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

Pediatric Pedestrian Injuries: Striking Too Close to Home

BACKGROUND

Pediatric pedestrian injuries (PPI) are a major public health concern. This study utilized geospatial analysis to characterize the risk and injury severity of PPI.

METHODS

A retrospective chart review of PPI patients (age < 18) from a level 1 trauma center was performed (2013-2020). A geographic information system geocoded injury location to home and other public landmarks. Incidents were aggregated to zip codes and the Local Indicators of Spatial Association statistic tested for spatial clustering of injury rates per 10,000 children. Predictors for increased injury severity were assessed by logistic regression.

RESULTS

PPI encompassed 6% (n = 188) of pediatric traumas. Most patients were black (54%), male (58%), >13 years (56%), and with Medicaid insurance (68%). Nine zip codes comprised a statistically significant cluster of PPI. Nearly half (40%) occurred within a quarter mile of home; 7% occurred at home. Most (65%) PPI occurred within 1 mile of a school, and 45% occurred within a quarter mile of a park. Nearly all (99%) PPI occurred within a quarter mile of a major intersection and/or roadway. Using admission to ICU as a marker for injury severity, farther distance from home (OR 1.060, 95% CI 1.001-1.121, p = 0.045) and age <13 years (3.662, 95% CI 1.854-7.231, p < 0.001) were independent predictors of injury severity.

CONCLUSIONS

There are significant sociodemographic disparities in PPI. Most injuries occur near patients' homes and other public landmarks. Multidisciplinary injury prevention collaboration can help inform policymakers, direct local safety programs, and provide a model for PPI prevention at the national level.

LEVEL OF EVIDENCE

Level IV.

Traffic Accidents in Children and Adolescents: A Complex Orthopedic and Medico-Legal Approach

Traffic accidents involving children and adolescents present complex challenges from both the medico-legal and orthopedic standpoints. Despite the implementation of road traffic safety laws, pediatric road traffic injuries continue to be a significant contributor to mortality rates, physical harm, and hospitalization on a global scale. For children and young people, automobile accidents are considered to be the primary culprit of mortality in developed nations. Even in highly developed nations, trauma is a significant factor in infant mortality. Each age category, from childhood to young adulthood, has its fracture patterns, as their skeletons are considerably different from those of adults. The consequences of traffic accidents extend beyond the immediate physical trauma. The medico-legal aspects surrounding these incidents add another layer of complexity, as legal repercussions may affect the responsible adult or parent, particularly in cases involving child fatalities. To effectively address traffic accidents in children and adolescents, a comprehensive approach is necessary. This approach should involve not only medical professionals but also legal experts and policymakers. Collaboration between orthopedic specialists, medico-legal professionals, law enforcement agencies, and relevant government bodies can facilitate the development and implementation of strategies aimed at prevention, education, the enforcement of traffic laws, and improved infrastructure. By addressing both the medical and legal aspects, it is possible to enhance road safety for children and adolescents, reducing the incidence of injuries and their associated long-term consequences. In this review, we aimed to summarize traffic accidents in children and adolescents from a complex orthopedic and medico-legal approach.

An Examination of Child Pedestrian Rule Compliance at Crosswalks around Parks in Montreal, Canada

This study aims to examine child pedestrian safety around parks by considering four rule-compliance measures: temporal, spatial, velocity and visual search compliance. In this regard, street crossing observations of 731 children were recorded at 17 crosswalks around four parks in Montreal, Canada. Information on child behaviors, road features, and pedestrian-vehicle interactions were gathered in three separate forms. Chi-square tests were used to highlight the individual, situational, behavioral and road environmental characteristics that are associated with pedestrian rule compliance. About half of our sampled children started crossing at the same time as the adults who accompanied them, but more rule violations were observed when the adult initiated the crossing. The child's gender did not have a significant impact on rule compliance. Several variables were positively associated with rule compliance: stopping at the curb before crossing, close parental supervision, and pedestrian countdown signals. Pedestrian-car interaction had a mixed impact on rule compliance. Overall, rule compliance among children was high for each of our indicators, but about two-thirds failed to comply with all four indicators. A few measures, such as longer crossing signals and pedestrian countdown displays at traffic lights, may help to increase rule compliance and, ultimately, provide safer access to parks.

Traffic as a Barrier to Walking Safely in the United States: Perceived Reasons and Potential Mitigation Strategies

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Almost a quarter of US adults perceive traffic as a barrier to safe walking.

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Vehicle speed is the leading perceived traffic characteristic of concern.

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Respondents perceive sidewalks as the most favorable strategy to mitigate risk.

Motor vehicle traffic is commonly cited as a barrier to walking, but national level perceptions of traffic characteristics that negatively influence walking and potential traffic mitigation strategies remain unclear. The objectives of this study were to describe perceptions of (1) traffic characteristics that make walking unsafe in the United States and (2) potential mitigation strategies to address these concerns among those who report traffic as a barrier to walking. Data were from FallStyles, a nationwide internet panel survey conducted in October 2019 (n = 3,284 adults). Respondents reported if traffic makes walking unsafe where they live; those who answered yes were then asked about traffic characteristics that make walking unsafe (number of vehicles, speed of vehicles, distracted or impaired driving, types of vehicles, and other reasons) and potential mitigation strategies (new or improved sidewalks, crosswalks, pedestrian signals, street lighting, things that slow vehicles down, separating the sidewalk from the road, fewer vehicle lanes, and other). Prevalence of responses was assessed overall and by select sociodemographic and geographic characteristics, and by walking status. Nearly 25% of US adults reported that traffic is a barrier to walking where they live. Of these, 79% selected vehicle speed as a contributing traffic characteristic, and 57% indicated new or improved sidewalks as a potential mitigation strategy. These top responses were shared across all sociodemographic, geographic, and walking behavior subgroups. Speed reduction efforts and built environment enhancements such as sidewalks may alleviate pedestrian safety concerns. Promotion campaigns may be needed to bring awareness to such changes.

