Pedestrian exposure and the risk of child pedestrian injury

Redefining the child pedestrian safety paradigm: identifying high fatality concentrations in urban areas

OBJECTIVES

Child pedestrians are some of the most vulnerable users of our transportation systems, and they deserve particular attention when we consider traffic safety. The objective of this work is to identify urban locations in which child pedestrians are at particular risk for fatal collisions with vehicles.

METHODS

This paper examines 30 years of crash data for six American cities to locate areas with high child pedestrian fatality concentrations. Phase I of the study, which examines Denver, Colorado, USA, reveals higher concentrations of child pedestrian fatalities around parks as compared with other areas that children have been shown to frequent. In phase II of the study, we specifically examine fatality concentrations near parks as compared with schools.

RESULTS

Statistical analyses suggest that, once exposure is controlled for, child pedestrian fatalities concentrate around parks in densities 1.04-2.23 times higher than around schools. Also, the concentration of child pedestrian fatalities around parks is 1.16-1.81 times higher than the respective citywide concentration.

CONCLUSION

Traffic risks for children around parks deserve further examination as we pursue the goals of Vision Zero and child safety on our streets.

Can child-pedestrians' hazard perception skills be enhanced?

OBJECTIVE

Traffic collisions yield a substantial rate of morbidity and injury among child-pedestrians. We explored the formation of an innovative hazard perception training intervention - Child-pedestrians Anticipate and Act Hazard Perception Training (CA(2)HPT). Training was based upon enhancing participants' ability to anticipate potential hazards by exposing them to an array of traffic scenes viewed from different angles.

METHOD

Twenty-four 7-9-year-olds have participated. Trainees underwent a 40-min intervention of observing typical residential traffic scenarios in a simulated dome projection environment while engaging in a hazard detection task. Trainees were encouraged to note differences between the scenarios presented to them from separate angles (a pedestrian's point-of-view and a higher perspective angle). Next, trainees and control group members were required to perform crossing decision tasks.

RESULTS

Trainees were found to be more aware of potential hazards related to restricted field of view relative to control.

CONCLUSIONS

Child pedestrians are responsive to training and actively detecting materialized hazards may enrich child-pedestrians' ability to cross roads.

Motor-vehicle collisions involving child pedestrians at intersection and mid-block locations

We study motor-vehicle collisions involving child pedestrians walking to school in Hamilton, Ontario, Canada to understand and contrast collision risks at mid-block and intersection locations. We use a matched case-control study design and apply it to intersection and mid-block locations instead of people. Cases are intersections/mid-blocks where collisions occurred and controls are locations where collisions did not occur. We match cases to controls on geography, socio-economic status and year. We use conditional logistic regression to predict the log-odds of collision risk at intersections and mid-blocks as a function of various environmental measures while controlling for volume of child pedestrian activity. Our results suggest that child pedestrian injuries at intersections are associated with intersection control type, traffic volume, and land use characteristics. In contrast, mid-block child pedestrian collisions are not associated with small scale environmental features. The results of this study suggest that some factors associated with the risk of collision differ across location types. These findings may be useful in the planning of safer walking journeys to school.

Comparative analysis of trends in paediatric trauma outcomes in New South Wales, Australia

Paediatric trauma centres seek to optimise the care of injured children. Trends in state-wide paediatric care and outcomes have not been examined in detail in Australia. This study examines temporal trends in paediatric trauma outcomes and factors influencing survival and length of stay. A retrospective review was conducted using data from the NSW Trauma Registry during 2003-2008 for children aged 15 years and younger who were severely injured (injury severity score >15). To examine trauma outcomes descriptive statistics and multivariable logistic and linear regression were conducted. There were 1138 children severely injured. Two-thirds were male. Road trauma and falls were the most common injury mechanisms and over one-third of incidents occurred in the home. Forty-eight percent of violence-related injuries were experienced by infants aged less than 1 year. For the majority of children definitive care was provided at a paediatric trauma centre, but less than one-third of children were taken directly to a paediatric trauma centre post-injury. Children who received definitive treatment at a paediatric trauma centre had between 3 and 6 times higher odds of having a survival advantage than if treated at an adult trauma centre. The number of severe injury presentations to the 14 major trauma centres in NSW remains constant. It is possible that injury prevention measures are having a limited effect on severe injury in NSW. This research provides stimulus for change in the provision and co-ordination in the delivery of trauma care for injured children.

