Why have child pedestrian death rates fallen?

Children's perceptions of a 'self-explaining road' intervention to improve neighbourhood safety

AIM

Safe neighbourhood environments can provide important spaces for child activity and well-being. Self-explaining roads (SERs), which reduce vehicle speeds by changing neighbourhood street design, are an intervention with known safety benefits. However, little is known about children's experiences of SERs.

METHODS

We engaged schoolchildren in developing a project to articulate children's perspectives of SERs. Students actively researched the experiences of other children at their school, and then participated in a researcher-led focus group.

RESULTS

Children emphasised safer spaces for play as an important benefit of SERs. As well as using new designated play spaces adjoining footpaths, children also felt the roadway became safer, and more fun for cycling. In contrast, children reported that parents held mainly negative views of SERs, considering them annoying and inconvenient.

CONCLUSION

From children's perspective, SERs can provide safe spaces for neighbourhood play, despite limited parental support. Potential benefits for children as well as established safety benefits should inform future implementation of SERs.

Pediatric emergency department visits for pedestrian and bicyclist injuries in the US

Background

Despite reductions in youth pedestrian and bicyclist deaths over the past two decades, these injuries remain a substantial cause of morbidity and mortality for children and adolescents. There is a need for additional information on non-fatal pediatric pedestrian injuries and the role of traumatic brain injury (TBI), a leading cause of acquired disability.

Methods

Using a multi-year national sample of emergency department (ED) records, we estimated annual motorized-vehicle related pediatric pedestrian and bicyclist (i.e. pedalcyclist) injury rates by age and region. We modeled in-hospital fatality risk controlling for age, gender, injury severity, TBI, and trauma center status.

Results

ED visits for pediatric pedestrian injuries declined 19.3% (95% CI 16.8, 21.8) from 2006 to 2012, with the largest decreases in 5-to-9 year olds and 10-to-14 year olds. Case fatality rates also declined 14.0%. There was no significant change in bicyclist injury rates.

TBI was implicated in 6.7% (95% CI 6.3, 7.1) of all pedestrian and bicyclist injuries and 55.5% (95% CI 27.9, 83.1) of fatalities. Pedestrian ED visits were more likely to be fatal than bicyclist injuries (aOR = 2.4, 95% CI 2.3, 2.6), with significant additive interaction between pedestrian status and TBI.

Conclusions

TBI in young pedestrian ED patients was associated with a higher risk of mortality compared to cyclists. There is a role for concurrent clinical focus on TBI recovery alongside ongoing efforts to mitigate and prevent motor vehicle crashes with pedestrians and bicyclists. Differences between youth pedestrian and cycling injury trends merit further exploration and localized analyses, with respect to behavior patterns and interventions. ED data captures a substantially larger number of pediatric pedestrian injuries compared to crash reports and can play a role in those analyses.

Electronic supplementary material

The online version of this article (10.1186/s40621-017-0128-5) contains supplementary material, which is available to authorized users.

School environments and social risk factors for child pedestrian-motor vehicle collisions: A case-control study

BACKGROUND

Child pedestrian-motor vehicle collisions (PMVCs) have decreased in Canada in the past 20 years. Many believe this trend is explained by the rise in automobile use for all travel. Initiatives to increase walking to school need to consider PMVC risk. Potential risk factors related to walking to school, the built environment and social factors were examined for schools with historically high child PMVC rates.

METHODS

Child PMVCs (age 4-12 years) from 2000 to 2013 and built environment features were mapped within school attendance boundaries in the City of Toronto, Canada. Case and control schools were in the highest and lowest PMVC quartiles respectively. Observational counts of travel mode to school were conducted. Logistic regression evaluated walking to school, built environment and social risk factors for higher PMVC rates, stratified by geographic location (downtown vs. inner suburbs).

RESULTS

The mean PMVC rates were 18.8/10,000/year (cases) and 2.5/10,000/year (controls). One-way street density (OR=4.00), school crossing guard presence (OR=3.65) and higher social disadvantage (OR=1.37) were associated with higher PMVCs. Higher residential land use density had a protective effect (OR=0.56). More walking was not a risk factor. While several built environment risk factors were identified for the inner suburbs; only social disadvantage was a risk factor within older urban neighbourhoods.

CONCLUSIONS

Several modifiable environmental risk factors were identified for child PMVCs. More walking to school was not associated with increased PMVCs after controlling for the environment. School social disadvantage was associated with higher PMVCs with differences by geographic location. These results have important implications for the design of roadways around schools.

Time trend analyses of child pedestrian morbidity in Japan

OBJECTIVES

Road traffic injuries, particularly pedestrian injuries, are a major health issue among children worldwide. The present study quantitatively analyzed the time trends of child pedestrian injuries in Japan from 1975 to 2013 by age.

STUDY DESIGN

Time trend analysis of nationally aggregated data.

METHODS

We analyzed police data on pedestrian injuries requiring medical treatment among children aged 0-15 years occurring between 1975 and 2013. To quantify the time trends of pedestrian injury morbidity rates and to identify change-points in the trends, joinpoint regression analysis was applied by age group. Children were categorized into the age groups of 0-3, 4-6, 7-9, 10-12, and 13-15 years old.

