Kenya, yet little research has been done to provide better understanding of the characteristics of pedestrian injuries. This paper presents the data obtained from road traffic injury admissions to Kenyatta National Hospital (KNH) over a 3-month period starting from 1 June to 31 August 2011. A total of 176 persons involved road traffic injuries in Nairobi were admitted to KNH during this period. Pedestrians comprised the highest (59.1 %) proportion of road traffic injury admissions, followed by motor vehicle passengers (24.4 %) and motor cyclists (9.7 %). Bicyclists and drivers accounted for 5.1 and 1.7 %, respectively. Cars (39.4 %) were the leading category of motorized four-wheeler vehicles that were involved in collisions with pedestrians, followed by matatus (35.5 %). Seventy percent of pedestrians were hit while crossing the road, 10.8 % while standing by the road, and 8.1 % while walking along the road. The highest proportion of pedestrian crashes occurred on Saturdays (25.5 %) and Sundays (16.7 %). Most of the pedestrian injuries (67.7 %) affected the limbs. The paper argues that safety of pedestrians should be a priority in road safety efforts in the city of Nairobi. Urban road safety planners should adopt existing cost-effective interventions to improve the safety of pedestrians such as area-wide traffic calming to limit the speeds of motor vehicles to 30 km/h, providing sidewalks for pedestrians, traffic calming in residential neighborhoods, people-and-not-car-oriented urban road designs, traffic education, and enforcement of traffic regulations.
PMCID: PMC3795196  PMID: 23430375
Pedestrian injuries; Nairobi; Urban; Kenyatta National Hospital
11.  Characteristics of Urban Sidewalks/Streets and Objectively Measured Physical Activity 
Journal of Urban Health   2007;85(2):178-190.
Several studies have found significant relationships between environmental characteristics (e.g., number of destinations, aesthetics) and physical activity. While a few of these studies verified that the physical activities assessed were performed in the environments examined, none have done this in an urban, neighborhood setting. This information will help efforts to inform policy decisions regarding the design of more “physically active” communities. Fourteen environmental characteristics of 60, 305-m-long segments, located in an urban, residential setting, were directly measured using standardized procedures. The number of individuals walking, jogging, and biking in the segments was assessed using an observation technique. The segments were heterogeneous with regards to several of the environmental characteristics. A total of 473 individuals were seen walking, bicycling, or jogging in the segments during 3,600 min of observation (60 min/segment). Of the 473 seen, 315 were walking, 116 bicycling, and 42 jogging. A greater number of individuals were seen walking in segments with more traffic, sidewalk defects, graffiti, and litter and less desirable property aesthetics. Only one environmental characteristic was associated with bicycling and none were significantly related with jogging. This study provides further evidence that environmental characteristics and walking are related. It also adds new information regarding the importance of scale (e.g., micro, macro) and how some environmental characteristics of urban, residential sidewalks and streets relate to physical activity.
PMCID: PMC2430121  PMID: 18161026
Cross-sectional study; Environment; Exercise.
12.  A Method for Observing Physical Activity on Residential Sidewalks and Streets 
Assessment of physical activity needs to improve in order to gain a more comprehensive understanding of the relationship between characteristics of the environment and physical activity. Our study evaluated a method [Block Walk Method (BWM)] for observing physical activity along residential sidewalks and streets. The BWM was utilized in 12 U.S. Census block groups over a three-month period. Examination transportation routes (ETRs), 1,524 m in length, were constructed and examined in each block group. On 6 days, ETRs were traversed by a trained observer for 50 min. Physical activities, street names, and geographical locations (e.g., addresses) were recorded. We found encouraging results for the BWM. The level of agreement between independent observers was >98% for activity type. The number of individuals seen walking, running, or biking did not differ significantly between the days of the week or observation times. The number of individuals observed was correlated with block group characteristics (e.g., percent walking/biking to work) and weather (e.g., temperature). The BWM is an easy to use, economically viable observational approach to obtaining reliable information concerning physical activities performed on residential streets and sidewalks. Its use could help advance our understanding about the environment–physical activity relationship.