Pediatric Traffic Injuries on Halloween in the United Kingdom: Prevalence and Injury Severity

The study results serve as a reminder for parents, children, and drivers to be alert to the danger of traffic crashes on Halloween. The aim of this study was to examine whether Halloween is associated with a higher incidence of traffic injuries and whether traffic injuries sustained on Halloween are more severe than those sustained on other days. The U.K. STATS19 database, including the data of all road traffic crashes occurring from 1990 to 2017, was employed. A total of 73,587 pediatric traffic casualties (involving pedestrians, cyclists, and moped riders) were included. Between 17:00 and 19:00 (17:00~18:59) on Halloween, the number of casualties was higher than that on other public holidays and usual days. The logistic regression model revealed that, between 17:00 and 18:00 (17:00~17:59), the risk of being killed or seriously injured on Halloween was 34.2% higher (odds ratio = 1.342; 95% CI = 1.065–1.692) than that on other days. Pediatric crashes occurring on Halloween are associated with a higher number of injuries and increased injury severity.

Understanding Sex Differences in Children's Injury Risk as Pedestrians

OBJECTIVE

Boys experience more injuries as pedestrians than girls. The aim of this study was to compare how boys and girls cross streets in order to identify factors that differentially influence their injury risk as pedestrians.

METHODS

Using a fully immersive virtual reality (VR) system interfaced with a 3D movement measurement system, various measures of children's street-crossing behaviors were taken.

RESULTS

At the start of the crossing, boys selected smaller (riskier) inter-vehicle gaps to cross into than girls. Subsequently, as they crossed, they showed greater attention to traffic, shorter start delay, and more evasive action than girls, which are strategies that could reduce risk as a pedestrian. Despite these efforts, however, boys experienced more hits and close calls than girls.

CONCLUSION

To enhance their safety as pedestrians, girls adopt a proactive approach and select larger inter-vehicle gaps to cross into, whereas boys apply a reactive approach aimed at managing the risk created by having selected smaller (riskier) gaps. Girls' proactive approach yielded safer outcomes than boys' reactive strategy.

Children's fear in traffic and its association with pedestrian decisions

INTRODUCTION

Research on risk for child pedestrian injury risk focuses primarily on cognitive risk factors, but emotional states such as fear may also be relevant to injury risk. The current study examined children's perception of fear in various traffic situations and the relationship between fear perception and pedestrian decisions.

METHOD

150 children aged 6-12-years old made pedestrian decisions using a table-top road model. Their perceived fear in the pedestrian context was assessed.

RESULTS

Children reported greater emotional fear when they faced quicker traffic, shorter distances from approaching traffic, and red rather than green traffic signals. Children who were more fearful made safer pedestrian decisions in more challenging traffic situations. However, when the least risky traffic situation was presented, fear was associated with more errors in children's pedestrian decisions: fearful children failed to cross the street when they could have done so safely. Perception of fear did not vary by child age, although safe pedestrian decisions were more common among the older children.

CONCLUSIONS

Children's emotional fear may predict risk-taking in traffic. When traffic situations are challenging to cross within, fear may appropriately create safer decisions. However, when the traffic situation is less risky, feelings of fear could lead to excessive caution and inefficiency. Practical applications: Child pedestrian safety interventions may benefit by incorporating activities that introduce realistic fear of traffic risks into broader safety lessons.

State-of-the-art review: preventing child and youth pedestrian motor vehicle collisions: critical issues and future directions

Aim

To undertake a comprehensive review of the best available evidence related to risk factors for child pedestrian motor vehicle collision (PMVC), as well as identification of established and emerging prevention strategies.

Methods

Articles on risk factors were identified through a search of English language publications listed in Medline, Embase, Transport, SafetyLit, Web of Science, CINHAL, Scopus and PsycINFO within the last 30 years (~1989 onwards).

Results

This state-of-the-art review uses the road safety Safe System approach as a new lens to examine three risk factor domains affecting child pedestrian safety (built environment, drivers and vehicles) and four cross-cutting critical issues (reliable collision and exposure data, evaluation of interventions, evidence-based policy and intersectoral collaboration).

Conclusions

Research conducted over the past 30 years has reported extensively on child PMVC risk factors. The challenge facing us now is how to move these findings into action and intervene to reduce the child PMVC injury and fatality rates worldwide.

Prevalence of distracted walking with mobile technology: an observational study of Calgary and Edmonton high school students

OBJECTIVES

Distracted walking poses a safety concern while crossing roads. A 2014 Canadian survey showed that 51% of teenagers were hit or almost hit while crossing the street, many of whom were distracted by mobile technology. An American study demonstrated that 1 in 5 high school students engaged in distracted walking; however, prevalence estimates in Canada have not been described. This study aimed to obtain a prevalence estimate of distracted walking in high school students in Calgary and Edmonton, Alberta, Canada.

METHODS

Students were observed crossing the street at 20 high schools following afternoon school dismissal times during September to November 2017. Behaviours included talking on mobile phone, using earbuds, looking down at phone, and engaging in more than one of these behaviours. Also recorded were median household income of surrounding neighbourhood, outside temperature, gender, and crosswalk type.

