Tetali, S (2017) Distance, transport mode, and road safety on school journeys in urban India. PhD thesis, London School of Hygiene & Tropical Medicine. DOI: https://doi.org/10.17037/PUBS.03449897 Downloaded from: http://researchonline.lshtm.ac.uk/3449897/ DOI: 10.17037/PUBS.03449897 Usage Guidelines Please refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna- tively contact [email protected]. Available under license: http://creativecommons.org/licenses/by-nc-nd/2.5/ Distance, transport mode, and road safety on school journeys in urban India SHAILAJA TETALI Thesis submitted in accordance with the requirements for the degree of Doctor of Philosophy University of London April 2016 Department of Population Health Faculty of Epidemiology and Population Health LONDON SCHOOL OF HYGIENE & TROPICAL MEDICINE Funded by Wellcome Trust Capacity Strengthening Strategic Award to the Public Health Foundation of India and a consortium of UK universities DECLARATION BY CANDIDATE I have written the entire thesis presented below. The manuscripts written for journal publications involved co-authors. The work in Chapter 4 and 5 was published in joint names in 2015 (Tetali S, Edwards P, Murthy G, Roberts I. Development and validation of a self-administered questionnaire to estimate the distance and mode of children’s travel to school in urban India. BMC Medical Research Methodology, October 2015, 15:92.) The work in Chapter 7 was published in joint names in 2015 (Tetali S, Edwards P, Murthy G, Roberts I. Road traffic injuries to children during the school commute in Hyderabad, India: cross-sectional survey. Inj Prev. 2015 Dec 23. pii: injuryprev-2015-041854. doi: 10.1136/injuryprev-2015-041854) The work in Chapter 6 was published in joint names in 2016 (Tetali S, Edwards P, Murthy G, Roberts I. How do children travel to school in urban India? A cross-sectional study of 5,842 children in Hyderabad. BMC Public Health, October 2016, 16:1099) For all three manuscripts, I collected, analysed and interpreted the data, and drafted and revised the manuscript. Phil Edwards guided the conception and design of the study, interpreted the data and made substantial contribution to drafting and revising the manuscript. Ian Roberts and GVS Murthy revised the manuscripts critically for important intellectual content. I have read and understood the School’s definition of plagiarism and cheating given in the Research Degrees Handbook. I have acknowledged all results and quotations from the published or unpublished work of other people. I declare that no copy editing and, or, proof reading services were availed by me in the preparation of this thesis. I have exercised reasonable care to ensure that the work is original and does not to the best of my knowledge break any UK law or infringe any third party’s copyright or other intellectual property right. Signed: Date: April 12, 2016 Full name: Shailaja Tetali ABSTRACT Background- A third of a billion children travel to school every day in India, yet little is known about this journey. Increasing motorisation in India is likely to have implications for road safety of children. This thesis develops methods to measure distance to school, transport modes, and risk of road traffic injury, on journeys to school in Hyderabad. Methods- Following a systematic review, a self-completion questionnaire was developed to estimate the distance and modes of travel to school in India. Its validity and reliability was assessed using the kappa statistic. A cross-sectional survey using a two-stage stratified cluster sampling design was conducted in government funded, government aided, and private schools in Hyderabad. The relationship between modes of travel and distance to school was analysed using logistic regression, adjusting for confounders. The prevalence of road traffic injury in the previous 12 months during school journeys was estimated, and the impacts of alternative transport scenarios on road injury was modelled. Results- The questionnaire provided reliable information on the usual mode of travel to school, and road injury. Distance to school measured by asking for the nearest landmark to a child’s home was found to be a valid measure of distance compared to a method based on in-depth interviews with children. Forty five schools including 5,842 children aged 11-14 years participated in the survey, with a response rate of 99%. Most children in Hyderabad walked or cycled to school. Others travelled by motorised 2-wheelers, auto-rickshaw, school bus, public transport bus, and car. Greater distance to school was strongly associated with the use of motorised transport. A sixth of all children reported a road injury during school journeys, which was strongly associated with travel mode and distance to school. The overall risk of road injury was 25/100,000 child km per year. Relative to school bus occupants, bicyclists, pedestrians and motorcycle passengers were more likely to be injured, for the same distance travelled. The model showed that road injuries can be prevented under transportation scenarios that restrict distance and motorised vehicles near schools. Conclusions- The questionnaire reliably measured mode of travel to school and estimated distances to school in Hyderabad. Most children walked or cycled to school and if these levels are to be maintained, there is an urgent need to ensure that walking and cycling may be done safely. ACKNOWLEDGEMENTS This thesis is dedicated to my dear husband, Venkatesh, my tireless motivator and strongest pillar of support. I am ever so grateful to my main supervisor, Dr. Phil Edwards, for his encouragement; crystal clear direction; and his special ability to impart critical thinking. I thank my India co- supervisor Prof. GVS Murthy, for his constructive feedback and support throughout the PhD, and for his comments on the final draft. I thank my UK co-supervisor Prof. Ian Roberts for his able guidance, and advice on the papers. I express my deep gratitude to my parents and my in-laws for their unconditional support, and my sister and brother, Pallavi and Phani, for their persistent encouragement. My special thanks to JK for being the eternal sounding board and to Bindu for the innumerable and enriching discussions on work and life. I thank Suresh, Junko, Thiago, and Amul, for the many exciting discussions and debates we had during my stay in London. I thank Hira for creating the database, and Kavi Bhalla and Krishnan Srinivasan for taking the time to discuss various ‘transportation scenarios’. Finally, I owe my deepest thanks to my daughters Mandira and Mandaakini, for constantly inspiring me with their perseverance and calm determination during their own studies, all through my PhD. Contents 1 INTRODUCTION ............................................................................................................... 12 1.1 Why is children’s travel to school important?........................................................................ 12 1.2 What are the public health impacts of the travel to school? ................................................. 15 1.2.1 Road traffic injury ................................................................................................................... 20 1.2.2 Physical activity ...................................................................................................................... 23 1.2.3 Air pollution ............................................................................................................................ 24 1.2.4 Noise ....................................................................................................................................... 25 1.3 Study setting ........................................................................................................................... 25 1.3.1 The city of Hyderabad ............................................................................................................ 26 1.3.2 Transportation in Hyderabad ................................................................................................. 28 1.4 School systems: India and Hyderabad .................................................................................... 43 1.5 PhD aims ................................................................................................................................. 46 1.6 Organisation of thesis ............................................................................................................. 46 1.7 Summary ................................................................................................................................. 48 2 HOW DOES DISTANCE TO SCHOOL INFLUENCE MODE OF TRAVEL? .............................. 50 2.1 Why it is important to do this review ..................................................................................... 50 2.2 Objectives of the review ......................................................................................................... 51 2.3 Methods ................................................................................................................................. 51 2.3.1 Eligibility criteria ..................................................................................................................... 51 2.3.2 Search methods for identification of studies ......................................................................... 52 2.3.3 Selection of studies ...............................................................................................................