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IntroductionTraffic injury is a leading and preventable cause of child death and disability, with child pedestrians and cyclists particularly vulnerable. Examining built environment correlates of child pedestrian and cyclist motor vehicle collisions (PCMVC) in different settings is needed to promote an evidence-based approach to road safety.MethodsWe conducted a cross-sectional study across multiple urban/suburban environments in Canada (Calgary, Toronto, Montreal, Laval, Peel Region). All public elementary schools were included (n=1030). We examined the role of land use/social environments, road environments and traffic safety interventions on the rates of child PCMVC within 1000 m of schools. Multivariable negative binomial regression was conducted for all cities and by individual city. In a subset of schools (n=389), we examined associations when controlling for active school transportation (AST).ResultsMean PCMVC rate per school ranged from 0.13 collisions/year in Peel to 0.35 in Montreal. Child PCMVC were correlated with land use, social and road environments and traffic safety interventions. In fully adjusted models, social and land use features remained the most important correlates. New immigrant population had the largest positive association with child PCMVC (incidence rate ratio (IRR): 1.26, 95% CI 1.06 to 1.50), while old housing (pre-1960) density was most protective (IRR: 0.83, 95% CI 0.77 to 0.90). AST was associated with PCMVC, but it had no effect on the relationships between PCMVC and other social/environmental correlates.ConclusionThe built environment and social factors influence rates of child PCMVC. Opportunities to reduce child PCMVC exist through modifications to city design and road environments and implementing traffic safety interventions.

Objectives The primary objective of this paper is to examine terrain park (TP) feature compliance with recommendations from a ski area industry guide (are TP features compliant with the guide?) and determine factors that could be associated with TP feature compliance in Québec ski areas (do factors influence TP feature compliance?), Canada. These recommendations on the design, construction and maintenance are provided by the Québec Ski Areas Association Guide. Methods A group of two to four trained research assistants visited seven ski areas. They used an evaluation tool to assess the compliance of 59 TP features. The evaluation tool, originally developed to assess the quality of TP features based on the guide, was validated in a previous study. Compliance was calculated by the percentage of compliant measures within a given feature. The potential influence of four factors on compliance (size of the TP, size of the feature, snow conditions and type of feature) were examined using a mixed-effects logistic regression model. Results The average TP feature compliance percentage was 93% (95% CI 88% to 99%) for boxes, 91% (95% CI 89% to 94%) for rails and 89% (95% CI 86% to 92%) for jumps. The logistic regression showed that none of the four factors examined were associated with TP feature compliance with the guide. Conclusion Our results suggest that TP features are highly compliant with the guide in Québec ski areas.

BackgroundPedestrians are commonly involved in vehicle collisions that result in injuries and fatalities. Pedestrian distraction has become an emerging safety issue as more pedestrians use their mobile phones while walking and crossing the street.ObjectivesThe purpose of this research synthesis and meta-analysis is to determine the extent to which cell phone conversation, text messaging or browsing, and listening to music affect a number of common pedestrian behavioural measures.MethodsA keyword search was developed with a subject librarian that used MeSH terms from selected databases including PsycINFO, SPORTDiscus, Medline and TRID. Supplemental searches were also conducted with Google Scholar and Mendeley.Effect size codingThirty-three studies met inclusion criteria and were subjected to data extraction. Statistical information (ie, M, SD, SE, 95% CI, OR, F, t) was extracted to generate standardised mean difference effect sizes (ie, Cohen’s d) and r effect sizes.ResultsFourteen experimental studies were ultimately included in an N-weighted meta-analysis (k=81 effect sizes), and eight observational studies were included in a qualitative overview. Both mobile phone conversation and text messaging increased rates of hits and close calls. Texting decreased rates of looking left and right prior to and/or during street crossing. As might be expected, text messaging was generally found to have the most detrimental effect on multiple behavioural measures.LimitationsA variety of study quality issues limit the interpretation and generalisation of the results, which are described, as are future study measurement and methods improvements.