RESULTS

A total of 3553 students were observed, with 666 engaged in distracted walking (18.7%). Females engaged in distracted walking more than males (19.9% vs. 17.6%, respectively). The most prevalent behaviour was using earbuds (66.5%). Males had a lower prevalence of distracted walking compared with females. Distracted walking was more prevalent when the temperature was above 10 °C compared with less than 0 °C and less prevalent at signaled compared with non-signaled intersections.

CONCLUSION

This study demonstrates that approximately 1 in 5 high school students in Calgary and Edmonton, Alberta, Canada, engage in distracted walking behaviours while crossing the street. These results may help raise awareness and inform policy to decrease risk of pedestrian injury.

Child pedestrian behaviors: Influence of peer social norms and correspondence between self-reports and crossing behaviors

OBJECTIVE

The aims of this study were to determine if children's perception of peers' behavioral norms for crossing streets relates to their personal norms for doing so and if children's self-reports about crossing relates to their actual crossing in a virtual traffic situation.

METHOD

Children (8-10 years, N = 86) completed questionnaires about peer's norms and their personal norms about crossing streets, and also reported on their recent crossing behaviors. These self-reports about crossing were then related to children's actual crossing behaviors measured using a fully immersive virtual reality (VR) system.

RESULTS

Children's perception of peers' behavioral norms for crossing related to their personal norms for doing so, and their norms related to their reports of how they have crossed in the past few weeks. When crossing virtual streets, children with higher scores on self-reports about risky crossing behaviors selected smaller (riskier) inter-vehicle gap sizes to cross into, showed less start delay (less time appraising traffic before starting), and experienced more hits. Conclusion and practicalapplications: Children's perception of peers' behavioral norms for crossing are relevant to their crossing behaviors and may be one way that peers elevate children's risk of pedestrian injury. Children's self-reports about crossing risk may be useful for identifying at-risk youth and strategically targeting interventions to these children.

National Safe Routes to School program and risk of school-age pedestrian and bicyclist injury

PURPOSE

Safe Routes to School (SRTS) was a federally funded transportation program for facilitating physically active commuting to and from school in children through improvements of the built environment. There is evidence that SRTS programs increase walking and bicycling in school-age children, but their impact on pedestrian and bicyclist safety has not been adequately examined. We investigate the impact and effects of the SRTS program on school-age pedestrian and bicyclist injuries in a nationwide sample in the United States.

METHODS

Data were crash records for school-age children (5-19 years) and adults (30-64 years), in 18 U.S. states for a 16-year period (1995-2010). Multilevel negative binomial models were used to examine the association between SRTS intervention and the risk of pedestrian and bicyclist injury in children aged 5-19 years.

RESULTS

SRTS was associated with an approximately 23% reduction (incidence rate ratio = 0.77, 95% confidence interval = 0.65-0.92) in pedestrian/bicyclist injury risk and a 20% reduction in pedestrian/bicyclist fatality risk (incidence rate ratio = 0.80, 95% confidence interval = 0.68-0.94) in school-age children compared to adults aged 30-64 years.

CONCLUSIONS

Implementation of the SRTS program appears to have contributed to improving traffic safety for school-age children in the United States.

Pedestrian injuries in children: who is most at risk?

INTRODUCTION

This study evaluates the demographics of paediatric pedestrian injuries with the aim of identifying the group of children who is most vulnerable and the risk factors for major trauma (MT).

METHODS

Data was extracted from the integrated trauma system of a regional paediatric referral hospital. All paediatric cases involving road traffic accidents from January 2011 to December 2013 were studied. Demographics, injury mechanism, treatment and outcome were evaluated. Patients were categorised as MT or non-MT (NMT) based on their Injury Severity Score, admission to the intensive care unit, type of surgery (e.g. life/limb-saving) and death. Data analysis was done using nonparametric tests and Fisher's exact test.

RESULTS

A total of 261 children were admitted for pedestrian injuries during the study period. The median age was ten years (range 14 months-16 years) and the median weight was 42.4 (range 8.6-93.7) kg. Half (i.e. 50.2%) of the children were primary-schoolers. The majority of the accidents occurred on roads (i.e. 83.1%), between 12 pm and 6 pm (i.e. 52.8%). Among the 261 children, 177 (67.8%) were unaccompanied by an adult at the time of the accident; 17 (6.5%) children sustained MT, while 244 (93.5%) suffered NMT. MT patients were more likely to have lost consciousness (p < 0.001) and been flung (p = 0.001).

CONCLUSION

Most paediatric pedestrian injuries involved primary-schoolers walking home from school unaccompanied by adults. This information should inform future road safety campaigns. Being flung and loss of consciousness predicted MT in children who sustained pedestrian injuries.

Using a Virtual Environment to Examine How Children Cross Streets: Advancing Our Understanding of How Injury Risk Arises

PURPOSE

To examine how risk of injury can arise for child pedestrians.

METHODS

Using a highly immersive virtual reality system interfaced with a 3-D movement measurement system, younger (M = 8 years) and older (M = 10 years) children's crossing behaviors were measured under conditions that introduced variation in vehicle speed, distance, and intervehicle gaps.

RESULTS

Children used distance cues in deciding when to cross; there were no age or sex differences. This increased risk of injury in larger intervehicle gaps because they started late and did not monitor traffic or adjust walking speed as they crossed. In contrast, injury risk in smaller intervehicle gaps of equal risk (i.e., same time to contact) occurred because crossing behavioral adjustments (starting early, increasing walking speed while crossing) were not sufficient.

