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1.  The use of cost–benefit analysis in road assessments: a methodological inquiry 
Background
Cost–benefit analysis is a useful tool for priority setting in road safety. The value of statistical life (VOSL) is a metric used to estimate the benefits of road interventions in cost–benefit analyses. The International Road Assessment Program (iRAP), for example, created a rule-of-thumb to calculate VOSL benefits of road infrastructure when performing cost–benefit assessments in countries where data on VOSL are sparse.
Aim
To evaluate the rapid assessment metric developed by iRAP and provide suggestions for improvement in these methods.
Methods
We replicated iRAP calculations in order to make a critical assessment of the sources, results and conclusions.
Conclusions
We found the iRAP metric a good example for highlighting some relevant aspects that should be considered in any VOSL estimation in order to enhance its use as a guiding principle for assessing road interventions. Specifically, we recommend the explicit disclosure of the assumptions, the use of sensitivity analysis and the avoidance of omitted variables bias.
doi:10.1136/injuryprev-2012-040708
PMCID: PMC4316734  PMID: 23710063
2.  A regionalised strategy for improving motor vehicle-related highway driver deaths using a weighted averages method 
Objective
The state of Florida has some of the most dangerous highways in the USA. In 2006, Florida averaged 1.65 fatalities per 100 million vehicle miles travelled (VMT) compared with the national average of 1.42. A study was undertaken to find a method of identifying counties that contributed to the most driver fatalities after a motor vehicle collision (MVC). By regionalising interventions unique to this subset of counties, the use of resources would have the greatest potential of improving statewide driver death.
Methods
The Florida Highway Safety Motor Vehicle database 2000–2006 was used to calculate driver VMT-weighted deaths by county. A total of 3 468 326 motor vehicle crashes were evaluated. Counties that had driver death rates higher than the state average were sorted by a weighted averages method. Multivariate regression was used to calculate the likelihood of death for various risk factors.
Results
VMT-weighted death rates identified 12 out of 67 counties that contributed up to 50% of overall driver fatalities. These counties were primarily clustered in central and south Florida. The strongest independent risk factors for driver death attributable to MVC in these high-risk counties were alcohol/drug use, rural roads, speed limit ≥45 mph, adverse weather conditions, divided highways, vehicle type, vehicle defects and roadway location.
Conclusions
Using the weighted averages method, a small subset of counties contributing to the majority of statewide driver fatalities was identified. Regionalised interventions on specific risk factors in these counties may have the greatest impact on reducing driver-related MVC fatalities.
doi:10.1136/ip.2010.030759
PMCID: PMC4304665  PMID: 21685144
3.  Emergency department-reported head injuries from skiing and snowboarding among children and adolescents, 1996-2010 
Objectives
To evaluate the incidence of snow-sports-related head injuries among children and adolescents reported to emergency departments (EDs), and to examine the trend from 1996 to 2010 in ED visits for snow-sports-related traumatic brain injury (TBI) among children and adolescents.
Methods
A retrospective, population-based cohort study was conducted using data from the National Electronic Injury Surveillance System for patients (aged ≤17 years) treated in EDs in the USA from 1996 to 2010, for TBIs associated with snow sports (defined as skiing or snowboarding). National estimates of snow sports participation were obtained from the National Ski Area Association and utilised to calculate incidence rates. Analyses were conducted separately for children (aged 4–12 years) and adolescents (aged 13–17 years).
Results
An estimated number of 78 538 (95% CI 66 350 to 90 727) snow sports-related head injuries among children and adolescents were treated in EDs during the 14-year study period. Among these, 77.2% were TBIs (intracranial injury, concussion or fracture). The annual average incidence rate of TBI was 2.24 per 10 000 resort visits for children compared with 3.13 per 10 000 visits for adolescents. The incidence of TBI increased from 1996 to 2010 among adolescents (p<0.003).