RESULTS

Preschool children aged 0-6 years old showed continuous declining trends throughout the study period; these declining trends accelerated in the 2000s. School-age children aged 7-15 years old showed minimal changes from the early 1970s to the 1990s; of this age group, children aged 7-12 years old showed slight but significant declining trends in the first half and increasing trends in the latter half of this period. Children aged 7-15 years old showed declining trends in the 2000s. Despite the consistent declining trends among all age groups in the 2000s, the younger age groups showed steeper declines during this period.

CONCLUSIONS

The declining trends in all age groups in the 2000s may reflect the improved traffic environments in Japan although the environmental approaches are not yet sufficiently adopted yielding modest effects. The continuing contrast between preschool and school-age children may reflect different behaviour changes by age such as more restricted outdoor activities among young children.

Keeping Children Safe

The aim of this article is to present qualitative data from a study of mothers on a housing estate in Leeds, UK, enabling them to voice their concerns about child safety. The estate contains many environmental hazards, from traffic, ‘drugusers’, ‘strangers’ and litter. A high profile given to the vulnerability of children in public places has resulted in parents becoming ever vigilant and subjecting children to increased surveillance, in the face of a lack of environmental measures which would support their efforts to keep children safe. There are costs to parents in time and activities foregone. Moreover, the emphasis on the key role of parents in child safety and the perception of increasing hazards to children is affecting parents' psychological well-being. The article attempts to place parents' concerns within a social context which may begin to explain parental behaviour and anxieties.

Pedestrian injuries due to collisions with bicycles in New York and California

INTRODUCTION

Scant attention has been given to pedestrians injured in accidents resulting from collisions with cyclists. This scholarly neglect is surprising given the growing popularity of cycling. This study examines the incidence of pedestrians injured by cyclists in New York between 2004 to 2011 and in California from 2005 to 2011. The study also profiles the pedestrians injured in these two states during these two time frames.

METHOD

The data for this study are based upon patient-level hospital records from New York and California. The data for New York comes from the Statewide Planning and Research Cooperative System (SPARCS) under the auspices of New York State's Department of Health. The data for California come from two sources: the Healthcare Cost and Utilization Project (HCUP) and the California Office of Statewide Health Planning and Development.

RESULTS

The rate of pedestrians injured in collisions with cyclists has decreased over time. This decline has occurred despite the increase in the number of cyclists in these states during this same time period. Two possible explanations for this decline are: (a) less exposure of children to cyclists, and (b) improvements in the cycling infrastructure.

PRACTICAL APPLICATIONS

Although the rate of injuries to pedestrians from collisions with cyclists has been decreasing, improvements to the cycling infrastructure will need to continue. Bike lanes, particularly protected bike lanes, have been shown to be an effective way of reducing cycling-pedestrian accidents. The results of the current study are consistent with this research. Educational campaigns aimed at cyclists that emphasize the safety of all road users--including pedestrians--will also need to continue to assure that this downward trend in the number of accidents is not reversed.

Estimating the prevalence of chronic conditions in children who die in England, Scotland and Wales: a data linkage cohort study

OBJECTIVES

To estimate the proportion of children who die with chronic conditions and examine time trends in childhood deaths involving chronic conditions.

DESIGN

Retrospective population-based death cohort study using linked death certificates and hospital discharge records.

SETTING

England, Scotland and Wales.

PARTICIPANTS

All resident children who died aged 1-18 years between 2001 and 2010.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the proportion of children who died with chronic conditions according to age group and type of chronic condition. The secondary outcome was trends over time in mortality rates involving chronic conditions per 100,000 children and trends in the proportion of children who died with chronic conditions.

RESULTS

65.4% of 23,438 children (95% CI 64.8%, 66.0%) died with chronic conditions, using information from death certificates. This increased to 70.7% (95% CI 70.1% to 71.3%) if hospital records up to 1 year before death were also included and was highest (74.8-79.9% depending on age group) among children aged less than 15 years. Using data from death certificates only led to underascertainment of all types of chronic conditions apart from cancer/blood conditions. Neurological/sensory conditions were most common (present in 38.5%). The rate of children dying with a chronic condition has declined since 2001, whereas the proportion of deaths affected by chronic conditions remained stable.

CONCLUSIONS

The majority of children who died had a chronic condition. Neurological/sensory conditions were the most prevalent. Linkage between death certificate and hospital discharge data avoids some of the under-recording of non-cancer conditions on death certificates, and provides a low-cost, population-based method for monitoring chronic conditions in children who die.

Child deaths due to injury in the four UK countries: a time trends study from 1980 to 2010

Background

Injuries are an increasingly important cause of death in children worldwide, yet injury mortality is highly preventable. Determining patterns and trends in child injury mortality can identify groups at particularly high risk. We compare trends in child deaths due to injury in four UK countries, between 1980 and 2010.

Methods

We obtained information from death certificates on all deaths occurring between 1980 and 2010 in children aged 28 days to 18 years and resident in England, Scotland, Wales or Northern Ireland. Injury deaths were defined by an external cause code recorded as the underlying cause of death. Injury mortality rates were analysed by type of injury, country of residence, age group, sex and time period.

