The impact of transportation infrastructure on bicycling injuries and crashes: a review of the literature

Background Bicycling has the potential to improve fitness, diminish obesity, and reduce noise, air pollution, and greenhouse gases associated with travel. However, bicyclists incur a higher risk of injuries requiring hospitalization than motor vehicle occupants. Therefore, understanding ways of making bicycling safer and increasing rates of bicycling are important to improving population health. There is a growing body of research examining transportation infrastructure and the risk of injury to bicyclists. Methods We reviewed studies of the impact of transportation infrastructure on bicyclist safety. The results were tabulated within two categories of infrastructure, namely that at intersections (e.g. roundabouts, traffic lights) or between intersections on "straightaways" (e.g. bike lanes or paths). To assess safety, studies examining the following outcomes were included: injuries; injury severity; and crashes (collisions and/or falls). Results The literature to date on transportation infrastructure and cyclist safety is limited by the incomplete range of facilities studied and difficulties in controlling for exposure to risk. However, evidence from the 23 papers reviewed (eight that examined intersections and 15 that examined straightaways) suggests that infrastructure influences injury and crash risk. Intersection studies focused mainly on roundabouts. They found that multi-lane roundabouts can significantly increase risk to bicyclists unless a separated cycle track is included in the design. Studies of straightaways grouped facilities into few categories, such that facilities with potentially different risks may have been classified within a single category. Results to date suggest that sidewalks and multi-use trails pose the highest risk, major roads are more hazardous than minor roads, and the presence of bicycle facilities (e.g. on-road bike routes, on-road marked bike lanes, and off-road bike paths) was associated with the lowest risk. Conclusion Evidence is beginning to accumulate that purpose-built bicycle-specific facilities reduce crashes and injuries among cyclists, providing the basis for initial transportation engineering guidelines for cyclist safety. Street lighting, paved surfaces, and low-angled grades are additional factors that appear to improve cyclist safety. Future research examining a greater variety of infrastructure would allow development of more detailed guidelines.


Background
Bicycling is an active mode of transportation that integrates physical activity into daily life. The bicycle is an attractive alternative to the automobile as an urban mode of transport. Cycling is associated with a range of individual and public health benefits such as improved physical and mental health, decreased obesity, and reduced risk of cardiovascular and other diseases [1][2][3][4][5][6], as well as ancillary benefits such as reduced emissions of noise, air pollutants and greenhouse gases [7,8]. There are significant economic costs of physical inactivity [9], and benefit-cost analyses suggest that the benefits of increased cycling are worth approximately four to five times the costs of investing in new cycling infrastructure [10,11]. These potential benefits suggest that it is important to increase the use of the bicycle as a mode of active transportation.
It is clear that the health benefits of cycling are significant, and at this point there is no reason to assume that health risks outweigh those benefits. However, a full public health understanding requires that attention be paid not only to long-term population health and environmental benefits of bicycling, but also to the factors that influence risk of injury and fatality. Bicyclists are vulnerable because they must frequently share the same infrastructure with motorized vehicles, and yet bicycles offer their users no physical protection in the event of a crash. In addition, the mass of a typical automobile is at least an order of magnitude greater than a bicycle plus its rider, and motorized vehicles have top speeds that are considerably faster than bicycles. As a result, bicycle riders who are involved in a crash are exposed to a much higher risk of injury compared to motor vehicle users (with the exception of motorcycle riders).
To date, most studies of cycling safety -especially in North America -have emphasized helmet design, regulation, and implementation to mitigate the severity of cycling injuries when a crash occurs [12,13]. This is particularly true for children [14,15]. In many North American jurisdictions children who cycle (and sometimes also adult cyclists) are required by law to use helmets, although this is not the case in most European countries. While helmets are effective in reducing the severity of head injuries, they do not address impacts to other parts of the body [16,17]. More importantly, they do not prevent incidents from occurring in the first place [18], and legislating their use may even discourage cycling [19].