CONCLUSIONS

Dependence on distance cues increases children's risk of injury as pedestrians when crossing in a variety of traffic situations.

Association of the Safe Routes to School program with school-age pedestrian and bicyclist injury risk in Texas

Background

Safe Routes to School (SRTS) is a federally funded transportation program for facilitating physically active commuting to and from school in children through improvements of the built environment, such as sidewalks, bicycle lanes, and safe crossings. Although it is evident that SRTS programs increase walking and bicycling in school-age children, their impact on pedestrian and bicyclist injury has not been adequately examined.

Methods

We analyzed quarterly traffic crash data between January 2008 and June 2013 in Texas to assess the effect of the SRTS program implemented after 2009 on school-age pedestrian and bicyclist injuries.

Results

The annualized rates of pedestrian and bicyclist injuries between pre- and post-SRTS periods declined 42.5% (95% confidence interval (CI) 39.6% to 45.4%) in children aged 5 to 19 years and 33.0% (95% CI 30.5% to 35.5%) in adults aged 30 to 64 years. Negative binomial modeling revealed that SRTS intervention was associated with a 14% reduction in the school-age pedestrian and bicyclist injury incidence rate ratio (IRR 0.86, 95% CI 0.75 to 0.98). The effect of the SRTS intervention on pedestrian and bicyclist fatalities was similar though smaller in magnitude and was not statistically significant (adjusted IRR 0.90, 95% CI 0.67 to 1.21).

Conclusions

These results indicate that the implementation of the SRTS program in Texas may have contributed to declines in school-age pedestrian and bicyclist injuries.

Risk of fatal unintentional injuries in children by migration status: a nationwide cohort study with 46 years' follow-up

BACKGROUND

Injuries are responsible for much child and adolescent mortality in the world.

OBJECTIVE

To study the effect of parental birth country on the risk of fatal unintentional injuries.

METHODS

We established a cohort by linkages between Swedish national registers through personal identification number. The main variable was country of birth of parents. Children with both parents born in Sweden were the reference group. The cohort was followed up from the starting date of the study (1 January 1961) or date of birth, whichever occurred last, until the exit date, which was death due to unintentional injury, first emigration or end of the follow-up (31 December 2007), whichever came first. We calculated HRs with 95% CIs adjusted for age at exit, parental education and calendar period of birth by Cox proportional hazards models.

RESULTS

We found a significantly higher risk of fatal unintentional injuries among children with a foreign background than among native children. We found a higher risk of fatal transportation-related injuries and drowning among boys with a foreign background and a higher risk of fatal burns/fire and falls among girls with a foreign background than among same sex native children. We also found a higher risk of fatal unintentional injuries among children with a foreign background at older ages than among native children at the same ages.

CONCLUSIONS

Injury prevention work against unintentional injuries among children of foreign origin is more complex than that among native children. We recommend designing specific studies to find out the factors responsible and planning preventive interventions aiming at this particular group of children with a foreign background.

Parental educational level and injury incidence and mortality among foreign-born children: a cohort study with 46 years follow-up

Background:

Injury risk during childhood and adolescence vary depending on socio-economic factors. The aim of this study was to study if the risk of fatal and non-fatal unintentional injuries among foreign-born children was similar across parental educational level or not.

Methods:

In this retrospective cohort study we followed 907,335 children between 1961 and 2007 in Sweden. We established the cohort by linkage between Swedish national registers including cause of death register and in-patient register, through unique Personal Identification Numbers. The main exposure variable was parental (maternal and paternal) educational level. The cohorts was followed from start date of follow-up period, or date of birth whichever occurred last, until exit date from the cohort, which was date of hospitalization or death due to unintentional injury, first emigration, death due to other causes than injury or end of follow-up, whichever came first. We calculated hazard ratios (HR) with 95% confidence intervals (95% CI) by Cox proportional hazards regression models.

Results:

Overall, we found 705 and 78,182 cases of death and hospitalization due to unintentional injuries, respectively. Risk of death and hospitalization due to unintentional injuries was statistically significantly 1.48 (95% CI: 1.24-1.78) and 1.10 (95% CI: 1.08-1.12) times higher among children with lowest parental educational level (9 years and shorter years of study) compared to children with highest parental educational level (+13 years of study). We found similar results when stratified our study group by sex of children, by maternal and paternal educational level separately, and injury type (traffic-related, fall, poisoning, burn and drowning).

Conclusions:

It seems injury prevention work against unintentional injuries is less effective among children with low parental education compared with those with higher parental education. We recommend designing specific preventive interventions aiming at children with low parental education.

Development and validation of a 10-year-old child ligamentous cervical spine finite element model

Although a number of finite element (FE) adult cervical spine models have been developed to understand the injury mechanisms of the neck in automotive related crash scenarios, there have been fewer efforts to develop a child neck model. In this study, a 10-year-old ligamentous cervical spine FE model was developed for application in the improvement of pediatric safety related to motor vehicle crashes. The model geometry was obtained from medical scans and meshed using a multi-block approach. Appropriate properties based on review of literature in conjunction with scaling were assigned to different parts of the model. Child tensile force–deformation data in three segments, Occipital-C2 (C0–C2), C4–C5 and C6–C7, were used to validate the cervical spine model and predict failure forces and displacements. Design of computer experiments was performed to determine failure properties for intervertebral discs and ligaments needed to set up the FE model. The model-predicted ultimate displacements and forces were within the experimental range. The cervical spine FE model was validated in flexion and extension against the child experimental data in three segments, C0–C2, C4–C5 and C6–C7. Other model predictions were found to be consistent with the experimental responses scaled from adult data. The whole cervical spine model was also validated in tension, flexion and extension against the child experimental data. This study provided methods for developing a child ligamentous cervical spine FE model and to predict soft tissue failures in tension.

