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1.  Characteristics of non-fatal abusive head trauma among children in the USA, 2003–2008: application of the CDC operational case definition to national hospital inpatient data 
An International Classification of Diseases code-based case definition for non-fatal abusive head trauma (AHT) in children <5 years of age was developed in March 2008 by an expert panel convened at the Centers for Disease Control and Prevention (CDC). This study presents an application of the CDC recommended operational case definition of AHT to US hospital inpatient data to characterise the AHT hospitalisation rate for children <5 years of age.
Nationwide Inpatient Sample (NIS) data from the Healthcare Cost and Utilisation Project from 2003 to 2008 were examined.
Inspection of the NIS data resulted in the identification of an estimated 10 555 non-fatal AHT hospitalisations with 9595 classified as definite/presumptive AHT and 960 classified as probable AHT. The non-fatal AHT rate was highest among children aged <1 year (32.3 per 100 000) with a peak in hospitalisations between 1 and 3 months of age. Non-fatal AHT hospitalisation rates for children <2 years of age were higher for boys (21.9 per 100 000) than girls (15.3 per 100 000). The non-fatal AHT hospitalisation rate showed little variation across seasons.
To reduce the burden of AHT in the USA, a preventable public health problem, concerted prevention efforts targeting populations at risk should be implemented. This report demonstrates a model procedure for using the new CDC definition for public health surveillance and research purposes. Such findings can be used to inform parents and providers about AHT (eg, dangers of shaking, strategies for managing infant crying) as well as to monitor better the impact of prevention strategies over time.
PMCID: PMC4772141  PMID: 22328632
2.  Assessing the accuracy of the International Classification of Diseases codes to identify abusive head trauma: a feasibility study 
To assess the accuracy of an International Classification of Diseases (ICD) code-based operational case definition for abusive head trauma (AHT).
Subjects were children <5 years of age evaluated for AHT by a hospital-based Child Protection Team (CPT) at a tertiary care paediatric hospital with a completely electronic medical record (EMR) system. Subjects were designated as non-AHT traumatic brain injury (TBI) or AHT based on whether the CPT determined that the injuries were due to AHT. The sensitivity and specificity of the ICD-based definition were calculated.
There were 223 children evaluated for AHT: 117 AHT and 106 non-AHT TBI. The sensitivity and specificity of the ICD-based operational case definition were 92% (95% CI 85.8 to 96.2) and 96% (95% CI 92.3 to 99.7), respectively. All errors in sensitivity and three of the four specificity errors were due to coder error; one specificity error was a physician error.
In a paediatric tertiary care hospital with an EMR system, the accuracy of an ICD-based case definition for AHT was high. Additional studies are needed to assess the accuracy of this definition in all types of hospitals in which children with AHT are cared for.
PMCID: PMC4757425  PMID: 24167034
3.  The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013 
Haagsma, Juanita A | Graetz, Nicholas | Bolliger, Ian | Naghavi, Mohsen | Higashi, Hideki | Mullany, Erin C | Abera, Semaw Ferede | Abraham, Jerry Puthenpurakal | Adofo, Koranteng | Alsharif, Ubai | Ameh, Emmanuel A | Ammar, Walid | Antonio, Carl Abelardo T | Barrero, Lope H | Bekele, Tolesa | Bose, Dipan | Brazinova, Alexandra | Catalá-López, Ferrán | Dandona, Lalit | Dandona, Rakhi | Dargan, Paul I | De Leo, Diego | Degenhardt, Louisa | Derrett, Sarah | Dharmaratne, Samath D | Driscoll, Tim R | Duan, Leilei | Petrovich Ermakov, Sergey | Farzadfar, Farshad | Feigin, Valery L | Franklin, Richard C | Gabbe, Belinda | Gosselin, Richard A | Hafezi-Nejad, Nima | Hamadeh, Randah Ribhi | Hijar, Martha | Hu, Guoqing | Jayaraman, Sudha P | Jiang, Guohong | Khader, Yousef Saleh | Khan, Ejaz Ahmad | Krishnaswami, Sanjay | Kulkarni, Chanda | Lecky, Fiona E | Leung, Ricky | Lunevicius, Raimundas | Lyons, Ronan Anthony | Majdan, Marek | Mason-Jones, Amanda J | Matzopoulos, Richard | Meaney, Peter A | Mekonnen, Wubegzier | Miller, Ted R | Mock, Charles N | Norman, Rosana E | Orozco, Ricardo | Polinder, Suzanne | Pourmalek, Farshad | Rahimi-Movaghar, Vafa | Refaat, Amany | Rojas-Rueda, David | Roy, Nobhojit | Schwebel, David C | Shaheen, Amira | Shahraz, Saeid | Skirbekk, Vegard | Søreide, Kjetil | Soshnikov, Sergey | Stein, Dan J | Sykes, Bryan L | Tabb, Karen M | Temesgen, Awoke Misganaw | Tenkorang, Eric Yeboah | Theadom, Alice M | Tran, Bach Xuan | Vasankari, Tommi J | Vavilala, Monica S | Vlassov, Vasiliy Victorovich | Woldeyohannes, Solomon Meseret | Yip, Paul | Yonemoto, Naohiro | Younis, Mustafa Z | Yu, Chuanhua | Murray, Christopher J L | Vos, Theo
Injury Prevention  2015;22(1):3-18.