PMCID: PMC2527197  PMID: 16739046
Behavior assessment; Exercise; Measurement
13.  Airborne concentrations of PM(2.5) and diesel exhaust particles on Harlem sidewalks: a community-based pilot study. 
Environmental Health Perspectives  2000;108(3):213-218.
Residents of the dense urban core neighborhoods of New York City (NYC) have expressed increasing concern about the potential human health impacts of diesel vehicle emissions. We measured concentrations of particulate matter [less than/equal to] 2.5 micro in aerodynamic diameter (PM(2.5)) and diesel exhaust particles (DEP) on sidewalks in Harlem, NYC, and tested whether spatial variations in concentrations were related to local diesel traffic density. Eight-hour (1000-1800 hr) air samples for PM(2.5 )and elemental carbon (EC) were collected for 5 days in July 1996 on sidewalks adjacent to four geographically distinct Harlem intersections. Samples were taken using portable monitors worn by study staff. Simultaneous traffic counts for diesel trucks, buses, cars, and pedestrians were carried out at each intersection on [Greater/equal to] 2 of the 5 sampling days. Eight-hour diesel vehicle counts ranged from 61 to 2,467 across the four sites. Mean concentrations of PM(2.5) exhibited only modest site-to-site variation (37-47 microg/m(3)), reflecting the importance of broader regional sources of PM(2.5). In contrast, EC concentrations varied 4-fold across sites (from 1.5 to 6 microg/m(3)), and were associated with bus and truck counts on adjacent streets and, at one site, with the presence of a bus depot. A high correlation (r = 0.95) was observed between EC concentrations measured analytically and a blackness measurement based on PM(2.5) filter reflectance, suggesting the utility of the latter as a surrogate measure of DEP in future community-based studies. These results show that local diesel sources in Harlem create spatial variations in sidewalk concentrations of DEP. The study also demonstrates the feasibility of a new paradigm for community-based research involving full and active partnership between academic scientists and community-based organizations.
PMCID: PMC1637978  PMID: 10706526
14.  Environmental factors influencing older adults’ walking for transportation: a study using walk-along interviews 
Current knowledge on the relationship between the physical environment and walking for transportation among older adults (≥ 65 years) is limited. Qualitative research can provide valuable information and inform further research. However, qualitative studies are scarce and fail to include neighborhood outings necessary to study participants’ experiences and perceptions while interacting with and interpreting the local social and physical environment. The current study sought to uncover the perceived environmental influences on Flemish older adults’ walking for transportation. To get detailed and context-sensitive environmental information, it used walk-along interviews.
Purposeful convenience sampling was used to recruit 57 older adults residing in urban or semi-urban areas. Walk-along interviews to and from a destination (e.g. a shop) located within a 15 minutes’ walk from the participants’ home were conducted. Content analysis was performed using NVivo 9 software (QSR International). An inductive approach was used to derive categories and subcategories from the data.
Data were categorized in the following categories and subcategories: access to facilities (shops & services, public transit, connectivity), walking facilities (sidewalk quality, crossings, legibility, benches), traffic safety (busy traffic, behavior of other road users), familiarity, safety from crime (physical factors, other persons), social contacts, aesthetics (buildings, natural elements, noise & smell, openness, decay) and weather.
The findings indicate that to promote walking for transportation a neighborhood should provide good access to shops and services, well-maintained walking facilities, aesthetically appealing places, streets with little traffic and places for social interaction. In addition, the neighborhood environment should evoke feelings of familiarity and safety from crime. Future quantitative studies should investigate if (changes in) these environmental factors relate to (changes in) older adults’ walking for transportation.
PMCID: PMC3499291  PMID: 22780948
Physical environment; Physical activity; Walking for transportation; Older adults; Qualitative study; Walk-along interviews
15.  The association of sidewalk walkability and physical disorder with area‐level race and poverty 
There are significant differences in physical inactivity in various geographical areas and among demographic groups. Previous research suggests that walking is the most common form of physical activity; however, not all built environments support walking for recreational or transportation purposes.
