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1.  Injury risk and severity in a sample of Maryland residents with serious mental illness 
Adults with serious mental illness experience premature mortality and heightened risk for medical disease, but little is known about the burden of injuries in this population. We conducted a retrospective cohort study of 6234 Maryland Medicaid recipients with serious mental illness from 1994–2001. Injuries were classified using the Barell Matrix. Relative risks were calculated to compare injury rates among the study cohort with injury rates in the United States population. Cox proportional hazards modeling with time dependent covariates was used to assess factors related to risk of injury and injury-related death. Forty-three percent of the Maryland Medicaid cohort had any injury diagnosis. Of the 7298 injuries incurred, the most common categories were systemic injuries due to poisoning (10.4%), open wounds to the head/face (8.9%), and superficial injuries, fractures, and sprains of the extremities (8.6%, 8.5%, and 8.4%, respectively). Injury incidence was 80% higher and risk for fatal injury was more than four and a half times higher among the cohort with serious mental illness compared to the general population. Alcohol and drug abuse were associated with both risk of injury and risk of injury-related death with hazard ratios of 1.87 and 4.76 at the P<.05 significance level, respectively. The superficial, minor nature of the majority of injuries is consistent with acts of minor victimization and violence or falls. High risk of fatal and non-fatal injury among this group indicates need for increased injury prevention efforts targeting persons with serious mental illness and their caregivers.
PMCID: PMC3821975  PMID: 22661205
Injury; Serious Mental Illness; Schizophrenia; Bipolar Disorder; Barell Matrix
2.  Acute alcohol intoxication and suicide: a gender-stratified analysis of the National Violent Death Reporting System 
Although it is well known that people with alcohol dependence are at a markedly elevated risk for suicide, much less is known about the role of acute alcohol use in suicidal behaviours. The primary aims of this epidemiological study were to assess the prevalence and factors associated with acute alcohol intoxication among 57 813 suicide decedents in 16 states.
Data from the restricted National Violent Death Reporting System 2003–2009 for male and female suicide decedents aged 18 years and older were analysed by multiple logistic regression to compare decedents with and without acute alcohol intoxication (defined as blood alcohol concentration (BAC) ≥0.08 g/dl).
Among men, those who were younger, American Indian/Alaska Native, Hispanic, veterans, of lower educational attainment, deceased from a self-inflicted firearm injury or hanging/suffocation and residing in rural areas were more likely to have been intoxicated at the time of death. Among women, the factors associated with a BAC ≥0.08 g/dl were younger age, being American Indian/Alaska Native, and using a firearm, hanging/suffocation or falling as method of death.
In both men and women, alcohol intoxication was associated with violent methods of suicide and declined markedly with age, suggesting that addressing risks associated with acute alcohol use may be of the greatest aid in the prevention of violent suicides among young and middle age adults.
PMCID: PMC3760342  PMID: 22627777
3.  Making the Message Meaningful: A Qualitative Assessment of Media Promoting All-Terrain Vehicle Safety 
Millions of all-terrain vehicles (ATV) are used around the world for recreation by both adults and youth. This increase in use has led to a substantial increase in the number of injuries and fatalities each year. Effective strategies for reducing this incidence are clearly needed; however, minimal research exists regarding effective educational interventions.
This study was designed to assess rural ATV riders’ preferences for and assessment of safety messages.
Thirteen focus group discussions with youth and adult ATV riders were conducted. Eighty-eight formative research participants provided feedback on existing ATV safety materials, which was used to develop more useful ATV safety messages. Sixty evaluative focus group participants critiqued the materials developed for this project.
Existing ATV safety materials are not effective. One reason is because they do not address the content or design needs of the target population. ATV riders want educational and action-oriented safety messages that inform youth and adult riders about their responsibilities to learn, educate, and implement safety behaviors (e.g., appropriate-sized ATV, safety gear, solo riding, speed limits, riding locations). Additionally, messages should be clear, realistic, visually appealing, and easily accessible. Newly designed ATV safety materials using the acronym TRIPSS (Training, Ride Off-Road, Impairment, Plan Ahead, Safety Gear, Single Rider) meets ATV riders’ safety messaging needs.
To best reach a target population, it is crucial to include them in the development and assessment of safety messages. Germane to this particular study, ATV riders provided essential information for creating useful ATV safety materials.