The Global Burden of Diseases (GBD), Injuries, and Risk Factors study used the disability-adjusted life year (DALY) to quantify the burden of diseases, injuries, and risk factors. This paper provides an overview of injury estimates from the 2013 update of GBD, with detailed information on incidence, mortality, DALYs and rates of change from 1990 to 2013 for 26 causes of injury, globally, by region and by country.
Injury mortality was estimated using the extensive GBD mortality database, corrections for ill-defined cause of death and the cause of death ensemble modelling tool. Morbidity estimation was based on inpatient and outpatient data sets, 26 cause-of-injury and 47 nature-of-injury categories, and seven follow-up studies with patient-reported long-term outcome measures.
In 2013, 973 million (uncertainty interval (UI) 942 to 993) people sustained injuries that warranted some type of healthcare and 4.8 million (UI 4.5 to 5.1) people died from injuries. Between 1990 and 2013 the global age-standardised injury DALY rate decreased by 31% (UI 26% to 35%). The rate of decline in DALY rates was significant for 22 cause-of-injury categories, including all the major injuries.
Injuries continue to be an important cause of morbidity and mortality in the developed and developing world. The decline in rates for almost all injuries is so prominent that it warrants a general statement that the world is becoming a safer place to live in. However, the patterns vary widely by cause, age, sex, region and time and there are still large improvements that need to be made.
PMCID: PMC4752630  PMID: 26635210
4.  Evaluating a Website to Teach Children Safety with Dogs 
Pediatric dog bites are a significant public health problem worldwide. Existing prevention programs focused on altering children’s risky behavior with pet dogs tend to be atheoretical and only moderately effective.
Test efficacy of a website to train young children in relevant cognitive skills to be safe with pet dogs in their home.
Birmingham, Alabama, USA.
A randomized trial will be conducted with an expected sample of two groups of 34 children ages 4-6 (total N = 68). One group will engage in the newly-designed website at home for two weeks and the other group will engage in a control website on transportation safety for an equivalent amount of time. All participants will complete a battery of laboratory-based tests to assess safety with dogs and cognitive functioning both at baseline and post-intervention.
Outcome Measures
Primary analyses will be conducted through linear mixed models testing change over time. Children’s cognitive functioning, knowledge about safety with dogs, and behavior with dogs in simulation and in vivo will serve as the primary outcomes.
Clinical Trial Registration
This study is exempt from registry at the US government website,, based on being a behavioral trial in the early phases of testing.
PMCID: PMC4250438  PMID: 24871960
dogs; dog bite; safety; injury; children; website; internet training
5.  Economic Contraction, Alcohol Intoxication and Suicide: Analysis of the National Violent Death Reporting System 
Although there is a large and growing body of evidence concerning the impact of contracting economies on suicide mortality risk, far less is known about the role alcohol consumption plays in the complex relationship between economic conditions and suicide. The aims were to compare the postmortem alcohol intoxication rates among male and female suicide decedents before (2005–07), during (2008–09), and after (2010–11) the economic contraction in the United States.
Data from the restricted National Violent Death Reporting System 2005–11 for male and female suicide decedents aged 20 years and older were analyzed by Poisson regression analysis to test whether there was significant change in the fractions of suicide decedents who were acutely intoxicated at the time of death (defined as blood alcohol concentration ≥ 0.08 g/dl) prior, during, and after the downturn.
The fraction of all suicide decedents with alcohol intoxication increased by 7% after the onset of the recession from 22.2% in 2005–07 to 23.9% in 2008–11. Compared to the years prior to the recession, male suicide decedents showed a 1.09-fold increased risk of alcohol intoxication within the first two years of the recession. Surprisingly, there was evidence of a lag effect among female suicide decedents, who had a 1.14-fold (95% CI, 1.02 to 1.27) increased risk of intoxication in 2010–11 compared to 2005–07.
