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Globally more than 50 million people are injured in road traffic every year. The incidence of road injuries is increasing while that of fatalities is decreasing. Road safety measures are being implemented in many countries to reduce the effects on public health. In highly motorized countries, the process is often managed by quantitative targets. Sweden has a target for 2020 based on Vision Zero: that no-one should be killed or seriously injured in road traffic. In Vision Zero, pedestrians in single crashes are not defined as road users, even when they move in the same areas as road users with vehicles. In this thesis the road space (pavements, tracks and roads) defines the road user.

The aim of the thesis is to study the development of serious injuries in rural and urban areas during a period when Vision Zero was being implemented through government efforts to direct the process in Sweden. The thesis adopts a regional perspective. Three of the four studies in the thesis are cross-sectional studies with data from Region Västmanland during twelve to fifteen years, 2003–2017. Data are also based on analyses of ten regional infrastructure plans in Sweden for the period 2014–2025.

On national roads in the region, the incidence of serious injuries decreased for car occupants, but on regional roads it increased. In urban areas the incidence for unprotected road users doubled on roads and more than doubled on tracks and pavements where the greatest number of unprotected road users are seriously injured. One factor in the increased incidence is the growing number of elderly people in the population caused by the large generation born in the 1940s and a lengthening lifespan. From 2012 the probability of being seriously injured increased for cyclists and pedestrians 80 years and older, and from 2015 for the group 65 years and older.

In urban areas during the period, there was a shift in serious injuries for pedestrians and cyclists from less head injuries to more injuries in lower extremities. The probability of receiving serious injuries to the lower extremities increased fourfold from the age of 50 for both pedestrians and cyclists, but for cyclists the probability increased with age.

For pedestrians, pavements and tracks were associated with decreased probability of all injuries except for head injuries, but for cyclists this decrease is only seen for the most severe injuries. For pedestrians, the probability of getting injuries in more than one bodily region decreased on Vision Zero roads.

Prioritized investments in regional plans are mostly justified by accessibility and increased walking and cycling, and only more sparsely by road safety. This reflects an imbalance in the government’s clarifications of the transport goals.

In directives for regional planning and in support of the objectives of Agenda 2030, the government has argued for more active mobility. There is a need to include pedestrian falls in the category of single crashes in the work with Vision Zero. Increased walking and cycling justifies more road safety measures especially in urban areas in order to achieve the targets of Vision Zero. To achieve Vision Zero it is important that the concerned road authorities and regions are committed to the goals and fulfil their tasks. More active mobility in combination with an increased number of older people is a challenge for municipalities as road authorities in urban areas.