Neighborhood social inequalities in road traffic injuries: the influence of traffic volume and road design

OBJECTIVES

We examined the extent to which differential traffic volume and road geometry can explain social inequalities in pedestrian, cyclist, and motor vehicle occupant injuries across wealthy and poor urban areas.

METHODS

We performed a multilevel observational study of all road users injured over 5 years (n=19,568) at intersections (n=17,498) in a large urban area (Island of Montreal, Canada). We considered intersection-level (traffic estimates, major roads, number of legs) and area-level (population density, commuting travel modes, household income) characteristics in multilevel Poisson regressions that nested intersections in 506 census tracts.

RESULTS

There were significantly more injured pedestrians, cyclists, and motor vehicle occupants at intersections in the poorest than in the richest areas. Controlling for traffic volume, intersection geometry, and pedestrian and cyclist volumes greatly attenuated the event rate ratios between intersections in the poorest and richest areas for injured pedestrians (-70%), cyclists (-44%), and motor vehicle occupants (-44%).

CONCLUSIONS

Roadway environment can explain a substantial portion of the excess rate of road traffic injuries in the poorest urban areas.

Modelling the effects of land use and temporal factors on child pedestrian casualties

This study investigates the suitability of land use variables in predicting the number of child pedestrian casualties; a subject of concern in Great Britain despite sustained improvements in road safety over the past decade. The relationship between land use and transport is used to establish a link between land use and child pedestrian travel; trip attractors and generators are considered as variables that lead child pedestrians to exposure to high risk environments. Casualty records for Newcastle upon Tyne are analysed to reveal trends of temporal variation of child pedestrian casualty numbers. Land use data is combined with the casualty data using GIS techniques to generate relevant inputs for the analysis. Six Generalized Linear Models (GLMs) are developed to analyse the association of child pedestrian casualty numbers and trip attractor land use types. Two are the main models; the first investigates all types of casualty data including slight, serious and fatal events and the second uses only KSI (Killed or Seriously Injured) data in the analysis. The other four models are developed to investigate the temporal variation of child pedestrian KSI and slight casualties over the day (school time and non-school time) and week (weekday and weekend). The results show that secondary retail and high density residential land use types are associated with all child pedestrian casualties. In addition, educational sites, junction density, primary retail and low density residential land use types are also associated with child casualties at different time periods of the day and week. The study findings are found to concur with the current child road safety policies in Great Britain and will, in fact, provide some guidance for local authorities to deliver successful child road safety audits.

Epidemiology of child pedestrian casualty rates: can we assume spatial independence?

Child pedestrian injuries are often investigated by means of ecological studies, yet are clearly part of a complex spatial phenomena. Spatial dependence within such ecological analyses have rarely been assessed, yet the validity of basic statistical techniques rely on a number of independence assumptions. Recent work from Canada has highlighted the potential for modelling spatial dependence within data that was aggregated in terms of the number of road casualties who were resident in a given geographical area. Other jurisdictions aggregate data in terms of the number of casualties in the geographical area in which the collision took place. This paper contrasts child pedestrian casualty data from Devon County UK, which has been aggregated by both methods. A simple ecological model, with minimally useful covaraties relating to measures of child deprivation, provides evidence that data aggregated in terms of the casualty's home location cannot be assumed to be spatially independent and that for analysis of these data to be valid there must be some accounting for spatial auto-correlation within the model structure. Conversely, data aggregated in terms of the collision location (as is usual in the UK) was found to be spatially independent. Whilst the spatial model is clearly more complex it provided a superior fit to that seen with either collision aggregated or non-spatial models. Of more importance, the ecological level association between deprivation and casualty rate is much lower once the spatial structure is accounted for, highlighting the importance using appropriately structured models.