The purpose of this study was to assess the extent to which area‐level factors, poverty rate and racial distribution, are associated with aspects of the street‐scale environment (i.e. sidewalk walkability and physical disorder) using community audits.
Street segments were randomly selected from 210 block groups. Pairs of trained auditors walked each street segment using an audit tool designed to capture aspects of the street environment. Multilevel logistic regression was used to assess the degree of neighborhood (i.e. block group) variation in sidewalk unevenness, sidewalk obstruction and the presence of physical disorder and the association with area‐level characteristics.
1780 street segments were audited. Block groups that were predominantly African–American were 38 times more likely to have a lot of unevenness, 15 times more likely to have many obstructions, and 12 times more likely to have physical disorder. Poverty rate was not independently associated with sidewalk walkability; however, block groups with the highest poverty rates were 21 times more likely to have physical disorder.
The results indicate that aspects of the built environment vary by characteristics of the neighborhood. This suggests that there is a differential investment in community infrastructures and resources in neighborhoods that are mostly African–American. This differential investment is likely to influence disparities in rates of physical activity.
PMCID: PMC2465610  PMID: 17933956
16.  The Built Environment Predicts Observed Physical Activity 
Background: In order to improve our understanding of the relationship between the built environment and physical activity, it is important to identify associations between specific geographic characteristics and physical activity behaviors.
Purpose: Examine relationships between observed physical activity behavior and measures of the built environment collected on 291 street segments in Indianapolis and St. Louis.
Methods: Street segments were selected using a stratified geographic sampling design to ensure representation of neighborhoods with different land use and socioeconomic characteristics. Characteristics of the built environment on-street segments were audited using two methods: in-person field audits and audits based on interpretation of Google Street View imagery with each method blinded to results from the other. Segments were dichotomized as having a particular characteristic (e.g., sidewalk present or not) based on the two auditing methods separately. Counts of individuals engaged in different forms of physical activity on each segment were assessed using direct observation. Non-parametric statistics were used to compare counts of physically active individuals on each segment with built environment characteristic.
Results: Counts of individuals engaged in physical activity were significantly higher on segments with mixed land use or all non-residential land use, and on segments with pedestrian infrastructure (e.g., crosswalks and sidewalks) and public transit.
Conclusion: Several micro-level built environment characteristics were associated with physical activity. These data provide support for theories that suggest changing the built environment and related policies may encourage more physical activity.
PMCID: PMC4033002  PMID: 24904916
walkable; micro characteristics; street view; objective measures; policy interventions
17.  Prescription Medicines and the Risk of Road Traffic Crashes: A French Registry-Based Study 
PLoS Medicine  2010;7(11):e1000366.
Using three nationwide databases in France, Ludivine Orriols, Emmanuel Lagarde, and colleagues provide evidence that prescribed medicines contribute to the risk of experiencing a road traffic crash.
In recent decades, increased attention has been focused on the impact of disabilities and medicinal drug use on road safety. The aim of our study was to investigate the association between prescription medicines and the risk of road traffic crashes, and estimate the attributable fraction.
Methods and Findings
We extracted and matched data from three French nationwide databases: the national health care insurance database, police reports, and the national police database of injurious crashes. Drivers identified by their national health care number involved in an injurious crash in France, between July 2005 and May 2008, were included in the study. Medicines were grouped according to the four risk levels of the French classification system (from 0 [no risk] to 3 [high risk]). We included 72,685 drivers involved in injurious crashes. Users of level 2 (odds ratio [OR]  = 1.31 [1.24–1.40]) and level 3 (OR  = 1.25 [1.12–1.40]) prescription medicines were at higher risk of being responsible for a crash. The association remained after adjustment for the presence of a long-term chronic disease. The fraction of road traffic crashes attributable to levels 2 and 3 medications was 3.3% [2.7%–3.9%]. A within-person case-crossover analysis showed that drivers were more likely to be exposed to level 3 medications on the crash day than on a control day, 30 days earlier (OR  = 1.15 [1.05–1.27]).