Risk factors associated with injury and mortality from paediatric low speed vehicle incidents: a systematic review

Objective. This study reviews modifiable risk factors associated with fatal and nonfatal injury from low-speed vehicle runover (LSVRO) incidents involving children aged 0–15 years. Data Sources. Electronic searches for child pedestrian and driveway injuries from the peer-reviewed literature and transport-related websites from 1955 to 2012. Study Selection. 41 studies met the study inclusion criteria. Data Extraction. A systematic narrative summary was conducted that included study design, methodology, risk factors, and other study variables. Results. The most commonly reported risk factors for LSVRO incidents included age under 5 years, male gender, and reversing vehicles. The majority of reported incidents involved residential driveways, but several studies identified other traffic and nontraffic locations. Low socioeconomic status and rental accommodation were also associated with LSVRO injury. Vehicles were most commonly driven by a family member, predominantly a parent. Conclusion. There are a number of modifiable vehicular, environmental, and behavioural factors associated with LSVRO injuries in young children that have been identified in the literature to date. Strategies relating to vehicle design (devices for increased rearward visibility and crash avoidance systems), housing design (physical separation of driveway and play areas), and behaviour (driver behaviour, supervision of young children) are discussed.

Spatial environmental risk factors for pedestrian injury collisions in Ciudad Juárez, Mexico (2008-2009): implications for urban planning

The aim of this study is to examine the spatial distribution of pedestrian injury collisions and analyse the environmental (social and physical) risk factors in Ciudad Juarez, Mexico. More specifically, this study investigates the influence of land use, density, traffic and socio-economic characteristics. This cross sectional study is based on pedestrian injury collision data that were collected by the Municipal Transit Police during 2008-2009. This research presents an analysis of vehicle-pedestrian collisions and their spatial risk determinants using mixed methods that included (1) spatial/geographical information systems (GIS) analysis of pedestrian collision data and (2) ordinary least squares (OLS) regression analysis to explain the density of pedestrian collisions data. In our model, we found a higher probability for pedestrian collisions in census tracts with population and employment density, large concentration of commercial/retail land uses and older people (65 and more). Interventions to alleviate this situation including transportation planning such as decentralisation of municipal transport system, investment in road infrastructure - density of traffic lights, pedestrian crossing, road design, improves lane demarcation. Besides, land use planning interventions should be implemented in commercial/retail areas, in particular separating pedestrian and vehicular spaces.

Are current law enforcement strategies associated with a lower risk of repeat speeding citations and crash involvement? A longitudinal study of speeding Maryland drivers

PURPOSE

To determine whether traffic court appearances and different court verdicts were associated with risk of subsequent speeding citations and crashes.

METHODS

A cohort of 29,754 Maryland drivers ticketed for speeding who either went to court or paid fines by mail in May/June 2003 was followed for 3 years. Drivers appearing in court were categorized by verdicts: 1) not guilty, 2) suspension of prosecution/no prosecution (STET/NP), 3) case dismissed, 4) probation before judgment (PBJ) and fines, or 5) fines and demerit points. Cox proportional hazard models were used to estimate adjusted hazard ratios (AHR).

RESULTS

Court appearances were associated with lower risk of subsequent speeding citations (AHR = 0.92; 95% confidence interval [CI], 0.88-0.96), but higher risk of crashes (AHR = 1.25; 95% CI, 1.16-1.35). PBJ was associated with significantly lower repeat speeding tickets (AHR = 0.83; 95% CI, 0.75-0.91) and a non-significant decrease in crashes (AHR = 0.87; 95% CI, 0.75-1.02). Both repeat speeding tickets and subsequent crashes were significantly lower in the STET/NP group.

CONCLUSIONS

PBJ and STET/NP may reduce speeding and crashes, but neither verdict eliminated excess crash risk among drivers who choose court appearances. Randomized, controlled evaluations of speeding countermeasures are needed to inform traffic safety policies.

Current trends and update on injury prevention

Injuries are a major and growing public health problem, a leading cause of death and disabilities among people aged 1-44 years around the world. Each year, 5.8 million people die from injuries, accounting for 10% of the world's deaths. Road traffic injuries (RTIs), self-inflicted injuries and violence are the top three leading causes of all injury deaths, while RTIs, falls and drowning are the top three leading causes of unintentional injury death. In many high-income countries, trends of injury death have been decreasing as a result of prevention measures. In contrast, trends in low- and middle-income countries have been rising. In this article, we review the prevention strategies for RTIs, violence, falls and drowning developed over decades to disseminate the knowledge and inform health care providers, especially acute care physicians, about the importance of injury prevention.

