Accident Analysis and Prevention 39 (2007) 313–318
Social, behavioral and driving characteristics of injured pedestrians:
A comparison with other unintentional trauma patients夽
Gabriel E. Ryb a,b,c,∗ , Patricia C. Dischinger a , Joseph A. Kufera a , Carl A. Soderstrom a,d
a
National Study Center for Trauma and Emergency Medical Systems, University of Maryland School of Medicine,
701 West Pratt Street, Fifth Floor, Baltimore, MD 21201, USA
b Program in Trauma, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
c Trauma Service, Prince Georges Hospital Center, Cheverly, Maryland, USA
d Medical Advisory Board, Maryland Motor Vehicle Administration, Baltimore, MD, USA
Received 7 April 2006; received in revised form 3 July 2006; accepted 2 August 2006
Presented as a poster at the 2005 National Injury and Violence Prevention and Control Conference. Injury and Violence in America:
Meeting Challenges, Sharing Solutions. Denver, CO, May 9–11.
Abstract
Pedestrian injuries represent 11% of all motor vehicle related injuries in the USA. This study attempts to define the epidemiology of the pedestrian
victim. Patients admitted to a regional adult trauma center were interviewed and evaluated for substance abuse. Pedestrians were compared with
the remaining unintentional trauma patients with regard to demographics, socioeconomics, possession of a driver’s license, injury prone behaviors,
risk taking dispositions, and BAC levels using the Student’s t-test and Pearson’s χ2 statistic (α = 0.05). Multivariate logistic regression models
were built with pedestrian mechanism as the outcome. When compared to the remaining unintentional trauma population (N = 661), pedestrians
(N = 113) were significantly more likely to be black, not married, unemployed, binge drinkers, alcohol dependent, drug dependent, BAC+, to
have a low income, low educational achievement, younger age, and to not have a driver license. Black race, unemployment of 1 year or more,
never licensed, lapsed license, revoked license and BAC > 200 mg/dl showed statistical significance in the multiple logistic regression. Pedestrians
represent a sub-population with a low socioeconomic status and high incidence of substance abuse. Unemployment, not having a driver’s license,
black race, and a BAC > 200 mg/dl were strongly linked to being an injured pedestrian.
© 2006 Elsevier Ltd. All rights reserved.
Keywords: Trauma; Pedestrian; Alcoholism; Driver license; Socioeconomic
1. Introduction
Pedestrian injuries represent approximately 11% of all motor
vehicle related injuries in the USA, and accounted for 4749
deaths and 70,000 injuries in 2003 (DOT HS 809 769, 2003).
These statistics do not include non-motor vehicle and nonroad injuries; hence, they underestimate injury and fatality rates
夽
Supported by a grant (RO1 AA09050) from the National Institute on Alcohol
Abuse and Alcoholism.
∗ Corresponding author at: National Study Center for Trauma and Emergency
Medical Systems, University of Maryland School of Medicine, 701 West Pratt
Street, Fifth Floor, Baltimore, MD 21201, USA. Tel.: +1 410 328 5085;
fax: +1 410 328 3699.
E-mail addresses: [email protected] (G.E. Ryb),
[email protected] (P.C. Dischinger), [email protected]
(J.A. Kufera), [email protected] (C.A. Soderstrom).
0001-4575/$ – see front matter © 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.aap.2006.08.004
(Stutts and Hunter, 1999a,b). Pedestrian injuries are linked to
urban location, darkness, male gender, alcohol intoxication and
risky crossing behaviors.
A decrease in pedestrian injury and fatality rates has been
documented since 1993. This occurred at the same time as the
proportion of vehicles with designs that accentuate the incompatibility between vehicles and pedestrians (i.e. SUVs and pickups) increased (Ballesteros et al., 2004). This trend could be
related to improvements in car design, better enforcement of
traffic rules, road safety engineering efforts or to a change in
exposure (miles walked per unit of population). Driver factors
have been found in 48% of single motor vehicle–pedestrian
events. Nevertheless, a pedestrian related factor was present in
at least 59% of the cases (Shankar, 2003).