The use of prescription medicines is associated with a substantial number of road traffic crashes in France. In light of the results, warning messages appear to be relevant for level 2 and 3 medications and questionable for level 1 medications. A follow-up study is needed to evaluate the impact of the warning labeling system on road traffic crash prevention.
Please see later in the article for the Editors' Summary
Editors' Summary
About 1.3 million people die each year on the world's road. 90% of road traffic deaths occur in developing countries, with pedestrians, cyclists, and users of two-wheel vehicles (scooters, motorbikes) the most vulnerable road users. Although the use of prescribed benzodiazepines has already been documented to be associated with road traffic accidents in industrialized countries, the effects of other medicines have not been well studied or have inconsistent results (for example opioids and antidepressant medications). In the European Union, it is mandatory for pharmaceutical companies to provide data about the effect of a medicine on ability to drive. In France, a multidisciplinary group of experts was appointed to classify all medicines into four levels of risk (from level 0, no or negligible risk, to level 3, major risk), in terms of their effect on driving performances. In 2006, the International Council on Alcohol, Drugs and Traffic Safety proposed a classification list similar to the French classification system.
Why Was This Study Done? There is a pressing need to understand the association between prescribed medicines and the risk of road traffic crashes and also to have a more accurate picture of the fraction of road traffic crashes that are attributable to the use of prescribed medicines. This large French study aimed to advance knowledge in this important area.
What Did the Researchers Do and Find? The researchers used three data sources to find the information they needed: the national health care insurance database (which covers the whole French population and includes data on reimbursed prescription medicines), police reports, and the national police database of injurious road traffic crashes. Drivers involved in road traffic crashes (identified by their national healthcare number) between July 2005 and May 2008 were included in the study. The researchers used a statistical model to conduct a responsibility analysis, which determined factors associated with each driver responsible for the road traffic crash and each driver who was not responsible (controls). In addition, the researchers compared medicine exposure during a period immediately before the crash (case period) with exposure during an earlier period (control period) for each driver involved in a crash. The researchers retrieved data on reimbursed medicines, dispensed within six months of the road traffic crash, by linking included drivers to the national health care insurance database using their national ID, gender, and date of birth and grouped all prescribed medicines according to the four risk levels of the French classification system.
During the study period, 72,685 drivers involved in injurious road traffic crashes were included. The researchers found that drivers who had been prescribed level 2 and level 3 medicines were at higher risk (odds ratio 1.31 and OR 1.25, respectively) of being responsible for the road traffic crash, an association that remained after the researchers adjusted for the presence of chronic diseases. Furthermore, the researchers found that the fraction of road traffic crashes attributable to the use of (prescriptions for) level 2 and 3 medicines was 3.3% and that drivers were more likely to be exposed to level 3 medicines on the day of the road traffic crash than on a control day.
What Do These Findings Mean? This study provides strong evidence for the contribution of medicines to the risk of experiencing a road traffic crash. The French drug risk classification scheme seems accurate for medicines classified as levels 2 and 3 of risk for road traffic crashes. The effect on driving abilities of level 2 medicines depends both on the pharmacodynamics of the drug and on individual susceptibility, whereas for level 3 medicines, the pharmacodynamic effect seems to be predominant. The effects of level 1 medicines seem to be so dependent on individual susceptibility that effects on driving abilities are rare, which raises questions about the relevance of the labels for these medicines. However, some limitations with the study methodology might affect the interpretation of these findings. For example, the researchers used dispensing dates for medications as a surrogate for ingestion and were not able to check for noncompliance.
However, this study provides some of the strongest evidence to date of the need for health care workers to provide patients with proper information on the potential effect of any medicine that they are prescribed (or take) on their driving abilities.
Additional Information Please access these Web sites via the online version of this summary at World Health Organization (WHO) provides information on road traffic accidentsTwo Web sites provide information for drivers about drugs that could affect their ability to driveThe US National Institute on Drug Abuse of the National Institutes of Health has an information sheet on drugged driving
PMCID: PMC2981588  PMID: 21125020
18.  Seed Spillage from Grain Trailers on Road Verges during Oilseed Rape Harvest: An Experimental Survey 
PLoS ONE  2012;7(3):e32752.