The built environment has been implicated as an important determinant of bicycling rate [20][21][22][23], but these relationships are complex and a positive correlation has not always been found [24]. It is equally important to understand how the built environment affects bicycling safety because there may be an opportunity to prevent injuries by modifying transportation infrastructure. Infrastructure improvement meets several important conditions for successful injury prevention measures: (a) it is population based, rather than requiring initiative on the part of the individual; (b) it is passive, rather than requiring active participation; and (c) it is accomplished with a single action, rather than requiring repeated reinforcement [18].
In this paper we review the evidence on how different types of transportation infrastructure affect bicyclists' safety. This paper is organized as follows: first we provide an overview of bicycling safety and ridership. Next we offer definitions of, and alternative terminology for, the transportation infrastructure used by cyclists that might be expected to influence their safety (Table 1). We describe our literature search methodology and the inclusion and exclusion criteria, and present the results of the search in two detailed tables. Table 2 describes studies that assess the safety of intersections for cyclists, and Table 3 describes studies related to straightaways (i.e. roads, lanes, paths). We conclude by discussing the findings of this review, critiquing the methodological approaches used, and offering recommendations for future research.

Ridership and Safety
North Americans remain less likely than Europeans to choose bicycle transport for either short or long trips. In part, this may be due to differences in urban form between North American and European cities, particularly density and interconnectedness [25], but perceived and actual injury risks are also important.
Data on the share of trips made by bicycle are not often directly comparable between jurisdictions owing to differences in the survey methods employed (e.g. sampling scheme, definition of a trip, etc.), but comparisons are typically justified by the inability of these methodological disparities to explain the substantial difference observed (e.g. about 1% of trips are made by cycling in North America vs. an estimated 10% of trips in Switzerland, Germany, Austria, Sweden, Finland, and Belgium (Flanders), and more than 20% of trips in Denmark and the Netherlands) [26]. Along with these lower cycling rates, there is also a higher risk of injury associated with cycling in North America: an analysis of traffic injuries indicated a two to three fold higher risk of death and an eight to 30 fold higher risk of injury while cycling in the United States vs. Holland and Germany, using either of the traditional transportation denominators: per trip or per kilometer traveled [27]. While these comparisons underscore cycling injury risks, they also provide reason for optimism. If cycling is safer in European cities, it can be made safer in North America. Bike route A paved residential or local road that is signed as being a "bike route", and may have cyclist-friendly crossings at major roads, such as traffic signals with push-buttons that are easily operated by cyclists.
Bike lane (marked cycle lane †) Part of the paved roadway marked with painted lines or a colored surface, to designate that it is reserved exclusively for cyclists. Bike lanes may terminate before an intersection, or continue through it.
Cycle track (separated cycle lane †) Paved lane, exclusively for bicycle use, next to a major city street or roundabout, but separated by a curb or other physical barrier.
Bike path Off-road paved or unpaved path or trail, for bicycles only.
Multi-use path Off-road paved or unpaved path or trail, shared with other non-motorized users (e.g. pedestrians, runners, or in-line skaters).

Sidewalk
Off-road paved walkway for pedestrian use, located by the side of road; known as "pavement" in some parts of the world (e.g. UK and Ireland).
Speed bumps/humps * Raised ridge across the road designed to slow motor vehicle traffic ("traffic calming"), particularly in residential areas. Speed humps are easier than speed bumps for cyclists to ride over because they are less steep-sided and more broad.

INTERSECTIONS Intersections
Where two or more roads either meet or cross at the same level.
Junctions * May be road intersections, but the term is usually used to refer to the point where a laneway, path, or driveway meets a road.

Roundabout
Intersection of arterial streets with a central circle of sufficient diameter that the road curvature accommodates all road vehicles, including trucks and buses. Roundabouts usually have splitter islands on the approaches, sidewalks around the edges, and crosswalks across the approaches set back from the intersection. Daniels et al. provide diagrams of different types of cycle facilities on roundabouts in the Netherlands [57]. Generally, entering traffic yields to traffic already in the intersection.
Traffic circle/rotary traffic island * Raised concrete circles placed in the centre of minor street intersections; there are no splitter islands and the design vehicle is a passenger car.
Bicycle crossing Distinct road crossings for cyclists that are sometimes raised or colored, and may have cyclist-operated traffic signals.
