Older driver retraining: An updated systematic review of evidence of effectiveness

Problem and Objective

The number of older drivers who might benefit from driver retraining is growing. A previous review on the effectiveness of older driver retraining included intervention studies up to 2004. The objective was to perform an updated systematic review of the effectiveness of older driver retraining for improving driving-related skills and reducing crash rates.

Method

Articles published from 2004-2008 were grouped according to the intervention provided and outcome studied. Randomized clinical trials (RCTs) were appraised using the Physiotherapy Evidence Database (PEDro) Scale and scored for quality according to their internal validity. Each intervention's effectiveness was then rated and assigned a level of evidence by combining pre- and post- 2004 findings.

Results

Three RCTs and one matched-pairs cohort design met the inclusion criteria. There is strong evidence (Level 1a) that education combined with on-road training improves driving performance and moderate evidence (Level 1b) that it improves knowledge. There is moderate evidence (Level 1b) that physical retraining improves driving performance. There is moderate evidence (Level 1b) that an educational intervention curriculum alone is not effective in reducing crashes.

Summary

The updated evidence on the effectiveness of retraining aimed at older drivers is sufficiently encouraging to merit assertive health promotion actions regarding intervention and program planning.

Impact on Industry

These positive findings warrant a comprehensive plan that has both behavioral and monetary incentives encouraging older driver participation in programs aimed at driver safety.     

Distraction in older drivers - A face-to-face interview study

The prevalence of older drivers’ engagement in distracting activities while driving is largely unexplored. Face-to-face interviews were conducted in the city of Braunschweig, Germany, comparing a sample of older drivers (n = 205) to a group of middle-aged drivers (n = 209). The drivers were interviewed on their engagement in distracting activities during the last half an hour of their driving trip, including the frequency and duration of these activities, their perception of the risk associated with these distracting activities and the role of these activities in at-fault crashes. Middle-aged drivers were significantly more likely to engage in certain distracting activities than older drivers. With regard to the duration of interactions with the passengers older drivers were significantly more talkative than middle-aged drivers. Middle-aged drivers rated most of the distracting activities as significantly less dangerous than older drivers. Distraction-related crashes are not a special problem of older drivers but seem to be very comparable to the middle-aged drivers. It is concluded that older drivers’ reluctance to engage in distracting tasks while driving is either a process of self-regulation or their age-related prudence. The study is the first to gather knowledge about distraction in German older drivers. Although older drivers are not currently overrepresented in distraction-related crashes, it is important to note that future cohorts of older drivers might differ in the way they engage with vehicles and technologies, which in turn may influence their driving patterns and willingness to engage in potentially distracting activities.     

Changes in driving performance after first and second eye cataract surgery: A driving simulator study

Introduction: This study investigated the separate impact of first eye and second eye cataract surgery on driving performance, as measured on a driving simulator. Method: Forty-four older drivers with bilateral cataract aged 55+ years, awaiting first eye cataract surgery participated in a prospective cohort study. They completed a questionnaire, visual tests and a driving simulator assessment at three time points: before first eye, after first eye, and after second eye cataract surgery. Generalized Estimating Equation Poisson or linear regression models were undertaken to examine the change in four driving outcomes of interest after adjusting for cataract surgery and other potential confounders. Results: The rate of crashes/near crashes decreased significantly by 36% (incidence rate ratio (IRR) 0.64, 95% CI 0.47–0.88, p = 0.01) after first eye surgery and 47% (IRR 0.53, 95% CI 0.35–0.78, p < 0.001) after second eye surgery, compared to before first eye cataract surgery, after accounting for confounders. The rate of crashes/near crashes also decreased with better contrast sensitivity (IRR 0.69, 95% CI 0.48–0.90, p = 0.041). A separate model found that time spent speeding 10 kilometers per hour or more over the limit after second eye surgery was significantly less (0.14 min, p = 0.002), compared to before first eye surgery, after accounting for confounders. As contrast sensitivity improved, the duration of speeding also decreased significantly by 0.46 min (p = 0.038). There were no statistically significant changes in lane excursions or speed variation. Practical applications: The findings highlight the importance of timely first and second eye cataract surgery to ensure driver safety, especially as older drivers wait for second eye cataract surgery. It also provides further evidence that contrast sensitivity is probably a better predictor of driving ability in older drivers with cataract than visual acuity, the measure on which driver licensing requirements are currently based, and should also be used when assessing fitness to drive.     