PMCID: PMC3704218  PMID: 22101098
4.  It Takes a Village to Prevent Falls: Reconceptualizing Fall Prevention and Management for Older Adults 
Systematic evidence reviews support the efficacy of physical activity programs and multifactorial strategies for fall prevention. However, community settings where fall prevention programs occur often differ substantially from the research settings in which efficacy was first demonstrated. Because of these differences, alternative approaches are needed to judge the adequacy of fall prevention activities occurring as part of standard medical care or community efforts. This paper uses the World Health Organization Innovative Care for Chronic Conditions (ICCC) framework to rethink how fall prevention programs might be implemented routinely in both medical and community settings. We highlight examples of innovative programs and policies that provide fall prevention strategies consistent with the ICCC framework, and provide evidence where available on the effects of these strategies on processes and outcomes of care. We close by proposing a “no wrong door” approach to fall prevention and management, in which older adults who are found to be at risk for falls in either a medical or community setting are linked to a standard fall risk evaluation across three domains (physical activity, medical risks and home safety).
PMCID: PMC3590814  PMID: 18676787
accidental falls; fall prevention; chronic care model; implementation research; program evaluation
5.  Young Egyptians’ perceptions, attitudes and knowledge of injuries 
The objective of this study was to qualitatively evaluate young Egyptians’ perceptions, attitudes, knowledge and behaviour towards injuries before implementation of an extensive questionnaire about injuries among Egyptian youth. In 2008, five focus groups of three to nine participants each were conducted in Cairo, Egypt in Arabic to evaluate young Egyptians’ attitudes towards injuries, injury prevention, and their understanding of ‘accidents’ and fatalism. Participants were 14–26 years of age and were from medium to high socioeconomic status. Focus group participants noted that the concept of hadthah (‘accident’) signified an event determined by destiny, whereas esabah (‘injury’) was the result of human actions. The results of these focus groups indicate that young, educated Egyptians are interested in injury prevention programmes despite low confidence in the preventability of injuries.
PMCID: PMC3570976  PMID: 20587813
6.  Backing collisions: a study of drivers’ eye and backing behaviour using combined rear-view camera and sensor systems 
Backing crash injures can be severe; approximately 200 of the 2,500 reported injuries of this type per year to children under the age of 15 years result in death. Technology for assisting drivers when backing has limited success in preventing backing crashes.
Two questions are addressed: Why is the reduction in backing crashes moderate when rear-view cameras are deployed? Could rear-view cameras augment sensor systems?
46 drivers (36 experimental, 10 control) completed 16 parking trials over 2 days (eight trials per day). Experimental participants were provided with a sensor camera system, controls were not. Three crash scenarios were introduced.
Parking facility at UMass Amherst, USA.
46 drivers (33 men, 13 women) average age 29 years, who were Massachusetts residents licensed within the USA for an average of 9.3 years.
Vehicles equipped with a rear-view camera and sensor system-based parking aid.
Main Outcome Measures
Subject’s eye fixations while driving and researcher’s observation of collision with objects during backing.
Only 20% of drivers looked at the rear-view camera before backing, and 88% of those did not crash. Of those who did not look at the rear-view camera before backing, 46% looked after the sensor warned the driver.
This study indicates that drivers not only attend to an audible warning, but will look at a rear-view camera if available. Evidence suggests that when used appropriately, rear-view cameras can mitigate the occurrence of backing crashes, particularly when paired with an appropriate sensor system.
PMCID: PMC3472446  PMID: 20363812
7.  Data sharing for prevention: a case study in the development of a comprehensive emergency department injury surveillance system and its use in preventing violence and alcohol-related harms 
Injury Prevention  2011;18(5):315-320.
To examine emergency department (ED) data sharing via a local injury surveillance system and assess its contribution to the prevention of violence and alcohol-related harms.
6-year (2004–2010) exploratory study analysing injury attendances to one ED in the North West of England using descriptive and trend analyses.
Over the 6-year period, there were 242 796 ED injury attendances, including 21 683 for intentional injuries. Compared with unintentional injury patients, intentional injury patients were more likely to be men, aged 18–34 years, live in the most deprived communities, have attended the ED at night/weekends, have been injured in a public place and have consumed alcohol prior to the injury. Detailed data collected on alcohol and violence-related ED attendances were shared with local partners to monitor local trends and inform prevention activity including targeted policing and licensing enforcement. Over the 6-year period, intentional ED injury attendances decreased by 35.6% and alcohol-related assault attendances decreased by 30.3%.