Education was associated with injuries requiring hospital admission

OBJECTIVES

We describe educational inequalities in the incidence of injuries resulting in hospital admission and explore the contribution of exposure variables and chronic diseases, alcohol consumption, and sedative use to the observed inequalities.

STUDY DESIGN AND SETTING

Data from the Dutch prospective GLOBE study were linked to the National Hospital Discharge Register after 7 years of follow-up.

RESULTS

Significantly higher hazard ratios (HRs) of traffic injuries in lower compared with higher educational groups were substantially reduced after adjustment for differences in the use of cars and mopeds between these groups. Significantly increased HRs in occupational, home, and sports (OHS) injuries in lower compared with higher educational groups were reduced after adjustment for higher prevalence rates of chronic diseases, very excessive alcohol consumption, and sedative use in lower educational groups.

CONCLUSION

Exposure variables, chronic diseases, alcohol consumption, and sedative use contribute to educational inequalities in traffic and OHS injuries resulting in hospital admission.

Urban sprawl as a risk factor in motor vehicle occupant and pedestrian fatalities

OBJECTIVES

We sought to determine the association between urban sprawl and traffic fatalities.

METHODS

We created a sprawl index by applying principal components analysis to data for 448 US counties in the largest 101 metropolitan areas. Regression analysis was used to determine associations between the index and traffic fatalities.

RESULTS

For every 1% increase in the index (i.e., more compact, less sprawl), all-mode traffic fatality rates fell by 1.49% (P <.001) and pedestrian fatality rates fell by 1.47% to 3.56%, after adjustment for pedestrian exposure (P <.001).

CONCLUSIONS

Urban sprawl was directly related to traffic fatalities and pedestrian fatalities. Subsequent studies should investigate relationships at a finer geographic scale and should strive to improve on the measure of exposure used to adjust pedestrian fatality rates.

Exposure to traffic among urban children injured as pedestrians

OBJECTIVES

To explore the immediate pre-crash activities and the routine traffic exposure (street crossing and play) in a sample of urban children struck by automobiles. In particular, the traffic exposure of children who were struck while playing was compared with that of those struck while crossing streets.

DESIGN

Cross sectional survey.

SETTING

Urban pediatric emergency department.

PATIENTS

A total of 139 children ages 4-15 years evaluated for acute injuries resulting from pedestrian-motor vehicle collisions during a 14 month period.

MAIN OUTCOME MEASURES

Sites of outdoor play, daily time in outdoor play, weekly number of street crossings, pre-crash circumstance (play v walking).

RESULTS

Altogether 39% of the children routinely used the street and 64% routinely used the sidewalks as play areas. The median number of street crossings per week per child was 27. There were no differences in exposures for the 29% who were hit while playing compared with the 71% who were hit while walking. Although 84% of the children walked to or from school at least one day per week, only 15% of the children were struck while on the school walking trip. The remainder were injured either while playing outdoors or while walking to other places.

CONCLUSIONS

Urban children who are victims of pedestrian crashes have a high level of traffic exposure from a variety of circumstances related to their routine outdoor playing and street crossing activities. The distributions of traffic exposures were similar across the sample, indicating that the sample as a whole had high traffic exposure, regardless of the children's activity preceding the crash. Future pedestrian injury programs should address the pervasive nature of children's exposure to traffic during their routine outdoor activities.