Anthropogenic vectors enhance the natural dispersal capacity of plant seeds significantly in terms of quantity and distance. Human-mediated seed dispersal (i.e. anthropochory) greatly increases the dispersal of crop species across agroecosystems. In the case of oilseed rape (OSR), spillage of seeds from grain trailers during harvest has never been quantified.
Our experimental approach involved establishing 85 seed trap-sites on the road verges of an agricultural area around the grain silo of Selommes (Loir-et-Cher, France). We recorded OSR spillage during harvest and applied a linear model to the data.
The amount of seed spilled was related positively to the area of the OSR fields served by the road, whereas the amount of seed spilled decreased with other variables, such as distance from the trap-site to the verge of the road and to the nearest field.
The distance to the grain silo, through local and regional effects, affected seed loss. Local effects from fields adjacent to the road resulted in a cumulative spillage on one-lane roads. On two-lane roads, spillage was nearly constant whatever the distance to the silo due to a mixture of these local effects and of grain trailers that joined the road from more distant fields.
From the data, we predicted the number of seeds lost from grain trailers on one road verge in the study area. We predicted a total spillage of 2.05×106 seeds (±4.76×105) along the road length, which represented a mean of 404±94 seeds per m2.
Containment of OSR seeds will always be challenging. However, seed spillage could be reduced if grain trailers were covered and filled with less seed. Reducing distances travelled between fields and silos could also limit seed loss.
PMCID: PMC3302880  PMID: 22427873
19.  Injury characteristics and outcome of road traffic crash victims at Bugando Medical Centre in Northwestern Tanzania 
Road traffic crash is of growing public health importance worldwide contributing significantly to the global disease burden. There is paucity of published data on road traffic crashes in our local environment. This study was carried out to describe the injury characteristics and outcome of road traffic crash victims in our local setting and provide baseline data for establishment of prevention strategies as well as treatment protocols.
This was a prospective hospital based study of road traffic crash victims carried out at Bugando Medical Centre in Northwestern Tanzania between March 2010 and February 2011. After informed consent to participate in the study, all patients were consecutively enrolled into the study. Data were collected using a pre-tested questionnaire and analyzed using SPSS computer software version 15.0.
A total of 1678 road traffic crash victims were studied. Their male to female ratio was of 2.1:1. The patients ages ranged from 3 to 78 years with the mean and median of 29.45 (± 24.22) and 26.12 years respectively. The modal age group was 21-30 years, accounting for 52.1% patients. Students (58.8%) and businessmen (35.9%) were the majority of road traffic crash victims. Motorcycle (58.8%) was responsible for the majority of road traffic crashes. Musculoskeletal (60.5%) and the head (52.1%) were the most common body region injured. Open wounds (65.9%) and fractures (26.3%) were the most common type of injuries sustained. The majority of patients (80.3%) were treated surgically. Wound debridement was the most common procedure performed in 81.2% of the patients. The complication rate was 23.7%. The overall average length of hospital stay (LOS) was 23.5 ± 12.3 days. Mortality rate was 17.5%. According to multivariate logistic regression analysis, patients who had severe trauma (Kampala Trauma Score II ≤ 6) and those with long bone fractures stayed longer in the hospital and this was significant (P < 0.001) whereas the age of the patient, severe trauma (Kampala Trauma Score II ≤ 6), admission Systolic Blood Pressure < 90 mmHg and severe head injury (Glasgow Coma Score = 3-8) significantly influenced mortality (P < 0.001).
Road traffic crashes constitute a major public health problem in our setting and contribute significantly to unacceptably high morbidity and mortality. Urgent preventive measures targeting at reducing the occurrence of road traffic crashes is necessary to reduce the morbidity and mortality resulting from these injuries. Early recognition and prompt treatment of road traffic injuries is essential for optimal patient outcome.
PMCID: PMC3292995  PMID: 22321248
Road traffic crashes; Victims; Injury characteristics; Outcome; Tanzania
20.  Protocol for a randomised controlled trial to improve cognitive functioning in older adults: the Iowa Healthy and Active Minds Study 
BMJ Open  2011;1(2):e000218.