Understanding the characteristics specific to motor vehicle
pedestrian victims should assist in designing programs to reduce
injuries from this highly lethal mechanism. This study will
314
G.E. Ryb et al. / Accident Analysis and Prevention 39 (2007) 313–318
attempt to define the demographic, socioeconomic status (SES),
psychoactive substance use disorders (PSUD), driving license
status and risk taking characteristics of the pedestrian struck victim. To further define vulnerabilities typical of pedestrian struck
victims we will compare them to the remaining unintentional
trauma population.
2. Methods
2.4. Alcohol use diagnoses
Alcohol and drug disorder diagnoses were made by using
the Psychoactive Substance Use Disorders section of the Structured Clinical Interview for the DSM-III-R (SCID) (Spitzer et
al., 1987; American Psychiatric Association, 1987). The SCID
is a widely accepted instrument that provides in-depth alcohol
and other drug use diagnoses according to standardized criteria
(Kitchens, 1994; NIAAA, 1991).
2.1. Study site/population
2.5. Patient interviews
This study reports data from a larger study, where 1118
trauma center patients where assessed in depth for substance
abuse disorders. The study was conducted at the R Adams Cowley Shock Trauma Center of the University of Maryland Medical
Center in Baltimore. The center is a regional adult Level I trauma
center that serves the most-populated counties of central Maryland. The center also serves the urban communities surrounding
the medical center. Approximately 85% of patients treated at
the trauma center are admitted from the scene of injury. Those
injured in rural/suburban settings are usually transported by
Medevac helicopters, and those injured in the city are transported by ambulance. In terms of mechanism of injury, age, and
sex, our patient profile is similar to the aggregate of patients
treated in trauma centers throughout the United States (Miller
et al., 1998). For patients admitted from the injury scene, time
from injury to admission averages about 1 h. For this study we
included all unintentional trauma patients from the total of 1118
trauma center patients who were interviewed. The interviewed
population is representative of the entire trauma population at
our trauma center.
2.2. Eligibility criteria
Patients were eligible for recruitment if they were 18 years of
age or older, were admitted from the scene of injury, had intact
cognition, and had a length of stay of 2 or more days. A length
of stay of 2 or more days was chosen to identify patients with
serious injuries. Patients were not eligible for interview while in
intensive care units. Patients initially in intensive care units or
who were cognitively impaired were followed until they became
eligible or were discharged. Finally, a patient was not eligible
for study if his or her attending surgeon thought that a patient
interview would have a negative impact on the clinical course.
The study design was approved by both the Institutional Review
Board of the University of Maryland School of Medicine and the
center’s research committee. Patients admitted from May 1994
through December 1995 were included in the study.
2.3. Data collection
Demographic data, injury type (unintentional [vehicular
crashes, falls, etc.] or intentional [shootings, stabbings, etc.]),
injury severity score and results of the admission blood alcohol
concentration (BAC) tests were obtained from the center’s toxicology database (Soderstrom et al., 1997a). The remaining data
were obtained through patient interview (see below).
Eligible subjects were approached for study consent by the
interviewers, who were trained in administration of the SCID
instrument and three interview screening tests for alcoholism.
Patients were considered cognitively competent if they had good
memory of recent and remote events. The interviewers had no
knowledge of admission BAC and other drug test results. (The
results of SCID assessments for alcohol and other drug diagnoses and the accuracy of the alcoholism screening tests were
published previously (Soderstrom et al., 1997b,c).) Injury history, socioeconomic status, demographics, motor traffic violations, driver’s license possession (or cause of license loss), injury
prone behaviors and risk-taking dispositions were assessed during the interview.