Effect of age and secondary task engagement on motor vehicle crashes in a naturalistic setting

ProblemAutomobile crashes are one of the leading causes of death in the United States, especially for younger and older drivers. Additionally, distracted driving is another leading factor in the likelihood of crashes. However, there is little understanding about the interaction between age and secondary task engagement and how that impacts crash likelihood and maneuver safety.MethodData from the Naturalistic Driving Study (NDS), which was part of the Second Strategic Highway Research Program (SHRP2), were used to investigate this issue.ResultsIt was found that the distribution of crashes per one million km driven during the NDS was similar to previous research, but with fewer crashes from older drivers. Additionally, it was found that older and middle-aged drivers engaged in distracted driving more frequently than was expected, and that crashes were significantly more likely if drivers of those age groups were engaged in secondary tasks. However, secondary task engagement did not predict judgment of safe/unsafe vehicle maneuvers.Practical ApplicationsMore research is needed to better understand the interaction of age and distraction on crash likelihood. However, this research could aid future researchers in understanding the likelihood of future use of new in-vehicle technologies for different age groups, as well as provide insight to the engagement patterns of distraction for different age groups.     

The role of off-path glances: A quantitative analysis of rear-end conflicts involving Chinese professional truck drivers as the striking partners

Introduction: Rear-end crashes are one of the most frequent crash types in China, leading to significant economic and societal losses. The development of active safety systems – such as Automatic Emergency Braking System (AEBS) – could avoid or mitigate the consequences of these crashes in Chinese traffic situations. However, a clear understanding of the crash causation mechanisms is necessary for the design of these systems. Method: Manually coded variables were extracted from a naturalistic driving study conducted with commercial vehicles in Shanghai. Quantitative analyses of rear-end crashes and near crashes (CNC) were conducted to assess the prevalence, duration, and location of drivers’ off-path glances, the influence of lead vehicle brake lights on drivers’ last off-path glance, and driver brake onset, and the influence of off-path glances and kinematic criticality on drivers’ response to conflicts. Results: The results indicate that the Chinese truck drivers in our study rarely engage in distracting activities involving a phone or other handheld objects while driving. Instead, they direct their off-path glances mainly toward the mirrors, and the duration of off-path glances leading to critical situations are shorter compared to earlier analyses performed in Western countries. The drivers also often keep small margins. Conclusions: Overall, the combination of short time headway with off-path glances directed toward the mirror originates visual mismatches which, associated to a rapid change in the kinematic situation, cause the occurrence of rear-end CNC. When drivers look back toward the road after an off-path glance, a fast response seems to be triggered by lower values of looming compared to previous studies, possibly because of the short time headways. Practical Application: The results have practical implications for the development of driver models, for the design of active safety systems and automated driving, and for the design of campaigns promoting safe driving.     

Antecedents of fatigue, close calls, and crashes among commercial motor-vehicle drivers

PROBLEM: Minimizing driver fatigue among commercial motor-vehicle (CMV) drivers is a major safety issue in the United States. This study examines the effects of potentially fatigue-inducing factors inherent in truck driving work and company safety management in explaining: (a) drivers driving while fatigued, (b) the frequency of close calls due to fatigue, and (c) actual crashes among CMV drivers. METHOD: Data for this study are derived from a survey of CMV drivers in 116 trucking firms, with all data being driver-reported. The relative roles of fatigue-inducing factors and safety management practices in explaining variation in fatigue, close calls, and crashes are reported, along with the roles of fatigue in affecting close calls and crashes via hierarchical regression. RESULTS: Findings indicated that fatigue-inducing factors inherent in driving work and safety practices accounted for appreciable variation in driving fatigued (R(2) =.42) and close calls (R(2) =.35), but not crash involvement. Driving while fatigued also accounted for incremental increases in the amount of variation in close calls, after consideration of inherent factors and safety practices. IMPACT ON INDUSTRY: Findings indicate that safety practices (e.g., establishment of a strong safety culture, dispatcher scheduling practices, company assistance with fatiguing behaviors such as loading and unloading) have considerable potential to offset fatigue-inducing factors associated with truck driving work.     

