This study investigated the potential roles of SES and cognitive status in the traffic 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 may avoid busy traffic 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 traffic violations and not adhering to traffic rules. The highest scores were obtained for the “no aggressive behavior” domain, and the lowest scores were obtained for the “adherence to traffic 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 traffic 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 findings on traffic behavior, the traffic behavior of the majority of elders was unsafe. Therefore, arranging traffic 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 traffic 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 difficult in old age. Therefore, training programs of safe traffic 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 traffic behavior by making it difficult 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 identified in the present study. Thus, high SES seems to be associated with improved cognitive status, which, in turn, enhances traffic behavior in the elderly. The results of the present study showed that elders with higher SES had safer traffic 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 traffic behavior and reducing the risk of injuries.
SES may play both direct and indirect roles in traffic 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 traffic behavior.
In the present study, the longer the walk, the safer the traffic behavior and its domains. In addition, the more the experience of being in a traffic environment, the safer the person’s traffic behavior. As mentioned above, it may be a good idea to first 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 aging-related 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, traffic 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 traffic 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 traffic behavior of elderly pedestrians and its determinants. Another strength was its focus on the effect of reduced cognitive function, one of the most common aging-related problems, on traffic behavior. In addition, we examined the effects of SES, which may play an important role in traffic 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 traffic behavior of elderly pedestrians should take account of the locations of traffic behavior and traffic behavior violations. We also suggest that safe traffic behavior training intervention programs should be designed and implemented for pedestrians.