The collection of additional ED data on assault details and alcohol use prior to injury, and its integration into multi-agency policy and practice, played an important role in driving local violence prevention activity. Further research is needed to assess the direct contribution ED data sharing makes to reductions in violence.
PMCID: PMC3461757  PMID: 22210640
Injury; violence; surveillance; emergency department; prevention; public health; case study; alcohol/drugs; recreation; behavioural; environment
8.  Explaining regional disparities in traffic mortality by decomposing conditional probabilities 
In the United States, the mortality rate from traffic injury is higher in rural and in southern regions, for reasons that are not well understood.
For 1754 (56%) of the 3142 US counties, we obtained data allowing for separation of the deaths/population (D/P) rate into deaths/injury (D/I), injuries/crash (I/C), crashes/exposure (C/E), and exposure/population (E/P), with exposure measured as vehicle miles traveled. A “decomposition method” proposed by Li and Baker was extended to study how the contributions of these components were affected by three measures of rural location, as well as southern location.
The method of Li and Baker extended without difficulty to include non-binary effects and multiple exposures. D/I was by far the most important determinant in the county-to-county variation in D/P, and accounted for the greatest portion of the rural/urban disparity. After controlling for the rural effect, I/C accounted for most of the southern/northern disparity.
The increased mortality rate from traffic injury in rural areas can be attributed to the increased probability of death given that a person has been injured, possibly due to challenges faced by emergency medical response systems. In southern areas, there is an increased probability of injury given that a person has crashed, possibly due to differences in vehicle, road, or driving conditions.
PMCID: PMC3446824  PMID: 21212443
Traffic; mortality; decomposition; rural; south
9.  Reporting on road traffic injury: content analysis of injuries and prevention opportunities in Ghanaian newspapers 
Injury Prevention  2010;16(3):194-197.
In order to analyse traffic injury reporting in Ghanaian newspapers and identify opportunities for improving road safety, the content of 240 articles on road traffic injury was reviewed from 2005 to 2006 editions of two state-owned and two privately owned newspapers. The articles comprised reports on vehicle crashes (37%), commentaries (33%), informational pieces (12%), reports on pedestrian injury (10%), and editorials (8%). There was little coverage of pedestrian injuries, which account for half of the traffic fatalities in Ghana, but only 22% of newspaper reports. Only two articles reported on seatbelt use. Reporting patterns were similar between public and private papers, but private papers more commonly recommended government action (50%) than did public papers (32%, p=0.006). It is concluded that Ghanaian papers provide detailed coverage of traffic injury. Areas for improvement include pedestrian injury and attention to preventable risk factors such as road risk factors, seatbelt use, speed control, and alcohol use.
PMCID: PMC3271730  PMID: 20570987
10.  Alcohol-Induced Memory Blackouts as an Indicator of Injury Risk among College Drinkers 
Injury Prevention  2011;18(1):44-49.
An alcohol-induced memory blackout represents an amnesia to recall events but does not involve a loss of consciousness. Memory blackouts are a common occurrence among college drinkers, but it is not clear if a history of memory blackouts is predictive of future alcohol-related injury above and beyond the risk associated with heavy drinking episodes. This analysis sought to determine if baseline memory blackouts can prospectively identify college students with alcohol-related injury in the next 24 months after controlling for heavy drinking days.
Data were analyzed from the College Health Intervention Project Study (CHIPS), a randomized controlled trial of screening and brief physician intervention for problem alcohol use among 796 undergraduate and 158 graduate students at four university sites in the US and one in Canada, conducted from 2004 to 2009. Multivariate analyses used generalized estimating equations (GEE) with the logit link.
The overall 24-month alcohol-related injury rate was 25.6%, with no significant difference between males and females (p=.51). Alcohol-induced memory blackouts at baseline exhibited a significant dose-response on odds of alcohol-related injury during follow-up, increasing from 1.57 (95% CI: 1.13–2.19) for subjects reporting 1–2 memory blackouts at baseline to 2.64 (95% CI: 1.65–4.21) for students acknowledging 6+ memory blackouts at baseline. The link between memory blackouts and injury was mediated by younger age, prior alcohol-related injury, heavy drinking, and sensation-seeking disposition.
Memory blackouts are a significant predictor of future alcohol-related injury among college drinkers after adjusting for heavy drinking episodes.
PMCID: PMC3210864  PMID: 21708813
alcohol drinking; alcohol abuse; blackout; memory
11.  Risk and protective factors associated with gang affiliation among high-risk youth: a public health approach 
Injury Prevention  2012;18(4):253-258.
