Risk Elimination on Walks to School (REmWAlkS)

Every child has the right to an education and the best start in life. A safe and clean journey to school is the least they should expect. However, many children lose their lives or sustain long-lasting health problems as a result of unsafe and unclean journeys to school. More than 350,000 children around their world lose their lives to road traffic crashes and traffic-related air pollutants every year, with 93% of these children living in low- or middle-income countries. Children walking to school are at particular risk as they often walk along congested, unsafe roads with vehicles travelling at high speeds and emitting high levels of pollutants. School are also frequently located along busy highways. While some work is being conducted in African countries around making the journey to school safer for school children, none, to our knowledge are addressing the issue of both road safety and air pollution despite some overlapping interventions.

This study therefore aims to develop a set of interventions, through a novel participatory approach, that would reduce both the risk of injury and exposure to poor air quality for children who walk to school in Blantyre, Malawi. The current road traffic death rate in Malawi is 31 per 100,000 population - one of the highest in the world and the levels of fine particulate matter are at least twice the level recommended by WHO. Pedestrian injuries, particularly among children, have seen a dramatic increase in the last decade and account for more than half of children admitted to hospital as a result of a collision.

There are a number of interventions, following the Safe Systems Approach, that we know reduce pedestrian injuries and deaths and are promoted by WHO through their Save LIVE package of road safety interventions. Some of these interventions, most notably vehicle speed reduction and vehicle emission policies, have a dual impact on safety and air pollution.

This study will build on a NIHR-funded Children's Air Pollution Profiles in Africa study which is also being conducted in Blantyre, Malawi, and will obtain air pollution data (and GPS coordinates) from children walking to school. We will use a mixed methods approach to better understand the risks that children who walk to schools in Blantyre, Malawi, experience and how these can best be ameliorated. We will engage all children aged 12-16 years from 4 purposefully sampled schools and select 16 children to photographically document the risks they encounter on their walk to school using PhotoVoice methodology. Discussion groups will be held with children their parents and teachers to further understand their challenges and ideas about how these can be remedied. We will use a Delphi process with local and international experts to prioritize interventions which we will then take to parents/teachers to discuss acceptability.

Due to the many overlapping causal factors linking road safety and personal air pollution exposure, there are significant opportunities for complementary mitigation measures driving improvements in child health, safety and well-being. The interventions proposed through this study therefore have significant implications for other low- and middle-income countries who are encouraging non-motorized transport.

More than 350,000 children around their world lose their lives to road traffic crashes and traffic-related air pollutants every year, with 93% of these children living in low- or middle-income countries. Children walking to school are at particular risk as they often walk along congested, unsafe roads with vehicles travelling at high speeds and emitting high levels of pollutants. School are also frequently located along busy highways. While some work is being conducted in African countries around making the journey to school safer for school children, none, to our knowledge are addressing the issue of both road safety and air pollution despite many overlapping interventions.

This proposal therefore aims to develop a set of interventions that will reduce both the risk of injury and exposure to poor air quality for children aged 12-16 years who walk to school in Blantyre, Malawi. This will be achieved through the follow specific objectives:
1. To describe how children, aged 12-16 years, get to school in Blantyre, Malawi.
2. To understand the risks that children encounter, both in terms of road safety and air quality, on their journeys to school.
3. To develop, through a participatory approach with children and their caregivers as well as local/international experts, a set of interventions that will reduce exposure to both road traffic collisions and poor air quality.
4. To assess the acceptability of the proposed set of interventions among a group of stakeholders.
5. To understand the pathways to policy and practice change in Blantyre, Malawi.

A novel, participatory, mixed methods approach, guided by the 6SQuID framework and the Safe Systems Approach, will be used to understand risks & develop a set of interventions. PhotoVoice, a Delphi Technique and Focus Group Discussions will be employed to develop, prioritize and test the set of interventions in anticipation of conducting an appropriate intervention study in the next phase.