Conclusions
Given the increasing incidence of TBI among adolescents and the increased recognition of the importance of concussions, greater awareness efforts may be needed to ensure safety, especially helmet use, as youth engage in snow sports.
doi:10.1136/injuryprev-2012-040727
PMCID: PMC3835801  PMID: 23513009
4.  Bicycle-related genitourinary injuries in the USA from 2002–2010 
Among children, the incidence of bicycle-related genitourinary (GU) injuries was 448 per 100 000 (95% CI 383 to 514) and, among adults, was 53 per 100 000 (95% CI 36 to 71). Although children sustained more injuries, adults were more likely to being admitted to the hospital for the GU injury (OR 1.95, 95% CI 1.13 to 3.37). Children sustain nearly 10 times more GU injuries due to bicycles than adults, but adults have higher odds of sustaining injuries requiring admission.
doi:10.1136/injuryprev-2013-041002
PMCID: PMC4161653  PMID: 24618096
5.  Why more male pedestrians die in vehicle-pedestrian collisions than females: a decompositional analysis 
Objective
Pedestrians account for a third of the 1.2 million traffic fatalities annually worldwide, and males are overrepresented. We examined the factors that contribute to this male-female discrepancy: walking exposure (kilometers walked per person-year), vehicle-pedestrian collision risk (number of collisions per kilometers walked), and vehicle-pedestrian collision case fatality rate (number of deaths per collision).
Design
The decomposition method quantifies the relative contributions of individual factors to death rate ratios among groups. The male-female ratio of pedestrian death rates can be expressed as the product of three component ratios: walking exposure, collision risk, and case fatality rate. Data sources included the 2008–2009 U.S. Fatality Analysis Reporting System, General Estimates System, National Household Travel Survey, and population estimates.
Setting
U.S.
Participants
Pedestrians age 5 and older.
Main outcome measures
death rate per person-year, kilometers walked per person-year, collisions per kilometers walked, and deaths per collision by sex.
Results
The pedestrian death rate per person-year for males was 2.3 times that for females. This ratio of male to female rates can be expressed as the product of three component ratios: 0.995 for walking exposure, 1.191 for collision risk, and 1.976 for case fatality rate. The relative contributions of these components were 1%, 20% and 79%, respectively.
Conclusions
The majority of the male-female discrepancy in 2008–2009 pedestrian deaths in the U.S. is attributed to a higher fatality per collision rate among male pedestrians.
doi:10.1136/injuryprev-2012-040594
PMCID: PMC3715558  PMID: 23197672
Pedestrian; epidemiology; health disparities; gender
6.  Graduated driver licensing and motor vehicle crashes involving teenage drivers: an exploratory age-stratified meta-analysis 
Objective
Graduated Driver Licensing (GDL) has been implemented in Australia, Canada, New Zealand, USA and Israel. We conducted an exploratory summary of available data to estimate whether GDL effects varied with age.
Methods
We searched MEDLINE and other sources from 1991–2011. GDL evaluation studies with crashes resulting in injuries or deaths were eligible. They had to provide age-specific incidence rate ratios with CI or information for calculating these quantities. We included studies from individual states or provinces, but excluded national studies. We examined rates based on person-years, not license-years.
Results
Of 1397 papers, 144 were screened by abstract and 47 were reviewed. Twelve studies from 11 US states and one Canadian province were selected for meta-analysis for age 16, eight were selected for age 17, and four for age 18. Adjusted rate ratios were pooled using random effects models. The pooled adjusted rate ratios for the association of GDL presence with crash rates was 0.78 (95% CI 0.72 to 0.84) for age 16 years, 0.94 (95% CI 0.93 to 0.96) for 17 and 1.00 (95% CI 0.95 to 1.04) for 18. The difference between these three rate ratios was statistically significant: p<0.001.
Conclusions
GDL policies were associated with a 22% reduction in crash rates among 16-year-old drivers, but only a 6% reduction for 17-year-old drivers. GDL showed no association with crashes among 18-year-old drivers. Because we had few studies to summarise, particularly for older adolescents, our findings should be considered exploratory.
doi:10.1136/injuryprev-2012-040474
PMCID: PMC4103686  PMID: 23211352
7.  Associations between childhood obesity and upper and lower extremity injuries 
Objectives
To estimate the overall and age-specific associations between obesity and extremity musculoskeletal injuries and pain in children.
