Authors #
Scientia Professor Rebecca Ivers AM, University of New South Wales
Reviewers #
Dr Muhammad Navid Tahir, University of the Punjab
Johann Tay, Traffic Vehicles & Logistics Pty Ltd.
Introduction #
Prevention is critical to our efforts to minimise the burden of road crashes on individuals and the community. If we can stop road crashes from occurring in the first place, and mitigate their severity, we can reduce the burden of deaths and serious injuries in the community. Prevention of road crashes is complex however, and requires multi-sectoral public health systems-level approaches.
It is worth starting from scratch and considering the definition of prevention. The World Health Organization (WHO) defines the meaning of prevention as: “approaches and activities aimed at reducing the likelihood that a disease or disorder will affect an individual, interrupting or slowing the progress of the disorder or reducing disability” (WHO, 2004).
Preventative measures can be applied in many ways – and can be categorised as primary, secondary or tertiary. Primary prevention includes strategies aimed at stopping injury events from taking place at all. Examples might include better public transport to reduce use of private motorised vehicles, road separation to prevent a head on crash, autonomous emergency braking installed in vehicles, or random breath testing to reduce alcohol related crashes. Secondary prevention aims to minimize harm that occurs in the event of a crash – so interventions might focus on seatbelt use or helmets. Tertiary prevention is focused on the post injury phase and includes efforts to treat and rehabilitate involved individuals.
Prevention of road crashes is, in fact, one of the great public health successes globally and in Australia. As motorised vehicles increased in volume across the 19th and 20th centuries, new rules and regulations were gradually introduced to maintain safety. However, it was not until the 1970s when road deaths reached enormous numbers that legislative preventative measures were applied. To take an example from Australia, in May 1959 a Senate Select Committee in the Commonwealth Government of Australia was established to investigate road safety and recommended the use of seatbelts in cars. However significant change did not occur until 1970 when the Government of Victoria was the first globally to introduce legislation to mandate seatbelt use, a move followed shortly afterwards by many other states and territories in Australia and globally (McDermott & Hough, 1979; Milne, 1985).
Following the introduction of seatbelts, there were a raft of interventions introduced both in Australia and globally, aimed at reducing the burden of road crashes. The impact of preventative measures on road deaths in Australia has been well documented, and the reduction of deaths despite increasing motorisation is seen globally as a great success, despite the 1.2 million people who still lose their lives each year globally on the roads.
But to understand current approaches to prevention it is worth understanding their genesis. Although there were earlier efforts to understand causation and prevent injury from occurring, it was not until the 1950s that a public health approach to prevention was applied to injury. In 1949, Gordon (1949) described an epidemiological approach to identify patterns and risk factors in injury occurrence, proposing that “accidents” resulted from the interaction of three factors: the host (person), agent (source of the injury) and environment (surrounding conditions). Others further developed these ideas with Haddon (1963) recognising energy as the agent of injury and Waller (1985) further defining principles of injury control.
These epidemiological frameworks were important as they articulated the deterministic chain of factors leading to an injury event, and as such, demonstrated that by removing factors that contribute to the outcome, the injury may be prevented. In the 1960s Haddon (1968), in a seminal paper, further developed this framework, also adding in a temporal component, producing a tool that could be used to describe the intersecting factors across time that lead to an injury event. He later added to this with a description of ten Countermeasure strategies that further elaborated on the importance of understanding the injury context and agent (Haddon, 1973). The Haddon Matrix was also updated in 1998 by Runyan, who added a third dimension, to incorporate the use of value criteria to aid in the decision-making process. These include considerations of cost, effectiveness and feasibility but also importantly considerations about equity, preferences and stigmatisation when making decisions about the application of road safety interventions (Runyan, 1998).
Runyan’s concept highlights the growing recognition of the need ensure that the needs of different population groups are both understood and addressed in order to prevent road crash. There are some obvious gaps remaining. Car testing has been traditionally conducted with crash test dummies modelled on the 50th percentile male (Linder & Svensson, 2019), meaning that the female body was ignored for many decades in the design and safety of vehicles, born out in research showing higher rates of injury in women for the same type of crash (Bose et al., 2011). While there are shifts in characteristics and diversity of dummies there remains a need to ensure that crash testing and design better takes into account women, as well as pregnant, older and overweight people to ensure optimum safety for all.
Similarly, Runyan’s modification of the Haddon Matrix also reflects the need for prevention efforts to address the inequitable burden of road injury, which impacts people in rural and remote areas, and from low socio-economic status backgrounds (Australian Institute of Health and Welfare [AIHW], 2023), and from low- and middle-income settings (WHO, 2023) more than others. In Australia, First Nations people are also disproportionately impacted (AIHW, 2023, Möller et al., 2025).
