Figure 1. Direct and underlying factors affecting pedestrian deaths and injuries in Iran.

An exploration of participant statements indicated that drivers can directly cause traffic collisions through various factors, including traffic law violations, visual distractions, and lack of knowledge or experience. Previous studies support these findings, showing that violations of traffic laws [13], visual distractions [14], and conversations with front-seat passengers significantly impaired driver performance [15]. Furthermore, research confirmed that younger and less experienced drivers were at higher risk of collisions, with increasing driving experience, the level of risk decreased [16]. Thus, the development and implementation of targeted laws, policies, and countermeasures are strongly recommended [15].

Pedestrian negligence, vulnerability, and lack of knowledge are other direct factors that endanger pedestrian safety. While pedestrian negligence occurs universally, damages and payments are addressed differently. England’s traffic law, for instance, imposes shared responsibility on both pedestrians and drivers regardless of fault [17]. Regarding the vulnerability of pedestrians, Holm and Jaani reported that children, as pedestrians, were one of the most vulnerable groups of road users, particularly children walking alone [18]. Sex and age significantly influence risk patterns: aerial camera studies revealed that male pedestrians commit more violations than females, with younger pedestrians demonstrating riskier behaviors such as shorter waiting times and reduced environmental awareness while crossings [19]. These patterns correlated with injury rates, as female pedestrians experienced fewer collisions [20]. Besides, elderly pedestrians, though typically more cautious, face elevated risks due to inadequate nighttime lighting in smaller urban areas—a danger compounded by dark clothing and visual impairments [21].

Among other direct factors responsible for pedestrian collisions, road, and street conditions emerged as critical direct factors in pedestrian collisions, with participants highlighting inadequate maintenance and substandard construction. Some previous studies confirmed these findings [22-24]. Similarly, a positive correlation was found between pedestrian collisions and the safety of road infrastructure. Besides, the length of state roads, unclassified streets, parking areas, and the number of bus stops had a positive relationship with pedestrian collisions [25]. In Iran, a qualitative study identified insufficient pedestrian safety infrastructure as a key concern [26]. Further investigations revealed that three variables had a remarkable effect on zebra crossing usage and reduced collisions: guardrail installation, the number of road lanes, and the width of the zebra crossing [27]. Highlighting the pedestrian crossing positively influenced driver’s behavior in reducing the speed [28]. Collectively, these findings underscored the vital role of road design, including street layouts, parking zones, sidewalk width, installation of roadside signs, and bus stop placement in pedestrian safety. Civil engineers must prioritize these infrastructure elements to mitigate collision risks [25].

The vehicle itself was also identified as a direct factor affecting pedestrian collisions. Participant statements highlighted two key concerns: non-standard vehicles and outdated manufacturing practices that fail to keep pace with global technological advancements These findings aligned with existing research demonstrating how vehicle technology could significantly reduce pedestrian collision risks [29, 30]. Yue Abdel-Aty’s study reported that modern vehicle technology is particularly effective in situations where pedestrian crossing intentions are ambiguous. In this scenario, the vehicle’s warning system changed the braking process from the “dreaded slow hard-reaction braking” to “comfortable soft fast-reaction braking” [29]. Modeling data further revealed that increasing the speed of reduction systems and lowering vehicle weight could significantly improve the performance of speed reduction systems during pedestrian collisions. The average maximum speed reduction capability has shown notable progression, increasing from 7.48 m/s in 2018 to 9.36 m/s in 2021 [31], suggesting continuous improvements in speed reduction system efficacy in recent years.

Environmental conditions emerged as the final category of direct factors influencing pedestrian-vehicle collisions, as evidenced by participant statements. Several studies confirmed the effect of day and night hours and weather conditions on pedestrian collisions [32-34]. Similarly, Alogaili and Mannering specifically identified notable variations in the severity of pedestrian injuries between daytime and nighttime incidents, with nighttime collisions resulting in more severe injuries [33]. Besides, bad weather conditions, such as rain, fog, snow, and wind, compromise the driver’s visibility and elevate collision risks [35]. A Scottish study examining injury severity determinants at both physically controlled and human-controlled intersections further confirmed that weather, road, location, vehicle, driver behavior, and time characteristics collectively affected the severity of injury [34]. Nevertheless, various findings suggested that good weather conditions might increase the likelihood of pedestrian collisions [36], highlighting the complex relationship between environmental factors and pedestrian safety.

2- Underlying Factors: Analysis of participant statements revealed four subcategories of governance factors, social determinants, cultural conditions, and economic status.