These findings suggest that acute alcohol intoxication in suicide interacts with economic conditions, becoming more prevalent during contractions.
PMCID: PMC4294995  PMID: 25024394
Economic contraction; alcohol intoxication; suicide
6.  Relationships between community social capital and injury in Canadian adolescents: a multilevel analysis 
Injury Prevention  2015;21(6):389-396.
Characteristics of social environments are potential risk factors for adolescent injury. Impacts of social capital on the occurrence of such injuries have rarely been explored.
General health questionnaires were completed by 8910 youth aged 14 years and older as part of the 2010 Canadian Health Behaviour in School-Aged Children study. These were supplemented with community-level data from the 2006 Canada Census of Population. Multilevel logistic regression models with random intercepts were fit to examine associations of interest. The reliability and validity of variables used in this analysis had been established in past studies, or in new analyses that employed factor analysis.
Between school differences explained 2% of the variance in the occurrence of injuries. After adjustment for all confounders, community social capital did not have any impact on the occurrence of injuries in boys: OR: 1.01, 95% CI 0.80 to 1.29. However, living in areas with low social capital was associated with lower occurrence of injuries in girls (OR 0.78, 95% CI 0.63 to 0.96). Other factors that were significantly related to injuries in both genders were younger age, engagement in more risky behaviours, and negative behavioural influences from peers.
After simultaneously taking into account the influence of community-level and individual-level factors, community levels of social capital remained a relatively strong predictor of injury among girls but not boys. Such gender effects provide important clues into the social aetiology of youth injury.
PMCID: PMC4717402  PMID: 26294708
7.  Does transport time help explain the high trauma mortality rates in rural areas? New and traditional predictors assessed by new and traditional statistical methods 
Injury Prevention  2015;21(6):367-373.
Trauma is a leading global cause of death. Trauma mortality rates are higher in rural areas, constituting a challenge for quality and equality in trauma care. The aim of the study was to explore population density and transport time to hospital care as possible predictors of geographical differences in mortality rates, and to what extent choice of statistical method might affect the analytical results and accompanying clinical conclusions.
Using data from the Norwegian Cause of Death registry, deaths from external causes 1998–2007 were analysed. Norway consists of 434 municipalities, and municipality population density and travel time to hospital care were entered as predictors of municipality mortality rates in univariate and multiple regression models of increasing model complexity. We fitted linear regression models with continuous and categorised predictors, as well as piecewise linear and generalised additive models (GAMs). Models were compared using Akaike's information criterion (AIC).
Population density was an independent predictor of trauma mortality rates, while the contribution of transport time to hospital care was highly dependent on choice of statistical model. A multiple GAM or piecewise linear model was superior, and similar, in terms of AIC. However, while transport time was statistically significant in multiple models with piecewise linear or categorised predictors, it was not in GAM or standard linear regression.
Population density is an independent predictor of trauma mortality rates. The added explanatory value of transport time to hospital care is marginal and model-dependent, highlighting the importance of exploring several statistical models when studying complex associations in observational data.
PMCID: PMC4717406  PMID: 25972600
8.  Risky Driving, Mental Health, and Health-Compromising Behaviors: Risk Clustering in Late Adolescents and Adults 
Health-compromising behaviors in adolescents and adults co-occur. Because motor vehicle crashes are the leading cause of death and disability for these age groups, understanding the association between risky driving and other health compromising behaviors is critical.
We performed a secondary analysis of data from a randomized controlled trial of an intervention for participants who screened positive for risky driving and problem drinking. Using baseline data, we examined relationships among conduct behavior problems before and after age 15, depressive symptoms, sleep, problem drinking, and risky driving (hostile, reckless and drinking and driving) in late adolescents ages 18–24 (n= 110) and adults ages 25–44 (n= 202). We developed a measurement model for the entire sample using confirmatory factor analysis, which was then specified as a multi-group structural equation model.
Late adolescents and adults had some similar associations for pathways through problem drinking to drinking and driving; depression to reckless driving; and conduct behavior problems after 15 to hostile driving. Late adolescents, however, had more complex relationships: depressive symptoms and conduct behavior problems before 15 were associated with more risky driving behaviors through multiple pathways and males reported more risky driving.
Risky driving is associated with other health-compromising behaviors and mental health factors. It is a multidimensional phenomenon more pronounced in late adolescence than adulthood. In order to promote safe driving, the findings support the need to consider behaviors that are a health threat in the late adolescent population during driving training and licensure.