Bicycle box/advanced cycle stop line * A right-angle extension to a bike lane at the head of an intersection, which allows cyclists to wait at the head of the traffic queue on a red traffic signal and then proceed through the intersection ahead of motor vehicle traffic on green.
Traffic diverter * Bike-permeable barriers that require motor vehicle traffic to turn instead of traveling straight ahead through an intersection, or that prevent motor vehicles from entering a street.
* These types of infrastructure were not investigated in any of the studies identified for this review. † Terminology used in the "European Cycling Lexicon" (published by the European Economic and Social Committee at the Vélocity 2009 conference in Brussels). It gives a list of key cycling terms with corresponding photographs for cyclists and policy makers, in all 23 official European languages. It is freely available to download at: http://www.eesc.europa.eu/sections/ten/european-cycling-lexicon There are clearly bicycling safety and popularity "gaps" between (and within) Europe and North America [28]. In addition, there is an important safety gap between cyclists and other transport modes: estimates from both continents suggest that cyclists are seven to 70 times more likely to be injured, per trip or per kilometer traveled, than car occupants [27,29]. It is likely that public perception of a lack of safety acts as a deterrent to cyclists in North America: in surveys asking about factors that affect the choice of cycling as a mode of transportation, concern about safety is one of the most frequently cited deterrents [ [30][31][32][33][34], and Winters M, Davidson G, Kao D, Teschke K: Motivators and deterrents of bicycling: factors influencing decisions to ride, submitted]. For example, in a survey of adults in the Vancouver metropolitan area, the following were among the top deterrents: the risk of injury from carbike collisions; the risk from motorists who don't know how to drive safely near bicycles; motorized vehicles driving faster than 50 km/hr; and streets with a lot of car, bus, and truck traffic [33]. The good news is that there is evidence that perceived safety improvements in bicycle transportation have an aggregate elasticity value greater than one (i.e. a 10% increase in perceived safety results in greater than 10% increase in the share of people commuting by bicycle) [32].
Increased ridership rates may result in improved safety for cyclists: injury rates have been shown to decrease with increased cycling rates. This principle of "safety in numbers" is supported by studies of injury and ridership patterns in California, Australia, and Europe, as well as between cities and within cities over time [35][36][37][38]. There are a number of potential explanations. Motor vehicle drivers may not expect cyclists when there are few of them on the roads, and thus make so-called "looked-but-failedto-see" errors that can result in collisions [39]. When motorists and cyclists are unaccustomed to sharing the road, both parties may hold incorrect assumptions about what the other party will do [40]. Increased cycling rates may mean that more motorists also use bicycles as a mode of transport, making motorists more attuned to cyclists and their movements, and encouraging them to drive in a way that accounts for potential interactions [36]. Finally, a larger cycling population means stronger lobbying power for cycling resources.
Finally, it is worth considering long-term temporal trends in motor vehicle injuries. The injury rate from motor-vehicle crashes has steadily declined since the 1920s in many parts of the world, in part attributable to improvements in road-related infrastructure [41]. This provides reason for optimism: the risk of injury or death from traffic crashes is modifiable, and this is likely to extend to the infrastructural determinants of cycling injuries.

Safety terminologyy
Bicycling safety is usually quantified by measuring one or more of the following metrics: injuries; crashes; and conflicts. Injuries may include fatalities and can be classified according to their type and severity using standardized methods such as the World Health Organization's International Classification of Diseases (ICD) [42] and the Association for the Advancement of Automotive Medicine's Abbreviated Injury Scale (AIS). Crashes can be classified as either a collision or a fall, where a collision is defined as an event in which the bicycle hits or is hit by any other object, regardless of fault, and a fall is an event (not caused by a collision) where the bicycle and/or bicyclist lands on the ground.
A conflict is normally defined as an interaction between a bicyclist and another road user such that at least one of the parties has to change speed or direction to avoid a collision. Types of conflict examined in bicycling safety studies include avoidance maneuvers at intersections [43][44][45], bicycle-motor vehicle interactions during passing events on roads, lanes, or paths [46][47][48][49], and "wrong side passing events" on multi-use paths [50]. Conflict studies may offer valuable insights into how cyclists and other road users behave during their interactions on various types of transportation infrastructure. However, it is not possible to determine whether the safety of the cyclists was compromised during the conflict events. In addition, the conflict studies we identified were generally based on a small number of observed events, which were made over a limited time period (usually several hours), and often in a single geographical location. Therefore, papers that used conflict as their sole outcome measure have not been included in this review.