Methods
This cross-sectional study used information from electronic medical records of 913 178 patients aged 2–19 years enrolled in an integrated health plan in the period 2007–2009. Children were classified as underweight, normal weight, overweight, or moderately/extremely obese and, using multivariable logistic regression methods, the associations between weight class and diagnosis of upper or lower extremity fractures, sprains, dislocations and pain were calculated.
Results
Overweight (OR 1.18, 95% CI 1.15 to 1.20), moderately obese (OR 1.24, 95% CI 1.20 to 1.27) and extremely obese (OR 1.34, 95% CI 1.30 to 1.39) children had statistically significantly higher odds of lower extremity injuries/pain compared to normal weight, adjusted for sex, age, race/ethnicity and insurance status. Age-stratified analyses yielded similar results. No consistent association was observed between body mass index and injuries/pain of the upper extremities.
Conclusions
Greater body mass index is associated with increased odds of lower extremity injuries and pain issues. Because the benefits of physical activity may still outweigh the risk of injury, attention should be paid to injury prevention strategies for these children at greater risk for lower extremity injuries.
doi:10.1136/injuryprev-2012-040341
PMCID: PMC3747966  PMID: 22789612
8.  Greening vacant lots to reduce violent crime: a randomised controlled trial 
Background
Vacant lots are often overgrown with unwanted vegetation and filled with trash, making them attractive places to hide illegal guns, conduct illegal activities such as drug sales and prostitution, and engage in violent crime. There is some evidence that greening vacant lots is associated with reductions in violent crime.
Methods
We performed a randomised controlled trial of vacant lot greening to test the impact of this intervention on police reported crime and residents’ perceptions of safety and disorder. Greening consisted of cleaning the lots, planting grass and trees, and building a wooden fence around the perimeter. We randomly allocated two vacant lot clusters to the greening intervention or to the control status (no intervention). Administrative data were used to determine crime rates, and local resident interviews at baseline (n=29) and at follow-up (n=21) were used to assess perceptions of safety and disorder.
Results
Unadjusted difference-in-differences estimates showed a non-significant decrease in the number of total crimes and gun assaults around greened vacant lots compared with control. People around the intervention vacant lots reported feeling significantly safer after greening compared with those living around control vacant lots (p<0.01).
Conclusions
In this study, greening was associated with reductions in certain gun crimes and improvements in residents’ perceptions of safety. A larger randomised controlled trial is needed to further investigate the link between vacant lot greening and violence reduction.
doi:10.1136/injuryprev-2012-040439
PMCID: PMC3988203  PMID: 22871378
9.  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.
doi:10.1136/injuryprev-2011-040309
PMCID: PMC3821975  PMID: 22661205
Injury; Serious Mental Illness; Schizophrenia; Bipolar Disorder; Barell Matrix
10.  Acute alcohol intoxication and suicide: a gender-stratified analysis of the National Violent Death Reporting System 
Objectives
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.
Methods
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).
Results
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.
Conclusions
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.
doi:10.1136/injuryprev-2012-040317
PMCID: PMC3760342  PMID: 22627777
11.  Making the Message Meaningful: A Qualitative Assessment of Media Promoting All-Terrain Vehicle Safety 
Background
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.
Objective
This study was designed to assess rural ATV riders’ preferences for and assessment of safety messages.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1136/injuryprev-2011-040132
PMCID: PMC3704218  PMID: 22101098
12.  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).
doi:10.1136/ip.2008.018549
PMCID: PMC3590814  PMID: 18676787
accidental falls; fall prevention; chronic care model; implementation research; program evaluation
13.  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.
doi:10.1136/ip.2009.024224
PMCID: PMC3570976  PMID: 20587813
14.  Backing collisions: a study of drivers’ eye and backing behaviour using combined rear-view camera and sensor systems 
Context
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.
Objectives
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?
Design
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.
Setting
Parking facility at UMass Amherst, USA.
