Racial disparities in pedestrian deaths and injuries were present in both hospitalization admission rates and outcomes. Mortality rates among Black, Hispanic, and Multiracial/Other and hospitalization admission rates among Black and Multiracial/Other race/ethnicity groups were particularly high compared to White and Asian or Pacific Islanders. The Black, Hispanic, and Multiracial/Other race/ethnic groups carry a larger burden of injury with increased hospital costs, cost per capita, severity of illness, and lengths of stay.
Results from this study align with a large body of literature related to racial disparities and health outcomes, which has consistently shown length of stay and cost disparities among Black, Hispanic, and Multiracial/Other race/ethnicities, compared to Whites [12, 13]. A study of nearly 50,000 U.S. pedestrian deaths using CDC annual mortality data (1999–2015) found significant disparities in death rates by racial/ethnic groups, with higher rates among Blacks, Latinos, and Native Americans, compared to Whites , whereas our results showed similar racial/ethnic disparities in injury severity and burden of injury among pedestrian hospitalizations with higher costs per capita, longer lengths of stay, and increased mortality among Blacks, Hispanics, and Multiracial/Others, compared to Whites. Our results also align with previous research that has established links between race and inequities in safety and accessibility of transportation, including walking,  and neighborhood social inequities, traffic volumes, road design, and road traffic injuries .
Accurate pedestrian exposure data by race/ethnicity are not available but are important for understanding the mechanisms behind these disparities. For example, differential exposure to walking (i.e., time spent walking and exposed to traffic) and risky pedestrian environments (e.g., higher traffic volumes, lack of pedestrian facilities) may contribute to these differences.
However, the specific mechanisms behind these disparities are complex, as evidenced within the existing literature. A UK-based study found higher rates of child pedestrian injuries among Blacks, regardless of area level deprivation, but found that area deprivation was an important factor among Whites and Asians with higher injury rates correlating with higher deprivation . Those results suggest neither race/ethnicity or area deprivation (e.g, built environment, socio-economic factors) alone can adequately explain race/ethnicity differences. A study of US fatality data found higher rates of pedestrian and bicyclist fatalities among neighborhoods with high proportions of Black and Hispanic residents as compared to predominant White or Asian neighborhoods . However, they also found predominant Black and Hispanic neighborhoods to be safer, overall, in terms of road traffic fatality rates compared to predominant non-Hispanic White neighborhoods . Another possible factor includes racial bias, which has been found in driver yielding behavior at crosswalks [18,19,20].
Access to transportation is a recognized social determinant of health, but disparities and inequities in transportation access and safety have largely been overlooked, despite having important ramifications related to health and well-being (access to food, jobs, etc.) . The persistence and variety of health outcomes which demonstrate racial disparity indicate that the focus of prevention would best be placed at the population-level and on systems-based factors, rather than at the individual level or on issues related to race/ethnicity directly [22, 23]. These factors include economic, built environment, and transportation policy changes and interventions. There is also evidence that focusing on the social environment and social determinants of health with a broad range of interventions, such as early childhood development programs, rental assistance programs, and de-concentration of public housing, can reduce racial disparities in health [24, 25].
Specific to reducing the burden from pedestrian injuries, interventions may include amending policies to resolve inequities in transportation access, improvements to the built environment to include pedestrian facilities (e.g., crosswalks, pedestrian signals), safety culture campaigns focused on geospatial areas at high risk, and geographic equity in road safety funding for both new projects and maintenance (e.g., repair and maintenance of roads and sidewalks).
This study is based on a nationally-weighted sample of hospital admissions, which should be strongly representative of the US population. Limitations include potential miscoding of pedestrian injuries, which can happen when the role of the injured person in the crash is not known at hospital admission, or miscoding of race and ethnicity. Lack of information about differential pedestrian exposure/activity by race/ethnicity, and particularly how built environments differ by race/ethnicity, are a limitation in making recommendations about prevention measures based on these findings.
Results from this study show that the burden of injury from pedestrian injuries is higher among non-Whites, which has important implications in development of prevention and intervention approaches as we work to combat the rising pedestrian fatality and injury toll in the United States. Detailed pedestrian exposure data are also needed to further examine possible mechanisms for these disparities.