Pediatric motor vehicle related injuries in the Navajo Nation: the impact of the 1988 child occupant restraint laws

Surveillance methods and interventions implemented in American Indian and Alaska Native communities to increase child restraint device and seat belt use in motor vehicles: a systematic review

BACKGROUND

American Indian/Alaska Native (AI/AN) children are disproportionately affected by injuries and deaths related to motor vehicle crashes. We aimed to synthesise published evidence on surveillance methods and interventions implemented in AI/AN communities and analyse characteristics that make them successful in increasing child restraint devices and seat belt use.

METHODS

Studies were collected from the PubMed, Scopus, and TRID databases and the CDC Tribal Road Safety website, Community Guide, and Indian Health Service registers. Included studies collected primary data on AI/AN children (0-17) and reported morbidity/mortality outcomes related to child restraint devices or seat belt use. Studies with poor methodological quality, published before 2002, whose data were collected outside of the USA, or were non-English, were excluded. Checklists from the Joanna Briggs Institute were used to assess the risk of bias. In the synthesis of results, studies were grouped by whether a surveillance method or intervention was employed.

RESULTS

The final review included 9 studies covering 72 381 participants. Studies conducted surveillance methods, interventions involving law enforcement only and multipronged interventions. Multipronged approaches were most effective by using the distribution of child restraint devices combined with at least some of the following components: educational programmes, media campaigns, enactment/enforcement of child passenger restraint laws, incentive programmes and surveillance.

DISCUSSION

Although this review was limited by the number and quality of included studies, available resources suggest that we need multipronged, culturally tailored and sustainable interventions fostered by mutually beneficial and trusting partnerships. Continued investment in AI/AN road safety initiatives is necessary.

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

Factors affecting use and nonuse of child safety car seats in Gorgan, Iran

Objective: Motor vehicle accidents, which are among the main causes of child mortality in Iran and the Middle East, impose staggering costs for the community. Ignoring use of safety devices for children in most motor vehicle crashes will lead to death or serious injury. Because few studies have been performed on effective and predictive factors regarding use of child safety seats, the purpose of this study was to examine the factors affecting the use and nonuse of child safety seats, along with the factors that can facilitate how a child safety seat is used. Method: This study was conducted in the urban area of Gorgan using a questionnaire. Through random selection, 204 parents with at least one child, aged 8 years or younger, reported their knowledge about the benefits of using a child safety seat. Results: The results showed that 80% of parents never use a child safety seat, and 13% always use a child safety seat. More than 93% thought that it was necessary to make usage of the child safety seat obligatory. In addition, 80% of parents believed that a child safety seat prevents children from injury in crashes. In addition, 38% of parents were not aware of child safety devices and child safety, less than 20% said that they did not use a child safety seat because their spouse did not support its use, and 28% of them thought that a child safety seat does not affect the safety of the child. In general, 91% of parents reported that if child safety seat use were mandated, the frequency of use would increase. A law on the use of child safety seats is a very important variable in their use, which can enhance the chance of using a child safety seat by 6.5 times. Conclusion: Special instructions should be developed to create incentive strategies for using a child safety seat. Mandating the use of a child safety seat, equipping cars with a child safety seat, encouraging children to use it, and providing continuous education and training are important factors for increasing the use of child safety seats.

The public health implications of maternal care trade-offs

The socioeconomic and ethnic characteristics of parents are some of the most important correlates of adverse health outcomes in childhood. However, the relationships between ethnic, economic, and behavioral factors and the health outcomes responsible for this pervasive finding have not been specified in child health epidemiology. The general objective of this paper is to propose a theoretical approach to the study of maternal behaviors and child health in diverse ethnic and socioeconomic environments. The specific aims are: (a) to describe a causal pathway between the utility that women obtain through work outside the home and through child care and disease hazard rates in childhood using an optimization model; (b) to specify the influence of ethnic and socioeconomic factors on model constraints; (c) to use the model as a tool to learn about how different combinations of maternal wage labor and child care time might influence child health outcomes in diverse social contexts; (d) to identify parameters that will require measurement in future research; (e) to discuss research strategies that will enable us to obtain these measurements; and (f) to discuss the implications of the model for biostatistical modeling and public health intervention. Optimization models are powerful heuristic tools for understanding how ethnic, environmental, family, and personal characteristics can place important constraints on both the quality and quantity of care that women can provide to their children. They provide a quantitative appreciation for the difficult trade-offs that most women face between working in order to purchase basic goods that children cannot do without (e.g., food, clothing, shelter, health insurance), and increasing offspring well-being through child care (e.g., training in social skills, affection, protection from environmental hazards, help with homework).