Gang violence accounted for 20% of homicides in large cities from 2002 to 2006. Preventing gang affiliation (ie, youth who either desire or have gang membership) might reduce subsequent gang activity. Previous research has focused on identifying risk factors for gang affiliation; however, little information is available on protective factors.
To identify risk and protective factors to provide more direction for gang violence prevention strategies.
The author analysed cross-sectional survey data from 4131 youths in grades 7, 9, 11 and 12. Data were collected in 2004 from students in a high-risk, urban public school district. Regression analyses were conducted to assess the association between gang affiliation and alcohol and drug use, delinquency, depressed mood, suicidal ideation, peer victimisation, parental monitoring and positive reinforcement, adult, family and peer support, coping skills, and school connectedness. Analyses were controlled for sex, race/ethnicity and age.
An estimated 7% of youths were gang affiliated. Adjusting for all factors, gang affiliation was positively associated with engaging in any delinquent behaviours (prevalence OR: 2.07; 95% CI 1.18 to 3.64), frequent alcohol use (OR: 2.62; 95% CI 1.85 to 3.72) and frequent drug use (OR: 1.95; 95% CI 1.15 to 3.29). Gang affiliation was negatively associated with moderate levels of parental monitoring (OR: 0.67; 95% CI 0.54 to 0.85) and coping skills (OR: 0.54; 95% CI 0.42 to 0.71).
The findings suggest the potential benefit of increasing parental monitoring and coping skills and reducing delinquency, alcohol use and drug use to prevent gang affiliation.
PMCID: PMC3406611  PMID: 22240265
Gang; protective factors; risk factors; primary prevention; youth; street youth; public health; violence; risk/determinants
12.  The impact of pedestrian countdown signals on pedestrian–motor vehicle collisions: a quasi-experimental study 
Injury Prevention  2011;18(4):210-215.
To determine whether pedestrian countdown signals (PCS) reduce pedestrian–motor vehicle collisions in the city of Toronto, Canada.
A quasi-experimental study design was used to evaluate the effect of PCS on the number of pedestrian–motor vehicle collisions in the city of Toronto, from January 2000 to December 2009. Each intersection acted as its own control. We compared the number of pedestrian–motor vehicle collisions per intersection-month before and after the intervention. Stratified models were used to evaluate effect modification by pedestrian age, injury severity and location (urban vs inner suburbs). Poisson regression analysis with repeated measures (generalised estimating equations) was used to estimate the RR and 95% CI.
The analysis included 9262 pedestrian–motor vehicle collisions at 1965 intersections. The RR of collisions after PCS installation was 1.014 (95% CI 0.958 to 1.073), indicating no statistically significant effect of PCS on collisions. There was no evidence to suggest effect modification between PCS and collisions by age, injury severity or location.
The installation of PCS at 1965 signalised intersections in Toronto did not reduce the number of pedestrian–motor vehicle collisions at these intersections.
PMCID: PMC3406612  PMID: 22157206
Accidents; bicycle; Canada; child; database; epidemiology; evaluation; MVTC; occupational; pedestrians; playground; public health; restraint; safety; surveillance; traffic/prevention and control; training
13.  Motor vehicle injuries in Qatar: time trends in a rapidly developing Middle Eastern nation 
Injury Prevention  2011;18(2):130-132.
Despite their wealth and modern road systems, traffic injury rates in Middle Eastern countries are generally higher than those in Western countries. The authors examined traffic injuries in Qatar during 2000–2010, a period of rapid population growth, focusing on the impact of speed control cameras installed in 2007 on overall injury rates and mortality. During the period 2000–2006, prior to camera installation, the mean (SD) vehicular injury death rate per 100 000 was 19.9±4.1. From 2007 to 2010, the mean (SD) vehicular death rates were significantly lower: 14.7±1.5 (p=0.028). Non-fatal severe injury rates also declined, but mild injury rates increased, perhaps because of increased traffic congestion and improved notification. It is possible that speed cameras decreased speeding enough to affect the death rate, without affecting overall injury rates. These data suggest that in a rapidly growing Middle Eastern country, photo enforcement (speed) cameras can be an important component of traffic control, but other measures will be required for maximum impact.