In the literature that examines traffic-related injuries and crashes (including many of the papers reviewed here) the word "accident" is frequently used, for example in the phrase "motor vehicle accident". However it has been argued that the term "accident" implies that the event in question has happened entirely by chance, and is therefore unpredictable and unpreventable [51] as opposed to being a result of modifiable risk factors. The editors of BMJ have even gone as far as to ban the use of the term [52]. We have refrained from using the word "accident" in this review, instead using the more specific terms "incident", "injury", "crash", "collision" and "fall" as appropriate. However, we do indicate if the original study authors used the word accident to describe the outcome measure.

Infrastructure terminology
Key terms that describe transportation infrastructure used by cyclists are defined in Table 1. We have indicated if a Change in crash and injury rates after intervention.
Corrected for the temporal trends in crash and injury rates across all intersections in the Netherlands: national data that showed a 2 to 13% decrease over the study period. A sevenmonth "transitional period" following roundabout construction was not included in before-after analysis.
8% reduction in bicyclists' crash rate and 30% reduction in injury rate were observed following installation of new roundabouts. Among the 3 styles of roundabouts, those with cycle tracks had the greatest reductions in injuries to cyclists and moped users (90%), compared to those with no bicycle infrastructure (41% reduction) and those with a cycle lane (25% reduction).

Brüde and Larsson (2000)
What roundabout design provides the highest possible safety? [54] Sweden Adjusted for traffic volume data collected on 2 intervention streets and 2 unchanged streets.
There was an 8% increase in crash frequency in the study area, but bicycle volume on these intervention sections grew by 50% more than unchanged streets -authors conclude that the intervention may have resulted in a safety improvement. *These studies used only the term "accident" to describe crashes (collisions and/or falls) that may or may not have resulted in injury. We have substituted the words "crash", "collision" and/or "fall" based on our reading of the studies, as explained in the "Safety terminology" section of the text. † In Japan, traffic drives on the left (so turns should be interpreted accordingly), and bicycles travel on sidewalks with pedestrians, not on the road.    Adjusted for hour of the day, darkness, and season, by summing log odds ratios calculated separately for these factors. Log odds ratios were weighted in inverse proportion to the variance of the odd ratio.
Presence of lighting on rural roads reduces bicyclist injuries by ~60%.
* This study used only the term "accident" to describe crashes (collisions and/or falls) that may or may not have resulted in injury. We have substituted the words "injury", "crash", "collision" and/ or "fall" based on our reading of the studies, as explained in the "Safety terminology" section of the text.
† Injury severity does not reflect risk of an incident, but rather the outcome of the incident once it occurs.

Search strategy
We searched the following bibliographic databases: Pubmed and Medline, which index over 3,600 international medical and health care journals (1949 to present); Web of Science, which includes the Science Citation Index, the Arts and Humanities Citation Index, and the Social Sciences Citation Index (1989 to present); and Transportation Research Information Services, which includes references to books, technical reports, conference proceedings and journal articles in the field of transportation (1960 to present). In order to identify relevant studies, we used search terms related to the safety of bicyclists, and to transportation infrastructure. Combinations of the following keywords were used in the searches, (with "wildcards" used where appropriate to capture variants on terms, e.g. bicycl*): bicycle, safety, injury, accident, crash, conflict, infrastructure, road, and intersection. Reference lists of all relevant papers including review papers were searched as a source of additional citations. The initial literature search was conducted in summer 2008 and updated through to June 2009.

Inclusion and exclusion criteria
All papers identified by the search were initially screened for relevance using the title and/or abstract. Specifically, we sought papers that met the description of injury epidemiology studies, injury severity studies, and crash/collision/fall rate studies, and that considered some aspect of infrastructure as a determinant/predictor of bicyclists' safety. These included "before and after" studies that examine the safety impact (change in injury or crash rate for cyclists) of some infrastructural change. Those papers considered potentially relevant were collected, and the full text versions were then further reviewed for relevance.