The absence of governance factors manifests through two subcategories: non-compliance with traffic regulations and poor management and planning. In several studies, the speed limit law had a significant impact on pedestrian safety [37-39]. The research performed by Mukherjee and Mitra further confirmed the importance of legal measures in speed management in urban areas of India [23]. The results of the present study also suggested how infrastructure design, including the construction of urban streets, parking allocation, the width of sidewalks, and the placement of signage and bus stations fundamentally influenced pedestrian safety. These findings underscored the necessity for transportation authorities to prioritize pedestrian-oriented infrastructure planning to effectively reduce collision risks [25].

Social determinants emerged as significant underlying factors, comprising two subcategories socioeconomic conditions (working and living circumstances) and social indifference. This collective indifference toward pedestrian safety concerns indirectly contributes to increased collision risks. A study reported that family and social determinants such as the size of the household, immigration, and the parent’s physical disability were associated with an increased risk of pedestrian injury [40]. Complementary studies revealed that pedestrian safety concerns extend beyond physical infrastructure. Participants emphasized crucial social dimensions, particularly the need for driver respect toward pedestrians and comprehensive safer environment design, alongside economic challenges such as insufficient traffic signage and lighting. These findings highlighted the multifaceted nature of pedestrian safety, where social attitudes and infrastructure jointly influence outcomes.

Educated pedestrians demonstrated the capacity to both identify safety hazards and propose practical solutions [41]. However, improving road safety requires broader societal transformation. A crucial step involves shifting public attitudes toward traffic violations - community members should actively report witnessed infractions to authorities. Strategic partnerships with sponsors could help cultivate this collective responsibility.

The economic dimension remains equally critical, as illustrated by the dilemma of motorcyclists who recognize the need for helmets but lack purchasing power. This paradox highlights how safety awareness alone proves insufficient without addressing underlying economic constraints. Effective collision reduction strategies must therefore incorporate: (1) targeted social support for low-income populations and (2) enhanced employment opportunities to improve economic conditions. Only through this dual approach, combining safety education with economic empowerment, can sustainable improvements in pedestrian safety be achieved.

Cultural factors, with two subcategories of citizenship culture and traffic culture, indirectly contribute to pedestrian collisions by shaping both driver and pedestrian behaviors. In an exploratory study on the influence of beliefs on the behavior of passers-by, it was found that pedestrians who attribute events to divine control, luck, and fate, demonstrated riskier attitudes and behaviors when crossing the streets [42]. These findings underscored the necessity of recognizing cultural variations across nations and developing targeted interventions to address these deep-rooted beliefs.

Several studies indicated that education could be effective in pedestrian safety [43-45]. In a study on the effect of education on elderly pedestrians, a miniature simulation device, used for education, improved street-crossing decisions and behaviors [43]. However, the evidence remains contradictory. While pedestrian collision reduction strategies ranged from vehicle speed control to pedestrian behavior modification, active speed measures had the greatest benefit, whereas pedestrian education programs had the least effect [46].

Economic instability emerged as the final underlying factor, identified by participants as significantly impacting both household and societal levels while contributing to traffic collisions. In research performed by Roll and McNeil, higher traffic-related injuries were observed in pedestrians with below-average incomes, particularly affecting African Americans, local Natives, and other minority communities [47]. Several studies indicated that the death risk due to road collisions in low-income countries was higher than that of high-income ones, underscoring their need for greater safety resources and attention [48-50]. These findings emphasized the necessity of prioritizing pedestrian safety improvements, especially in school areas where many minority groups and the poor live [51].

Declaration

Ethical approval and consent to participate: This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Tehran University of Medical Sciences (code: IR.TUMS.SPH.REC.1402.098). Written informed consent was obtained from all participants prior to their involvement in the study.

Consent for publication: Hereby the authors declared that informed consent was obtained from all participants, and the participants were aware of the study’s purpose, potential risks, and benefits.

Conflict of Interest: The authors declared no competing interests, financial or otherwise, relevant to the content of this article.

Funding: No financial or non-financial support was received that could be disclosed as influencing the outcomes or interpretation of this research.

Authors’ Contribution: All authors contributed to the conception and writing the main manuscript. EH analyzed the data, AA and JH prepared tables. All authors reviewed the manuscript.

Availability of Data and Materials: All data generated or analyzed during this study are included in this article.

Acknowledgment: The authors would like to offer their special thanks to Ms. Fatemeh Javadi, PhD candidate in Translation Studies at Allameh Tabataba’i University, Iran, for assistance in translating the manuscript into English.