Older driver training programs: A systematic review of evidence aimed at improving behind-the-wheel performance

IntroductionAge- and health-related changes, alongside declines in driving confidence and on-road exposure, have been implicated in crashes involving older drivers. Interventions aimed at improving behind-the-wheel behavior are diverse and their associated impact remains unclear. This systematic review examined evidence on older driver training with respect to (1) road safety knowledge; (2) self-perceived changes in driving abilities; and (3) behind-the-wheel performance. Method Nine databases were searched for English-language articles describing randomized controlled trials (RCTs) and non-RCTs of driver training interventions aimed at those aged 55+ who did not have medical or other impairments that precluded licensure. Quality appraisals were conducted using Cochrane’s Risk of Bias Tool (RoB) and Risk Of Bias In Non-randomized Studies – of Interventions tool (ROBINS – I). [PROSPERO; registration no. CRD42018087366]. Results Twenty-five RCTs and eight non-RCTs met the inclusion criteria. Interventions varied in their design and delivery where classroom-based education, or a combination of classroom-based education with on-road feedback, improved road safety knowledge. Training tailored to individual participants was found to improve self-perceived and behind-the-wheel outcomes, including crashes. Conclusions Interventions comprised of tailored training can improve knowledge of road safety, changes to self-perception of driving abilities, and improved behind-the-wheel performance of older drivers. Future research should compare modes of training delivery for this driver population to determine the optimal combinations of off- and/or on-road training. Practical applications Training programs aimed at older drivers should be supported by theory and research evidence. By conducting comparative trials with a sufficient sample size alongside well-defined outcomes that are designed in accordance with reporting guidelines, the most effective approaches for training older drivers will be identified.     

Individual difference factors in risky driving among older adults

INTRODUCTION: Motor-vehicle crashes kill roughly 4,500 American adults over the age of 75 annually. Among younger adults, one behavioral factor consistently linked to risky driving is personality, but this predictor has been overshadowed by research on cognitive, perceptual, and motor processes among older drivers. METHOD: In this study, a sample of 101 licensed drivers, all age 75 and over, were recruited to complete self-report measures on personality, temperament, and driving history. Participants also completed a virtual environment (VE) course designed to assess risk-taking driving behavior. State records of motor-vehicle crashes were collected. RESULTS: Results suggest both a sensation-seeking personality and an undercontrolled temperament are related to risky driving among older adults. Sensation-seeking was particularly related to history of violations and tickets, while temperamental control was more broadly related to a number of risky driving measures. Methodological and crash prevention issues are discussed.     

The effect of extending graduated driver licensing to older novice drivers in Indiana

Introduction: Graduated driver licensing (GDL) systems have been shown to reduce rates of crashes, injuries, and deaths of young novice drivers. However, approximately one in three new drivers in the United States obtain their first driver’s license at age 18 or older, and thus are exempt from most or all provisions of GDL in most states. Method: In July 2015, the state of Indiana updated its GDL program, extending its restrictions on driving at night and on carrying passengers during the first 6 months of independent driving, previously only applicable to new drivers younger than 18, to all newly-licensed drivers younger than 21 years of age. The current study examined monthly rates of crashes per licensed driver under the affected conditions (driving at night and driving with passengers) among Indiana drivers first licensed at ages 18, 19, and 20 under the updated GDL system compared with drivers licensed at the same ages under the previous GDL system. We used Poisson regression to estimate the association between the GDL system and crash rates, while attempting to control for other factors that might have also influenced crash rates. We used linear regression to estimate the association between the GDL system and the proportion of all crashes that occurred under conditions restricted by the GDL program. Results: Results showed, contrary to expectations, that rates of crashes during restricted nighttime hours and with passengers were higher among drivers licensed under the updated GDL system. This mirrored a statewide increase in crash rates among drivers of all ages over the study period and likely reflected increased overall driving exposure. The proportions of all crashes that were at night or with passengers did not change. Practical Applications: More research is needed to understand how older novice drivers respond when GDL systems originally designed for younger novice drivers are applied to them.     