Papers were considered relevant and included in the review if they met the following criteria: • they investigated a relationship between transportation infrastructure (designed for either motorized or nonmotorized use) and a clearly-defined metric of bicyclist safety (injury, injury severity, crash/collision/fall); and • they were English-language publications describing empirical research conducted in an Organisation for Economic Co-operation and Development (OECD) country. For countries outside the OECD, it was expected that the transportation infrastructure and bicycling rates (as well as the socio-economic motivators of bicycling) would be different, and consequently the study results may not be applicable across regions. The literature search did not locate any relevant papers describing studies conducted outside the OECD.
We excluded papers from further review if they met any of the following criteria: • studies of injuries or crashes that occurred when the bicycle was being used for bicycle racing, "off-road mountain-biking", trick/trials riding, or play; • studies only examining non-infrastructural determinants of safety such as helmet-use, bicycle type, personal characteristics of the bicyclists or motor vehicle drivers (e.g. age, sex, experience); • studies of injuries not related to a crash event, e.g. chronic injuries related to riding position; • studies examining gross numbers/types of injuries in a region for a given time period, without either calculating rates (per exposure/riding time) or considering infrastructural determinants of those injuries; • studies that reported only subjective perceptions of safety or risk, whether by lay-public or experts; and • studies that examined only "conflict" between cyclists and other road users (refer to the section on "safety terminology"), but where crashes or injuries were not identified.
Ten of the 23 studies reviewed used injuries (or both injuries and crashes) as a metric of bicyclist safety, four examined injury severity, and nine examined crashes (i.e. collisions and/or falls). Most of the studies were published since 1994, except two US studies which were published in the mid-70s [61,62] and one which was published in 1988 [63]. All the study designs were observational. Five of the intersection-related papers [53,[56][57][58][59], but only one of the road/lane/path-related papers [63], were "before-after" studies that quantified the change in cyclist safety before and after some infrastructure-related intervention took place. The remaining papers were classified as "non-intervention" observational studies. Most of the studies based their analyses and conclusions on at least 150 observations of injury or crash events, and seven studies based their analyses on more than one thousand observations. However one study of roundabouts examined only 67 crashes, 58 of which resulted in injuries [54], and two non-intersection studies examined 87 and 89 crashes on roads with and without marked bike lanes [63], and on sidewalks versus roads [71] respectively.
Thirteen of the studies were published in public health related journals (mainly Accident Analysis & Prevention and the Journal of Safety Research), and nine were published in transportation engineering journals (mostly Transportation Research Record). The remaining study (on the safety of different road/lane/path infrastructure types) was conducted as part of a Master of Science thesis [61].
All but one of the studies about intersection-related infrastructure (Table 2) were conducted in European countries. Five of the European intersection-related studies examined the safety of roundabouts and two examined marked bicycle crossings. The non-European study examined how intersection design in Japan influenced number of bicycle-motor vehicle collisions [60]. Cyclists in Japan are required by law to travel on the sidewalk, so the results from this study may not be generalizable to countries with different traffic rules.
The findings of the roundabout studies show some consistency, with elevated risks for cyclists after installation of roundabouts with multiple traffic lanes or with marked bike lanes, whereas there were risk reductions or no apparent increase in risk at roundabouts with separated cycle tracks [54,56,57]. One study showed a decreased risk for cyclists and moped riders after installation of roundabouts in the Netherlands [53], but the authors did not disaggregate the results for these two road-user groups. The finding from this study -that roundabouts with separated cycle tracks had a greater safety effect than those with onroad marked bike lanes or no bicycle infrastructure -is consistent with other research. Another study on roundabout safety in Flanders found a similar effect for "vulnerable road users" [74], but we have not included this study in our table because the vulnerable road user population included pedestrians and motorized two-wheeler riders as well as cyclists. It is likely that the safety effect of roundabouts, as measured in such "before-after" studies, will depend on the "before" configuration of the intersections in question.