It is therefore critical that prevention programs address those at greatest risk, and are designed and delivered with end-users such that they address both community priorities but are also tailored in such a way they are acceptable and effective. For First Nations peoples globally, this means investing in both First Nations policy and community leadership, and a deliberative approach to partnership and co-design of road safety programs. While there are examples globally of tailored Indigenous road safety programs, including from the US (Letourneau & Crump, 2016), there remain significant gaps and a need for much greater investment, both in Australia and globally.
Other frameworks have also been applied to the science of injury prevention and control. The three “E” of injury prevention, while now considered outdated and largely discredited, was long regarded as an effective trifecta in the prevention of road injury. This approach consists of the application of education, engineering and enforcement. Education is key to implementation of effective countermeasures, including public awareness and media campaigns, advocacy and personal education, although it is generally not believed to be effective when delivered in isolation. Engineering approaches for road injury prevention include safe road design, airbags or restraint systems in cars. Given that so many preventative interventions in road injury prevention are legislative – enforcement is also key. An excellent example of this is motorcycle helmet legislation in Vietnam, which was introduced in 2001. However, there was no change in helmet wearing rates until 2007, when revised legislation in combination with police enforcement and education was introduced (Pervin et al., 2009; Passmore et al., 2010).
Trinca et al. (1988) also outline five injury reduction strategies for road injury. These include exposure control policies to reduce unsafe road use or substitution for safer forms of transport; crash prevention strategies for safer roads and vehicles; behaviour modification for road users; injury prevention including separation of traffic and occupant protection, and finally post injury management (Trinca et al., 1988). These strategies provide a useful framework for conceptualising road safety initiatives and directly informed the structure of the following Prevention and Intervention section of the Road Safety Body of Knowledge. While there have been multiple theoretical and practical applications of these approaches to prevention of road crashes, the need for more holistic, systems-level approaches to road safety has been recognised, incorporating knowledge and input from multiple disciplines and sectors.
As such, many of the world’s jurisdictions now apply various modifications of what is called the Safe System Approach, which is described later in this chapter. The Safe System Approach is fundamentally all about understanding vulnerability of the human body and designing the transportation system such that if a mistake is made, the energy transfer does not exceed the capacity of the human body. The Safe System Approach has been adopted in many countries and jurisdictions, and is central to the global plan for the Decade of Action for Road Safety 2021-2030, which provides a global vision for road safety (WHO, 2021).
However, the application of the Safe System Approach can be challenging, and the application in many jurisdictions takes a very reductionist approach to prevention, failing to consider upstream factors that also contribute to road injury prevention – often focusing only on roads, vehicles and road use. While seeking to reduce death and serious injury, it can also be seen to promote an overall tolerance for crash and injury.
A true Safe System Approach also should consider and include action on the bigger, systems-level measures that also reduce road crashes. For example, the role of urban design – ensuring our cities are designed in such a way that people live close to where they work, transport policy aimed at minimising use of personal cars, maximising safer forms of transport like public transport, and providing safe infrastructure for safe walking and cycling. Prevention strategies might also tackle the commercial determinants of road safety and include better management of vehicle advertising (for example, limiting those that focus on speed) or alcohol advertising at sporting events, and online.
Whilst many of these approaches arguably could be implemented under a Safe System Approach, the reality is that policy change is highly politicised in road safety, making it tricker to tackle system level changes that are expensive or that require culture change. Implementation generally sits with national, sub-national or regional government departments, and siloed government activity can make cross-sectoral activity challenging. Perhaps having intergovernmental task forces with responsibility for outcomes, and changing the name from ‘road safety’ to ‘safe mobility’ might help break down the silos.
Data systems are also key to prevention – without high quality, temporal data that can be used to monitor burden and evaluate program delivery, it is difficult to monitor progress. There has been substantial progress on development of large linked data sets linking crash, injury and death data for both research and evaluation in Australia in recent years, and these will rapidly evolve and include access to more data sets with wider benefits. Having appropriate governance (including Indigenous data sovereignty frameworks built in), consistency in definitions, and accessibility will be critical.
The evolution of frameworks and approaches to better understand and prevent the burden of road injury reflects the complexity of the issue. Our thinking and theoretical frameworks, and their implementation, will no doubt continue to shift as our transport system and technology also evolve. However, given the complexity of the system in which transport is delivered, any preventative solution must be a multi-sectoral approach that thinks and acts bigger than just roads and cars, and one that does not trade off injury against mobility.