PMCID: PMC4225190  PMID: 24814717
Risky driving; health-compromising behaviors; depression; conduct behavior problems; sleep
9.  Can child injury prevention include healthy risk promotion? 
Injury Prevention  2014;21(5):344-347.
To reflect on the role of risk-taking and risky play in child development and consider recommendations for the injury prevention field, a symposium was held prior to the November 2013 Canadian Injury Prevention and Safety Promotion Conference. Delegates heard from Canadian and international researchers, practitioners and play safety experts on child development, play space design and playground safety, provision of recreation, and legal and societal perceptions of risk and hazard. The presenters provided multidisciplinary evidence and perspectives indicating the potential negative effect on children's development of approaches to injury prevention that prioritise safety and limit children's opportunities for risky play. Delegates considered the state of the field of injury prevention and whether alternative approaches were warranted. Each presenter prepared a discussion paper to provide the opportunity for dialogue beyond attendees at the symposium. The resulting discussion papers provide a unique opportunity to consider and learn from multiple perspectives in order to develop a path forward.
PMCID: PMC4621367  PMID: 25535208
10.  Risk and protective behaviours for residential carbon monoxide poisoning 
Unintentional, non-fire-related carbon monoxide (CO) poisoning is a leading cause of poisoning death and injury in the USA. Residential poisonings caused by faulty furnaces are the most common type of CO exposure. However, these poisonings are largely preventable with annual furnace inspections and CO alarm installation.
This study aimed to identify the knowledge, attitudes and beliefs that might lead consumers to adopt these protective behaviours.
In August 2009, four focus groups (n=29) were conducted with homeowners in Chicago, Illinois, USA, to identify the knowledge, attitudes and beliefs that lead consumers to adopt risk and protective behaviours. Discussions were transcribed and the findings were analysed using an ordered meta-matrix.
Focus group participants were aware of CO poisoning and supported the idea of regular furnace inspections. However, few participants consistently scheduled professional inspections for fear of costly repairs and unscrupulous contractors. Participants often owned CO alarms, but many did not locate them properly, nor maintain them. Some participants confused CO and natural gas and were unsure how to react if a CO alarm sounds. Participants stated that incentives, such as discounts and inspector selection tips, would make them more likely to schedule furnace inspections. Participants also identified trustworthy sources for CO education, including realtors, fire departments, home insurance agents and local media outlets.
Participants’ residential CO risk behaviours are not random but driven by underlying knowledge, attitudes and beliefs. Correcting misperceptions, providing incentives and partnering with trustworthy sources might encourage greater consumer adoption of protective behaviours.
PMCID: PMC4556265  PMID: 22653781
11.  Non-fatal work-related traumatic brain injuries treated in US hospital emergency departments, 1998–2007 
Little is known about work-related traumatic brain injuries (WRTBI). This study describes non-fatal WRTBIs treated in US emergency departments (ED) from 1998 through 2007.
Non-fatal WRTBIs were identified from the National Electronic Injury Surveillance System occupational supplement (NEISS-Work) using the diagnoses of concussion, internal organ injury to the head and skull fracture. WRTBI rates and rate ratios were calculated, and the trend in rates was assessed.
An estimated 586 600 (95% CI=±150 000) WRTBIs were reported during the 10-year period at a rate of 4.3 (CI=±1.1) per 10 000 full-time equivalent (FTE) workers (1 FTE=2000 h per year). From 1998 through 2007, the rate of WRTBIs increased at an average of 0.21 per 10 000 FTE per year (p<0.0001) and the rate of fall-related WRTBIs increased at an average of 0.10 per 10 000 FTE (p<0.0001). During the same period, the annual rate of WRTBIs resulting in hospitalisation increased 0.04 per 10 000 FTE (p<0.0001). Ten percent of WRTBIs were hospitalised, compared with hospitalisation of 2% all NEISS-Work injuries. Also, workers with highest fall-related TBI rates per 10 000 FTE were the youngest (2.4; CI=±1.4) and oldest (55 and older) workers (1.9; CI=±0.8).
Non-fatal WRTBIs are one of the most serious workplace injuries among ED-treated work-related injuries. Non-fatal WRTBIs are much more likely to result in hospitalisation compared with other types of injuries. The upward trend of WRTBI rates from 1998 through 2007 underscore the need for more directed effective prevention methods to reduce WRTBI injuries.
PMCID: PMC4535168  PMID: 25216672
12.  Higher Psychological Distress is Associated with Unintentional Injuries in U.S. Adults 
Links between mental illness, self-inflicted injury, and interpersonal violence are well recognized, but the association between poor mental health and unintentional injuries is not well understood.