PMCID: PMC3311870  PMID: 21994881
Qatar; traffic injuries; mortality; epidemiology; speed cameras; public health; motor vehicle; occupant; occupational injury; campaign; enforcement; legislation; policy; concussion; behaviour change; pedestrian; implementation/translation
14.  Preventing unintentional injuries to children under 15 years in the outdoors: a systematic review of the effectiveness of educational programs 
Injury Prevention  2011;18(2):113-123.
Unintentional injuries to children in the outdoors have a significant impact on child mortality, development and healthcare costs. This paper presents the findings of a systematic review about the effectiveness of programs that provided information, advice or education about the prevention of unintentional injuries to children under 15 years during outdoor play and leisure.
A structured search strategy was conducted in a range of databases. All report titles and abstracts were screened using pre-defined criteria. Included reports were quality appraised using a modified Graphical Appraisal Tool for Epidemiological studies (GATE) tool. All quality appraisals and data extraction were checked by a second reviewer. If not provided in the original reports, ORs and mean differences were calculated, where sufficient data were available.
Twenty-three studies met the inclusion criteria. There was a paucity of robust study designs. The majority of studies only reported a short-term follow-up of intermediate outcome measures. Only two studies measured injury rates; both reported a reduction, but both studies also had considerable methodological weaknesses. The five studies that measured the use of protective equipment reported mixed results, although there is some evidence that suggests that more extensive educational programs (such as health fairs and media campaigns) increase their use. The 20 studies that measured behaviour, attitude or knowledge outcomes reported highly mixed results.
Methodological weaknesses of the included studies limit support for a particular course of action. To better inform policy and practice, future research should (1) use robust study designs and (2) not rely on short-term proxy outcome measures.
PMCID: PMC3311869  PMID: 21890579
Health education; systematic review; child; adolescent; public health; qualitative research; health services
15.  Histories including number of falls may improve risk prediction for certain non-vertebral fractures in older men 
To determine whether information on number of falls on a falls history screen predicts risk of non-vertebral and hip fracture.
A cohort of 5995 community-dwelling men aged 65 years and older (mean 73.7) was followed over 7.2 years for incident non-vertebral fractures. Cox proportional hazard models were used to calculate hazard ratios (HRs) (95% CI) for incident fracture comparing a history of one and two or more falls with no falls. Models were adjusted for age, clinic, body mass index, height, femoral neck bone mineral density and whether the participant had a non-trauma fracture after the age of 50. p≤0.05 was considered to denote significance.
There were 498 incident non-vertebral fractures (15.5/1000 person-years) and 121 incident hip fractures (3.6/1000 person-years). Compared with men who had had no falls, the risk of non-vertebral and lower extremity fractures was significantly higher in men with one fall (HR = 1.54 (95% CI 1.22 to 1.96) and 1.91 (95% CI 1.36 to 2.67), respectively) and men with two or more falls (HR = 1.81 (95% CI 1.40 to 2.34) and 1.79 (95% CI 1.23 to 2.61), respectively). The risk of head/chest, upper extremity and hip fractures (HR = 2.22 (95% CI 1.42 to 3.49), 2.08 (95% CI 1.01 to 4.28) and 1.79 (95% CI 1.07 to 2.98), respectively) was significantly higher for two or more falls than no falls; however, equivalent risks were not significantly higher (HR = 1.36 (95% CI 0.88 to 2.20), 1.55 (95% CI 0.74 to 3.25) and 1.41 (95% CI 0.87 to 2.27), respectively) comparing men with one fall versus no falls.
Expanding clinical screens to include an assessment of fall frequencies may improve prediction of older men at risk of head/chest, upper extremity and hip fractures.
PMCID: PMC3145210  PMID: 19805598
16.  Emergency department coding of bicycle and pedestrian injuries during the transition from ICD-9 to ICD-10 
Injury Prevention  2011;18(2):88-93.
The international classification of diseases version 10 (ICD-10) uses alphanumeric expanded codes and external cause of injury codes (E-codes).
To examine the reliability and validity of emergency department (ED) coders in applying E-codes in ICD-9 and -10.
Bicycle and pedestrian injuries were identified from the ED information system from one period before and two periods after transition from ICD-9 to -10 coding. Overall, 180 randomly selected bicycle and pedestrian injury charts were reviewed as the reference standard (RS). Original E-codes assigned by ED coders (ICD-9 in 2001 and ICD-10 in 2004 and 2007) were compared with charts (validity) and also to ICD-9 and -10 codes assigned from RS chart review, to each case by an independent (IND) coder (reliability). Sensitivity, specificity, simple, and chance-corrected agreements (κ statistics) were calculated.
