Keeping kids off the streets: pedestrian injury and active transport

1. Keeping kids off the streets: pedestrian injury and active transport

2. Overview of the talk • A bit of history • What is the burden of pedestrian injuries-in Canada?-in Alberta? • What are the long-term consequences?

3. Overview of the talk • What are some of the risk factors and proposed prevention strategies?- Environmental/Engineering factors- Child factors- Socioeconomic factors - Educational factors • What happens when kids walk to school?-meeting daily PA requirements-safety in numbers • Conclusions

6. The car was owned by the Anglo-French Motor Car (Roger-Benz) Company who were offering demonstration rides to the public. At the time of the crash, the car was being driven by Arthur Edsell, an employee of the company. He had had been driving for only 3 weeks (no driving tests or licenses existed at that time). He had apparently tampered with the belt, causing the car to go at twice the intended speed and was also said to have been talking to the young lady passenger beside him. • After a six-hour inquest, the jury returned a verdict of "Accidental Death". No prosecution was proposed or brought against the driver or the company. The Coroner at the enquiry is reported to have remarked: • 'I trust that this sort of nonsense will never happen again'.

7. What is the burden of child pedestrian injury?

8. A CHILD PEDESTRIAN IS KILLED BY A VEHICLE IN CANADA 60 TIMES A YEAR. • He is around 8 years old. He is likely to be from a poor neighbourhood. It is between 5 and 9 pm on an October day in an urban environment in Canada. There is no traffic signal where he crosses the road, but there may be crosswalk markings painted on the road. There is high traffic volume and a vehicle is travelling straight ahead, and it is speeding. It is likely that he ran into the road while playing or was crossing at an intersection. He is hit by the vehicle and dies from his injuries. • This situation will be repeated in 6 days -- and it is 100% preventable. From SafeKids Canada “Making it Happen: Pedestrian Safety: A Guide for Communities”

9. From SafeKids Canada: Child and Youth Unintentional Injury: 10 years in Review

12. Deaths from pedestrian injuries in Canada 1994-2003

13. Long-term impact of pedestrian injuries • Poorest functional outcomes among pedestrian injuries compared to other common mechanisms • 72% of children injured as pedestrians required help with daily activities 6 months post-injury (Macpherson, Rothman, McKeag, Howard, J Trauma 2003)

14. Relative risk of requiring assistance at 6 months by mechanism of injury

15. War on the roads? • “The street has always been the scene of conflict...between living and access, between resident and traveler, between street life and the threat of harm.” • Charter on Transport, Environment and Health, World Health Organization; 1999.

16. Risk factors and prevention strategies for child pedestrian injuries • Recent overview by Schreiber et al (Injury Prevention 2002) highlight 4 areas for risk factors and prevention: • Environmental/engineering factors • Child factors: Age/gender • Sociological factors: the role of SES in pedestrian injury • Educational factors: Does child pedestrian education work?

17. Environmental risk factors • Roberts (BMJ, 1995) conducted a case-control study of pedestrian injury in New Zealand • Measured SES, child and environmental variables including traffic volume, speed and curb parking

19. Evidence for engineering strategies Retting et al (AJPH 2003) examined 3 evidence-based engineering strategies 1) Reduce traffic speeds 2) Separate pedestrians from cars in time 3) Separate pedestrians from cars in space

20. A few examples: reducing traffic speed • Roundabouts: In Europe converting traditional intersections to modern roundabouts ↓ pedestrian injuries 75% (Brilon et al 1993) • Speed humps: Can reduce odds of injury in neighbourhood: • OR 0.47, (95% CI: 0.24-0.95) • and in front of the child’s home: • OR 0.40, (95% CI: 0.15-1.06) (Tesler et al AJPH 2004)

21. Traffic calming • Traffic calming: Cochrane systematic review (Bunn et al) and meta-analysis (Elvik) suggest traffic calming CAN work, but doesn’t always • More evaluation is needed to assess in what situation traffic calming is most effective

22. Elvik R. Area-wide urban traffic calming schemes: a meta-analysis of safety effects. Accident Analysis and Prevention2001; 33: 327-336.