Subjects
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.
Interventions
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.
Results
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.
Conclusions
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.
doi:10.1136/ip.2009.021535
PMCID: PMC3472446  PMID: 20363812
15.  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.
Objective
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.
Methods
6-year (2004–2010) exploratory study analysing injury attendances to one ED in the North West of England using descriptive and trend analyses.
Results
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%.
Conclusions
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.
doi:10.1136/injuryprev-2011-040159
PMCID: PMC3461757  PMID: 22210640
Injury; violence; surveillance; emergency department; prevention; public health; case study; alcohol/drugs; recreation; behavioural; environment
16.  Explaining regional disparities in traffic mortality by decomposing conditional probabilities 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1136/ip.2010.029249
PMCID: PMC3446824  PMID: 21212443
Traffic; mortality; decomposition; rural; south
17.  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.
doi:10.1136/ip.2009.024174
PMCID: PMC3271730  PMID: 20570987
18.  Alcohol-Induced Memory Blackouts as an Indicator of Injury Risk among College Drinkers 
Injury Prevention  2011;18(1):44-49.
Objective
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.
Methods
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.
Results
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.
Conclusions
Memory blackouts are a significant predictor of future alcohol-related injury among college drinkers after adjusting for heavy drinking episodes.
doi:10.1136/ip.2011.031724
PMCID: PMC3210864  PMID: 21708813
alcohol drinking; alcohol abuse; blackout; memory
19.  Risk and protective factors associated with gang affiliation among high-risk youth: a public health approach 
Injury Prevention  2012;18(4):253-258.
Background
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.
Aim
To identify risk and protective factors to provide more direction for gang violence prevention strategies.
Methods
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.
Results
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).
Conclusions
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.
doi:10.1136/injuryprev-2011-040083
PMCID: PMC3406611  PMID: 22240265
Gang; protective factors; risk factors; primary prevention; youth; street youth; public health; violence; risk/determinants
20.  The impact of pedestrian countdown signals on pedestrian–motor vehicle collisions: a quasi-experimental study 
Injury Prevention  2011;18(4):210-215.
Objective
To determine whether pedestrian countdown signals (PCS) reduce pedestrian–motor vehicle collisions in the city of Toronto, Canada.
Methods
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.
Results
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.
Conclusion
The installation of PCS at 1965 signalised intersections in Toronto did not reduce the number of pedestrian–motor vehicle collisions at these intersections.
doi:10.1136/injuryprev-2011-040173
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
21.  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.
doi:10.1136/injuryprev-2011-040147
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
22.  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.
Introduction
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.
Methods
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.
Results
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.
Discussion
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.
doi:10.1136/injuryprev-2011-040043
PMCID: PMC3311869  PMID: 21890579
Health education; systematic review; child; adolescent; public health; qualitative research; health services
23.  Histories including number of falls may improve risk prediction for certain non-vertebral fractures in older men 
Objective
To determine whether information on number of falls on a falls history screen predicts risk of non-vertebral and hip fracture.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1136/ip.2009.021915
PMCID: PMC3145210  PMID: 19805598
24.  Emergency department coding of bicycle and pedestrian injuries during the transition from ICD-9 to ICD-10 
Injury Prevention  2011;18(2):88-93.
Background
The international classification of diseases version 10 (ICD-10) uses alphanumeric expanded codes and external cause of injury codes (E-codes).
Objective
To examine the reliability and validity of emergency department (ED) coders in applying E-codes in ICD-9 and -10.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1136/ip.2010.031302
PMCID: PMC3313444  PMID: 21705466
Reliability; ICD codes; bicycling; pedestrian; injury; bicycle; e-code; pedestrian; surveillance
25.  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.
Background
Road traffic injury is a major cause of death among youths.
Aims
To estimate mortality differences in family socioeconomic position (SEP) and municipal disadvantage level.
Methods
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.
Results
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).
Conclusion
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.
doi:10.1136/ip.2011.031682
PMCID: PMC3262988  PMID: 21606470
Gender; socio economic status

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