Sensitivity of E-coding bicycle injuries by the IND coder in comparison with the RS ranged from 95.1% (95% CI 86.3 to 99.0) to 100% (95% CI 94.0 to 100.0) for both ICD-9 and -10. Sensitivity of ED coders in E-coding bicycle injuries ranged from 90.2% (95% CI 79.8 to 96.3) to 96.7% (95% CI 88.5 to 99.6). The sensitivity estimates for the IND coder ranged from 25.0% (95% CI 14.7 to 37.9) to 45.0% (95% CI 32.1 to 58.4) for pedestrian injuries for both ICD-9 and -10.
Bicycle injuries are coded in a reliable and valid manner; however, pedestrian injuries are often miscoded as falls. These results have important implications for injury surveillance research.
PMCID: PMC3313444  PMID: 21705466
Reliability; ICD codes; bicycling; pedestrian; injury; bicycle; e-code; pedestrian; surveillance
17.  Social inequalities in road traffic deaths at age 16–20 years among all 611 654 Norwegians born between 1967 and 1976: a multilevel analysis 
Injury Prevention  2011;18(1):3-9.
Road traffic injury is a major cause of death among youths.
To estimate mortality differences in family socioeconomic position (SEP) and municipal disadvantage level.
Data on all Norwegians born in 1967–76, gathered from national registries, were linked by a unique national identification number. The 611 654 participants were followed-up for 5 years from age 16 years. Parental education level, father's income level, and proportion of high-income earners in the municipality served as SEP indicators. Associations between SEP and road traffic deaths were analysed by multilevel Poisson regression.
Road traffic deaths (n=676, rate 22.2 per 100 000 person-years) constituted a major cause of death, of which 91.9% were motor vehicle occupants. SEP distributions differed according to gender and type of motor vehicle crash (collision, non-collision). There was an inverse relationship between municipal proportions of high-income earners and mortality (population attributable fraction (PAF) 0.43, 95% CI 0.30 to 0.53) in all categories of gender-specific crash types. Family SEP gradients were not found except for male non-collision deaths, where increasing mortality was found in association with decreasing parental education level (PAF 0.94, 95% CI 0.59 to 0.99) and increasing paternal income (PAF 0.25, 95% CI 0.06 to 0.40).
The different SEP patterns for road traffic deaths across gender and motor vehicle crash type illustrate that heterogeneity of social inequalities in health can be found even within narrow age bands and for similar causes of death.
PMCID: PMC3262988  PMID: 21606470
Gender; socio economic status
The Latino Epidemiologic Paradox describes favorable health profiles for Latinos compared to non-Latino Whites despite poverty, low education, and low access to health care. Our study objective was to determine if the anomaly to the Latino Epidemiological Paradox and the Latino Adolescent Male Mortality Peak in California mortality data persists.
Cases were California residents (1999–2006) of any race and ethnicity that died (N = 1,866,743) in California from any cause of death. Mortality rates and rate ratios were calculated according to causes of death for 5 year age groups.
For males and females combined, age-adjusted mortality rates were 509 for Latinos and 681 for non-Latino Whites per 100,000/yr. Latino male mortality rate ratios exceeded 1.0 compared to non-Latino White males only for 15–19 yrs (1.41 95%CI 1.35–1.49) and 20–24 yrs (1.24 95%CI 1.19–1.29). Latinas had lower mortality rates than non-Latino White females for all ages over 15 years. Male homicide rates for Latinos increased over the study period, but did not reach the rates reported for the years 1989–1997. Both male homicide and motor vehicle crash mortality rates were higher for Latinos than non-Latino Whites and peaked at 20–24 yrs. Latino crash mortality rate exceeded the rate for non-Latino Whites overall and for each year 2003–2006. Crash mortality for males 15–24 yrs increased from 2000–2006.
The anomaly and the mortality peak persist with notable attribution to homicide and crashes. Without homicide, the mortality peak would not exist. Mortality disparities for Latino adolescent males from these two causes of death in California appear to be growing.
PMCID: PMC3065499  PMID: 21134905
Anomaly; Disparity; Injury; Latino; Paradox
19.  Evaluation of skiing and snowboarding injuries sustained in terrain parks versus traditional slopes 
This study compares skiing and snowboarding injuries in terrain parks versus slopes at two ski areas, 2000–05. A total of 3953 (26.7%) injuries occurred in terrain parks, predominantly among young male snowboarders. Terrain park injuries were more likely to be severe, involving head (RR 1.31, 95% CI 1.16 to 1.48) or back (RR 1.96, 95% CI 1.67 to 2.29).