Results

Child mortality due to injury has declined in all countries of the UK. England consistently experienced the lowest mortality rate throughout the study period. For children aged 10 to 18 years, differences between countries in mortality rates increased during the study period. Inter-country differences were largest for boys aged 10 to 18 years with mortality rate ratios of 1.38 (95% confidence interval 1.16, 1.64) for Wales, 1.68 (1.48, 1.91) for Scotland and 1.81 (1.50, 2.18) for Northern Ireland compared with England (the baseline) in 2006–10. The decline in mortality due to injury was accounted for by a decline in unintentional injuries. For older children, no declines were observed for deaths caused by self-harm, by assault or from undetermined intent in any UK country.

Conclusion

Whilst child deaths from injury have declined in all four UK countries, substantial differences in mortality rates remain between countries, particularly for older boys. This group stands to gain most from policy interventions to reduce deaths from injury in children.

Effectiveness of a safe routes to school program in preventing school-aged pedestrian injury

BACKGROUND

In 2005, the US Congress allocated $612 million for a national Safe Routes to School (SRTS) program to encourage walking and bicycling to schools. We analyzed motor vehicle crash data to assess the effectiveness of SRTS interventions in reducing school-aged pedestrian injury in New York City.

METHODS

Using geocoded motor vehicle crash data for 168 806 pedestrian injuries in New York City between 2001 and 2010, annual pedestrian injury rates per 10 000 population were calculated for different age groups and for census tracts with and without SRTS interventions during school-travel hours (defined as 7 am to 9 am and 2 pm to 4 pm, Monday through Friday during September through June).

RESULTS

During the study period, the annual rate of pedestrian injury decreased 33% (95% confidence interval [CI]: 30 to 36) among school-aged children (5- to 19-year-olds) and 14% (95% CI: 12 to 16) in other age groups. The annual rate of school-aged pedestrian injury during school-travel hours decreased 44% (95% CI: 17 to 65) from 8.0 injuries per 10 000 population in the preintervention period (2001-2008) to 4.4 injuries per 10 000 population in the postintervention period (2009-2010) in census tracts with SRTS interventions. The rate remained virtually unchanged in census tracts without SRTS interventions (0% [95% CI: -8 to 8]).

CONCLUSIONS

Implementation of the SRTS program in New York City has contributed to a marked reduction in pedestrian injury in school-aged children.

Controlling factors of the parental safety perception on children's travel mode choice

The travel mode of children changed significantly over the last 20 years, with a decrease of children travelling as pedestrians or cyclists. This study focuses on six to twelve year old children. Parents determine to a large extent the mode choice of children in this age category. Based on the analysis of an extensive survey, the research shows that traffic infrastructure has a significant impact on parental decision making concerning children's travel mode choice, by affecting both the real and the perceived traffic safety. Real traffic safety is quantified in terms of numbers of accidents and road infrastructure. For the perceived traffic safety a parental allowance probability is calculated per road type to show that infrastructure characteristics influence parental decision making on the children's mode choice. A binary logistic model shows that this allowance is determined by age, gender and traffic infrastructure near the child's home or near destinations frequently visited by children. Since both real and perceived traffic safety are influenced by infrastructure characteristics, a spatial analysis of parental perception and accident statistics can be used to indicate the locations where infrastructure improvements will be most effective to increase the number of children travelling - safely - as pedestrians or cyclists.

Roadway characteristics and pediatric pedestrian injury

Changing the built environment is a sound, but often underutilized approach to injury control. The authors reviewed the literature and conducted a meta-analysis to synthesize the evidence on the association of roadway characteristics with risk of pediatric pedestrian injury. To synthesize the data, they converted results to odds ratios based on direct results or abstracted outcomes and used Bayesian meta-analytic approaches by modeling outcomes as the logit of a normally distributed set of outcomes with vague prior distributions for the central measure of effect and its variance. On the basis of 10 studies of roadway features restricted exclusively to pediatric populations, the synthesized effect estimate for the association of roadway characteristics with pedestrian injury risk was 2.5 (95% credible interval: 1.8, 3.2). The probability of a new study showing an association between the built roadway and pediatric pedestrian injury was nearly 100%. The authors concluded that the built environment is directly related to the risk of pedestrian injury. This review and meta-analysis suggests that even modest interventions to the built roadway environment may result in meaningful reductions in the risk of pediatric pedestrian injury.

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.

Pedestrian road traffic injuries in urban Peruvian children and adolescents: case control analyses of personal and environmental risk factors

Background

Child pedestrian road traffic injuries (RTIs) are an important cause of death and disability in poorer nations, however RTI prevention strategies in those countries largely draw upon studies conducted in wealthier countries. This research investigated personal and environmental risk factors for child pedestrian RTIs relevant to an urban, developing world setting.

Methods

This is a case control study of personal and environmental risk factors for child pedestrian RTIs in San Juan de Miraflores, Lima, Perú. The analysis of personal risk factors included 100 cases of serious pedestrian RTIs and 200 age and gender matched controls. Demographic, socioeconomic, and injury data were collected. The environmental risk factor study evaluated vehicle and pedestrian movement and infrastructure at the sites in which 40 of the above case RTIs occurred and 80 control sites.