Exploring differential trends in severe and fatal child pedestrian injury in New South Wales, Australia (1997-2006)

The study explores trends in severe and fatal child pedestrian injuries in New South Wales (NSW), over the 10-year period 1997-2006, in comparison to adults and for various subgroups. Data on pedestrian injury (reported as fatalities or hospitalisations) were obtained from the Traffic Accident Database System (TADS; Roads and Traffic Authority of New South Wales) which captures road traffic events reported to police, and from the NSW Admitted Patients Data Collection (APDC) which captures all hospital inpatient separations. Annual percentage changes in injury counts and rates were compared using Poisson regression. A substantial drop in the pedestrian injury rate was observed; however, the rate of decline was steeper for children (aged less than 15 years) than for adults. The drop in child pedestrian injury was manifest in both the police report data and the hospital admission data. The annual percentage decrease was significantly greater for boys than for girls, and the three major urban centres compared with elsewhere in the state. No differences were detected in the annual rate decrease between school days and non-school days (a proxy for safe school zones), or between different road types (a proxy for restricted speed limits). Past research suggests that injury rate reductions are not solely due to decreased exposure. There remains, however, limited data on the extent of pedestrian mobility. Differences in relative reduction in pedestrian injury rates suggest a differential benefit arising from road safety initiatives.

Lasting effects of short-term training on preschoolers' street-crossing behavior

Can short-term training improve preschoolers' knowledge of road-crossing concepts as well as behavior in a real traffic situation? Forty children, aged four to five years, were assigned to one of four conditions (game, story, song, and control). Each condition participated in four 15-min classroom-based lessons over four weeks. Two assessments measuring knowledge of street-crossing concepts and one assessment measuring behavior on a real street were used to evaluate performance at baseline and one week and six months post-training. Children in all three experimental conditions showed a significant improvement over the control on the two conceptual assessments. Only children in the game condition significantly improved their behavior on the street-crossing assessment. Furthermore, children in all three experimental conditions retained the same levels of improvement at the six-month follow-up. These results demonstrate that one hour of training can create lasting improvements on preschool children's conceptual knowledge of traffic safety and road-crossing behavior on a real street.

An area-level model of vehicle-pedestrian injury collisions with implications for land use and transportation planning

There is growing awareness among urban planning, public health, and transportation professionals that design decisions and investments that promote walking can be beneficial for human and ecological health. Planners need practical tools to consider the impact of development on pedestrian safety, a key requirement for the promotion of walking. Simple bivariate models have been used to predict changes in vehicle-pedestrian injury collisions based on changes in traffic volume. We describe the development of a multivariate, area-level regression model of vehicle-pedestrian injury collisions based on environmental and population data in 176 San Francisco, California census tracts. Predictor variables examined included street, land use, and population characteristics, including commute behaviors. The final model explained approximately 72% of the systematic variation in census-tract vehicle-pedestrian injury collisions and included measures of traffic volume, arterial streets without transit, land area, proportion of land area zoned for neighborhood commercial and residential-neighborhood commercial uses, employee and resident populations, proportion of people living in poverty and proportion aged 65 and older. We have begun to apply this model to predict area-level change in vehicle-pedestrian injury collisions associated with land use development and transportation planning decisions.

Jumping off and being careful: children's strategies of risk management in everyday life

This article addresses the complexity of children's risk landscapes through an ethnography of 10- to 12-year-old Danish children. The data revealed how children individually and collectively engaged with risk in their everyday activities. The children assessed risks in relation to their perceptions of their health as strength and control, negotiated the conditions of playing, and attuned their responses to situations of potential social and physical conflict. In the paper this risk engagement is illustrated in a variety of contexts: children's decisions to wear or not to wear a bicycle helmet; playing and games and routine pushing and shoving at school. In looking after themselves, children negotiate rules of participation and they safeguard personal and collective interests. Gender differences in these processes are addressed and discussed. The article argues that risk engagement is an important resource through which children also learn from their own mistakes. This is a necessary learning process when children engage with their personal health and safety. The article critically discusses different sociological frameworks and shows the significance of the study for the growing literature on understanding the meaning of risk in childhood.

United States pedestrian fatality rates by vehicle type

OBJECTIVE

To describe the relation between motor vehicle type and the risk of fatally injuring a pedestrian.

DESIGN

The risk of killing a pedestrian was measured as the number of pedestrian fatalities per billion miles of vehicle travel by each vehicle type in the US in 2002 as reported by the National Highway Traffic Safety Administration's Fatality Analysis Reporting System.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Rates for each vehicle type by sex, age, and rural/urban roadway type and rate comparisons using relative risks (RR) and 95% confidence intervals (CIs).

RESULTS

Passenger cars and light trucks (vans, pickups, and sport utility vehicles) accounted for 46.1% and 39.1%, respectively, of the 4875 deaths, with the remainder split among motorcycles, buses, and heavy trucks. Compared with cars, the RR of killing a pedestrian per vehicle mile was 7.97 (95% CI 6.33 to 10.04) for buses; 1.93 (95% CI 1.30 to 2.86) for motorcycles; 1.45 (95% CI 1.37 to 1.55) for light trucks, and 0.96 (95% CI 0.79 to 1.18) for heavy trucks. Compared with cars, buses were 11.85 times (95% CI 6.07 to 23.12) and motorcycles were 3.77 times (95% CI 1.40 to 10.20) more likely per mile to kill children 0-14 years old. Buses were 16.70 times (95% CI 7.30 to 38.19) more likely to kill adults age 85 or older than were cars. The risk of killing a pedestrian per vehicle mile traveled in an urban area was 1.57 times (95% CI 1.47 to 1.67) the risk in a rural area.

CONCLUSIONS

Outcomes reflect the ways in which a vehicle's characteristics (mass, front end design, and visibility) and its degree of interaction with pedestrians affect its risk per mile. Modifications in vehicle design might reduce pedestrian injury. The greatest impact on overall US pedestrian mortality will result from reducing the risk from the light truck category.