Characteristics of vehicles driven by teens and adults killed in crashes, 2013–2017

Introduction: Teen drivers experience higher crash risk than their experienced adult counterparts. Legislative and community outreach methods have attempted to reduce this risk; results have been mixed. The increasing presence of vehicle safety features across the fleet has driven fatality numbers down in the past decades, but the disparity between young drivers and others remains. Method: We merged Fatality Analysis Reporting System (FARS) data on fatal crashes with vehicle characteristic data from the Highway Loss Data Institute (HLDI). The analysis compared the vehicle type, size, age, and the presence of select safety features in vehicles driven by teens (ages 15–17 years) and adult drivers (ages 35–50 years) who were killed in crashes from 2013 to 2017. Results were compared with a similar analysis conducted on data from 2007 to 2012. Results: Teen drivers were more likely than their adult counterparts to be killed while driving older, smaller vehicles that were less likely to have the option to be equipped with side airbags. Discussion: Teenage drivers remain more likely to be killed while driving older, smaller vehicles than adult drivers. Parents and guardians are mainly responsible for teen vehicle choice, and should keep vehicle size, weight, and safety features in mind when placing their teen in a vehicle. Practical Application: These findings can help guide safer vehicle choice for new teen drivers.     

The impact of intersection design on simulated driving performance of young and senior adults

PURPOSE: The Federal Highway Administration (FHWA) proposed guidelines for highway design to increase the safe driving ability of older drivers; however, little empirical evidence exists to support the effectiveness of these guidelines. The purpose of this study was to investigate the effects of implementing these guidelines (in 4 pairs of intersections) on safe driving performance of older and younger drivers using a high-fidelity driving simulator. DESIGN AND METHODS: We replicated four intersection pairs (improved versus unimproved) in a high-fidelity, virtual reality driving simulator. Simulator scenarios were created from actual road locations, replicating road geometrics and traffic control devices. The simulator's controls were integrated with an actual vehicle to make the driving experience as realistic as possible. Kinematic measures were obtained from the simulator in conjunction with driving errors recorded by trained driving evaluators sitting in the cab of the car. Thirty-nine subjects, 19 younger and 20 older adults, participated in the study. RESULTS: For the kinematic data we found greater lateral control, as indicated by significantly smaller maximum yaw during the turn phase, at all of the improved intersections when compared to the unimproved intersections. We found some significant age differences, but mostly in only one of the intersection-pairs. For the behavioral data, there were significant differences in driving errors between improved and unimproved intersections in two intersection-pairs; however, there were no significant differences in driving errors between the older and younger drivers. IMPLICATIONS: The findings suggest that both young and older drivers may benefit from roadways with safety features recommended by the FHWA guidelines as indicated by the increased lateral control of the vehicle when negotiating these intersections. These findings generate critical information for those involved in the design of roadway systems.     

A cost-benefit analysis of risk-reduction strategies targeted at older drivers

OBJECTIVE: The risk of motor-vehicle collisions increases as driving-related functional abilities decline. These declines can accompany normal or pathological aging and can be identified through driving-related functional screening exams upon license renewal. The objective of this cost-benefit analysis was to determine the utility of four functional screening procedures used to identify drivers at risk for motor-vehicle collisions, as well as an intervention designed to maintain or improve functional abilities. Additionally, this study sought to determine the expected cost per driver if an intervention was designed to target only those drivers who failed the functional ability-based driving screen, versus the expected cost per driver if the intervention was distributed en masse to all drivers 75 years and older. Improving functional abilities in older adults has potential far-reaching health and financial impacts which are broader than their impact of maintaining mobility. METHODS: A decision tree was constructed to evaluate the expected costs and benefits of (a) screening all drivers and intervening when indicated (several screening batteries of varying length were considered), (b) no screening, but intervening with all drivers of older age, or (c) neither screening nor intervening (i.e., re-licensing per usual). Test characteristics and risk probabilities were based on a cohort of drivers aged 75 and older from a previous study (Ball et al., 2006). Relevant sensitivity analyses were conducted. RESULTS: Providing all drivers with the speed-of-processing intervention is the most cost-beneficial option (expected cost per driver = $493.30), even if the cost of the intervention doubles. Sensitivity analysis indicated the effectiveness of the intervention could drop from 86% to 25% and the preventative approach of intervening with all drivers remains the most cost-beneficial strategy. The least cost-beneficial option is almost always re-licensing per usual (expected cost per driver = $1,562.84). CONCLUSION: Screening drivers upon license renewal is not currently beneficial because the available technology cannot consistently identify drivers at risk for a collision. However, the speed-of-processing intervention has demonstrated efficacy in improving driving competence (Roenker et al., 2003) and is a non-invasive, moderate-cost intervention that has the potential to protect the safety and mobility, as well as the financial interests, of older drivers and the community at large.     