PMCID: PMC3069711  PMID: 20363819
20.  Risk of injury for bicycling on cycle tracks versus in the street 
Injury Prevention  2011;17(2):131-135.
Most individuals prefer bicycling separated from motor traffic. However, cycle tracks (physically separated bicycle-exclusive paths along roads, as found in The Netherlands) are discouraged in the USA by engineering guidance that suggests that facilities such as cycle tracks are more dangerous than the street. The objective of this study conducted in Montreal (with a longstanding network of cycle tracks) was to compare bicyclist injury rates on cycle tracks versus in the street. For six cycle tracks and comparable reference streets, vehicle/bicycle crashes and health record injury counts were obtained and use counts conducted. The relative risk (RR) of injury on cycle tracks, compared with reference streets, was determined. Overall, 2.5 times as many cyclists rode on cycle tracks compared with reference streets and there were 8.5 injuries and 10.5 crashes per million bicycle-kilometres. The RR of injury on cycle tracks was 0.72 (95% CI 0.60 to 0.85) compared with bicycling in reference streets. These data suggest that the injury risk of bicycling on cycle tracks is less than bicycling in streets. The construction of cycle tracks should not be discouraged.
PMCID: PMC3064866  PMID: 21307080
Bicycle; engineering; environment; public health; safe community
21.  Using Virtual Reality to Train Children Safe Street-Crossing Skills 
Pedestrian injuries are among the leading causes of morbidity and mortality in middle childhood. One limitation to existing pedestrian safety interventions is that they do not provide children with repeated practice needed to develop the complex perceptual and cognitive skills required for safe street-crossing. Virtual reality (VR) offers training through repeated unsupervised practice without risk; automated feedback on success of crossings; adjustment of traffic to match children’s skill; and a fun, appealing environment for training.
Test efficacy of VR to train child pedestrians in safe street-crossing.
Birmingham, Alabama, USA.
A randomized controlled trial is underway with an expected sample of four groups of 60 children ages 7-8 (total N = 240). One group receives training in an interactive, immersive virtual pedestrian environment. A second receives pedestrian safety training via widely-used video and computer strategies. The third group receives what is judged to be the most efficacious treatment currently available, individualized behavioral training at streetside locations. The fourth group serves as a no-contact control group. All participants are exposed to a range of field- and laboratory-based measures of pedestrian skill during baseline and post-intervention visits, as well as during a six-month follow-up assessment.
Outcome Measures
Primary analyses will be conducted through linear mixed models testing change over time in the four intervention groups. Three pedestrian safety measures will serve as primary outcomes: temporal gap before initiating crossing, temporal gap remaining after crossing, and attention to traffic while waiting to cross.
Clinical Trial Registration
This study is registered at the US government website,, under the title, “Using Virtual Reality to Train Children in Pedestrian Safety”, registration number NCT00850759.
PMCID: PMC2829738  PMID: 20179024
pedestrian; safety; injury; children; virtual reality; street-crossing
22.  A protocol for evidence-based targeting and evaluation of statewide strategies for preventing falls among community-dwelling older people in Victoria, Australia 
Injury Prevention  2010;17(2):e3.
Falls are a significant threat to the safety, health and independence of older citizens. Despite the now substantial evidence about effective falls prevention interventions, translation into falls reductions has not yet been fully realised. While the hip fracture rate is decreasing, the number and rate of fall-related hospital admissions among older people is increasing. The challenge now is to deliver the most effective interventions efficiently at a population level, and for these interventions to be taken up by older people.
To support the development, and evaluation of, effective falls prevention policy and practice in the state of Victoria, Australia.
The RE-AIM model (Reach, Efficacy, Adoption, Implementation, Maintenance) was used to identify strategies for an effective programme. Research objectives were developed to support the strategies. These include: (1) identification of subgroups of older people most frequently admitted to hospital for falls; (2) examining the acceptability of established falls interventions; (3) identification of factors that encourage and support relevant lifestyle changes; (4) identifying opportunities to incorporate confirmed interventions in existing programmes and services; (5) developing guidelines for sustainability. The research results will subsequently guide strategy details for the falls prevention plan. RE-AIM will provide the framework for the evaluation structure.