A systematic review of community interventions to improve Aboriginal child passenger safety

We evaluated evidence of community interventions to improve Aboriginal child passenger safety (CPS) in terms of its scientific merit and cultural relevance. We included studies if they reported interventions to improve CPS in Aboriginal communities, compared at least pre- and postintervention conditions, and evaluated rates and severity of child passenger injuries, child restraint use, or knowledge of CPS. We also appraised quality and cultural relevance of studies. Study quality was associated with community participation and cultural relevance. Strong evidence showed that multicomponent interventions tailored to each community improves CPS. Interventions in Aboriginal communities should incorporate Aboriginal views of health, involve the community, and be multicomponent and tailored to the community's circumstances and culture.

Interventions for motor vehicle crashes among Indigenous communities: strategies to inform Canadian initiatives

OBJECTIVES

Motor vehicle crashes (MVCs) are a leading cause of death for Canadian Aboriginal peoples; developing effective interventions should be a public health priority. While intervention research has been conducted outside of Canada, few formal program evaluations have been conducted in Canada. We reviewed Canadian and non-Canadian Indigenous road safety initiatives to inform future program development in Canada.

METHODS

A systematic review of the published and grey literature examining MVC intervention programs in Indigenous communities was performed. Studies published after 1980 reporting pre-post comparisons of MVC interventions in Indigenous communities were included in the review. These studies were assessed using a modified Participatory Action Research quality assessment tool. Haddon's Matrix of injury epidemiology and prevention was used to categorize crash-related risk factors targeted in the MVC interventions.

SYNTHESIS

A total of 11 studies met inclusion criteria, including 1 Canadian study and 10 non-Canadian studies. Successful intervention components included focus groups, training community members, educational activities, distribution of safety devices, collaboration with local law officials to enhance enforcement, driver-licensing courses, and incentive programs. Potential barriers to successful implementation and evaluation involved lack of incorporation of cultural and contextual factors, enforcement factors, and methodological limitations.

CONCLUSION

Several effective strategies to reduce MVCs can be adapted and implemented at the community and national levels. Future directions might include using multiple intervention components and incorporating a collaborative, culturally and contextually appropriate approach, while promoting evaluation initiatives and widespread dissemination of findings.

Trends and correlates of child passenger restraint use in 6 Northwest tribes: the Native Children Always Ride Safe (Native CARS) project

OBJECTIVES

We compared proportions of children properly restrained in vehicles in 6 Northwest American Indian tribes in 2003 and 2009, and evaluated risks for improper restraint.

METHODS

During spring 2009 we conducted a vehicle observation survey in Oregon, Washington, and Idaho tribal communities. We estimated the proportions of children riding properly restrained and evaluated correlates of improper restraint via log-binomial regression models for clustered data.

RESULTS

We observed 1853 children aged 12 years and younger in 1207 vehicles; 49% rode properly restrained. More children aged 8 years and younger rode properly restrained in 2009 than 2003 (51% vs 29%; P < .001). Older booster seat-eligible children were least likely to ride properly restrained in 2009 (25%). American Indian children were more likely to ride improperly restrained than nonnative children in the same communities. Other risk factors included riding with an unrestrained or nonparent driver, riding where child passenger restraint laws were weaker than national guidelines, and taking a short trip.

CONCLUSIONS

Although proper restraint has increased, it remains low. Tribe-initiated interventions to improve child passenger restraint use are under way.

The decrease in the unintentional injury mortality disparity between American Indians/Alaska Natives and non-American Indians/Alaska Natives in New Mexico, 1980 to 2009

OBJECTIVES

We tracked the unintentional injury death disparity between American Indians/Alaska Natives and non-American Indians/Alaska Natives in New Mexico, 1980 to 2009.