Environmental audit tools must be reliable in order to accurately estimate the association between built environmental characteristics and bicycling injury risk.To examine the inter-rater agreement of a built environment audit tool within a case-control study on the environmental determinants of bicycling injuries.Auditor pairs visited locations where bicycling injuries occurred and independently recorded location characteristics using the Systematic Pedestrian and Cyclist Environmental Scan (SPACES). Two case groups were defined: (1) where a bicyclist was struck by a motor-vehicle (MV) and (2) where the bicyclist's injuries required hospitalisation. The two corresponding control groups were (1) where non-MV bicycle-related injuries occurred and (2) where minor bicycle-related injuries occurred. Inter-rater reliability of each item on the tool was assessed using observed agreement and κ with 95% CI.Ninety-seven locations were audited. Inter-observer agreement was generally high (≥95%); most items had a 1-2% difference in responses. Items with ≥5% differences between raters included path condition, slope and obstructions. For land use, path and roadway characteristics, κ ranged from 0.3 for presence of offices and cleanliness to 0.9 for schools and number of lanes; overall, 78% of items had at least substantial agreement (κ≥0.61). For bicyclists struck by a MV the proportion of items with substantial agreement was 60%, compared with 73% for non-MV related injuries. For hospitalisations and minor bicycle-related injuries, 76% of items had substantial agreement.Agreement was substantial for most, but not all SPACES items. The SPACES provides reliable quantitative descriptions of built environmental characteristics at bicycling injury locations.

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.

Objective To provide an overview of the two-stage case–control study design and its potential application to ED injury surveillance data and to apply this approach to published ED data on the relation between brain injury and bicycle helmet use. Methods Relevant background is presented on injury aetiology and case–control methodology with extension to the two-stage case–control design in the context of ED injury surveillance. The design is then applied to data from a published case–control study of the relation between brain injury and bicycle helmet use with motor vehicle involvement considered as a potential confounder. Taking into account the additional sampling at the second stage, the adjusted and corrected odds ratio and 95% confidence interval for the brain injury–helmet use relation is presented and compared with the estimate from the entire original dataset. Contexts where the two-stage case–control study design might be most appropriately applied to ED injury surveillance data are suggested. Results The adjusted odds ratio for the relation between brain injury and bicycle helmet use based on all data (n=2833) from the original study was 0.34 (95% CI 0.25 to 0.46) compared with an estimate from a two-stage case–control design of 0.35 (95% CI 0.25 to 0.48) using only a fraction of the original subjects (n=480). Conclusion Application of the two-stage case–control study design to ED injury surveillance data has the potential to dramatically reduce study time and resource costs with acceptable losses in statistical efficiency.

Objectives (1) To apply novel population health theory to the modelling of injury experiences in one particular research context. (2) To enhance understanding of the conditions and practices that lead to farm injury. Design Prospective, cohort study conducted over 2 years (2007–09). Setting 50 rural municipalities in the Province of Saskatchewan, Canada. Subjects 5038 participants from 2169 Saskatchewan farms, contributing 10 092 person-years of follow-up. Main measures Individual exposure: self-reported times involved in farm work. Contextual factors: scaled measures describe socioeconomic, physical, and cultural farm environments. Outcome: time to first self-reported farm injury. Results 450 farm injuries were reported for 370 individuals on 338 farms over 2 years of follow-up. Times involved in farm work were strongly and consistently related to time to first injury event, with strong monotonic increases in risk observed between none, part-time, and full-time work hour categories. Relationships between farm work hours and time to first injury were not modified by the contextual factors. Respondents reporting high versus low levels of physical farm hazards at baseline experienced increased risks for farm injury on follow-up (HR 1.54; 95% CI 1.16 to 1.47). Conclusions Based on study findings, firm conclusions cannot be drawn about the application of population health theory to the study of farm injury aetiology. Injury prevention efforts should continue to focus on: (1) sound occupational health and safety practices associated with long work hours; (2) physical risks and hazards on farms.