Injury prone behaviors were explored with questions evaluating the frequency or likelihood of the patient engaging in
certain injury prone behaviors (IPB) (low seatbelt use, drinking
and driving, riding with a drunk driver, binge drinking, speeding for the thrill). Similar questions have been used by several
authors and by the behavioral risk factor surveillance system
(BRFSS) (Cherpitel, 1993, 1999; Soderstrom et al., 2001; Field
and O’Keefe, 2004; Hunt et al., 1992; Field et al., 2001). Risktaking dispositions (impulsivity, risk perception and sensation
seeking) were evaluated using questions utilized in the National
Alcohol Survey in 1990. Risk perception evaluation included six
questions with answers graded from 1 (very unlikely) to 5 (very
likely). Impulsivity and sensation seeking evaluation included
five and four questions, respectively, with answers graded from
1 (not at all) to 4 (quite a lot). Actual format of the questions
is found elsewhere (Cherpitel, 1993, 1999; Soderstrom et al.,
2001; Field and O’Keefe, 2004).
2.6. Analysis of results
Pedestrians were compared with the remaining unintentional
trauma patients in regard to demographics (age, gender, ethnicity
and marital status), SES (education, income and unemployment), PSUD (alcohol and drug dependence), trauma history,
possession of a driver’s license, injury prone behaviors (seatbelt
use, drinking and driving, riding with a drunk driver, binge drinking, speeding for the thrill), risk taking disposition (measures of
risk perception, impulsivity and sensation seeking), and elevated
BAC levels. Comparisons were made using the Student’s t-test
and Pearson’s χ2 statistic (α = 0.05).
“Low seatbelt use” was defined as less often than “nearly
always”. “Drinking and driving” and “riding with a drunk driver”
G.E. Ryb et al. / Accident Analysis and Prevention 39 (2007) 313–318
315
were defined as the self-reported occurrence of the event during
the previous 30 days. “Speeding for the thrill” was considered
positive when individuals reported the behavior more often than
rarely.
In order to identify the predominant factors placing individuals at risk for pedestrian injuries and to adjust for possible
confounding, multivariate logistic regression models were constructed using step-down selection methods, with pedestrian
mechanism as the outcome. Independent variables included substance abuse diagnosis, demographic and socioeconomic status
factors, and driver licensing information. For this exploratory
analysis, a p-value < 0.05 was employed to remove and enter
variables. Adjusted odds ratios and corresponding 95% confidence intervals (CI) were calculated for each independent variable to determine characteristics of pedestrians admitted to a
trauma center.
Table 2
Demographic and socioeconomic characteristics (%)
3. Results
Risk factor
Non-pedestrian
(N = 661)
Pedestrian
(N = 113)
p
Binge drinking
Binge drinking (monthly or more)
Drink and drive
Rides with drunk
Seatbelt low-use
45
25
18
20
33
58
37
8
28
42
0.01
0.005
0.009
0.06
0.06
A total of 774 unintentional trauma patients were included
in this study. Characteristics of the cohort and comparison
with the Maryland BRFSS population (representative of the
non-institutionalized adult civilian population) are presented in
Table 1. Unintentional trauma patients, in general, were younger
and more likely to be male, uninsured, unemployed, alcohol
dependent, not married and of lower income and educational
achievement. They also were more likely to not use seatbelts,
and to engage in binge drinking, drinking and driving, and smoking.
Demographic and SES characteristics of the pedestrian population (N = 113) are described in Table 2. When compared to
the remaining unintentional trauma population (N = 661), pedestrians were significantly more likely to be black, not married,
unemployed and to have a low income. Mean age difference
(40.2 versus 38.7 for pedestrians) was not statistically significant. However, pedestrians were more likely to be younger than
55 years old. They were also more likely to have not completed
or have been suspended from high school (Table 2).
Table 1
Characteristics of injured patients and general population (%)
Risk factor
State BRFSSa
(N = 5093)
Unintentional injury
(N = 774)
Mean age (years)
Male gender
Black
Income < 15,000
Education < 12 years
Unemployed
Not Married
Uninsured
Binge drinking
Alcohol dependence
Drink and drive
Seatbelt low-use
Smoking
45
41
23
6
11
4
45
9
7
2
1
24
20
40
65
26
43
25
15
65
27
26
10
16
34
46
a The Behavioral Risk Factor Survey System (BRFSS) represents the civilian
non-institutionalized adult population.