We used the 2010 National Health Interview Survey to assess the association between psychological distress and unintentional non-occupational injuries among U.S. adults. Psychological distress was measured by the Kessler Psychological Distress Scale, a symptom scale shown to identify community-dwelling persons with mental illness. Multivariable logistic regression was used to estimate adjusted odds ratios (AOR) and 95% confidence intervals.
Of the 26,776 individuals analyzed, 2.5% reported a medically-attended unintentional injury in the past three months. Those with moderate and severe psychological distress had 1.5 [1.2-1.8] and 2.0 [1.4 -2.8] times higher odds of injury, respectively, as compared to those with low distress levels, after adjusting for age, sex, race, marital status, education level, alcohol use, physical functional limitation, medical comorbidity, employment status, and health insurance status. Psychological distress was significantly associated with falls [AOR 1.4 (1.1-1.9)] and sprain/strain injuries [AOR 2.0 (1.5-2.8)], but not transportation-related injuries [AOR 1.2 (0.7-1.9)] or fractures [AOR 1.1 (0.8-1.6)].
Among community-dwelling U.S. adults, psychological distress is significantly associated with unintentional non-occupational injury, and the magnitude of association increases with severity of distress. The association between psychological distress and injury may be particularly strong for falls and sprain/strain injuries. These findings draw attention to a large group of at-risk individuals that may merit further targeted research, including longitudinal studies.
PMCID: PMC4006313  PMID: 24174466
mental health; wounds and injuries; risk factors; psychological distress
13.  Emergency department-reported injuries associated with mechanical home exercise equipment in the USA 
The goal of this study was to generate national estimates of injuries associated with mechanical home exercise equipment, and to describe these injuries across all ages. Emergency department (ED)-treated injuries associated with mechanical home exercise equipment were identified from 2007 to 2011 from the National Electronic Injury Surveillance System. Text narratives provided exercise equipment type (treadmill, elliptical, stationary bicycle, unspecified/other exercise machine). Approximately 70 302 (95% CI 59 086 to 81 519) mechanical exercise equipment-related injuries presented to US EDs nationally during 2007–2011, of which 66% were attributed to treadmills. Most injuries among children (≤4 years) were lacerations (34%) or soft tissue injuries (48%); among adults (≥25 years) injuries were often sprains/strains (30%). Injured older adults (≥65 years) had greater odds of being admitted, held for observation, or transferred to another hospital, compared with younger ages (OR: 2.58; 95% CI 1.45 to 4.60). Mechanical exercise equipment is a common cause of injury across ages. Injury awareness and prevention are important complements to active lifestyles.
PMCID: PMC4306571  PMID: 24061163
To identify barriers to life jacket use.
Cross-sectional survey.
Nine public boat ramps in western Washington State, USA, August-November, 2008.
675 adult boaters (>18 years) on motor boats <26 feet long.
Main outcome
Low or no life jacket use (0–50% of time) versus high life jacket use (51–100% of time).
Low/no life jacket use (0%–50% of time) was associated with longer boat length (per foot, risk ratio [RR] 1.03, 95% confidence interval [CI] 1.02–1.05), alcohol use (RR 1.11, 95% CI 1.01–1.20), perception of life jackets as “uncomfortable” (RR 1.29, 95%CI 1.09–1.52), perceived greater level of swimming ability (RR 1.25, 95% CI 1.03–1.53 for “expert swimmer”), and possibly with lack of confidence that a life jacket may save one from drowning (RR 1.13, 95%CI 0.96–1.32). Low life jacket use was less likely when a child was onboard (RR 0.88, 95% CI 0.79–0.99), or if the respondent had taken a boating safety class (RR 0.94, 95% CI 0.87–1.01).
Life jacket use may increase with more comfortable devices, such as inflatable life jackets, and with increased awareness of their efficacy in preventing drowning. Boater education classes may be associated with increased life jacket use among adults.
PMCID: PMC4310692  PMID: 24686261
Drowning; Risk Assessment; Swimming/*Education; Boats/*Recreation; Personal Flotation Devices
15.  A geospatial analysis of the relationship between neighbourhood socioeconomic status and adult severe injury in Greater Vancouver 
Injury Prevention  2015;21(4):260-265.
Every year, injuries cost the Canadian healthcare system billions of dollars and result in thousands of emergency room visits, hospitalisations and deaths. The purpose of this study was to explore the relationship between neighbourhood socioeconomic status (NSES) and the rates of all-cause, unintentional and intentional severe injury in Greater Vancouver adults. A second objective was to determine whether the identified associations were spatially consistent or non-stationary.