Background Incorrect bicycle helmet use increases head injury risk. Objective To evaluate the patterns of incorrect helmet use based on unobtrusive field observations. Methods Two observational surveys conducted in Alberta in 2000 and 2006 captured information on cyclist characteristics, including correct helmet use. Prevalence of correct helmet use was compared across multiple factors: age, gender, riding companionship, and environmental factors such as riding location, neighbourhood median family income, and region. Poisson regression analysis was used to relate predictor variables to the prevalence of incorrect helmet use, adjusting for clustering by site of observation. Results Among helmeted cyclists (n=5862), 15.3% were wearing their helmet incorrectly or were using a non-bicycle helmet. Children (53%) and adults (51%) tended to wear their helmet too far back, while adolescents tended not have their straps fastened (48%). Incorrect helmet use declined approximately 50% over the study period for children and adolescents, but 76% (95% CI 68% to 82%) in adults. Children were 1.8 times more likely to use their helmets incorrectly in 2000 compared with adults, but this effect increased to 3.9 (95% CI 2.9 to 5.4) in 2006. Adolescents were more likely to use their helmets incorrectly in 2006 compared with adults (prevalence ratio 2.76; 95% CI 1.9 to 4.02). Children and adolescents cycling alone, compared with adults cycling alone, cycling at non-school sites and cycling in Edmonton, was associated with incorrect helmet use. Conclusions Important factors not previously identified were associated with incorrect bicycle helmet use. This information can be used to target interventions to increase correct use.

Background: Bicycle helmets effectively reduce the risk of bicycle-related head injuries and trauma; however, they must fit properly to be effective. Little is known about the prevalence of correctly worn helmets and factors associated with proper helmet use. Objective: To examine proper bicycle helmet use through a systematic review. Methods: Comprehensive searches of electronic medical databases were performed, and completed by grey literature and reference list checks to identify eligible studies. Studies eligible for inclusion had to involve cyclists and report on the prevalence of correct or incorrect helmet use. Two reviewers independently selected studies and data were extracted regarding the prevalence and factors influencing proper helmet wearing of cyclists. Results: An inclusive search strategy led to 2285 prescreened citations; 11 of the studies were finally included in the review. Overall, correct helmet use varied from 46% to 100%, depending on the criteria used by researchers to define proper helmet use; stricter criteria reduced the proportion of properly worn helmets. Adulthood, female sex and educational interventions were associated with correct helmet use in some studies. Self-reported poor helmet fit (OR = 1.96; 95% CI 1.10 to 3.75), posterior positioning of helmet (OR = 1.52; 95% CI 1.02 to 2.26) and helmet loss in crash (OR = 3.25; 95% CI 1.82 to 5.75) increased the risk of head injury. In addition, educational programmes on helmet use in schools increased correct helmet use among schoolchildren. Conclusions: This systematic review outlines the current state of the literature including the variability in research methodology and definitions used to study proper helmet-wearing behaviour among cyclists.

Objective: To evaluate the effectiveness of an agricultural health and safety program in reducing risks of injury. Design: Cross-sectional survey. Setting: 50 rural municipalities in the Province of Saskatchewan, Canada. Intervention: The Agricultural Health and Safety Network (AHSN), a mainly educational program that administered 112 farm safety interventions over 19 years. Subjects: 5292 farm people associated with 2392 Saskatchewan farms. Farms and associated farm people were categorized into three groups according to years of participation in the AHSN. Main measures: Impact: self-reported prevalence of: (1) farm safety practices; (2) physical farm hazards. Outcome: (1) self-reported agricultural injuries. Results: After adjustment for group imbalances and clustering at the rural municipality level, the prevalence of all impact and outcome measures was not significantly different on farms grouped according to years of AHSN participation. To illustrate, the adjusted relative risk of reporting no rollover protection on tractors among farms with none (0 years) versus high (>8 years) levels of AHSN participation was 0.95 (95% CI 0.69 to 1.30). The adjusted relative risk for agricultural injuries (all types) reported for the year before the survey was 0.99 (95% CI 0.74 to 1.32). Conclusions: Educational interventions delivered via the AHSN program were not associated with observable differences in farm safety practices, physical farm hazards, or farm-related injury outcomes. There is a need for the agricultural sector to extend the scope of its injury prevention initiatives to include the full public health model of education, engineering, and regulation.