The two studies of the safety effect of marked bicycle crossings at intersections looked at different design aspects (one on physically elevated crossings, one on colored crossings) and did not provide clear conclusions.
Although the study on elevated crossings showed a small increase in the number of crashes after the crossing was installed, the bicycle traffic volume grew by 50% on the streets after the intervention, as compared to unchanged streets in the area, and this was not adjusted for in the analysis [58]. The second study showed a reduction in injury or crash risk when there was one colored bicycle crossing at an intersection, but an increase in injury or crash risk when there were two or more colored crossings [59].
Of studies examining infrastructure related to straightaways on roads, lanes, and paths (Table 3), all but one were conducted in Canada or the US. The only European study in this category is very different in its focus: the safety effect of rural street lighting in the Netherlands [73]. Perhaps unsurprisingly, that study found that the presence of street lighting on rural roads reduced the rate of cyclists' injuries by half. The effect was corroborated by an injury severity study that found that crashes resulting in more severe injuries were significantly associated with unlit roads at night [69].
Most of the remaining studies in this category compared cyclist injury or crash rates on different types of road-or path-related infrastructure that cyclists commonly travel, namely major and minor roads without specific cycling facilities, roads with wide curb lanes or marked bike lanes, on-road bike routes, off-road bike-specific or multi-use paths, and sidewalks. A difficulty with this literature was that several facilities (between two and seven in number) were grouped into categories, such that facilities with potentially different risks were classified within a single category. In addition, the categorizations differed from study to study, and the terminology used was sometimes not clearly defined or consistently used. Despite these limitations, there are still some consistent messages.
On-road marked bike lanes were found to have a positive safety effect in five studies, consistently reducing injury rate, collision frequency or crash rates by about 50% compared to unmodified roadways [61,62,[65][66][67]. Three of those studies [61,66,67] found a similar effect for bike routes. One study [63] found that there was an increase in crash rates in the year following installation of marked bike lanes on a major road, especially for a section counter to on-road traffic flow, but this effect was not sustained over the long term.
There is less consistent evidence about off-road riding, possibly because this category encompassed a wide variety of facility types. There may have been confounding factors such as whether the surface was paved or unpaved, or for bicycles only or multiple user groups. Two studies examined off-road bike paths and found reduced risks, ranging  [64,67]. Two studies that grouped paved and unpaved, bicycle only and multi-use urban trails in their off-road path category found elevated risks, 1.6 to 3.5 times higher than riding on-road [29,66,68]. Studies that examined unpaved off-road trails as a separate category found risks of injury 2.5 to 7.2 times higher than on-road cycling [61,65,66] and 8 to 12 times higher than bike routes, lanes, or paths [65,66].
Most studies that considered sidewalk-riding suggested that it is particularly hazardous for cyclists, with estimates of 1.8 to 16 times the risk of cycling on-road [29,[66][67][68]71]. However one study found that the risk of traveling on the sidewalk was the same or lower than riding on residential streets [64]. Another considered the direction of travel and found that the elevated risk when sidewalk cyclists entered intersections was almost exclusively related to cycling against the flow of adjacent on-road traffic [71].
Four studies examined the association between various infrastructural characteristics and injury severity [16,69,70,72]. More severe injuries were significantly associated with motor vehicle involvement, unlit roads at night, wider roads, perceptible road grades, and one-way streets. Injury severity does not reflect risk of an incident, but rather the outcome of the incident once it occurs. In comparison, the studies that examined injury or crash rates, as opposed to those that concentrated on injury severity, were our primary focus since we are most interested in shaping transportation infrastructure for injury prevention.

Discussion
In this review we have described two categories of infrastructure: the first related to intersections; and the second related to straightaways on roads, lanes, and paths. It is of interest to note that studies of the former type of infrastructure were conducted almost entirely in Europe, while studies of the latter were conducted almost entirely in North America. The reason for this may be the substantial differences in urban form, existing cycling infrastructure, cycling rates, and even the culture of cycling between Europe and North America. Pucher and colleagues have discussed this issue extensively [26,75]. There is also significant variety in infrastructure design from one country to another, and even within a given city. Despite this, our review has revealed that relatively few types of infrastructure have been studied. For example, some common types of infrastructure in North American cities have not been assessed: traffic circles; bike boxes; sharrows; speed bumps/humps; and traffic diverters (Table 1). In addition, except for studies of roundabouts, we did not find any injury or crash studies that investigated cycle "tracks", a bicycle-specific design that is frequently available in high modal share European cities. One of the limitations of this review is that we have only included studies in the English scientific literature, although we are aware that there may be studies reported only in other (particularly European) languages.