Risk factor
Non-pedestrian
(N = 661)
Pedestrian
(N = 113)
p
Age < 55
Male gender
Black
Income < $ 15,000
Education < 12 years
Unemployment
Unemployment > 1 year
Not married
Uninsured
Average school performance
School suspension
79
63
21
39
22
12
5
63
24
9
31
87
72
57
64
38
38
27
79
40
21
48
0.049
0.19
<0.001
<0.001
<0.001
<0.001
<0.001
0.001
<0.001
<0.001
0.002
Table 3
Injury related behavioral risk factors (%)
Binge drinking (during the previous days and monthly or
more) was higher among pedestrians. Remaining injury prone
behaviors were not statistically significantly higher among
pedestrians (Table 3). The significantly lower frequency of
drinking and driving among pedestrian is more likely related
to the fact that pedestrians are less likely to drive (see below).
Smoking, diagnosis of current alcohol and drug dependence,
BAC+ and BAC above 200 mg/dl rates were higher among
pedestrians (Table 4).
Similarly, moving traffic violations, loss of a driver’s license,
recent marital change, past history of assault, and a previous
alcohol related injury during the previous year were also more
frequent among pedestrians (Tables 5 and 6). However, measures
of sensation seeking, risk taking and risk perception were similar
between groups.
Black ethnicity, unemployment of 1 year or more, never
licensed, lapsed license, revoked license and BAC > 200 mg/dl
showed statistical significance in the multiple logistic regression.
Marital status, alcohol dependence, drug dependence, income
below $ 15,000, less than a high school education, gender and
Table 4
Alcohol intoxication and substance dependence (%)
Risk factor
Non-pedestrian
(N = 661)
Pedestrian
(N = 113)
p
Alcohol dependence
Smoking
Drug dependent
BAC+
BAC > 80 mg/dl
BAC+ 200 mg/dl
19
43
8
23
19
5
35
65
20
39
35
23
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
316
G.E. Ryb et al. / Accident Analysis and Prevention 39 (2007) 313–318
Table 5
Injury history (%)
Risk factor
Non-pedestrian
(N = 661)
Pedestrian
(N = 113)
p
MVCa history
Assault history
Other injury history
Any injury history
Alcohol related injury
during previous year
35
20
47
69
17
38
40
42
77
33
0.50
<0.001
0.30
0.08
<0.001
a
Motor vehicle crash.
Table 6
Driver’s license and moving traffic violations (%)
Risk factor
Non-pedestrian
(N = 661)
Pedestrian
(N = 113)
p
Never licensed
Lapsed license
Revoked license
Moving traffic violation
Drinking and driving conviction
7
3
4
37
13
27
10
13
24
19
<0.001
<0.001
<0.001
0.007
0.11
Table 7
Significant results of multivariate stepwise logistic regression models to predict
pedestrian as mechanism of injurya
Risk factor
Odds ratios
95% Confidence intervals
Black
Unemployment > 1 year
Never licensed
Lapsed license
Revoked license
BAC > 200 mg/dl
3.01
2.19
3.01
3.30
4.09
3.14
1.86–4.88
1.14–4.18
1.61–5.49
1.31–7.98
1.86–8.66
1.64–5.89
a Marital status, alcohol dependence, drug dependence, income below $
15,000, less than a high school education, gender and age did not reach statistical significance, hence fell out of the model.
age did not reach statistical significance, hence fell out of the
model (Table 7).
4. Discussion
By comparing pedestrians to the remaining of unintentional
trauma population, we were able to distinguish the characteristics particular to the pedestrian subpopulation. In our study
these characteristics were being black, unemployed, having an
alcohol level >200 mg/dl and not being licensed. The other characteristics typical of injured patients that did not differentiate
pedestrians from the other injured patients (in multivariate analyses) were marital status, alcohol dependence, drug dependence,
income below $ 15,000, less than a high school education, gender
and age (Table 1). Individuals risk taking dispositions (sensation
seeking, risk perception and impulsivity) also were similar for
pedestrians and other patients.