Outcome measures
Measures to monitor the implementation of the selected interventions will be determined for each intervention, based on the five key factors of the RE-AIM model. The overall effect of the falls prevention plan will be monitored by time series analysis of fall-related hospital admission rates for community-dwelling older people.
PMCID: PMC3064867  PMID: 21186224
Accidental falls; aged; elderly; evidence-based practice; falls; policy development
23.  Effectiveness and cost-effectiveness of an injury prevention programme for adult male amateur soccer players: design of a cluster-randomised controlled trial 
Injury Prevention  2010;17(1):e2.
Background and aims
Approximately 16% of all sports injuries in the Netherlands are caused by outdoor soccer. A cluster-randomised controlled trial has been designed to investigate the effectiveness and cost-effectiveness of an injury prevention programme (‘The11’) for male amateur soccer players. The injury prevention programme The11, developed with the support of the World Football Association FIFA, aims to reduce the impact of intrinsic injury risk factors in soccer.
Teams playing at first-class amateur level in two districts in the Netherlands are participating in the study. Teams in the intervention group were instructed to apply The11 during each practice session throughout the 2009–10 season. All participants of the control group continued their practice sessions as usual. All soccer-related injuries and related costs for each team were systematically reported online by a member of the medical staff. Player exposure to practice sessions and matches was reported weekly by the coaches. Also the use of The11 during the season after the intervention season will be monitored.
Our hypothesis is that integrating the The11 exercises in the warm-up for each practice session is effective in terms of injury incidence, injury severity, healthcare use, and its associated costs and/or absenteeism. Prevention of soccer injuries is expected to be beneficial to adult soccer players, soccer clubs, the Royal Dutch Football Association (KNVB), health insurance companies and society.
PMCID: PMC3063459  PMID: 21177664
Soccer; injuries; prevention; effectiveness; cost-effectiveness; economics; methods; program; sports
24.  Maternal depression, child behavior, and injury 
Injury Prevention  2007;13(6):403-408.
Few data exist on the effect of maternal depression on child injury outcomes and mediators of this relationship.
To examine the relationship between mothers' depressive symptoms and medically attended injuries in their children and the potential mediating role of child behavior.
A cohort of mother–child dyads from the National Longitudinal Study of Youth followed from 1992 to1994. The primary exposure variable was maternal depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale in 1992. Child behavior was assessed by the Behavior Problems Index externalizing subscale. Logistic regression was used to examine the relationship between depressive symptoms, child behavior, and injury reported in the prior year in 1994.
94 medically attended injuries were reported in the 1106 children (8.5%); two‐thirds were sustained in the home environment. Maternal depressive symptoms significantly increased the risk of child injury; injury risk increased 4% for every 1‐point increase in depressive symptoms (adjusted OR 1.04, 95% CI 1.01 to 1.08, p = 0.02). Increasing maternal depressive symptoms also increased the risk of externalizing behavior problems (adjusted OR 1.06, 95% CI 1.03 to 1.09), but externalizing behavior problems did not significantly mediate the relationship between maternal symptoms and child injury.
Increasing depressive symptoms in mothers was associated with an increased risk of child injury. Child behavior did not significantly mediate the association between maternal depressive symptoms and child injury in this cohort. Greater recognition, referral, and treatment of depressive symptoms in mothers may have effects on child behavior and injury risk.
PMCID: PMC2598291  PMID: 18056318
25.  Barriers to, and facilitators of, the prevention of unintentional injury in children in the home: a systematic review and synthesis of qualitative research 
Injury Prevention  2010;17(2):119-126.
This review considers barriers to, and facilitators of, success for interventions to reduce unintentional injury to children in the home through supply and/or installation of home safety equipment, and looks at risk assessments.
A systematic review of qualitative research. Bibliographic databases were searched for studies on interventions to reduce unintentional child injury in the home, or on related attitudes and behaviours. Studies were quality appraised, findings extracted, and a conceptual framework was developed to assess factors affecting the success of interventions.
Nine peer-reviewed journal articles were included. Barriers and facilitators were highlighted at organisational, environmental and personal levels. Effective provision of safety equipment involves ongoing support with installation and maintenance. Take up and success of interventions depends on adjusting interventions according to practical limitations and parents' cultural expectations. A particular barrier was parents' inability to modify rented or shared accommodation.
The review highlights ways in which health inequalities affect the take up and success of home safety interventions, and how health workers can use this knowledge to facilitate future interventions.
PMCID: PMC3184217  PMID: 21097943
Child; home; qualitative; systematic review

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