The principal trend that emerges from the papers reviewed here is that clearly-marked, bike-specific facilities (i.e. cycle tracks at roundabouts, bike routes, bike lanes, and bike paths) were consistently shown to provide improved safety for cyclists compared to on-road cycling with traffic or off-road with pedestrians and other users. Marked bike lanes and bike routes were found to reduce injury or crash rates by about half compared to unmodified roadways. The finding that bicycle-specific design is important applies also to intersections with roundabouts, where it was found that cycle tracks routing cyclists around an intersection separately from motor vehicles were much safer than bike lanes or cycling with traffic. It has been suggested that the reason for high rates of bicycle-motor vehicle collisions at intersections is that motor vehicle drivers may be making "looked-but-failed-to-see" errors, whereby they search for oncoming motor vehicles but do not recognize that a cyclist is approaching because they are not looking for them [39,40].
Although roundabouts at intersections are not common in North America, they are relatively popular in many European countries. It is possible that they may see more widespread use in North America in the future because of evidence that conversion of intersections to roundabouts reduces crash risk for motor vehicle road users by 30-50% [76], especially when they replace intersections that were not previously signal-controlled. However, because the cyclist-specific safety effect of roundabouts appears to be highly dependent on their design, transportation infrastructure planners should carefully consider interactions between cyclists and other traffic modes. A literature review on the safety effect of roundabouts, prepared for the 18th Workshop of the International Co-operation on Theories and Concepts in Traffic Safety [77], came to similar conclusions. It may be prudent to avoid installing roundabouts in areas where there is a high proportional volume of bicycle traffic, for example along designated bicycle routes on residential roads. In some North American cities there is retrofitting of "traffic circles" at intersections in residential areas. Since these are quite different from the larger-diameter roundabouts found in Europe, their effect on cyclist safety should be investigated before more widespread use is advocated.
The reviewed literature also confirms some things that may already be "common-sense" for transportation planners and safety experts: that streets used by cyclists at night should have good street-lighting, road surfaces should be paved and well-maintained, and bike routes should avoid excessive grades wherever possible.
An issue with the literature to date, especially that related to roads, lanes, and paths, is that some investigators did not define the terminology used. For example, the meaning of bike "path" was not defined in the paper by Tinsworth et al. [64]. Other investigators clearly defined their infrastructure terms, but grouped facilities that may have different injury risks. For example, the studies of Aultman-Hall et al. [29,68] defined paths as "an off-road (usually multi-use) paved or unpaved path or trail," grouping paths for bikes only, which were found by others to have lower risks than cycling on roads [64,67], with unpaved trails, which were found by others to have higher risks [61,65,66]. Definitions of terminology are especially important in questionnaire-based studies to ensure that study participants are all answering with the same infrastructure in mind; photos can be helpful in this regard [33].
Clear and specific categorization is also vital to transportation planners and engineers, so they can distinguish sometimes subtle differences between successful and problematic design characteristics. One of the difficulties of the studies in the English-language literature to date is that the range of infrastructure studied is small compared to the range of configurations used between and within jurisdictions. Some examples are described above, but there are many other features that merit investigation: stop signs; numbers of roads intersecting; junctions such as driveways and lanes; cyclist lane of travel in relation to parked cars; surface features such as cobble stones or street-car (tram) tracks; traffic calming measures such as diverters or road humps; and road/lane/path curvature.