Background: Deficiencies in emergency department (ED) charting is a common international problem. While unintentional falls account for the largest proportion of injury related ED visits by youth, insufficient charting details result in more than one third of these falls being coded as “unspecified”. Non-specific coding compromises the utility of injury surveillance data. Objective: To re-examine the ED charts of unspecified youth falls to determine the possibility of assigning more specific codes. Methods: 400 ED charts for youth (aged 0–19 years) treated at four EDs in an urban Canadian health region between 1997 and 1999 and coded as “Other or unspecified fall” (ICD-9 E888) were randomly selected. A structured chart review was completed and a blinded nosologist recoded the cause of injury using the extracted data. Differences in coding specificity were compared with the original data, and logistic regression was undertaken to examine variables that predicted assignment of a specific E-code. Results: A more specific code was assigned to 46% of cases initially coded as unspecified. Of these, 73% were recoded as “Slips, trips, and stumbles” (E885), which still lacks the specificity required for injury prevention planning; 2% of charts had no fall documented. Multivariate analysis revealed that dichotomized injury severity (adjusted odds ratio (OR) = 1.75 (95% confidence interval, 1.11 to 2.78)), arrival at the ED by ambulance (adjusted OR = 5.41 (1.07 to 27.0)), and the availability of nurse’s notes or triage forms, or both, in the chart (adjusted OR = 3.75 (2.17 to 6.45)) were the strongest predictors of a more specific E-code assignment. Conclusions: Deficiencies in both chart documentation and coding specificity contribute to the use of non-specific E-codes. More comprehensive triage coding, improved chart documentation, and alternative methods of data collection in the acute care setting are required to improve ED injury surveillance initiatives.

Objective: To determine the reliability of reporting of information on risk factors from a standard accident report form used by ski patrols and a follow up mail questionnaire or telephone interview among injured skiers and snowboarders. Setting: 19 ski areas in the Canadian province of Quebec between November 2001 and April 2002. Participants: 4377 injured skiers and snowboarders seen by the ski patrol, who completed a follow up mail questionnaire or telephone interview. Main outcome measures: κ and weighted κ statistics were used to measure the chance corrected agreement for self reported ability, age, skiing time on day of injury, lessons, type of practice, use of helmet at time of injury, and hill difficulty. Results: The κ value for helmet use at the time of injury was 0.88 (95% confidence interval 0.87 to 0.90) and for other risk factors ranged from 0.45 (skiing time on day of injury) to 0.98 (age). Few differences were seen in reporting by body region of injury. Reporting consistency was lower for respondents who completed telephone interviews compared with those who completed mail questionnaires and those who responded more than four months after the injury. Conclusions: Moderate to almost perfect agreement, depending on the risk factor, exists between ski patrols' accident report forms and follow up information. Ski patrol reports can be a reliable and readily available source of information on risk factors for skiing and snowboarding.

Objective—To provide an overview of hospital admissions for the treatment of farm injuries. Methods—Design: descriptive analysis of data from the Canadian Agricultural Injury Surveillance Program (CAISP). Population: persons experiencing a farm injury requiring hospitalization, April 1991 to March 1995. Access to hospital separation data was negotiated within Canadian provinces.Individual cases were verified by medical records personnel and supplemental data describing injury circumstances were obtained. Analysis:descriptive analyses characterizing farm injuries by: persons involved, mechanisms, primary diagnoses, and agents of injury. Results—Data from 8/10 Canadian provinces representing 98% of the farm population were obtained. A total of 8263 farm injuries were verified. Adults aged 60 years and older were over-represented in these injuries. Leading external causes of agricultural machinery injury included entanglements, being pinned/struck by machinery, falls, and runovers. Nonmachinery causes included falls from heights, animal related trauma, and being struck/by against objects. Leading diagnoses varied by age group, but included: limb fractures/open wounds, intracranial injuries, skull fractures, and spinal/ truncal fractures. Conclusions—CAISP is a new agricultural injury surveillance program in Canada. Data from this system are actively used to inform prevention initiatives, and to indicate priorities for etiological and experimental research in the Canadian agricultural setting. (Injury Prevention 2001;7:123‐128)