Findings

After adjustment, factors associated with increased risk of child pedestrian RTIs included high vehicle volume (OR 7·88, 95%CI 1·97–31·52), absent lane demarcations (OR 6·59, 95% CI 1·65–26·26), high vehicle speed (OR 5·35, 95%CI 1·55–18·54), high street vendor density (OR 1·25, 95%CI 1·01–1·55), and more children living in the home (OR 1·25, 95%CI 1·00–1·56). Protective factors included more hours/day spent in school (OR 0·52, 95%CI 0·33–0·82) and years of family residence in the same home (OR 0·97, 95%CI 0·95–0·99).

Conclusion

Reducing traffic volumes and speeds, limiting the number of street vendors on a given stretch of road, and improving lane demarcation should be evaluated as components of child pedestrian RTI interventions in poorer countries.

Paediatric pedestrian trauma: the danger after school

AIM

To examine the demographics of road pedestrian trauma in children in the Auckland region and to provide data that can help target prevention strategies.

METHODS

A retrospective analysis was conducted of all children (0-14 years) in the Auckland region admitted to the hospital or killed following a pedestrian versus vehicle injury for the 6-year period 2000-2005. Excluded were pedestrians injured in a driveway.

RESULTS

Over the 6-year period, 364 children were involved in pedestrian crashes resulting in 25 deaths. The median age was 7 years. Males comprised 63%. Pacific Islanders and Maori were over-represented. Three hundred seventeen patients had injury times recorded. Of these, 49% occurred between 3 and 7 pm. Injury peaks for school days showed a tri-modal pattern with injury peaks at 8-9 am, 3-4 pm and 5-6 pm with the 3-4 pm after-school peak predominating.

CONCLUSION

Prevention strategies should concentrate on the hours after school finishes and should be tailored for Maori and Pacific Island communities.

Why does Sweden have the lowest childhood injury mortality in the world? The roles of architecture and public pre-school services

Of interest is how some countries have achieved a profound reduction of child injury mortality. Still little is reported on the impact of a combination of urban planning, social welfare development and safety measures. We therefore present trends in childhood (0-14 years) injury mortality in Sweden 1966-2001 and discuss the factors behind any reductions observed. Annual total and cause-specific injury mortality rates were computed by age subgroups and gender. Trend analyses were performed with year as independent and mortality rate as dependent variable. A piecewise linear function was fitted to the annual mortality rates. Data were categorized into five 7-year intervals. In total, there were 5264 deaths due to injury in the study population during the period 1966-2001, of which 3368 (64%) were of boys and 1896 (36%) girls. The most frequent external cause of death was transport injury (48%), drowning (14%), homicide (5.8%), fire (5%), and fall (2.7%). About 66% (n=3474) of deaths occurred during the first half of the study period (1966-1981) with an average incidence rate of mortality 13.0 compared to 5.6 per 100,000 inhabitants during the second half of the period (1982-2001). For total injuries, there was a statistically significant decrease in mortality among all subgroups of children in both sexes. The slopes are greater among the younger children (0-4, 5-9 years) than the older ones (10-14 years). Several factors behind this strong decline of childhood injury mortality of interest to evaluate are (i) the implementation of the functionalist architectural style including transport separation, legislation and safety in cars; (ii) the expansion of public child day-care centers including more organized leisure activities; (iii) the establishment of long-term nationwide mandatory program for swim training among school children and (iv) local child-safety programs considering differences in exposure to risk between urban and rural areas.

Relation between increased numbers of safe playing areas and decreased vehicle related child mortality rates in Japan from 1970 to 1985: a trend analysis

OBJECTIVES

To examine vehicle related mortality trends of children in Japan; and to investigate how environmental modifications such as the installation of public parks and pavements are associated with these trends.

DESIGN

Poisson regression was used for trend analysis, and multiple regression modelling was used to investigate the associations between trends in environmental modifications and trends in motor vehicle related child mortality rates.

SETTING

Mortality data of Japan from 1970 to 1994, defined as E-code 810-23 from 1970 to 1978 and E810-25 from 1979 to 1994, were obtained from vital statistics. Multiple regression modelling was confined to the 1970-1985 data. Data concerning public parks and other facilities were obtained from the Ministry of Land, Infrastructure, and Transport.

SUBJECTS

Children aged 0-14 years old were examined in this study and divided into two groups: 0-4 and 5-14 years.

MAIN RESULTS

An increased number of public parks was associated with decreased vehicle related mortality rates among children aged 0-4 years, but not among children aged 5-14. In contrast, there was no association between trends in pavements and mortality rates.

CONCLUSIONS

An increased number of public parks might reduce vehicle related preschooler deaths, in particular those involving pedestrians. Safe play areas in residential areas might reduce the risk of vehicle related child death by lessening the journey both to and from such areas as well as reducing the number of children playing on the street. However, such measures might not be effective in reducing the vehicle related mortalities of school age children who have an expanded range of activities and walk longer distances.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Traffic calming for the prevention of road traffic injuries: systematic review and meta-analysis

OBJECTIVE

To assess whether area-wide traffic calming schemes can reduce road crash related deaths and injuries.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials, Medline, EMBASE, Sociological Abstracts Science (and social science) citation index, National Technical Information service, Psychlit, Transport Research Information Service, International Road Research Documentation, and Transdoc, and web sites of road safety organisation were searched; experts were contacted, conference proceedings were handsearched, and relevant reference lists were checked.