Individual and contextual effects in injury morbidity in Barcelona (Spain)

OBJECTIVE

To determine the relationship between socioeconomic level (measured through individual educational level and material deprivation in the areas of residence) and injury morbidity in different age groups and in males as well as in females.

DESIGN

Cross-sectional survey.

SETTING

Barcelona (Spain).

METHODS

The study population included all cases over the age of 19 who, as a result of an injury (motor vehicles injuries, falls, hits and cuts), were admitted to the emergency departments of the six main hospitals of the city during the years 1990-1991. Age- and sex-specific morbidity rates were calculated for each educational level and each cause of injury. The contextual variable included was the proportion of unemployment in each neighbourhood. Multilevel Poisson regression models were fitted.

RESULTS

Morbidity rates were higher in males, in young people and for lower educational levels. Results from the multilevel models show that, at contextual level, neighbourhoods with more unemployment present a higher risk of injuries. At individual level, after adjusting for contextual variables, the risk of sustaining injuries was higher among young men and women for all injury causes except falls among women where the risk was higher in the elderly; among both men and women, the risk of sustaining injury was higher in the population with lower educational level (RR = 1.79, 95% CI = 1.73-1.86 in men; RR = 2.12, 95% CI = 2.04-2.21 in women). This trend was also observed separately for traffic injuries, falls, hits and cuts.

CONCLUSION

Our results provide information about individual and contextual social inequalities in injury morbidity, the highest risks of injury occur in individuals of lower educational level and who reside in the more private neighbourhoods. These results underscore the need to implement injury prevention strategies not only at the individual level, but also to tailor them to the socioeconomic position of the population.

Optimal driving conditions are the most common injury conditions for child pedestrians

OBJECTIVES

Motor vehicle-pedestrian crashes are one of the leading causes of serious injury in children. Prior studies have focused on child and traffic factors contributing to these crashes. The objective of the current study was to examine the role of driving conditions on the occurrence of motor vehicle crashes involving child pedestrians.

METHODS

Detailed information was abstracted for the period January 1994 to December 1999 from the Philadelphia Police Department accident reports for all pediatric (age <18 years) pedestrian crashes in a single, urban county. Data included pedestrian age, road and weather conditions, illumination, pedestrian location, and intent, time of day, and date of incident.

RESULTS

For the 6-year period of review, there were 3823 children under 18 years of age struck by motor vehicles (range 518 to 726 crashes per year), representing an average of 1.7 per day and a rate of 181 crashes per 100,000 children per year. The mean age was 7.9 years +/- 3.9 (range 1 to 17 years). Crashes occurred when the street was dry (>90%), with no adverse weather conditions (>90%), and during daylight hours or under streetlights (>92%). The most frequent day of the week was Friday (18.1%). The most common time of day was 3:00 to 6:00 PM (38.7%). The spring months (39.1%) predominated, with May (14.0%) being the most common month and January the least. When the circumstances were known, children were struck crossing in midblock 87.9% of cases and crossing behind a vehicle 38.8% of the time; only 4.8% were struck while playing in the street. Injuries as reported by the police exceeded minor in 32.3% with an overall fatality rate of 0.7%.

CONCLUSIONS

Urban pediatric pedestrian crashes are common and occur most frequently during optimal driving conditions (good lighting, a dry road, and good weather). The data also suggest that pedestrian crashes are related to the saturation of the streets with children (optimal play conditions) compounded by poor street-crossing technique. Prevention efforts should reinforce the fact that optimal driving conditions are also likely to represent optimal conditions for child play and may increase the risk for pediatric pedestrian injuries through increased exposure.

What are the most effective ways of improving population health through transport interventions? Evidence from systematic reviews

STUDY OBJECTIVE

To review systematic review literature that describes the effectiveness of transport interventions in improving population health.

METHODS

Systematic review methodology was used to evaluate published and unpublished systematic reviews in any language that described the measured health effects of any mode of transport intervention.

MAIN RESULTS

28 systematic reviews were identified. The highest quality reviews indicate that the most effective transport interventions to improve health are health promotion campaigns (to prevent childhood injuries, to increase bicycle and motorcycle helmet use, and to promote children's car seat and seatbelt use), traffic calming, and specific legislation against drink driving. Driver improvement and education courses are associated with increases in crash involvement and violations.

CONCLUSIONS

Systematic reviews are able to provide evidence about effective ways of improving health through transport related interventions and also identify well intentioned but harmful interventions. Valuable additional information may exist in primary studies and systematic reviews have a role in evaluating and synthesising their findings.

Family characteristics and pedestrian injury risk in Mexican children

BACKGROUND

Family characteristics have been described as risk factors for child pedestrian and motor vehicle collision. Research results come mainly from developed countries, where family relationships could be different than in developing ones.

OBJECTIVE

To examine family characteristics as risk factors for pedestrian injury in children living in Guadalajara City, Mexico.

METHODS

Case-control study of injuries among children 1-14 years of age involved in pedestrian-motor vehicle collisions. Cases resulting in death or injuries that required hospitalization or medical attention were included and identified through police reports and/or emergency room registries. Two neighborhood matched controls were selected randomly and compared with cases to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Significant risk factors were: male (OR 2.3, 95% CI 1.2 to 4.4), number of siblings in household (two siblings, OR 3.2, 95% CI 1.4 to 6.6; three siblings, OR 4.5, 95% CI 1.9 to 11.0; four or more siblings, OR 3.7, 95% CI 1.1 to 12.9), and number of non-siblings/non-parents in household (four or more, OR 6.2, 95% CI 1.5 to 26.6). Children of a sole mother, working mother, or grandmother living in house did not show increased risk after adjusting for socioeconomic conditions.

