Determinants of Elderly Pedestrian Trac Behavior in Iran: The Role of Socio Economic and Cognition Status

Background: Elderly pedestrians are among the most vulnerable groups in terms of trac-related injuries. This study aimed to investigate trac behavior and its determinants among elderly pedestrians in Iran. Methods: This cross-sectional study examined the trac behavior of 600 elderly pedestrians in Zanjan, northwestern Iran. Pedestrian trac behavior was evaluated in ve domains (trac violations, trac distraction, adherence to trac rules, aggressive behaviors, and positive behaviors) using the Pedestrian Behavior Questionnaire (PBQ). Participants’ socioeconomic status (SES) was assessed by an SES questionnaire, and cognitive function was assessed by the Abbreviated Mental Test score (AMTS). The participants were selected using the multistage random sampling method. Results: 50% of elders were man. 488 (81.3%) of them had 60-74 and 112 (18.7%) were 75 years old and above. More than 90% of elderly pedestrians showed unsafe trac behavior. This included trac violations and failure to adhere to trac rules. Almost half the elders were aggressive and distracted when walking and crossing the street. Higher SES was associated with both higher cognitive status and safer trac behavior. Higher SES, healthy cognitive function, male sex, walking more than 1 hour a day, higher levels of education, and being married were among the determinants of safe trac behavior. Conclusion: The majority of the elders showed unsafe trac behavior Elderly pedestrians with high SES and healthy cognitive function were more likely to exhibit safe behavior than those with low SES and cognitive dysfunction. . Interventions are needed to improve the trac behavior of elderly pedestrians special with low SES. its determinants among elderly pedestrians in Iran.


Data analysis
Data were analyzed using Stata/MP16 software. Mean and standard deviation were used to describe quantitative data, and frequency and percentage were used to describe qualitative data. Before the analyses, the normality of the data was con rmed by the Kolmogorov-Smirnov test. A P-value of 0.05 was considered statistically signi cant in all the tests. A chi-square test was used to evaluate the correlation between SES, cognitive status, and demographic characteristics. An analysis of variance was employed to assess the association of various tra c behaviors with SES and cognitive status. In cases of a signi cant difference, the groups were compared in pairs using the Sidak test. Finally, multivariate regression was used to investigate the combined effect of the dependent variables. .

Results
The majority of participants were married (77.5%), illiterate (36.2%) and primary education (36.5%). Most of the participants walked less than half an hour a day (32.3%), and most (33%) were current drivers. More than half the elders in the study population had low SES. The majority of the participants (63%) had good cognitive status. Those with higher SES obtained signi cantly higher scores in all the domains of the PBQ than those with lower SES (Table 1). Lower SES scores were associated with unsafe tra c behavior, with the lower the score the more unsafe the behavior. Higher SES was associated with improved pedestrian tra c behavior, except in the distraction domain. Married elderly males, with a university education and without cognitive impairment, exhibited the safest tra c behavior. The distance walked daily played a role in pedestrian tra c behavior, with longer daily walking distances associated with safer tra c behavior. Elders who no longer drove but walked instead behaved more safely than those who used cars or other means of transportation (Table 2). The results showed that pedestrian tra c behavior of approximately 7% of the elders was safe. More than 90% of the elders engaged in tra c violations and failed to adhere to tra c rules. In the study, 33.5% exhibited aggressive behavior and were easily distracted. Among the tra c behavior domains, the highest and lowest scores were obtained in the "no aggressive behavior" and "adherence to tra c rules" domains, respectively (Table 3). a Items are reverse scored, so that the total score could be calculated. Higher scores indicate more safe pedestrian behaviors.
The results of the multivariate regression analysis predicted the pedestrian tra c behavior of elders in three SES groups. In the moderate to high SES group, elders who walked for more hours per day exhibited safer behavior than those who walked fewer hours per day. For example, in the high SES group, elders who walked more than 2 hours a day behaved 13.59 times more safely than those who walked less than half an hour a day. In the low SES group, the safety behavior score of elders who generally used bicycles or motorcycles for transportation was 4.47 points lower than the safety behavior score of those who usually used their own car for transportation, controlling for the effect of other variables (P = 0.044, β = -4.47). In other words, cyclists and motorcyclists behaved more dangerously than those who used cars, walked or other means of transportation. Elders Who had better cognitive function and high SES behaved more safely than those who had cognitive impairment and with low SES (Table 4).