Gradual age-related cognitive deteriorations are common and are hypothesised to be partially attributable to declines in information-processing speed. The Iowa Healthy and Active Minds Study will evaluate the efficacy and effectiveness of a computerised visual processing speed training programme (Road Tour, Posit Science Corporation, San Francisco, California).
Methods and analysis
Using a 3:3:4:4 ratio within two age strata (50–64 vs ≥65 years old), 681 men and women attending family care clinics were randomised to four treatment groups: 10 h of on-site Road Tour training, 10 h of on-site Road Tour training with 4 h of booster training at 11 months postrandomisation, 10 h of on-site attention control using computerised crossword puzzles (Boatload of Crosswords, Boatload Puzzles, LLC, Yorktown Heights, New York) and 10 h of at-home Road Tour training using the participant's personal computer. The primary outcome, visual processing speed, was assessed at randomisation and post-training (6–8 weeks postrandomisation), and is being reassessed at 1-year postrandomisation using the Useful Field of View test. Five secondary outcomes (Symbol Digit Modalities Test, Trail Making Tests A and B, Controlled Oral Word Association Test, Digit Vigilance Test, and the Stroop Colour and Word Test) were assessed at randomisation and will be reassessed at 1-year postrandomisation. Seven hypotheses will be tested using intent-to-treat analyses involving multiple linear, logistic, Poisson and negative binomial regression.
Ethics and dissemination
Ethics approval was provided by the University of Iowa Institutional Review Board (IRB-03 protocol 200908789). All participants completed signed informed consent prior to enrolment. Road Tour is commercially available from Posit Science Corporation, which provided it to Iowa Healthy and Active Minds Study at no cost. All participants will receive a free copy of Road Tour for unlimited perpetual use at study completion.
Clinical Trial Registration Number
Article summary
Article focus
Given that age-related declines in cognitive functioning are part of the normal ageing process, there is a pressing need for efficient and effective training interventions that improve cognitive functioning in older adults.
This protocol paper outlines the design of a study that overcomes several important limitations of a prior, large, multisite randomised controlled trial (RCT) that used memory, reasoning and speed of processing interventions, but found that only the latter effectively translated to improved health outcomes.
This RCT evaluates the efficacy and effectiveness of a second-generation computerised visual speed-of-processing intervention using three modes of delivery (on-site without booster training, on-site with booster training and at-home use) versus an attention control (on-site computerised crossword puzzles without booster training) in improving cognitive processing speed and health outcomes.
Key messages
This is an RCT protocol.
Iowa Healthy and Active Minds Study is the first RCT to evaluate the efficacy and effectiveness of a commercially available computerised visual speed of processing intervention known as Road Tour.
If this intervention is successful, the product vendor pledges to make the computerised intervention software available to governments for widespread distribution and use at a fraction of the current commercial cost.
Strengths and limitations of this study
This study uses six well-established, objective neuropsychological assessments of cognitive processing speed, as well as three highly reliable and valid self-reported measures of health outcomes in a large sample of men and women 50 years old and older.
Although the sample is large, it was drawn from just one large primary care centre in which minorities are under-represented and the key assessments are only conducted at randomisation, after initial training (6-8 weeks postrandomisation) and at 1-year postrandomisation, thereby reducing the opportunity to demonstrate the long-term effects of the intervention.
PMCID: PMC3191599  PMID: 22021885
21.  Seeing Steps and Ramps with Simulated Low Acuity: Impact of Texture and Locomotion 
Detecting and recognizing steps and ramps is an important component of the visual accessibility of public spaces for people with impaired vision. The present study, which is part of a larger program of research on visual accessibility, investigated the impact of two factors that may facilitate the recognition of steps and ramps during low-acuity viewing. Visual texture on the ground plane is an environmental factor that improves judgments of surface distance and slant. Locomotion (walking) is common during observations of a layout, and may generate visual motion cues that enhance the recognition of steps and ramps.