Reference List #
Australian Institute of Health and Welfare. (2025). Transport accidents. https://www.aihw.gov.au/reports/injury/transport-accidents
Bose, D., Segui-Gomez M., Fau- Crandall, J. R., & Crandall, J. R. (2011). Vulnerability of female drivers involved in motor vehicle crashes: An analysis of US population at risk. American Journal of Public Health, 101(12), 2368-2373. https://doi.org/https://doi.org/10.2105/AJPH.2011.300275
Gordon, J. E. (1949). The epidemiology of accidents. American Journal of Public Health and the Nation’s Health, 39(4), 504-515. https://doi.org/https://doi.org/10.2105/ajph.39.4.504
Haddon, W. (1968). The changing approach to the epidemiology, prevention, and amelioration of trauma: the transition to approaches etiologically rather than descriptively based. American Journal of Public Health and the Nation’s Health, 58(8), 1431-1438. https://doi.org/https://doi.org/10.2105/ajph.58.8.1431
Haddon, W. (1973). Energy damage and the ten Countermeasure strategies. Human Factors, 15(4), 355-366. https://doi.org/10.1177/001872087301500407
Haddon, W. F. (1963). A note concerning accident theory and research with special reference to motor vehicle accidents. Annals of the New York Academy of Sciences, 107(2). https://nyaspubs.onlinelibrary.wiley.com/doi/abs/10.1111/j.1749-6632.1963.tb13307.x?sid=nlm%3Apubmed
Letourneau, R. J., & Crump, C. E. (2016). Tribal motor vehicle injury prevention (TMVIP): Best Practices Guide 2016. The University of North Carolina at Chapel Hill.
Linder, A., & Svensson, M. Y. (2019). Road safety: the average male as a norm in vehicle occupant crash safety assessment. Interdisciplinary Science Reviews, 44(2), 140-153. https://doi.org/10.1080/03080188.2019.1603870
McDermott, F. T., & Hough, D. E. (1979). Reduction in road fatalities and injuries after legislation for compulsory wearing of seat belts: experience in Victoria and the rest of Australia. The British Journal of Surgery, 66(7), 518-521.
Milne, P. W. (1985). Fitting and Wearing Seatbelts in Australia: This history of a successful Countermeasure. Australian Government Publishing Service. https://www.infrastructure.gov.au/sites/default/files/migrated/roads/safety/publications/1985/pdf/Belt_Analysis_4.pdf
Möller, H., Ivers, R. Q., Shannon, B., Gray, J., Haji Ali Afzali, H., Hossain, S., Campbell, M., Kimlin, R., Porykali, B., Sharpe, P., & Ryder, C. (2025). Road transport injury in Aboriginal and Torres Strait Islander people in New South Wales, Australia. Australian and New Zealand Journal of Public Health, 49(6), 100270. https://doi.org/https://doi.org/10.1016/j.anzjph.2025.100270
Passmore, J., Nam, N. P., Huong, N. L., & Ha, N. T. (2010). The development and implementation of mandatory motorcycle helmet legislation in Vietnam. Injury Prevention, 16, A217-A218. http://dx.doi.org/10.1136/ip.2010.029215.776
Pervin, A., Passmore, J., Sidik, M., McKinley, T., Nguyen, T. H., & Nguyen, P. N. (2009). Viet Nam’s mandatory motorcycle helmet law and its impact on children. Bulletin of the World Health Organization, 87, 369-373. https://doi.org/10.2471/blt.08.057109
Runyan, C. W. (1998). Using the Haddon matrix: introducing the third dimension. Injury Prevention, 4(4), 302. https://doi.org/10.1136/ip.4.4.302
Trinca, G. W., Johnston, I. R., Campbell, B. J., Haight, F. A., Knight, P. R., Mackay, M., McLean, A. J., & Petrucelli, E. (1998). Reducing traffic injury – A global challenge. Royal Australasian College of Surgeons.
Waller, J. A. (1985). Injury control: A guide to the causes and prevention of trauma. Lexington Books.
World Health Organization. (2004). WHO Global Forum IV on Chronic Disease Prevention and Control, Ottawa, Canada.
World Health Organization. (2021). Global Plan for the Decade of Action for Road Safety 2021-2030. https://www.who.int/publications/m/item/global-plan-for-the-decade-of-action-for-road-safety-2021-2030
World Health Organization. (2023). Global status report on road safety 2023. https://www.who.int/teams/social-determinants-of-health/safety-and-mobility/global-status-report-on-road-safety-2023