METHODS

We calculated age-adjusted rates and rate ratios for unintentional injury deaths and their external causes among American Indians/Alaska Natives and non-American Indians/Alaska Natives. We tested trend significance with the Mann-Kendall test.

RESULTS

The unintentional injury death rate ratio of American Indians/Alaska Natives to non-American Indians/Alaska Natives declined from 2.9 in 1980-1982 to 1.5 in 2007-2009. The rate among American Indians/Alaska Natives decreased 47.2% from 1980-1982 to 1995-1997. Among non-American Indians/Alaska Natives, the rate declined 25.3% from 1980-1982 to 1992-1994, then increased 31.9% from 1992-1994 to 2007-2009. The motor vehicle traffic and pedestrian death rates decreased 57.8% and 74.6%, respectively, among American Indians/Alaska Natives from 1980-1982 to 2007-2009.

CONCLUSIONS

The unintentional injury death rate disparity decreased substantially from 1980-1982 to 2007-2009 largely because of the decrease in motor vehicle crash and pedestrian death rates among American Indians/Alaska Natives and the increase in the poisoning death rate among non-American Indians/Alaska Natives.

Comparison of on-reserve road versus off-reserve road motor vehicle crashes in Saskatchewan, Canada: a case control study

BACKGROUND

There is an overwhelmingly high incidence of severe injuries caused by motor vehicle crashes (MVCs) among Aboriginal Canadians as compared with the general population.

METHODS

The authors obtained MVC data for a 3-year period, 2003-2005, from Saskatchewan Government Insurance (SGI) for collisions occurring on on-reserve roads (n = 1270) together with a randomly selected sample of MVCs from off-reserve roads (n = 1270) in Saskatchewan. They compared the collision characteristics using bivariate and multiple logistic regressions.

RESULTS

On-reserve MVCs were more likely to include multiple collisions and result in severe injuries than the off-reserve sample. A number of factors were significantly related to the increased risk of on-reserve collisions as compared with the reference group for each variable.

INTERPRETATION

Factors from all 3 levels (human, environmental, and vehicle factors) are associated with on-reserve MVCs.

Injuries and injury prevention among indigenous children and young people

Throughout the world, injuries and violence are a leading cause of mortality and suffering among Indigenous communities. Among American Indian and Alaska Native children aged 1 to 19 years, 71% of deaths are from injuries. Motor-vehicle accidents, attempted suicide, and interpersonal violence are the most common causes of injuries in highly industrialized countries. For Indigenous populations in middle- and low-income countries, trauma caused by motor-vehicle accidents, agricultural injuries, interpersonal violence, child labor, and the ravages of war are priorities for intervention. To be effective, injury-prevention efforts should be based on scientific evidence, be developmentally and culturally appropriate, and draw on the inherent strengths of Indigenous communities.

Utilização de assentos de segurança por crianças matriculadas em creches

OBJETIVO: Estimar a prevalência de utilização de assentos de segurança infantil e fatores associados. MÉTODOS: Estudo transversal observacional, com amostragem estratificada, realizado em 15 creches da cidade de Maringá, PR, entre os meses de março e maio de 2007. Cada creche foi visitada em apenas um dia letivo. O desfecho considerado foi a utilização de assento de segurança infantil por crianças de até quatro anos de idade. Carros (N=301) que transportavam crianças menores de quatro anos de idade foram abordados e as informações foram coletadas por meio de questionários semi-estruturados. Variáveis relacionadas a distribuição de adultos e crianças nos assentos do veículo, situação de restrição dos ocupantes e sexo do condutor foram analisadas. Para análise dos dados aplicou-se o teste exato de Fisher, qui-quadrado de Mantel-Haenszel e regressão logística. RESULTADOS: Entre os motoristas abordados, 51,8% usavam cinto de segurança (60,4% das mulheres, 44,9% dos homens). Entre as crianças, 36,1% usavam assentos de segurança infantil, 45,4% eram transportadas soltas, 16,0% estavam no colo de adultos, 2,7% usavam o cinto de segurança. Segundo a regressão logística, os fatores que mais influenciaram o uso dos assentos de segurança infantil foram: idade da criança inferior a 15 meses (OR= 3,76), uso de cinto de segurança pelo condutor (OR= 2,45) e crianças pertencentes aos estratos sociocupacionais de maior renda e escolaridade (OR= 1,37). CONCLUSÕES: A utilização de assentos de segurança infantil mostrou-se associada à idade da criança, uso de cinto de segurança pelo condutor e estrato sociocupacional da creche. Frente ao baixo índice de utilização, o uso dos assentos de segurança infantil surge como desafio à medicina preventiva no Brasil, exigindo atenção e atuação para sua disseminação na população.