Haddon et al. (1959) reported on the characteristics of 50
adult pedestrians fatally injured in Manhattan in 1959. In an
interesting case control design (matched by gender, location,
time and day of the week), he found the fatally injured pedestri-
ans to be more often BAC+, foreign born, of lower SES, and less
often married. The case group was older than the control group.
They also found a significantly lower rate of holding a driver’s
license among pedestrians than the age and gender adjusted rates
in New York City that were indicated at that time. During the
same study Haddon noted that the age of non-fatally injured
pedestrians was lower than the fatally injured but older than the
control population.
Baker suggested that the “virulence” of city traffic is related to
the proportion of non-impaired individuals among the pedestrian
deaths (Baker, 1977). Urban sprawl has been shown to be directly
related to pedestrian fatalities in an ecological study (Ewing et
al., 2003).
“Area” effects (i.e. density) as well as social deprivation have
been also implicated by other authors (Graham et al., 2005;
Abdalla et al., 1997). Demographic (age, gender, marital status, educational level, unemployment and income) and environmental (traffic flow, complexity of roadway system, population
density and alcohol availability) factors at the census tract level
have been linked to “hot spots” of pedestrian injuries (La Scala
et al., 2000).
Our findings support at the individual level the findings at the
“area” and census tract level. We found high rates of unemployment, alcoholism, low income, low education and unmarried
status for injured pedestrians. The black ethnicity prevalence in
our study could be a function of exposure or simply a reflection of the ethnicity of the population surrounding the trauma
center (people involved in a motor vehicle crash will typically
be drawn from a larger catchment area). The age prevalence is
probably affected by the inability to interview a greater segment
of injured elderly because of their higher mortality or morbidity
(see Section 2).
In general, these risk factors are also related to motor vehicle occupant injuries (Cubbin et al., 2000; Cubbin and Smith,
2002). Our regression model shows which factors are typical of
pedestrians. A BAC level greater than 200 mg/dl (but not alcohol dependence or lower BACs) and lack of a driver’s license,
together with unemployment and black ethnicity, differentiated
pedestrians from the remaining unintentional trauma patients.
Individuals without a driver’s license will typically walk more
and be more exposed as pedestrians. This probably mediates
partly the “area” effect. People of low income typically do not
travel far from their residence, further concentrating the exposed
population in their neighborhood (Murakami and Young, 1997).
Limitations of this study include the lack of representativeness of the trauma center population with relation to the entire
injury population (Waller, 1988). Typically, pedestrians in the
trauma center population are more likely to be injured in a
motor vehicle collision than in a non-motor vehicle collision
(e.g., slipping on a sidewalk). Pedestrians who are involved in
a non-motor vehicle collision account for 62% of all pedestrians in emergency room (ER) based studies (Stutts and Hunter,
1999a,b). Furthermore, ER based studies have shown that only
40% of pedestrians who are struck by a motor vehicle on a road
and 30% of pedestrians who are struck by a motor vehicle off
of the road (e.g., driveway) require hospitalization (Stutts and
Hunter, 1999a,b).
G.E. Ryb et al. / Accident Analysis and Prevention 39 (2007) 313–318
The exclusion of fatal injuries, severe brain injuries, early
discharges, and transfers selects a population that could underrepresent the elderly or the minimally injured (Lane et al., 1994).
The catchment area may over represent black ethnicity and lower
incomes in the pedestrian than in the other unintentional trauma
patient group.
This study confirms published data and common believes in
relation to adult trauma center patients involved in pedestrian
injuries. The uniqueness of this study is that the population was
evaluated in depth in relation to (1) substance abuse diagnosis
(Diagnostic and Statistical Manual of Mental Disorders criteria
were used), (2) demographics, (3) SES, (4) risk taking dispositions (risk perception, impulsivity and sensation seeking), (5)
injury prone risk taking behaviors, and (6) injury and driving
history.