INCLUSION CRITERIA

Randomised controlled trials, and controlled before/after studies of area-wide traffic calming schemes designed to discourage and slow down through traffic on residential roads.

METHODS

Data were collected on road user deaths, injuries, and traffic crashes. For each study rate ratios were calculated, the ratio of event rates before and after intervention in the traffic calmed area divided by the corresponding ratio of event rates in the control area, which were pooled to give an overall estimate using a random effects model.

FINDINGS

Sixteen controlled before/after studies met our inclusion criteria. Eight studies reported the number of road user deaths: pooled rate ratio 0.63 (95% confidence interval (CI) 0.14 to 2.59). Sixteen studies reported the number of injuries (fatal and non-fatal): pooled rate ratio 0.89 (95% CI 0.80 to 1.00). All studies were in high income countries.

CONCLUSION

Area-wide traffic calming in towns and cities has the potential to reduce road traffic injuries. However, further rigorous evaluations of this intervention are needed, especially in low and middle income countries.

Seatbelt legislation in Japan: high risk driver mortality and seatbelt use

OBJECTIVES

To clarify why seatbelt legislation did not achieve the expected reduction in mortality in Japan. LOCATION AND BACKGROUND: Seatbelt legislation was enacted in Japan in September 1985 and penalties were introduced in November 1986.

METHODS

The driver deaths per vehicle km traveled (D/VKT) were calculated to adjust for changes in traffic volume. Decreases in D/VKT were compared with the reduction expected after legislation. The association between percentage changes of driver D/VKT, seatbelt use rate, and seatbelt non-use rate were explored. Deaths of passengers, pedestrians, and cyclists were also examined. Mortality data were obtained from vital statistics, traffic volume figures from the Ministry of Land, Infrastructure, and Transport, and seatbelt use rates from the National Police Agency.

RESULTS

Although the decrease in D/VKT after the law was enforced was larger than the absolute number of deaths, it was far less than predicted. The percentage decrease in seatbelt non-use rate showed the strongest correlation with the percentage decrease in driver mortality. Mortality did not increase among other road users after the law was enacted.

CONCLUSION

Accurate evaluation of the effect of seatbelt legislation must take into account changes in traffic volume. The selective recruitment hypothesis-that high risk drivers were less responsive to seatbelt legislation-fits well with the findings. There was no conclusive evidence supporting risk compensation-that is, an increase in injuries among other road users.

The spatial and temporal dimensions of child pedestrian injury in Edmonton

OBJECTIVES

This paper describes the temporal and spatial distribution of child pedestrian injury within Edmonton, Alberta for four fiscal years (1995-96 through 1998-99), and compares this pattern to temporal and spatial data on traffic volume.

METHODS

We used injury data obtained through an ongoing emergency department (ED) surveillance system involving all hospitals in Alberta's Capital Health Region. We identified peak times of injury occurrence and the location of high injury incidence as indicated by census tract of residence. Empirical Bayes estimation procedures were used to calculate stable injury incidence ratios. Cartographic and correlation analyses identified the relationship between traffic volume and injury incidence.

RESULTS

Child pedestrian injury occurred most frequently during morning (0700-0900 hrs) and late afternoon (1500-1800 hrs) which corresponds with peak periods of vehicular traffic flow. The highest incidence rates occurred in or near areas of high traffic volume, notably in the central and west-central parts of Edmonton.

DISCUSSION

These findings emphasize the importance of considering spatial and temporal patterns in pedestrian injury research, as well as the need to incorporate these patterns in prevention strategies. Changing the times that children attend school may reduce the convergence of pedestrian and vehicular traffic.

Mobilizing for pedestrian safety: an experiment in community action

In contrast to the steady reduction in mortality and morbidity from collisions involving motor vehicle occupants, relatively little progress has been made in controlling motor vehicle/pedestrian collisions. Engineering modifications are the most effective means of reducing such collisions, but mainly because of their cost, and public apathy about pedestrian safety, are too rarely employed. A modest experiment in community action was undertaken by attempting to induce the authorities of 10 small cities to apply for state funds to create a single model pedestrian refuge in their respective communities. Our hope was that this model would later lead to more widespread improvements. The key elements of the campaign were organizing local pedestrian safety task forces, compiling local pedestrian injury statistics, and publicizing the stories of pedestrian injury victims. At the conclusion of the planning process, all 10 target communities submitted grant applications and all 10 received full grant funding. Five projects were completed as planned, two are under construction, and the plans for three were abandoned. Pedestrian safety is not an issue that captures public attention. To make progress, goals must be modest, and a dedicated constituency must be developed. "Victim advocacy" is a vital part of this process. Progress in injury control requires concerted community action.

The spatial and temporal dimensions of child pedestrian injury in Edmonton

OBJECTIVES

This paper describes the temporal and spatial distribution of child pedestrian injury within Edmonton, Alberta for four fiscal years (1995-96 through 1998-99), and compares this pattern to temporal and spatial data on traffic volume.

METHODS

We used injury data obtained through an ongoing emergency department (ED) surveillance system involving all hospitals in Alberta's Capital Health Region. We identified peak times of injury occurrence and the location of high injury incidence as indicated by census tract of residence. Empirical Bayes estimation procedures were used to calculate stable injury incidence ratios. Cartographic and correlation analyses identified the relationship between traffic volume and injury incidence.