Assessment of hospital and police ascertainment of automobile versus childhood pedestrian and bicyclist collisions

Information about automobile versus pedestrian or bicyclist collisions differ according to the source of collision ascertainment. Hospital records and police reports focus on different characteristics of a collision, which reflects differences in case finding as well as information regarding risk factors. Pedestrians and bicyclists 0-14 years of age who were involved in a motor vehicle collision in the city of Long Beach, CA, between January 1, 1992 and June 30, 1995, were included in the study. Police reports and medical records were used to identify cases. Police reports were found for 1,015 cases, and medical records identified 474 cases; 379 cases were common to both sources. A capture-recapture model was used to evaluate the degree of overlap between the two sources and to derive "ascertainment corrected" injury rates. The injury rate from combined sources was 333.5/100,000 children per year, the pedestrian injury rate was 210.6/100,000 children per year and the bicyclist injury rate was 122.9/100,000 children per year. The "ascertainment corrected" injury rate overall was 381.3/100,000 children per year, 233.0/100,000 for pedestrians and 153.9/100,000 children per year for bicyclists. Eighty percent of hospital-reported cases were captured in the police database, whereas only 37% of police-reported cases were captured by the hospital database. We found that hospital sources identified younger children, fewer bicyclists, more Asian and Hispanic children, and fewer African-American children when compared to police sources. For more comprehensive surveillance resulting in more accurate incidence rates and more complete information, it is better to use multiple sources of data.

An evaluation of a suburban railway pedestrian crossing safety programme

This study evaluated a programme of educational and environmental (access prevention) interventions designed to reduce the incidence of illegal and unsafe crossing of the rail corridor at a suburban station in Auckland, New Zealand. Immediately after the programme of interventions, the proportion of those crossing the rail corridor by walking across the tracks directly rather than using the nearby overbridge had decreased substantially. Three months later, the decrease was even greater. However, the educational and environmental interventions were introduced simultaneously so that the effects of each could not be separated; nor could other unmeasured factors be ruled out. Anonymous surveys administered immediately before and 3 months after the interventions indicated that while awareness of the illegality of walking across the tracks had increased slightly, perception of risk had not changed. This suggests that the educational interventions may have had less effect than the access prevention measures.

Are child pedestrians at increased risk of injury on one-way compared to two-way streets?

OBJECTIVES

To compare child pedestrian injury rates on one-way versus two-way streets in Hamilton, and examine whether the characteristics of child pedestrian injuries differ across street types.

METHODS

The rates of injury per child population, per kilometre, per year were calculated by age, sex and socio-economic status (SES). Child, environment and driver characteristics were investigated by street type.

RESULTS

The injury rate was 2.5 times higher on one-way streets than on two-way streets and 3 times higher for children from the poorest neighbourhoods than for those from wealthier neighbourhoods. SES, injury severity, number of lanes, collision location and type of traffic control were also found to be significantly different across street types.

CONCLUSIONS

One-way streets have higher rates of child pedestrian injuries than two-way streets in this community. Future risk factor and intervention studies should include the directionality of streets to further investigate its contribution to child pedestrian injuries.

Associations between road traffic accidents and socio-economic deprivation on Scotland's west coast

Road traffic accidents (RTAs) are declining, but remain a public health concern locally and world-wide. Scottish RTAs killed 316 people and injured over 20,000 in 1996. By 2020, they are predicted to become the world's third-leading cause of sickness and death. Little is know about associations between RTAs and deprivation; it has never been explored on Scotland's West Coast. This study analysed hospital A&E admissions and investigated associations between RTAs and socio-economic status. 1,300 attendance records at a 575-bed NHS Trust Accident & Emergency in North Lanarkshire were reviewed and 1,020 records analysed in conjunction with Health Board socio-economic data. Findings strongly suggest (p = 0.00461) a positive trend between RTA activity and deprivation. Significance held for gender, victim role, purpose of journey and age, except for drivers 60 and over. Given the preventative nature of RTAs and their contribution to morbidity and mortality, further research between RTAs and deprivation is suggested.

A review of risk factors for child pedestrian injuries: are they modifiable?