Underreporting of some events is an issue that is common to all studies of bicycle injuries and crashes. Many of the studies reviewed here relied on administrative data sources including hospital records [16,62,64], police reported accidents [54][55][56][57][58][59][60][61][69][70][71][72][73], and national or citymaintained registries [53,63], all of which are likely to miss less severe events. For example, one of the large surveys [67] found that 9.8% of the respondents had had a crash in the last year, but only two in five crashes (38.2%) had been reported to police. Over half (56.6%) required medical attention, but only one in twenty crashes (5.5%) required admission to a hospital. This underreporting may create bias in infrastructure-specific risk calculations, since collisions involving motor vehicles may be more likely to be reported to police for insurance reasons and to hospitals because they are more severe, as compared to collisions that happen with non-motorized users (which may happen more frequently on off-street paths). Results of studies using these data sources should be interpreted as reflecting risk of severe events. Other studies in this review used data from cyclist surveys that may capture a wider range of crash types, including those that are less severe [29,61,[65][66][67][68]. However, survey data will not capture events that resulted in fatalities (though these are extremely rare) or catastrophic incapacitating brain, spinal cord or other injuries and, depending on the method of survey administration, may not capture individuals who no longer cycle following a crash [29,68]. No single study design can overcome these reporting problems, thus the importance of looking for consistency of results across different designs.
A great challenge in studying cycling injuries is ensuring that comparisons control for the number of cyclists at risk (also called "exposure to risk"). The before-after studies reviewed here aimed to do this by comparing numbers of injuries on the same intersection or roadway prior to and post introduction of an infrastructure intervention, with the assumptions that underlying traffic levels, injury rates, and types of cyclists stay the same. These assumptions may not hold [58], so some of these studies also adjusted for temporal trends in traffic volumes [58,59,63] or injury rates in the area [53], or made additional comparisons to unchanged intersections [56][57][58][59]. The non-intervention studies needed to include methods to derive bicycling trip volumes on the infrastructure types being compared. Sometimes these came from administrative data collected by transportation authorities [54,55,60,71,73], and sometimes from study participants describing the route of an injury trip or their typical cycling location [29,61,[64][65][66][67][68]. Injury severity studies made comparisons within the injured populations, so did not require trip volume denominators [16,69,70,72], but this meant that they examined differences in severity of the outcome once in an injury event, not the original risk of the event itself.
Though the most basic requirement for studies examining risk of crashes or injuries is to account for exposure to risk, there are many other factors that may confound comparisons and that ideally would be controlled in study design or adjusted for in analyses. For example, men and women or people in different age groups may choose to cycle on different facility types, and might have different skill levels or risk-taking behavior, thus creating the potential for confounding associations between infrastructure and injury. While it is difficult to control for all potential confounders, many of the non-intervention studies reviewed here did adjust for personal factors such as age [16,29,64,65,70,71], sex [29,64,65,71], cycling experience [29,68], bicycle type [65], and environmental factors such as time of day [64,69,70,72,73] and weather [65,69,70,72]. Most injury severity studies adjusted for helmet use [16,69,72]. A style of observational study that can control for most potential confounders is the casecrossover design [78]. Such a study is underway in the Canadian cities of Toronto and Vancouver. It will compare infrastructure at the injury site to that of randomly selected control sites on the same trip, thus within-trip factors (including age, sex, cycling experience, propensity for risk taking, alcohol or drug use, bicycle type and condition, visibility via clothing or bicycle lights, weather, time of day, etc.) are controlled in the design.

Conclusion
Although the effect of infrastructure design on cyclist safety was first studied more than three decades ago, the literature on the topic remains remarkably sparse. This review highlights opportunities for more detailed and controlled studies of infrastructure and cycling injuries.
The evidence to date suggests that purpose-built bicycleonly facilities (e.g. bike routes, bike lanes, bike paths, cycle tracks at roundabouts) reduce the risk of crashes and injuries compared to cycling on-road with traffic or offroad with pedestrians. Street lighting, paved surfaces, and low-angled grades are additional factors that appear to improve cyclist safety. The major advantage of infrastructure modifications, compared to helmet use, is that they provide population-wide prevention of injury events without requiring action by the users or repeated reinforcement. Given the influence of safety on individuals' decisions to cycle, the importance of cycling modal share to safety, and the ancillary benefits of this active and sustainable mode of transportation, infrastructure enhancements have the opportunity to promote an array of improvements to public health.