RESULTS

Child pedestrian injury occurred most frequently during morning (0700-0900 hrs) and late afternoon (1500-1800 hrs) which corresponds with peak periods of vehicular traffic flow. The highest incidence rates occurred in or near areas of high traffic volume, notably in the central and west-central parts of Edmonton.

DISCUSSION

These findings emphasize the importance of considering spatial and temporal patterns in pedestrian injury research, as well as the need to incorporate these patterns in prevention strategies. Changing the times that children attend school may reduce the convergence of pedestrian and vehicular traffic.

The safe journeys of an enterprising school: negotiating landscapes of opportunity and risk

In this paper, we discuss recent efforts to improve the safety of children travelling to and from New Zealand's largest primary school. The results of a travel survey completed by parents and pupils are reported, together with our recommendations for reducing congestion at the school gate and promoting healthy alternatives to car travel. Reflecting on this research, we find that market-oriented education reforms have provided schools with strong incentives for increasing their rolls--a course of action which may endanger pupils' well-being. At the same time, they have provided some schools with opportunities for resisting the present urban (dis)order and promoting community health.

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

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

A prospective health impact assessment of the international astronomy and space exploration centre

STUDY OBJECTIVES

Assess the potential health impacts of the proposed International Astronomy and Space Exploration Centre on the population of New Wallasey. Contribute to the piloting of health impact assessment methods.

DESIGN

Prospective health impact assessment involving brainstorming sessions and individual interviews with key informants and a literature review.

SETTING

New Wallasey Single Regeneration Budget 4 area.

PARTICIPANTS

Key stakeholders including local residents' groups selected through purposeful snowball sampling.

MAIN RESULTS

Recommendations are made that cover issues around: transport and traffic; civic design; security; public safety, employment and training.

CONCLUSIONS

Health impact assessment is a useful pragmatic tool for facilitating wide consultation. In particular engaging the local population in the early planning stages of a proposed development, and assisting in highlighting changes to maximise the positive health influences on affected communities.

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.

Pathologic features of childhood pedestrian fatalities

A retrospective analysis of 68 cases of fatal childhood pedestrian accidents in South Australia that occurred over a 20-year period from January 1977 to December 1996 was undertaken. The age range was 12 months to 16 years (average, 7.6 years), with a male to female ratio of 41:27. The most common site of significant injury was the head (91.2%), followed by the abdomen (50%), chest (47.1%), and neck (38.2%). The most frequently encountered significant injury combinations involved the head, chest, and abdomen (14.7%); the head and chest (11.8%); and the head, neck, and abdomen (11.8%). Injuries were severe, consisting of extensive compound and comminuted skull fractures, neck fractures, and massive intraparenchymal brain and internal organ damage with avulsions and fragmentation. Non-life-threatening limb injuries occurred in 88% of cases. A distinct subgroup involved infants and younger children playing in driveways at home who were hit by reversing vehicles. The injuries were often of such a severe nature that death was instantaneous and with no possibility of successful medical intervention. More deaths occurred during the winter than summer months.

Epidemiology and prevention of traffic injuries to urban children and adolescents

OBJECTIVES

To describe the incidence of severe traffic injuries before and after implementation of a comprehensive, hospital-initiated injury prevention program aimed at the prevention of traffic injuries to school-aged children in an urban community.

MATERIALS AND METHODS

Hospital discharge and death certificate data on severe pediatric injuries (ie, injuries resulting in hospital admission and/or death to persons age <17 years) in northern Manhattan over a 13-year period (1983-1995) were linked to census counts to compute incidence. Rate ratios with 95% CIs, both unadjusted and adjusted for annual trends, were calculated to test for a change in injury incidence after implementation of the Harlem Hospital Injury Prevention Program. This program was initiated in the fall of 1988 and continued throughout the study period. It included 1) school and community based traffic safety education implemented in classroom settings in a simulated traffic environment, Safety City, and via theatrical performances in community settings; 2) construction of new playgrounds as well as improvement of existing playgrounds and parks to provide expanded off-street play areas for children; 3) bicycle safety clinics and helmet distribution; and 4) a range of supervised recreational and artistic activities for children in the community.