Severe injury cases occurring between 2001 and 2006 were identified using the British Columbia's Coroner's Service records and the British Columbia Trauma Registry, and mapped by census dissemination areas using a geographical information system. Descriptive statistics and exploratory spatial data analysis methods were used to gain a better understanding of the data sets and to explore the relationship between the rates of severe injury and two measures of NSES (social and material deprivation). Ordinary least squares and geographically weighted regression were used to model these relationships at the global and local levels.
Inverse relationships were identified between both measures of NSES and the rates of severe injury with the strongest associations located in Greater Vancouver's most socioeconomically deprived neighbourhoods. Social deprivation was found to have a slightly stronger relationship with the rates of severe injury than material deprivation.
Results of this study suggest that policies and programmes aimed at reducing the burden of severe injury in Greater Vancouver should take into account social and material deprivation, and should target the most socioeconomically deprived neighbourhoods in Greater Vancouver.
PMCID: PMC4518736  PMID: 25694418
16.  Identifying clusters of falls-related hospital admissions to inform population targets for prioritising falls prevention programmes 
Injury Prevention  2015;21(4):254-259.
There has been limited research investigating the relationship between injurious falls and hospital resource use. The aims of this study were to identify clusters of community-dwelling older people in the general population who are at increased risk of being admitted to hospital following a fall and how those clusters differed in their use of hospital resources.
Analysis of routinely collected hospital admissions data relating to 45 374 fall-related admissions in Victorian community-dwelling older adults aged ≥65 years that occurred during 2008/2009 to 2010/2011. Fall-related admission episodes were identified based on being admitted from a private residence to hospital with a principal diagnosis of injury (International Classification of Diseases (ICD)-10-AM codes S00 to T75) and having a first external cause of a fall (ICD-10-AM codes W00 to W19). A cluster analysis was performed to identify homogeneous groups using demographic details of patients and information on the presence of comorbidities. Hospital length of stay (LOS) was compared across clusters using competing risks regression.
Clusters based on area of residence, demographic factors (age, gender, marital status, country of birth) and the presence of comorbidities were identified. Clusters representing hospitalised fallers with comorbidities were associated with longer LOS compared with other cluster groups. Clusters delineated by demographic factors were also associated with increased LOS.
All patients with comorbidity, and older women without comorbidities, stay in hospital longer following a fall and hence consume a disproportionate share of hospital resources. These findings have important implications for the targeting of falls prevention interventions for community-dwelling older people.
PMCID: PMC4518748  PMID: 25618735
17.  Census-based socioeconomic indicators for monitoring injury causes in the USA: a review 
Injury Prevention  2015;21(4):278-284.
Unlike the UK or New Zealand, there is no standard set of census variables in the USA for characterising socioeconomic (SES, socioeconomic status) inequalities in health outcomes, including injury. We systematically reviewed existing US studies to identify conceptual and methodological strengths and limitations of current approaches to determine those most suitable for research and surveillance.
We searched seven electronic databases to identify census variables proposed in the peer-reviewed literature to monitor injury risk. Inclusion criteria were that numerator data were derived from hospital, trauma or vital statistics registries and that exposure variables included census SES constructs.
From 33 eligible studies, we identified 70 different census constructs for monitoring injury risk. Of these, fewer than half were replicated by other studies or against other causes, making the majority of studies non-comparable. When evaluated for a statistically significant relationship with a cause of injury, 74% of all constructs were predictive of injury risk when assessed in pairwise comparisons, whereas 98% of all constructs were significant when aggregated into composite indices. Fewer than 30% of studies selected SES constructs based on known associations with injury risk.
There is heterogeneity in the conceptual and methodological approaches for using census data for monitoring injury risk as well as in the recommendations as to how these constructs can be used for injury prevention. We recommend four priority areas for research to facilitate a more unified approach towards use of the census for monitoring socioeconomic inequalities in injury risk.
PMCID: PMC4518757  PMID: 25678685
18.  Database improvements for motor vehicle/bicycle crash analysis 
Injury Prevention  2015;21(4):221-230.
Bicycling is healthy but needs to be safer for more to bike. Police crash templates are designed for reporting crashes between motor vehicles, but not between vehicles/bicycles. If written/drawn bicycle-crash-scene details exist, these are not entered into spreadsheets.
To assess which bicycle-crash-scene data might be added to spreadsheets for analysis.