Teenage driver crash incidence and factors influencing crash injury by rurality

BackgroundPrevious research has identified teenage drivers as having an increased risk for motor-vehicle crash injury compared with older drivers, and rural roads as having increased crash severity compared with urban roads. Few studies have examined incidence and characteristics of teen driver-involved crashes on rural and urban roads.MethodsAll crashes involving a driver aged 10 through 18 were identified from the Iowa Department of Transportation crash data from 2002 through 2008. Rates of overall crashes and fatal or severe injury crashes were calculated for urban, suburban, rural, and remote rural areas. The distribution of driver and crash characteristics were compared between rural and urban crashes. Logistic regression was used to identify driver and crash characteristics associated with increased odds of fatal or severe injury among urban and rural crashes.ResultsFor younger teen drivers (age 10 through 15), overall crash rates were higher for more rural areas, although for older teen drivers (age 16 through 18) the overall crash rates were lower for rural areas. Rural teen crashes were nearly five times more likely to lead to a fatal or severe injury crash than urban teen crashes. Rural crashes were more likely to involve single vehicles, be late at night, involve a failure to yield the right-of-way and crossing the center divider.ConclusionsIntervention programs to increase safe teen driving in rural areas need to address specific risk factors associated with rural roadways.Impact on IndustryTeen crashes cause lost work time for teen workers as well as their parents. Industries such as safety, health care, and insurance have a vested interest in enhanced vehicle safety, and these efforts should address risks and injury differentials in urban and rural roadways.     

Driver licensing,motor-vehicle crashes,and moving violations among older adults

IntroductionDriving is important for well-being among older adults, but age-related conditions are associated with driving reduction or cessation and increased crash risk for older drivers. Our objectives were to describe population-based rates of older drivers’ licensing and per-driver rates of crashes and moving violations.Methods: We examined individual-level statewide driver licensing, crash, and traffic citation data among all New Jersey drivers aged ≥ 65 and a 35- to 54-year-old comparison group during 2010–2014. Rate ratios (RR) of crashes and moving violations were estimated using Poisson regression.Results: Overall, 86% of males and 71% of females aged ≥ 65 held a valid driver’s license. Older drivers had 27% lower per-driver crash rates than middle-aged drivers (RR: 0.73, 95% CI: 0.73, 0.74)—with appreciable differences by sex—but 40% higher fatal crash rates (RR: 1.40 [1.24, 1.58]). Moving violation rates among older drivers were 72% lower than middle-aged drivers (RR: 0.28 [0.28, 0.28]).Conclusion: The majority of older adults are licensed, with substantial variation by age and sex. Older drivers have higher rates of fatal crashes but lower rates of moving violations compared with middle-aged drivers.Practical applications: Future research is needed to understand the extent to which older adults drive and to identify opportunities to further reduce risk of crashes and resultant injuries among older adults.     

Temporal patterns of crashes of 16-to 17-year-old drivers in Fairfax County, Virginia

OBJECTIVE: To develop a better understanding of the frequency and characteristics of teenage driver crashes occurring during school commute times. METHOD: Data were obtained from police reports of crashes involving drivers ages 16-17 that occurred between September 2001 and August 2004 in Fairfax County, Virginia. Temporal patterns and other characteristics of crash involvement during the school year were examined, and crashes during school commute times were compared with those at other times. RESULTS: Teenage driver crash involvement spiked during weekday school commute times. Compared with other times, crashes during school commute times were significantly more likely to involve multiple vehicles but less likely to result in injuries or involve drivers who were male, made driving errors, or had been drinking alcohol. Crashes during school commute times were more likely to involve more than one teenage driver and occur close to schools. CONCLUSIONS: Crashes involving teenage drivers are prevalent during school commute times. Many of these crashes involve multiple teenage drivers and occur near schools. Schools and communities should consider programs and policies that reduce teenage driving to school and enhance the safety of teenagers that do drive.     