In two experiments, normally sighted subjects viewed the targets monocularly through blur goggles that reduced acuity to either approx. 20/150 Snellen (mild blur) or 20/880 (severe blur). The subjects judged whether a step, ramp or neither was present ahead on a sidewalk. In the texture experiment, subjects viewed steps and ramps on a surface with a coarse black-and-white checkerboard pattern. In the locomotion experiment, subjects walked along the sidewalk toward the target before making judgments.
Surprisingly, performance was lower with the textured surface than with a uniform surface, perhaps because the texture masked visual cues necessary for target recognition. Subjects performed better in walking trials than in stationary trials, possibly because they were able to take advantage of visual cues that were only present during motion.
We conclude that under conditions of simulated low acuity, large, high-contrast texture elements can hinder the recognition of steps and ramps while locomotion enhances recognition.
PMCID: PMC3454499  PMID: 22863792
visual accessibility; texture; locomotion; low vision; low acuity; mobility; visual recognition; steps; ramps
22.  Exploring Associations between Physical Activity and Perceived and Objective Measures of the Built Environment 
Journal of Urban Health   2007;84(2):162-184.
The built environment may be responsible for making nonmotorized transportation inconvenient, resulting in declines in physical activity. However, few studies have assessed both the perceived and objectively measured environment in association with physical activity outcomes. The purpose of this study was to describe the associations between perceptions and objective measures of the built environment and their associations with leisure, walking, and transportation activity. Perception of the environment was assessed from responses to 1,270 telephone surveys conducted in Forsyth County, NC and Jackson, MS from January to July 2003. Participants were asked if high-speed cars, heavy traffic, and lack of crosswalks or sidewalks were problems in their neighborhood or barriers to physical activity. They were also asked if there are places to walk to instead of driving in their neighborhood. Speed, volume, and street connectivity were assessed using Geographic Information Systems (GIS) for both study areas. Locations of crashes were measured using GIS for the NC study area as well. Objective and perceived measures of the built environment were in poor agreement as calculated by kappa coefficients. Few associations were found between any of the physical activity outcomes and perception of speed, volume, or presence of sidewalks as problems in the neighborhood or as barriers to physical activity in regression analyses. Associations between perceptions of having places to walk to and presence of crosswalks differed between study sites. Several associations were found between objective measures of traffic volume, traffic speed, and crashes with leisure, walking, and transportation activity in Forsyth County, NC; however, in Jackson, MS, only traffic volume was associated with any of the physical activity outcomes. When both objective and perceived measures of the built environment were combined into the same model, we observed independent associations with physical activity; thus, we feel that evaluating both objective and perceived measures of the built environment may be necessary when examining the relationship between the built environment and physical activity.
PMCID: PMC2231636  PMID: 17273926
Physical activity; Built environment; Geographic Information Systems (GIS); Perceptions; Objective measures
23.  Multi-level examination of correlates of active transportation to school among youth living within 1 mile of their school 
Active transportation to school is a method by which youth can build physical activity into their daily routines. We examined correlates of active transportation to school at both individual- (characteristics of the individual and family) and area- (school and neighborhood) levels amongst youth living within 1 mile (1.6 km) of their school.
Using the 2009/10 Canadian Health Behaviour in School-Aged Children (HBSC) survey, we selected records of students (n = 3 997) from 161 schools that resided in an urban setting and lived within 1 mile from their school. Student records were compiled from: (1) individual-level HBSC student questionnaires; (2) area-level administrator (school) questionnaires; and (3) area-level geographic information system data sources. The outcome, active transportation to school, was determined via a questionnaire item describing the method of transportation that individual students normally use to get to school. Analyses focused on factors at multiple levels that potentially contribute to student decisions to engage in active transportation. Multi-level logistic regression analyses were employed.
Approximately 18% of the variance in active transportation was accounted for at the area-level. Several individual and family characteristics were associated with engagement in active transportation to school including female gender (RR vs. males = 0.86, 95% CI: 0.80-0.91), having ≥2 cars in the household (RR vs. no cars = 0.87, 0.74-0.97), and family socioeconomic status (RR for ‘not well off’ vs. ‘very well off’ = 1.14, 1.01-1.26). Neighborhood characteristics most strongly related to active transportation were: the length of roads in the 1 km buffer (RR in quartile 4 vs. quartile 1 = 1.23, 1.00-1.42), the amount of litter in the neighborhood (RR for ‘major problem’ vs. ‘no problem’ = 1.47, 1.16-1.57), and relatively hot climates (RR in quartile 4 vs. quartile 1 = 1.33 CI, 1.05-1.53).