Police crash templates from 50 states were analysed. Reports for 3350 motor vehicle/bicycle crashes (2011) were obtained for the New York City area and 300 cases selected (with drawings and on roads with sharrows, bike lanes, cycle tracks and no bike provisions). Crashes were redrawn and new bicycle-crash-scene details were coded and entered into the existing spreadsheet. The association between severity of injuries and bicycle-crash-scene codes was evaluated using multiple logistic regression.
Police templates only consistently include pedal-cyclist and helmet. Bicycle-crash-scene coded variables for templates could include: 4 bicycle environments, 18 vehicle impact-points (opened-doors and mirrors), 4 bicycle impact-points, motor vehicle/bicycle crash patterns, in/out of the bicycle environment and bike/relevant motor vehicle categories. A test of including these variables suggested that, with bicyclists who had minor injuries as the control group, bicyclists on roads with bike lanes riding outside the lane had lower likelihood of severe injuries (OR, 0.40, 95% CI 0.16 to 0.98) compared with bicyclists riding on roads without bicycle facilities.
Police templates should include additional bicycle-crash-scene codes for entry into spreadsheets. Crash analysis, including with big data, could then be conducted on bicycle environments, motor vehicle potential impact points/doors/mirrors, bicycle potential impact points, motor vehicle characteristics, location and injury.
PMCID: PMC4518761  PMID: 25835304
19.  Unintentional drowning mortality, by age and body of water: an analysis of 60 countries 
Injury Prevention  2014;21(e1):e43-e50.
To examine unintentional drowning mortality by age and body of water across 60 countries, to provide a starting point for further in-depth investigations within individual countries.
The latest available three years of mortality data for each country were extracted from WHO Health Statistics and Information Services (updated at 13 November 2013). We calculated mortality rate of unintentional drowning by age group for each country. For countries using International Classification of Disease 10 (ICD-10) detailed 3 or 4 Character List, we further examined the body of water involved.
A huge variation in age-standardised mortality rate (deaths per 100 000 population) was noted, from 0.12 in Turkey to 9.19 in Guyana. Of the ten countries with the highest age-standardised mortality rate, six (Belarus, Lithuania, Latvia, Russia, Ukraine and Moldova) were in Eastern Europe and two (Kazakhstan and Kyrgyzstan) were in Central Asia. Some countries (Japan, Finland and Greece) had a relatively low rank in mortality rate among children aged 0–4 years, but had a high rank in mortality rate among older adults. On the contrary, South Africa and Colombia had a relatively high rank among children aged 0–4 years, but had a relatively low rank in mortality rate among older adults. With regard to body of water involved, the proportion involving a bathtub was extremely high in Japan (65%) followed by Canada (11%) and the USA (11%). Of the 13 634 drowning deaths involving bathtubs in Japan between 2009 and 2011, 12 038 (88%) were older adults aged 65 years or above. The percentage involving a swimming pool was high in the USA (18%), Australia (13%), and New Zealand (7%). The proportion involving natural water was high in Finland (93%), Panama (87%), and Lithuania (85%).
After considering the completeness of reporting and quality of classifying drowning deaths across countries, we conclude that drowning is a high-priority public health problem in Eastern Europe, Central Asia, Japan (older adults involving bathtubs), and the USA (involving swimming pools).
PMCID: PMC4501178  PMID: 24944343
20.  An international review of the frequency of single-bicycle crashes (SBCs) and their relation to bicycle modal share 
Injury Prevention  2014;21(e1):e138-e143.
To study cyclists’ share of transport modes (modal share) and single-bicycle crashes (SBCs) in different countries in order to investigate if the proportion of cyclist injuries resulting from SBCs is affected by variation in modal share.
A literature search identified figures (largely from western countries) on SBC casualties who are fatally injured, hospitalised or treated at an emergency department. Correlation and regression analyses were used to investigate how bicycle modal share is related to SBCs.
On average, 17% of fatal injuries to cyclists are caused by SBCs. Different countries show a range of values between 5% and 30%. Between 60% and 95% of cyclists admitted to hospitals or treated at emergency departments are victims of SBCs. The proportion of all injured cyclists who are injured in SBCs is unrelated to the share of cycling in the modal split. The share of SBC casualties among the total number of road crash casualties increases proportionally less than the increase in bicycle modal share.
While most fatal injuries among cyclists are due to motor vehicle–bicycle crashes, most hospital admissions and emergency department attendances result from SBCs. As found in previous studies of cyclists injured in collisions, this study found that the increase in the number of SBC casualties is proportionally less than the increase in bicycle modal share.