Using a driving simulator to identify older drivers at inflated risk of motor vehicle crashes

PROBLEM: To develop appropriate assessment criteria to measure the performance of older drivers using an interactive PC-based driving simulator, and to determine which measures were associated with the occurrence of motor-vehicle crash. METHOD: One hundred and twenty-nine older drivers residing in a metropolitan city volunteered to participate in this retrospective cohort study. Using the driving simulator, appropriate driving tasks were devised to test the older drivers, whose performances were assessed by 10 reliable assessment criteria. Logistic regression analysis was then undertaken to determine those criteria that influence the self-reported crash outcome. RESULTS: As expected, driving skill of older drivers was found to decline with age. Over 60% of the sample participants reported having at least one motor-vehicle crash during the past year. Adjusting for age in a logistic regression analysis, the cognitive abilities associated with the crash occurrence were working memory, decision making under pressure of time, and confidence in driving at high speed. SUMMARY: The findings of this retrospective study indicated those individuals at inflated risk of vehicle crashes could be identified using the PC-based interactive driving simulator. Prospective studies need to be undertaken to determine whether the driving simulator can predict future crash events. IMPACT ON INDUSTRY: This study demonstrated an economical driving simulator approach to screen out problematic or unsafe older drivers before a more detailed but expensive road test is considered.     

Multi-agent traffic simulations to estimate the impact of automated technologies on safety

Abstract

Objective: The objective of this article was to develop a multi-agent traffic simulation methodology to estimate the potential road safety improvements of automated vehicle technologies.

Methods: We developed a computer program that merges road infrastructure data with a large number of vehicles, drivers, and pedestrians. Human errors are induced by modeling inattention, aimless driving, insufficient safety confirmation, misjudgment, and inadequate operation. The program was applied to simulate traffic in a prescribed area in Tsukuba city. First, a 100% manual driving scenario was set to simulate traffic for a total preset vehicle travel distance. The crashes from this simulation were compared with real-world crash data from the prescribed area from 2012 to 2017. Thereafter, 4 additional scenarios of increasing levels of automation penetration (including combinations of automated emergency braking [AEB], lane departure warning [LDW], and SAE Level 4 functions) were implemented to estimate their impact on safety.

Results: Under manual driving, the system simulated a total of 859 crashes including single-car lane departure, car-to-car, and car-to-pedestrian crashes. These crashes tended to occur in locations similar to real-world crashes. The number of crashes predicted decreased to 156 cases with increasing level of automation. All of the technologies considered contributed to the decrease in crashes. Crash reductions attributable to AEB and LDW in the simulations were comparable to those reported in recent field studies. For the highest levels of automation, no assessment data were available and hence the results should be carefully treated. Further, in modeling automated functions, potentially negative aspects such as sensing failure or human overreliance were not incorporated.

Conclusions: We developed a multi-agent traffic simulation methodology to estimate the effect of different automated vehicle technologies on safety. The crash locations resulting from simulations of manual driving within a limited area in Japan were preliminary assessed by comparison with real-world crash data collected in the same area. Increasing penetration levels of AEB and LDW led to a large reduction in both the frequency and severity of rear-end crashes, followed by car-to-car head-on crashes and single-vehicle lane departure crashes. Preliminary estimations of the potential safety improvements that may be achieved with highly automated driving technologies were also obtained.     

MaryPODS revisited: updated crash analysis and implications for screening program implementation

PROBLEM: Due to the relative scarcity of crashes, there has consistently been a problem with analyses that use crashes as a criterion measure in their analyses. METHOD: Previous analyses of the relationships between functional capacity measures and at-fault crash involvement for older drivers as reported in the NHTSA Model Driver Screening and Evaluation Program Final Technical Report have been updated to include one additional year of driving experience. Eighteen new at-fault crashes involving drivers who previously had no crash involvement were recorded for the Maryland Motor Vehicle Administration (MVA) test sample during this interval. The method of odds ratio (OR) calculation was used to examine the relationships between functional status predictors and the most salient among the safety outcome measures identified in the Maryland research. Peak valid OR values for the prior and current analyses were contrasted, and the stability of candidate pass-fail cut-points for each predictor relative to values identified in the Final Technical Report was examined. RESULTS: Results indicate that the predictive value of functional tests appears to decrease over time, particularly for the perceptual-cognitive measures. IMPACT ON INDUSTRY: The impact of these findings on programs and policies is to underscore a need for periodic reevaluation, spaced at the shortest practical intervals but not more than 2 years apart, in order for functional capacity screening to be applied effectively by licensing authorities, health care professionals, and others to reduce personal risk and enhance public safety.