Background The standard response time benchmark for Emergency Medical Services (EMS) has been set at eight minutes or less for ground ambulances in many parts of the world. It has not been extensively studied, especially in paediatric patients who suffered a traumatic injury. As injury is the leading cause of death for those under the age of 18 it is important to determine if this benchmark for EMS response time may be a factor in paediatric mortality and morbidity outcomes. Methods All paediatric calls made to EMS between April 2010 to September 2013 in the cities of Calgary and Edmonton, Alberta, Canada were examined to select patients who had suffered a traumatic injury. These records were then linked to emergency department records and hospitalisation records using a deterministic linkage strategy using personal healthcare number, sex, and receiving facility. Patients were excluded if they were ≥18 years old, attended to outside of Calgary or Edmonton areas or suffered a medical complaint not related to an injury. Response time, the exposure, was defined as time of call to 9–1–1 to arrival of ambulance on scene. Response time was dichotomized into Results 42 620 patients were attended to between April 2010 and September 2013. Overall, 6778 patients were included in the study. 52 patients died and 628 patients were admitted to hospital. The adjusted mortality risk ratio given a response time of ≥8 minutes was 0.635 (95% CI: 0.346–1.166; p = 0.143). The adjusted hospital admission risk ratio given a response time of ≥8 minutes was 1.165 (95% CI: 0.985–1.379; p = 0.075). Conclusions A response time of ≥8 minutes was not associated with a difference in all cause mortality or hospital admission for paediatric patients suffering from a traumatic injury.

Background Sport injuries are a significant burden, and while there are studies demonstrating the effectiveness of injury prevention programs, there is less guidance on how they are adopted and implemented successfully. The aim of this project was to conduct a process and formative evaluation of an injury prevention program implemented in a school setting. Methods This study proposes two frameworks [RE-AIM and the Consolidated Framework for Implementation Research (CFIR)] to evaluate the implementation of a neuromuscular training program (iSPRINT) to reduce sport injury and improve health-related measures in a junior high school population. The five dimensions of the RE-AIM and CIFR frameworks will be used. Results A total of 245/320 students were willing to participate in the program (68% reach). There was a lower risk of injury in intervention schools (n = 2) compared to controls (n = 2) [RR = 0.52 (95% CI: 0.33–0.81)]. 76% of students and 83% of teachers reported positive attitudes towards the program, 60% of students reported they believed the program could reduce the risk of injury, and 74% reported the program could improve fitness. 14% of the schools approached agreed to participate in the program (adoption). For students, the most frequently reported reason for participating was the belief that the program would reduce injury and increase fitness. Factors related to successful implementation of the program in schools included clear explanation and demonstration of the program, and barriers included difficulty in executing certain program components. Finally, 88% of teachers reported interest in maintaining the program. Ongoing formative evaluation will be collected via focus groups using CFIR constructs (2015–2016). Conclusions Teachers were able and keen to continue to use the iSPRINT program. We will provide further discussion on the dimensions of REAIM, and report the specific constructs that facilitated and impeded implementation of the iSPRINT program.

Background Bicycling injuries in young people represent a substantial cost to health care systems. The objective of this review was to examine the individual and environmental factors associated with bicycling-related injury risk in children and youth. Methods Fourteen electronic databases were searched using exploded subject headings and keywords. Two authors independently screened article titles and abstracts for inclusion. The full-text of the potential articles was assessed to determine eligibility. The inclusion criteria were bicyclists less than 18 years old; individual and environmental characteristics of bicycling outcomes; comparisons between injured and uninjured bicyclists, injury type or severity level; study designs with a pre-determined comparison group; and publications in English from 1990 to May 2015. The exclusion criteria were injury outcomes related to helmet use, helmet legislation or mountain biking; comparisons of census-based injury rates; cross-sectional studies; and letters to the editor. A modified version of the Newcastle-Ottawa Scale was used to assess study quality. Results Fifteen articles met the inclusion and exclusion criteria. Overall, 46 different risk factors were examined. The most commonly reported risk factors were age (N = 10 studies), sex (N = 7), equipment related factors (N = 6), bicycling exposure (N = 5), bicycling purpose (N = 5), and motor vehicle (MV) collision (N = 4). The reviewed studies varied in quality; the main weaknesses were inadequate definitions of study groups, lack of control for potential confounders, and the use of self-reported data. Conclusions While many of the studies had significant limitations, one recurring theme was that young bicyclists received more severe injuries when exposed to MV collisions. To reduce injuries in children and adolescents, we recommend separating bicyclists from MVs on the road and implementing strategies to reduce traffic speed and volume.