PMCID: PMC4453165  PMID: 24408962
21.  Adolescent development and risk of injury: Using developmental science to improve interventions 
In adolescence, there is a complex interaction among physical, cognitive, and psychosocial developmental processes, culminating in greater risk-taking and novelty-seeking. Concurrently, adolescents face an increasingly demanding environment, which results in heightened vulnerability to injury. In this paper, we provide an overview of developmental considerations for adolescent injury interventions based on developmental science including findings from behavioral neuroscience and psychology. We examine the role that typical developmental processes play in the way adolescents perceive and respond to risk and how this integrated body of developmental research adds to our understanding of how to do injury prevention with adolescents. We then highlight strategies to improve the translation of developmental research into adolescent injury prevention practice, calling on examples of existing interventions including graduated driver licensing.
PMCID: PMC4405033  PMID: 20876765
22.  Children reporting rescuing other children drowning in rural Bangladesh: a descriptive study 
Injury Prevention  2014;21(e1):e51-e55.
SwimSafe, a basic swimming and safer rescue curriculum, has been taught to large numbers of Bangladeshi children since 2006. This study examines the frequency and characteristics of rescues reported by children who graduated from SwimSafe and compares them with age-matched and sex-matched children who did not participate in SwimSafe.
Interviews were conducted during the swimming season in Raiganj, Bangladesh. Data were collected from 3890 SwimSafe graduates aged 6–14. Two age-matched and sex-matched controls were selected; one who had learned to swim naturally, the other who had not learned to swim.
188 rescues were reported by the three groups. The 12–14-year age groups reported the highest monthly rate of rescues (SwimSafe 10.5/100 000 (95% CI 3.4 to 24.5), natural swimmers 8.5/100 000 (95% CI 2.2 to 21.2)) and annual rate of rescue reported (SwimSafe 25.4/100 000 (95% CI 13.2 to 43.9), natural swimmers 35.4/100 000 (20.8 to 56.2)). Reported rescue numbers among both swimming groups was similar. Mean victim age was 4.1 years and 92.5% were under 7 years. All victims were younger than their rescuer (mean 5.9 years less). Most rescues (73.7%) took place in ponds or ditches with most (86.6%) within 10 m of the bank. Most victims had entered the water to bathe (53.8%). A large majority of reported rescues (90.9%) were conducted with the rescuer in the water, half requiring the rescuer to swim.
Children report frequent drowning rescues of younger children in rural Bangladesh. Most reported are contact rescues with the rescuer in the water. Formal training for in-water rescue techniques may be needed to reduce the risk to the child rescuer.
PMCID: PMC4392303  PMID: 24686262
23.  Socioeconomic and disability consequences of injuries in the Sudan: a community-based survey in Khartoum State 
Injury Prevention  2013;21(e1):e56-e62.
Fatal and non-fatal injuries are of increasing public health concern globally, particularly in low and middle-income countries. Injuries sustained by individuals also impact society, creating a loss of productivity with serious economic consequences. In Sudan, there is no documentation of the burden of injuries on individuals and society.
A community-based survey was performed in Khartoum State, using a stratified two-stage cluster sampling technique. Households were selected in each cluster by systematic random sampling. Face-to-face interviews during October and November 2010 were conducted. Fatal injuries occurring during 5 years preceding the survey and non-fatal injuries occurring during 12 months preceding interviews were included.
The total number of individuals included was 5661, residing in 973 households. There were 28 deaths due to injuries out of a total of 129 reported deaths over 5 years. A total of 441 cases of non-fatal injuries occurred during the 12 months preceding the survey. The number of disability days differed significantly between mechanisms of injury. Road traffic crashes and falls caused the longest duration of disability. Men had a higher probability than women of losing a job due to an injury.
This study demonstrates the importance of prioritising prevention of road traffic crashes and falls. The loss of productivity in lower socioeconomic strata highlights the need for social security policies. Further research is needed for estimating the economic cost of injuries in Sudan.
PMCID: PMC4392305  PMID: 24225061
24.  The use of cost–benefit analysis in road assessments: a methodological inquiry 
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.
To evaluate the rapid assessment metric developed by iRAP and provide suggestions for improvement in these methods.
We replicated iRAP calculations in order to make a critical assessment of the sources, results and 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.
PMCID: PMC4316734  PMID: 23710063
25.  A regionalised strategy for improving motor vehicle-related highway driver deaths using a weighted averages method 
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.
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.
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.
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.
PMCID: PMC4304665  PMID: 21685144

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