PURPOSE

To identify modifiable risk factors for child pedestrian injuries.

DATA SOURCES

(1) MEDLINE search from 1985 to 1995; search term used was traffic accidents; (2) review of reference lists from retrieved articles and books; (3) review of reference lists from three systematic reviews on childhood injuries and (4) consultation with 'key informants'.

STUDY SELECTION

All studies that examined the risk factors for child pedestrian injuries were targeted for retrieval. Seventy potentially relevant articles were identified using article titles, and, when available, abstracts. Of the 70 retrieved articles, 44 were later assessed as being relevant.

QUALITY ASSESSMENT

Articles were classified on the basis of study design as being either descriptive (hypothesis generating) (26) or analytical (hypothesis testing) (18) studies. Consensus was used for difficult to classify articles.

DATA EXTRACTION

Variables judged to be risk factors for child pedestrian injuries were extracted by one author.

DATA SYNTHESIS

A qualitative summary of the information extracted from relevant articles is presented in tabular form.

RESULTS

Risk factors for child pedestrian injuries were classified as: (1) child, (2) social and cultural, (3) physical environment, and (4) driver. Risk factors within each classification are summarized and discussed.

A case-control study of child bicycle injuries: relationship of risk to exposure

In order to assess the relationship of the risk of injury requiring hospital attendance in children riding bicycles to sociodemographic factors and to measures of exposure, a population-based case-control study is being undertaken in a large area of suburban Melbourne, Australia. Particular attention is given to the measurement of individual exposure in several dimensions. Analysis of interim data from 109 cases and 118 controls shows that 51% of injuries occurred while the child was playing rather than making a trip on the bicycle and only 22% involved another vehicle. Boys used bicycles more commonly than girls but there was minimal evidence of an increased risk of injury in boys, adjusting for exposure. There was no evidence for an age trend in injury risk, but children from families in the lowest income category were at significantly increased risk. Exposure measures showed complex patterns of association with injury risk. Estimated time spent riding was more closely associated with risk than distance travelled, with an odds ratio of 2.2 (95% confidence interval 1.1-4.2) for children riding for more than 3 hours per week compared to children riding less than 1 hour. Riding more than 5 km on the sidewalk was also associated with increased risk (odds ratio 3.1, 95% CI 1.1-8.5). The elevated risk associated with sidewalk riding may be due to difficulties in negotiating uneven surfaces. The case-control study provides an ideal design for this type of investigation but valid and reliable measurement of exposure is difficult.

Social policy as a cause of childhood accidents: the children of lone mothers

Almost one in five British mothers is a lone mother. Their children have injury rates that are twice those of children in two parent families. In this article the link between lone parenthood and childhood injury is examined. The increased injury rates for the children of lone mothers can be explained by the poverty, poor housing conditions, and social isolation of lone mothers in Britain. The problem of reconciling the demands of paid work with the demands of the unpaid work of childrearing is particularly difficult for lone mothers, who find themselves in a benefit dependent poverty trap. Many such mothers would seek paid work if affordable day care were available. Day care would also provide a safe environment for their children, who are otherwise exposed to the environmental hazards of poor housing. Provision of day care is a social policy that would have important effects on the health and welfare of lone mothers and their children. These effects deserve to be properly evaluated.

Methodologic issues in injury case-control studies

In this paper some methodological problems particularly relevant to case-control studies of injury are illustrated by reference to previous childhood injury case-control studies. In contrast to studies of disease, where 'person time' constitutes the observational experience of interest, in injury studies person time engaged in a particular activity to often more appropriate. The implications for the definition of the study base are discussed. The potential for hospital admission bias in injury case-control studies is considered along with potential strategies for avoiding it. The importance of errors in exposure measurement, including those arising from inappropriate induction time assumptions, are illustrated. Finally, the potential for bias resulting from the combination of etiologically unrelated injury outcomes into a single outcome measure is illustrated and discussed.