PRIMARY RESULTS

Traffic injuries were a leading cause of severe childhood injury in this population, accounting for nearly 16% of the injuries, second only to falls (24%). During the preintervention period (1983-1988), severe traffic injuries occurred at a rate of 147.2/100 000 children <17 years per year. Slightly <2% of these injuries were fatal. Pedestrian injuries accounted for two thirds of all severe traffic injuries in the population. Among school-aged children, average annual rates (per 100 000) of severe injuries before the intervention were 127.2 for pedestrian, 37.4 for bicyclist, and 25.5 for motor vehicle occupant injuries. Peak incidence of pedestrian and bicyclist injuries occurred during the summer months and afternoon hours, whereas motor vehicle occupant injuries showed little seasonal variation and were more common during evening and night-time hours. Age-specific rates showed peak incidence of pedestrian injuries among 6- to 10-year-old children, of bicyclist injuries among 9- to 15-year-old children, and of motor vehicle occupant injuries among adolescents between the ages of 12 and 16 years. The peak age for all traffic injuries combined was 15 years, an age at which nearly 3 of every 1000 children each year in this population sustained a severe traffic injury. Among children hospitalized for traffic injuries during the preintervention period, 6.3% sustained major head trauma (including concussion with loss of consciousness for >/=1 hour, cerebral laceration and/or cerebral hemorrhage), and 36.9% sustained minor head trauma (skull fracture and/or concussion with no loss of consciousness >/=1 hour and no major head injury). The percentage of injured children with major and minor head trauma was higher among those injured in traffic than among those injured by all other means (43.2% vs 14.2%, respectively; chi2 = 336; degrees of freedom = 1). The percentages of children sustaining head trauma were 45.4% of those who were injured as pedestrians, 40.2% of those who were injured as bicyclists, and 38.9% of those who were injured as motor vehicle occupants. During the intervention period, the average incidence of traffic injuries among school aged children declined by 36% relative to the preintervention period (rate ratio:.64; 95% CI:.58,.72). After adjusting for annual trends in incidence, pedestrian injuries declined during the intervention period among school aged children by 45% (adjusted rate ratio:.55; 95% CI:.38,.79). No comparable reduction occurred in nontargeted injuries among school-aged children (adjusted rate ratio:.89; 95% CI:.72, 1.09) or in traffic injuries among younger children who

Children's exposure to traffic and pedestrian injuries

OBJECTIVES

The purpose of this study was to estimate children's exposure to traffic (number of streets crossed) and to determine the role of exposure in pedestrian injury.

METHODS

Questionnaires were distributed to a random sample of 4080 first- and fourth-grade children in 43 Montreal schools.

RESULTS

When analyzed by police district, injury and exposure rates were positively correlated (r2 = 0.53). Crossings were similar by sex but increased with age and were inversely related to socioeconomic status.

CONCLUSIONS

These results suggest that although children's exposure to traffic could be reduced by transporting them to school, a more reasonable prevention strategy involves environmental changes.

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

PURPOSE

To identify modifiable risk factors for child pedestrian injuries.

DATA SOURCES

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

STUDY SELECTION

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

QUALITY ASSESSMENT

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

RESULTS

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

Road traffic accidents: early psychological consequences in children and adolescents

BACKGROUND

Although road traffic accidents are a major cause of injury and death in children and adolescents, research into their psychological consequences consists mainly of case reports.

METHOD

A prospective study was made of young road traffic accident victims: 57 subjects, aged 5-18 years, who had been injured in road traffic accidents, and their parents, were interviewed 2-16 days post-accident and re-examined after 12-15 weeks.

RESULTS

Post-accident stress symptoms occurred at both times. There was a decrease of symptom severity between the two interviews, but at the later time, 14% still suffered from moderate or severe post-traumatic stress disorder, 17% from serious traffic-related fears, and parents reported increased mood disturbance in their children compared with the pre-accident period. High levels of distress during and immediately after the accident were associated with severe post-traumatic stress symptoms.

CONCLUSIONS

There is an urgent need for healthcare staff working with children and adolescents involved in road traffic accidents to be aware of the potential psychological consequences and the importance of the immediate accident experience on subsequent coping.

A case-control study of childhood pedestrian injuries in Perth, Western Australia

STUDY OBJECTIVES

To identify the determinants of childhood pedestrian injuries, taking the child's exposure to the road environment into account.

DESIGN

This was a case-control study.

SETTING AND PARTICIPANTS

The study was conducted in Perth, Western Australia between 1991 and 1993. Altogether 100 injured and 400 uninjured child pedestrians aged 1 to 14 years were studied. Aspects of the child's social and physical environments, measures of his or her behaviour, cognitive skills, and "habitual" exposure to the road environment, as well as his or her knowledge of road safety, were recorded.

MAIN RESULTS

The likelihood of injury increased by 12% with each 10,000 vehicles per day increase in the volume of traffic (odds ratio (OR) 1.12, 95% confidence interval (CI) = 1.05, 1.19) on roads most frequently crossed. In addition, the presence of visual obstacles on the verge of the child's street of residence increased the likelihood of injury by more than 2.6 times (OR 2.68, 95% CI = 1.42, 5.02). In contrast, the absence of footpaths was associated with a 52% reduction in the likelihood of injury compared with the presence of footpaths on the child's street of residence (OR 0.48, 95% CI = 0.27, 0.87).

CONCLUSION

The amount of exposure to the road environment and the nature of the road environment to which the child pedestrian was exposed partly influenced the likelihood of injury in children from low socioeconomic areas, male children, and children aged 13 to 14 years. Until now, the excess incidence of childhood pedestrian injuries in these subgroups of the population had not been explained because the child's exposure per se had not been examined.

Child pedestrian deaths: sensitivity to traffic volume--evidence from the USA

STUDY OBJECTIVE

In case centred epidemiological studies, traffic volume has been shown to be a potent risk factor for child pedestrian injuries. Nevertheless, over the past two decades child pedestrian death rates have fallen in many countries despite large increases in traffic volumes, suggesting that other factors are responsible for the long term decline in death rates. This study aimed to investigate the relationship between short term changes in traffic volume and child pedestrian death rates.