Public health legal preparedness in Indian country

American Indian/Alaska Native tribal governments are sovereign entities with inherent authority to create laws and enact health regulations. Laws are an essential tool for ensuring effective public health responses to emerging threats. To analyze how tribal laws support public health practice in tribal communities, we reviewed tribal legal documentation available through online databases and talked with subject-matter experts in tribal public health law. Of the 70 tribal codes we found, 14 (20%) had no clearly identifiable public health provisions. The public health-related statutes within the remaining codes were rarely well integrated or comprehensive. Our findings provide an evidence base to help tribal leaders strengthen public health legal foundations in tribal communities.

Comparison of methods to correct the miscounting of multiple episodes of care when estimating the incidence of hospitalised injury in child motor vehicle passengers

This study evaluates the performance of different case selection criteria to account for multiple episodes of care when estimating the hospitalisation rate due to road trauma amongst children. The internally linked NSW Inpatient Statistics Collection (ISC) dataset for the period between 1st July, 2000 and 30th June, 2003 was used to identify the "single" episode of care for each hospitalised child motor vehicle passenger residing in NSW. We used two hospitalised injury definitions of a case based on (1) all-diagnoses and (2) principal diagnosis only. We then developed case selection criteria, based on (a) linkage methods only available from linked ISC datasets; (b) selected variables available in both the linked and unlinked ISC datasets, to exclude repeat episodes of care for an injury. Changes in the estimated hospitalisation rate, and sensitivity and specificity, were calculated for each selection criteria compared to the findings from linkage methods as the "gold standard". None of the correction methods for multiple episodes of care was clearly superior in terms of incidence estimation, sensitivity, and specificity concurrently. However, the correction criterion which is optimal may vary depending on different study objectives and different types of hospitalised injuries.

Injury mortality rates in Native and non-Native children: a population-based study

OBJECTIVES

To examine injury mortality rates in Native and non-Native children in the province of Alberta, Canada, over a 10-year period, temporal trends in injury mortality rates (Native vs. non-Native), as well as relative risks of injury mortality (Native vs. non-Native) by injury mechanism and intent, were calculated.

METHODS

An observational, population-based study design was used. Mortality data were obtained from provincial vital statistics, with injury deaths identified using external injury codes (E-codes). The relative risk (RR) of injury mortality (Native vs. non-Native) along with 95% confidence intervals (CIs) were calculated. Stratified analyses and Poisson regression modeling were used to calculate adjusted relative risk.

RESULTS

Injury mortality rates declined over the study period, with no difference in the rate of decline between Native and non-Native children. The adjusted relative risk for all-cause injury death (Native vs. non-Native) was 4.6 (95% CI 4.1 to 5.2). The adjusted relative risks (Native vs. non-Native) by injury intent categories were: unintentional injuries, 4.0 (95% CI 3.5 to 4.6); suicide, 6.6 (95% CI 5.2 to 8.5); and homicide, 5.1 (95% CI 3.0 to 8.5). Injury mortality rates were consistently higher for Native children across all injury mechanism categories. The largest relative risks (Native vs. non-Native) were pedestrian injury (RR = 17.0), accidental poisoning (RR = 15.4), homicide by piercing objects (RR = 15.4), and suicide by hanging (RR = 13.5).

CONCLUSION

The burden of injury mortality is significantly greater in Native children compared with non-Native children. Therefore, injury prevention strategies that target both intentional and unintentional injuries are needed.