Discussion
This study investigated the potential roles of SES and cognitive status in the tra c behavior of elderly pedestrians. A review study showed that elderly pedestrians accounted for 48.1% of RTIs involving elders (23). Studies conducted in Iran (24,25) and worldwide demonstrated that the highest rate of RTIs in the elderly population involved elderly pedestrians (26). Several factors, including physiological changes, reduced physical abilities and reaction times, and decreased vision, account for the increased risk of pedestrian collisions with vehicles among the elderly population. These factors increase the risk of RTIs in the elderly population 2.5 times as compared to that in other age groups (3). When other factors associated with aging are considered, the risk may be even higher. Due to age-related changes affecting mobility, many elders β β β may avoid busy tra c junctions and environments. Thus, rather than cross at a place that they perceive to be dangerous, they may lengthen their route to cross at a place they perceive to be less dangerous (3). Elders may also go out less often than younger individuals do due to a fear. Thus, the risk of vehicle collisions involving elderly pedestrians may be higher than that reported.
The results of the present study showed that more than 90% of the elders behaved in an unsafe manner. Unsafe behaviors included engaging in tra c violations and not adhering to tra c rules. The highest scores were obtained for the "no aggressive behavior" domain, and the lowest scores were obtained for the "adherence to tra c rules" domain compared to those obtained for the other domains. 33.5% and 43% of the elders exhibited aggressive and distracted behaviors, respectively. Other studies showed that pedestrians exhibited lower aggressive behavior and higher positive behavior than other domains of PBQ(28-30).
A study conducted in six high-, middle-, and low-income countries indicated that the lowest and highest violation scores were observed in China and Bangladesh, respectively (31). The lowest and highest aggressive behavior scores were reported in Vietnam and Kenya, respectively. In the same study, the lowest and highest lapse scores were found in Thailand and Bangladesh, respectively. As can be seen, behavior domains vary in different countries. This can be attributed to the culture and infrastructure of different societies. The same study found that people were more likely to show safe tra c behavior in countries, such as the U.K., that offer pedestrian safety training courses and have particular agencies in charge of roads, sidewalks, and pedestrian crossings (31). Therefore, as suggested previously (27), pedestrian safety training courses targeting the elderly could be offered in Iran.
In the present study, as shown by the ndings on tra c behavior, the tra c behavior of the majority of elders was unsafe. Therefore, arranging tra c knowledge development programs and safe behavior training seems to be required to develop safe passages for pedestrians. In respect of the above, the quality of sidewalks for pedestrians, especially elderly pedestrians, should be improved to enable pedestrians to utilize these sidewalks rather than having to walk on the street. Given that the physical environment plays an important role in pedestrian tra c behavior, places designated for pedestrians to cross, especially those with special needs, such as the elderly, should be designed to enable them to cross the road safely (31). However, it is important to note that training and behavioral change may be di cult in old age. Therefore, training programs of safe tra c behavior should start in childhood and continue to stabilize the desired behavior in old age and reduce the risk of RTIs in the elderly.
In the present study, the cognitive function analysis showed that 37% of the elderly had mild to major cognitive impairment. The prevalence of cognitive impairment among the elderly population was reported to vary from 5-36% in different countries (15,33,34). The difference may be explained by the use of different measurement tools. In the present study, healthy elders without cognitive impairment had high scores in all the domains of the PBQ. Several previous studies demonstrated that elders without cognitive impairment performed better on the PBQ than elders with cognitive impairment (35,36). Based on the literature and results of the present study, it can be concluded that impaired cognitive function adversely affects tra c behavior by making it di cult for elders to estimate distance and crossing times. Therefore, measures should be taken before old age to maintain and improve cognitive function in older adults and improve their quality of life, various measures, such as group reminiscence (37) and memory rehabilitation (38) should be implemented.
Previous studies found a correlation between cognitive function and SES (15,39,40), similar to that identi ed in the present study. Thus, high SES seems to be associated with improved cognitive status, which, in turn, enhances tra c behavior in the elderly. The results of the present study showed that elders with higher SES had safer tra c behavior than those who had low and middle SES.
According to previous studies, higher levels of education and income were among the factors that were effective in reducing RTIs (17,41,42). It can be said that these factors such as higher levels of education and income may be involved in improving tra c behavior and reducing the risk of injuries.
SES may play both direct and indirect roles in tra c behavior. In terms of indirect effects, someone with high SES usually has a high level of education, and higher education can indirectly affect people's knowledge and behavior. In terms of the direct effects, individuals with higher income levels tend to reside in better quality and safer environments that individuals with lower incomes. Therefore, improving SES can help to improve tra c behavior.
In the present study, the longer the walk, the safer the tra c behavior and its domains. In addition, the more the experience of being in a tra c environment, the safer the person's tra c behavior. As mentioned above, it may be a good idea to rst provide a suitable and safe physical environment for pedestrians and then encourage the elderly to be more in the environment. This may also be useful in preventing other agingrelated problems such as social isolation and depression (12,43). Various studies using an ecological approach have indicated that a suitable physical environment and observing others when doing the right behavior will encourage the person to do the same behavior (44,45). As RTIs are the second leading cause of death in Iran, tra c behavior and its determinants need to be examined in all target groups, especially vulnerable groups such as the elderly and to implement intervention programs aimed at improving the tra c behavior of elderly pedestrians and reducing RTIs.
Our study has a number of strengths and weaknesses. One of its strengths was the use of Iranian PBQ to examine the tra c behavior of elderly pedestrians and its determinants. Another strength was its focus on the effect of reduced cognitive function, one of the most common agingrelated problems, on tra c behavior. In addition, we examined the effects of SES, which may play an important role in tra c behavior, simultaneously with those of cognitive function. In terms of the weaknesses of the study, we did not determine whether the behaviors reported by the elderly pedestrians occurred inside or outside of the city. Future studies aimed at shedding light on the factors underpinning the tra c behavior of elderly pedestrians should take account of the locations of tra c behavior and tra c behavior violations. We also suggest that safe tra c behavior training intervention programs should be designed and implemented for pedestrians.

Conclusion
The pedestrian tra c behavior of the majority of Iranian elders in the present study was unsafe. Unsafe tra c behavior was associated with cognitive impairment, single status, lower SES, and shorter daily walk times. Effective interventions should be implemented to maintain and improve elderly pedestrians' cognitive function, SES, and tra c behavior. Decision makers must design and implement speci c programs to strengthen the cognitive of the elderly. To improve the socio-economic situation, policymakers at higher levels need to take activities. Availability of data and materials The data collection tools and datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

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

Funding
Tabriz University of Medical Sciences provided funding sources for this study. Employees of the funder (FBA, MG, HSB, SP, ZR) participated as scienti c collaborators in the study. The ndings and conclusions in this paper are those of the authors and do not represent the views of the Tabriz University of Medical Sciences. The funding body had no role in the design of the study and collection, analysis, interpretation of the data, in writing the manuscript and publication as well.
Author contributions statement: FBA and HSB wrote the rst draft. MG, SP and ZR were involved in the data analyses. KP restructured and rewrote the rst draft. All authors reviewed the nal version of the manuscript.