DESIGN

The relationship between child pedestrian death rates and traffic volume in the USA for the period 1970-88 was investigated. Trends in death rates and in traffic volume were removed by the time series method of differencing.

RESULTS

After removing the long term trends, there was a close relationship between the year to year variation in traffic volume and the year to year variation in the child pedestrian death rate. Most notably, in the two periods when traffic volume actually fell, the falls in the child pedestrian death rate were considerably larger than those seen at any other time. Overall, decelerations in the rate of increase in traffic volume were accompanied by accelerations in the rate of decline in the child pedestrian death rate.

CONCLUSION

While other factors may determine long term trends in child pedestrian death rates, they are very sensitive to short term changes in traffic volume. Public policy changes which limit the growth in traffic volume have the potential to accelerate the decline in child pedestrian death rates.

Effect of environmental factors on risk of injury of child pedestrians by motor vehicles: a case-control study

OBJECTIVE

To identify and assess contribution of environmental risk factors for injury of child pedestrians by motor vehicles.

DESIGN

Community based case-control study. Environmental characteristics of sites of child pedestrian injury were compared with the environmental characteristics of selected comparison sites. Each comparison site was the same distance and direction from home of control child as was the injury site from home or relevant case child. Two control sites were selected for each injury site.

SETTING

Auckland region of New Zealand.

SUBJECTS

Cases were 190 child pedestrians aged < 15 who were killed or hospitalised after collision with a motor vehicle on a public road during two years and two months. Controls were 380 children randomly sampled from population and frequency matched for age and sex.

MAIN OUTCOME MEASURE

Traffic volume and speed and level of parking on curbs at injury sites and comparison sites.

RESULTS

Risk of injury of child pedestrians was strongly associated with traffic volume: risk of injury at sites with highest traffic volumes was 14 times greater than that at least busy sites (odds ratio 14.30; 95% confidence interval 6.98 to 29.20), and risk increased with increasing traffic volume. High density of curb parking was also associated with increased risk (odds ratio 8.12; 3.32 to 19.90). Risk was increased at sites with mean speeds over 40 km/h (odds ratio 2.68; 1.26 to 5.69), although risk did not increase further with increasing speed.

CONCLUSION

Reducing traffic volume in urban areas could significantly reduce rates of child pedestrian injury. Restricting curb parking may also be effective.

Pedestrian exposure and the risk of child pedestrian injury

The authors used data from the New Zealand Household Travel Survey to examine the extent to which children's pedestrian exposure varies with age, sex and household income. Pedestrian injury morbidity data were combined with pedestrian exposure data to examine age-specific pedestrian injury risk. The annual number of road crossings for girls was greater than that for boys. Pedestrian exposure increased with increasing age. Children aged 5-9 years in the lowest household income bracket crossed approximately 50% more roads than those in the middle and upper income brackets. However, for children aged 10-14 years there was little variation with household income. Sex differences in pedestrian injury rates cannot be explained by differences in exposure although increased exposure may partly explain the increased injury rates for children in lower socio-economic groups. Prevention strategies might aim to reduce pedestrian exposure for alternatively to reduce pedestrian injury risk per unit of exposure by making safer urban living environments.

Preventing child pedestrian injury: pedestrian education or traffic calming?

The traditional approach to the prevention of child pedestrian injuries in New Zealand is pedestrian education. However, none of the programs currently being implemented in New Zealand have ever been shown to reduce injury rates. The allocation of scarce resources to pedestrian education must therefore be questioned. In this paper we estimate the number of serious child pedestrian injuries which might be prevented if the resources allocated to pedestrian education were allocated instead to environmental approaches, in particular, to traffic calming. It is estimated that approximately 18 hospitalisations of child pedestrians could be prevented each year under this alternative resource allocation, disregarding any other benefits of traffic calming. These results emphasise the need to consider the potential sacrifices involved in the allocation of scarce resources to child pedestrian education.

Measuring exposure to injury risk in schoolchildren aged 11-14

OBJECTIVE

To apply a measure of exposure to injury risk for schoolchildren aged 11-14 across a population and to examine how risk factors vary with sex, age, and affluence.

DESIGN

Self completion questionnaire survey administered in schools in May 1990.

SETTING

24 schools in Newcastle upon Tyne.

SUBJECTS

5334 pupils aged 11-14, of whom 4637 (87%) completed the questionnaire.

RESULTS

Boys were exposed to greater risk than girls in journeys to places to play outdoors; they took longer trips and were more likely to ride bicycles (relative risk 5.30 (95% confidence interval 4.23 to 6.64)) and less likely to travel by public transport or car. Younger pupils (aged 11-12) were less exposed to traffic during journeys to and from school: their journeys were shorter, they were less likely to walk (trip to school, relative risk 0.88 (0.83 to 0.94)), and they were more likely to travel by car (trip to school, relative risk 1.33 (1.13 to 1.56)) or school bus (1.33 (1.10 to 1.62)). Poorer children were exposed to greater risk than affluent children (from families that owned a car and a telephone): they were less likely to travel to school by car (relative risk 0.26 (0.20 to 0.33)) or to be accompanied by an adult (0.39 (0.32 to 0.48)).

CONCLUSION

Injury risk data can provide useful information on child injury prevention and can be used to identify priorities and target resources for injury prevention on a citywide scale or for an individual school.