No other single study, to our knowledge, has documented all
these characteristics in an adult injured population. Even though
some of the conclusions seem self-evident, these have not been
clearly documented in any single study since Haddon’s report
of 50 pedestrians in 1959 (Haddon et al., 1959).
This study reports data from a larger study (the only of its
kind) where 1118 trauma center patients were assessed in depth
for substance abuse disorders. The main results of this study
were reported elsewhere (Soderstrom et al., 1997b,c).
We acknowledge that the prevalence of pedestrian injury may
have changed since the study was performed. Nevertheless, the
strength of this study is in describing the characteristics of the
injured pedestrians particularly because of the depth in which
substance disorders, behavioral risks and risk taking dispositions
were assessed. Because these characteristics are likely to remain
unchanged over time, the results of this study remain relevant.
Even though pedestrian fatalities have decreased since 1993
(Shankar, 2003), they remain approximately a 5% of all traffic
fatalities (DOT HS 809 769, 2003). As reported by the National
Highway Traffic Safety Administration (NHTSA), pedestrian
fatalities are mostly males and occur predominantly in urban
areas and at night time (DOT HS 809 769, 2003). Pedestrian
injury case fatality, as expected, is higher on the elderly.
While NHTSA Traffic safety facts 2003 and FARS pedestrian
fatality report focus mainly on alcohol intoxication as the only
behavioral risk factor, only 34% and 33% of the injured and
dead, respectively, were acutely intoxicated (BAC > 0.08) (DOT
HS 809 769, 2003; Shankar, 2003). These proportions (similar
than our study’s 35%), point to the importance of other risk
factors to properly explain the vulnerability of individuals and
populations to pedestrian injuries.
Whereas low educational achievement and unemployment
were similarly prevalent than alcohol intoxication among the
pedestrian group, the following risk factors were markedly more
prevalent: lack of driver’s license (50%), low income (64%),
smoking (65%), binge drinking history (58%), “non-married”
marital status (79%), and history of school suspension (48%).
Whether the association of this cluster of factors with pedestrian injuries is mediated strictly by exposure (i.e. urban location,
lack of vehicle, night time exposure), by behavioral patterns
(crossing at non-intersections, impulsivity, poor attention, etc.)
or both will require further studies. While risk taking per-
317
sonality trait measures were similar between pedestrian and
non-pedestrian unintentional trauma patients, the previously
mentioned SES and behavioral factors seem to more strongly
predispose individuals to be injured as pedestrians. Plausibly,
both behavioral and SES factors are needed to increase the exposure to pedestrian injuries.
The effectiveness of brief motivational interventions in reducing harmful drinking has changed the trauma community perspective in their approach to preventing recidivism among
trauma center patients with alcohol problems (Schermer et al.,
2003). As shown by the recommendations from the conference
“Alcohol Problems Among the Hospitalized Trauma Patients:
Controlling Complications Mortality and Trauma recidivism”
during, May 2003, the trauma community (its leaders and organizations), is moving towards implementing effective interventions to address harmful drinking (CDC, 2005).
Similar interventions need to be developed to address other
co-existing behavioral traits among this “risk taking” population. While SES vulnerabilities cannot be directly addressed by
the healthcare system, these factors could be used to identify
populations at risk. Environmental interventions could reduce
the risk in “hot” spots for pedestrian injuries (lights, crossings,
speed bumps, etc.) (DOT HS 808 742, 1998; Leaf and Preusser,
1999). Effective educational and cognitive interventions, combined with brief motivational interventions for alcohol abuse,
may reduce the risk among the population at risk. As it was with
alcohol problems, the challenge remains to find and implement
effective interventions for a population with high needs and low
resources.
In summary, pedestrian trauma center patients in this study
had a higher prevalence of alcohol dependence, higher prevalence and frequency of binge drinking, lower SES and lower
rate of driver’s license possession. Unemployment, BAC level
greater than 200 mg/dl, black ethnicity and lack of a driver’s
license seem to be the stronger risk factors. These factors may
mediate the exposure to pedestrian trauma and should be taken in
account for injury prevention. Further studies and interventions
should focus on populations exposed to these risk factors.
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