23. Separating pedestrians from cars in time • Traffic signals: increasing the time for yellow and red phases decreased crashes by 37% (Retting et al Accid Anal Prev 2002) • Lights prompting drivers to yield to pedestrians reduced car/pedestrian conflicts by between 40 and 90%(Hughes et al Transport Res 2000) • Intersections with exclusive pedestrian signal phase had 50% fewer crashes than other intersections (Zeeger et al, Transportation Res 1982)

24. Separating pedestrians from cars in space • Pedestrian overpasses↓ collisions by 91% in Japan (Japan Road Assn, 1969) • Fences that prevent pedestrians crossing mid-block reduced injuries BUT fences that did not obscure driver’s view better, especially for children (Berger 1975, Stewart 1988) • Refuge islands can reduce # of conflicts by 66% (Garder, 1989)

25. Improving the urban environment: planting trees and adding signals

26. Child factors • Age, gender strongest child determinants • Boys of all ages at increased risk • 5-9 years at greatest risk (start of independent mobility?)

27. Socio-economic status and child pedestrian injuries • Overwhelming evidence that poor children at increased risk (Laflamme et al 2000): • Rivara and Barber (US): crowded housing best predicted # of injuries • Pless et al (Canada): crowding, family problems, placed in care of authorities • Roberts (NZ): sole parenthood

29. Socioeconomic status summary • Poor kids at increased risk of injury in Canada and around the world • Combination of environmental factors and supervision

30. Educational factors • Can we teach children to cross streets safely? • Duperrex et al Cochrane review (BMJ 2002) • Safety education can improve attitudes and intentions for children • No evidence of reduction in injury or death • No trial conducted in low and mid income countries

31. Is it really a war on the roads if one side is not there? Credit:  BMJ (Robert Knoth/Panos)

32. Children’s exposure to traffic • Children’s exposure to traffic has fallen by 28% since 1972 (DiGuiseppi and Roberts 1998) • Roberts suggested that decline in pedestrian injuries is due to decline in children’s independent mobility (BMJ, 1993)

33. Children’s exposure to traffic in Montréal • Measured number of streets crossed on one day • - does number of streets crossed vary by SES? • -Is child pedestrian injury rate associated with number of streets crossed? • (Macpherson, Roberts, Pless, AJPH,1998)

34. Table 1 Number of Streets Crossed by Age and Socio-economic Indicators*

36. Exposure and SES • Poorer children in Canada and around the world have higher exposure to traffic • Their parents may have fewer options to protect them • Posner et al (Inj Prev 2003) found that poor children more likely to play on street and be hit by cars while playing

37. The paradoxical effect of SES • Wealthier kids with access to motororized transport drive, increasing traffic volume and the risk for those that walk

38. Active transport and physical activity

41. But what happens if children walk? • Spinks et al examined cohort of Australian school children • Association between non-compliance with daily activity guidelines and other variables including TV viewing and walking/biking to school

42. Variables associated with non-compliance with physical activities guidelines (Spinks et al 2006)

44. Safety in numbers? • Jacobsen evaluated walking and bicycling in European cities, Denmark, California • Wanted to assess whether increases in walking and bicycling were associated with increases in pedestrian and bicyclist injury

47. Safety in numbers • Concluded “Where or when more people walk or bicycle, the less likely any of them are to be injured by motorists” • “Policies that increase walking and bicycling appear to be an effective route to improving the safety of people walking and bicycling

48. Conclusions • Child pedestrian injuries are an important child health problem • Long-term or deadly consequences • Death rate has not declined substantially • Poorest children most at-risk, most exposed • Increased motorized transport may be one reason for decline in injuries

49. Conclusions • Increase in car travel benefits wealthy kids and is associated with decreases in physical activity • Environmental strategies (traffic signals, overpasses) currently provide best evidence for prevention • Increasing the number of children involved in active transport (walking, biking) also appears to be a promising strategy

50. Implications for prevention: What can clinicians, researchers do? • Use an evidence-based approach: • Work towards engineering solutions (traffic signals, reducing car speed) that benefit all children • Walk your children to school • Encourage others to walk too • Advocate for safer, healthier streets