CONCLUSION

Household size has implications for child pedestrian and motor vehicle collision prevention efforts and is relatively easy to identify. Also, the lack of risk association with working mothers may indicate that grandmothers are not part of the social support network that cares for children of working mothers.

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.

Safety education of pedestrians for injury prevention

BACKGROUND

Each year about one million people die and about 10 million are seriously injured on the world's roads. Educational measures to teach pedestrians how to cope with the traffic environment are considered to be an essential component of any prevention strategy, and pedestrian education has been recommended in many countries. However, as resources available for road safety are limited, a key question concerns the relative effectiveness of different prevention strategies.

OBJECTIVES

To quantify the effectiveness of pedestrian safety education programmes in preventing pedestrian-motor vehicle collisions.

SEARCH STRATEGY

We searched the Injuries Group specialised register, Cochrane Controlled Trials Register, TRANSPORT, MEDLINE, EMBASE, ERIC, PSYCHLIT, SPECTR, and the WHO database on the Internet. We checked reference lists of relevant reviews and papers and contacted experts in the field. Most database searching was conducted in 1999.

SELECTION CRITERIA

Randomised controlled trials of safety education programmes for pedestrians of all ages.

DATA COLLECTION AND ANALYSIS

One reviewer screened records. Two reviewers independently extracted data and assessed methodological quality of trials. Because of differences in the types of interventions and outcome measures used in the trials, meta-analyses were not carried out.

MAIN RESULTS

We found 15 randomised-controlled trials of pedestrian safety education programmes, conducted between 1976 and 1997. Methodological quality of the included trials was generally poor. Allocation concealment was adequate in three trials, outcome assessment was blinded in eight, and in most of the studies large numbers of participants were lost to follow-up. Study participants were children in 14 studies and institutionalised adults in one. Eight studies involved the direct education of participants, seven used parents as educators. No trials were conducted in a developing country and there were none of pedestrian safety training in the elderly. None of the included trials assessed the effect of pedestrian safety education on the occurrence of pedestrian injury but six trials assessed the effect on observed behaviour. Some of these trials showed evidence of behavioural change following pedestrian safety education but it is difficult to predict what effect this might have on pedestrian injury risk.

REVIEWER'S CONCLUSIONS

Pedestrian safety education can result in improvement in children's knowledge and can change observed road crossing behaviour but whether this reduces the risk of pedestrian motor vehicle collision and injury occurrence is unknown. There is evidence that changes in safety knowledge and observed behaviour decline with time suggesting that safety education must be repeated at regular intervals.

Neighborhood characteristics of alcohol-related pedestrian injury collisions: a geostatistical analysis

This study conducted a geostatistical analysis of ecological data to examine the relationships of neighborhood characteristics, including alcohol availability and alcohol consumption patterns to pedestrian injury collisions. The central research question asked whether it was possible to identify unique neighborhood characteristics related to alcohol- and non-alcohol-involved pedestrian injuries. It was hypothesized that greater numbers of alcohol-involved pedestrian injuries would be observed in areas with greater concentrations of alcohol outlets, even after adjusting for socioeconomic characteristics, environmental factors, and drinking patterns of neighborhood residents. It was also hypothesized that independent of drinking patterns and alcohol availability, greater numbers of pedestrian injuries would be observed in areas with higher unemployment, lesser income, greater population, and a predominance of younger or older age populations. Archival and individual-level data from a general population telephone survey were obtained from four California communities. The survey data included sociodemographic and drinking pattern measures. Archival data included environmental measures relevant to pedestrian travel and measures of alcohol availability. Units of analysis were geographic areas within each community defined by the spatial clustering of telephone survey respondents. The results showed that alcohol-involved pedestrian collisions occurred more often in areas with greater bar densities and greater population, and where the local population reported drinking more alcohol per drinking occasion. Pedestrian collisions not involving alcohol occurred more often in lower income areas with greater population and cross-street densities, and in areas having either younger or older age populations. The identification of neighborhood variables associated with pedestrian collisions has important implications for policy formation and targeted prevention efforts.

Maternal reports of child injuries in Canada: trends and patterns by age and gender

OBJECTIVES

This study examines gender and age differences in maternal reports of injuries in a cross sectional group of children aged 0-11 years. The cause, nature, body part injured, and location of injury are explored, as are the associations with family socioeconomic indicators and associations with limitations in activities.

METHODS

Data for 22831 children and their families come from cycle 1 of the Canadian National Longitudinal Survey of Children and Youth collected in 1995. Descriptive analyses and chi2 tests for trends are used to examine injury variations by child gender and age. Logistic regressions are used to examine the relationship between socioeconomic indicators and injury and the associations between injury and limitations in activities.

RESULTS

Consistent with findings from hospital data, boys experience more injuries than girls, and injuries increase with child age. Falls are the most common sources of maternally reported injuries, followed by scalds/poisonings for young children and sports injuries for school aged children. The majority of injuries occur in or around the home for young children, but at school for older children. For maternal reports of childhood injuries, single marital status is a risk factor for boys.

CONCLUSIONS

Maternally reported injuries occur in 10% of Canadian children and many of these are associated with limitations in activities. Preventative strategies should take both child age and gender into consideration.

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.