This population-based study describes the road use pattern, and context and risk factors for RTI in children from a large city in India. Extrapolating from a 3-month recall period, we found that 5.8% of children aged 5–14 years had experienced a non-fatal RTI during the previous year which had required a recovery period of more than 7 days. The majority of these RTI were sustained by cyclists or pedestrians. These data confirm the need to consider injuries experienced by children, particularly those who are vulnerable road users, as a public health priority in urban India.
To the best of our knowledge, these are the first population-based data on road use pattern of children from a developing country setting. A distinct difference in the road use pattern was seen between boys and girls and based on socioeconomic strata. Girls were less likely to use a cycle and were more likely to walk. This is probably because boys are given more freedom and are less restrained by the parents to move around as compared with girls.3,42
This is also reflected in the larger number and variety of cycles available for boys than for girls in India.19–21
It is conceivable that the households with lower income are less able to afford a cycle for their children and hence the children belonging to the lower per capita household income quartile were the least likely to be making road trips using a cycle.
A high number of road trips per day were reported for children with the majority making six or more road trips. It is unlikely that the trips were over-reported as the interviewers asked the respondent to mention each road trip on usual days which were then counted to arrive at the number of trips. A little over 80% of RTI were reported during trips which were not related to school/work. More information including qualitative research that explores the reasons and context for these trips is needed to identify the most appropriate road safety interventions that can reduce RTIs in this age group.
Though only 3% of children were reported to be currently driving a motorised two-wheeled vehicle, they were significantly more likely to be injured in RTC. This finding is of concern as they were driving a vehicle at an age below the legal age of obtaining a learners license for a motorised two-wheeled vehicle with 50cc engine or less in India (16 years).47
In addition, none of them reported using a helmet which increases their vulnerability for head injury in case of a crash. We have previously reported that 7.3% of motorised two-wheeled vehicle drivers currently aged 16 years or more in Hyderabad had started driving the motorised two-wheeled vehicle below the age of 16 years.8
Stricter law enforcement is needed to prevent such driving by children,9,35
and measures involving parents, schools and alternative safe public transport systems can also be explored to reduce underage driving on roads.
The annual rate of non-fatal RTI requiring a recovery period of more than 7 days for boys and girls in our study was 7.0% and 4.5%, respectively. Compared with the relatively sparse data on childhood RTI reported from many developing countries,15,17,22,25,30,32,34
the RTI rate was higher in our study. We have previously reported that the relatively higher magnitude of RTI in this population may be related to the methods that we used, which included detailed explanation and probing as well as a short recall period of 3 months to estimate the annual rate.6
It is important to note that the incidence of minor non-fatal RTI may be underreported in our study because the information on RTI was documented from parents/guardian for children aged 10 years or less, and those 11 years of age may have underreported RTI in the presence of their parents/guardian. The over-representation of cyclists and pedestrians and preponderance of children among RTI victims has been reported in several low- and middle-income countries.22–24,35,36,39,43,44,46
Globally, a variety of risk factors relating to the child, vehicle and environment have been identified for unintentional injuries in children, and these the risk factors can vary from one setting to another.1,5,11–13,18,35,38,41,45
We found a higher RTI risk as a cycle user for boys and among those who could ride a cycle. One-third of the cycle injuries were a result of collision with another vehicle and nearly 45% due to skidding/fall from cycle. Cycle is primarily used as a mode of transport and not for recreation in India by children and adults and without a helmet. In addition to increased access to cycles for boys, exposure and mixed traffic patterns are among the major risks for RTI as a cycle user.4,31
Pedestrian injuries in children are known to be the highest in Asia and Africa.22,28
These data also highlight the protective effect of higher per capita monthly household income on pedestrian RTI. Most pedestrian injuries occurred while walking, crossing or playing on road. It is not uncommon for children to play on roads in India as not many neighbourhoods have playgrounds and residential areas often do not have speed or traffic volume restrictions thereby increasing the risk of RTI for children. They are often unsupervised while playing or while running errands to the local market, and research has shown increased RTI risk with the lack of parental supervision,37
and that parental supervision can reduce the RTI risk in children.14
Physical and cognitive developmental factors also increase the risk of RTC among young pedestrians.35
Injuries to arms and legs were the most common types of injuries sustained, and more than half of the injured children reported seeking medical care as an out-patient. Fractures to arms and legs are reported to be the most common injuries requiring hospital admissions for children.50
The injury severity and burden are further highlighted by the days needed for recovery and days lost from school and work.
The specific road use pattern and RTI data presented in this paper can be utilised to adapt for our setting the proven strategies used in high-income countries to reduce RTI in children,35
and to target appropriate sub-populations for these strategies. Further studies that explore the particular relationships between the transport and social environments and the communities in which children are raised and experience RTI could guide further development of interventions that can respond appropriately and efficiently to the Indian context.