Engagement in active transportation to school was related to multiple factors at multiple levels. We identified gender, perception of residential neighborhood safety, the percentage of streets with sidewalks, and the total length of roads as the most important correlates of active transportation to school.
PMCID: PMC3538612  PMID: 23067247
Active transportation; Adolescent; School; Neighborhood
24.  Prediction and analysis of near-road concentrations using a reduced-form emission/dispersion model 
Environmental Health  2010;9:29.
Near-road exposures of traffic-related air pollutants have been receiving increased attention due to evidence linking emissions from high-traffic roadways to adverse health outcomes. To date, most epidemiological and risk analyses have utilized simple but crude exposure indicators, most typically proximity measures, such as the distance between freeways and residences, to represent air quality impacts from traffic. This paper derives and analyzes a simplified microscale simulation model designed to predict short- (hourly) to long-term (annual average) pollutant concentrations near roads. Sensitivity analyses and case studies are used to highlight issues in predicting near-road exposures.
Process-based simulation models using a computationally efficient reduced-form response surface structure and a minimum number of inputs integrate the major determinants of air pollution exposures: traffic volume and vehicle emissions, meteorology, and receptor location. We identify the most influential variables and then derive a set of multiplicative submodels that match predictions from "parent" models MOBILE6.2 and CALINE4. The assembled model is applied to two case studies in the Detroit, Michigan area. The first predicts carbon monoxide (CO) concentrations at a monitoring site near a freeway. The second predicts CO and PM2.5 concentrations in a dense receptor grid over a 1 km2 area around the intersection of two major roads. We analyze the spatial and temporal patterns of pollutant concentration predictions.
Predicted CO concentrations showed reasonable agreement with annual average and 24-hour measurements, e.g., 59% of the 24-hr predictions were within a factor of two of observations in the warmer months when CO emissions are more consistent. The highest concentrations of both CO and PM2.5 were predicted to occur near intersections and downwind of major roads during periods of unfavorable meteorology (e.g., low wind speeds) and high emissions (e.g., weekday rush hour). The spatial and temporal variation among predicted concentrations was significant, and resulted in unusual distributional and correlation characteristics, including strong negative correlation for receptors on opposite sides of a road and the highest short-term concentrations on the "upwind" side of the road.
The case study findings can likely be generalized to many other locations, and they have important implications for epidemiological and other studies. The reduced-form model is intended for exposure assessment, risk assessment, epidemiological, geographical information systems, and other applications.
PMCID: PMC2914002  PMID: 20579353
25.  Spatial Analysis of Urban Form and Pedestrian Exposure to Traffic Noise 
In the Macao Peninsula, the high population density (49,763 inhabitants/km2) and the lack of control over the number of vehicles (460 vehicles/km) have led to an increase in urban pollution. To provide useful information to local government and urban planners, this paper investigates the spatial distribution of traffic noise in the Macao Peninsula. The interactions among urban form, traffic flow and traffic noise are addressed. Considering the spatial nature of urban geometry and traffic, a high-resolution GIS-based traffic noise model system is applied. Results indicate that the Macao Peninsula has fallen into a situation of serious traffic noise pollution. About 60% of traffic noise levels along the major pedestrian sidewalks in the evening peak hour exceed the National Standard of 70 dB(A) in China. In particular, about 21% of traffic noise levels along the pedestrian sidewalks are above the National Standard by 5 dB(A). Noticeably, the high pedestrian exposure to traffic noise in the historical urban area reduces the comfort of tourists walking in the historic centre and is ruining the reputation of the area as a World Cultural Heritage site.
PMCID: PMC3138008  PMID: 21776213
urban form; traffic volume; traffic noise; GIS

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