Variability in pediatric injury patterns by age and ethnic groups in Israel

BACKGROUND

. In Israel, nearly 10,000 children are hospitalized due to injury every year.

OBJECTIVES

To define injury patterns in subgroups of the pediatric population, in order to focus prevention programs on vulnerable groups.

METHODS

A retrospective study of Israel's National Trauma Registry (ITR) data on patients aged 0-17 years hospitalized between 1 January 1998 and 31 December 2002 due to trauma. Data includes patient demographic details, information on the injury, hospital resource utilization, length of stay and outcome. Descriptive statistics were used to characterize injury patterns and bivariate and multivariate analysis was used to compare injury severity and cause between population groups.

RESULTS

A total of 32,009 children were included. Falls were the cause of injury for 51% of the population, 6% of falls sustaining severe injuries (ISS 16+). Road traffic accidents (RTA) injured 23%, of which 14% were severe injuries. Burns (7%) accounted for long hospitalizations -- nearly 20% stayed for over 14 days. Crude data showed that the proportion of severe injuries and inpatient death rate among non-Jewish children was double that of Jewish children (12% vs 6% and 1% vs 0.5%, respectively (chi2, p<0.0001)). When looking at children from low socio-economic status (SES) townships, the difference in proportion of severe injuries between Jewish and non-Jewish children is reduced, yet it remains higher in non-Jewish than among Jewish children (7% vs 5%) (chi2, p=0.0001). These results were verified by multivariate logistic regression analysis adjusting for SES, age, gender and external injury cause. Non-Jewish children had a significantly higher rate of burns (10% vs 6%), falls from heights above 2.5 meters (16% vs 6% of all falls) and pedestrian injuries (51% vs 37% of all injured in RTA). When SES is taken into account, the only outstanding injury among non-Jewish children is fall from height: 13%, n=376 among non-Jewish children vs 8%, n=85 among Jewish children, living in townships with low SES cluster (1-4) (chi2, p<0.0001).

CONCLUSIONS

The findings of this study show that there is variability in external cause of injury and severity by age and ethnic group. Falls were most frequent among young children and burns among non-Jews. Non-Jewish children in SES clusters 1-4 are at high risk for falls from height, suggesting intervention and prevention activities should be directed in this direction.

Factors influencing the use of booster seats: a state-wide survey of parents

This study used telephone interview data on booster seat use from a state-wide probability sample of parents with children ages 4-8-years-old who were living in Michigan. Interviews were completed with parents of children in 350 households. Analyses examined the entire sample, and three sub-groups: always users, part-time booster seat users, and booster seat non-users. Results indicated that booster seat legislation was a key determinant of the level of use and the motivation to use booster seats. Nearly 70% of part-time users said that they used booster seats because they believed it was the law. Similarly, 60% of part-time and non-booster seat users said that they would be more likely to use booster seats if use were mandated by law, with non-users being 3.5 times more likely than part-time users to agree that a law would increase their booster seat use. Finally, over 90% of part-time and non-booster seat users said it would be easier for them to use booster seats if a law required it, and non-users were almost six times more likely than part-time users to agree that a law would make use easier. The need for booster seat laws, issues of social equity, and implications for intervention were discussed.

Restraint use among northwest American Indian children traveling in motor vehicles

OBJECTIVES

We sought to estimate motor vehicle passenger restraint use among Northwest American Indian children 8 years old or younger and to determine factors associated with using proper (i.e., age and weight appropriate) passenger restraint systems.

METHODS

We surveyed vehicles driven by members of 6 tribes in Idaho, Oregon, and Washington. Associations between proper restraint and child, driver, and vehicle characteristics were analyzed using logistic regression for clustered data.

RESULTS

We observed 775 children traveling in 574 vehicles; 41% were unrestrained. Proper restraint ranged from 63% among infant seat-eligible children to 11% among booster seat-eligible children and was associated with younger child's age (odds ratio (OR) per year = 0.60; 95% confidence interval (CI) = 0.48, 0.75), seating location (OR front vs rear=0.27; 95% CI=0.16, 0.44), driver seat belt use (OR=2.39; 95% CI=1.51, 3.80), and relationship (OR for nonparent vs parent=0.28; 95% CI=0.14, 0.58). More than half of drivers felt children could use an adult seat belt earlier than recommended guidelines, and 63% did not correctly identify whether their tribe had child safety seat laws.

CONCLUSIONS

Children in these communities are inadequately restrained. Restraint use was exceedingly low among booster-eligible children and children riding with unrestrained adults. Interventions emphasizing appropriate restraint use and enforcement of passenger safety laws could reduce the risk of injury or death in motor vehicle accidents.

Traumatic brain injury hospitalizations among American Indians/Alaska Natives

OBJECTIVES

To compare the incidence of nonfatal traumatic brain injury (TBI) hospitalization among American Indians/Alaska Natives (AI/AN) with that of other race groups and to assess alcohol and protective equipment (PE) use among those who sustained TBI related to a motor vehicle (MV) incident.

METHODS

Data were obtained from 13 states funded by the Centers for Disease Control and Prevention to conduct TBI surveillance from 1997 to 1999. Rates by race and by cause were calculated for the 13 states combined. Blood alcohol concentration (BAC) levels and PE use were compared between AI/AN and "other" races in a subgroup of these states.

RESULTS

Although not significantly different, AI/AN had the highest overall age-adjusted TBI hospitalization rate (71.5 per 100,000). Rates were significantly higher among AI/AN than among whites for ages 20 to 44 years (78.5 per 100,000 vs 54.7 per 100,000, P < .0001). MV incidents were the leading cause of TBI (40.1% of cases) among AI/AN, and AI/AN injured in MV incidents had higher BAC levels (65.7% > or = 0.08 g/dL vs 31.6% > or = 0.08 g/dL, P < .0001) and lower PE use (22.0% vs 40.4%, P < .0001) than the "other" race group.

CONCLUSION

AI/AN have high rates of TBI hospitalization compared with other races. High BAC levels and low use of PE in MV incidents appear to be associated with the higher rates in this population.

Motor vehicle crash fatalities by race/ethnicity in Arizona, 1990-96

OBJECTIVE

To compare rates of motor vehicle crash (MVC) fatalities among different race/ethnic groups in urban and rural Arizona.

METHOD

Using the Fatality Analysis Reporting System and the National Center for Health Statistics Multiple Cause of Death file, MVC fatalities in Arizona from 1990-96 inclusive were classified by gender, race/ethnicity, and urban or rural residence. Age adjusted rates of total, occupant, pedestrian, and alcohol related fatalities were calculated. The total MVC fatality rate for each race/ethnic group was then adjusted for proportion of rural residence.

RESULTS

Compared with non-Hispanic whites (NHWs), American Indians had raised relative risks for MVC fatality in all gender and residence subgroups. Hispanic females and rural Hispanic males had lower relative risks, as did rural African-American men. Raised relative risks for American Indian men and women included all subgroups: total, occupant, pedestrian, and alcohol related. Hispanic and African-American men both had raised relative risks of pedestrian related fatalities, and Hispanic men had a slightly higher relative risk while Hispanic women had a lower relative risks, for alcohol related fatality. Hispanic men and women and African-American men had lower occupant fatality rates. Close to half (45%) of the excess MVC fatality among American Indians can be attributed to residence in rural areas, where MVC fatality rates are higher. There were 1.85 occupants in crashes involving NHW deaths compared with 2.51 for Hispanics and 2.71 for American Indians (p<0.001). The proportion of occupants not using a seatbelt was higher in Hispanics and American Indians in both urban and rural areas.

CONCLUSION

The major disparity in MVC fatality in Arizona is among American Indians. The higher MVC fatality rates among American Indians occur in all age groups, in both urban and rural areas, and among occupants and pedestrians. Rural residence, lower rates of seatbelt use, higher rates of alcohol related crashes, a greater number of occupants, and higher rates of pedestrian deaths all contribute to the American Indian MVC fatality disparity. High rates of pedestrian fatality occur in men in all three race/ethnic minorities in Arizona and among American Indian women. In contrast to other studies, African-Americans and Hispanics did not have raised total MVC fatality rates and compared to NHWs actually had lower rates in the rural areas of the state.