Direct medical charges of all parties in teen-involved vehicle crashes by culpability.

BACKGROUND: Motor vehicle crashes among teen drivers often involve passengers in the teen's vehicle and occupants of other vehicles, and the full cost burden for all individuals is largely unknown. This analysis estimated direct hospitalisation and emergency department charges for teen-involved crashes by teen culpability, comparing charges for the teen driver, passengers and occupants of other vehicles. METHODS: Probabilistic linkage was performed to link the Iowa police crash reports with Iowa emergency department and Iowa hospital inpatient data. Teen drivers aged 14-17 involved in a crash from 2016 through 2020 were included. Teen culpability was determined through the crash report and examined by teen and crash characteristics. Direct medical charges were estimated from charges through linkage to the Iowa hospital inpatient and the Iowa emergency department databases. RESULTS: Among the 28 062 teen drivers involved in vehicle crashes in Iowa between 2016 and 2020, 62.1% were culpable and 37.9% were not culpable. For all parties involved, the inpatient charges were $20.5 million in culpable crashes and $7.2 million in non-culpable crashes. The emergency department charges were $18.7 million in teen culpable crashes and $6.8 million in teen non-culpable crashes. Of the $20.5 million total inpatient charges in which a teen driver was culpable, charges of $9.5 million (46.3%) were for the injured teen driver and $11.0 million (53.7%) for other involved parties. CONCLUSIONS: Culpable teen-involved crashes lead to higher proportions of injury and higher medical charges, with most of these charges covering other individuals in the crash.

Association of traumatic brain injury severity and time to definitive care in three low-middle-income European countries.

BACKGROUND: Low-middle-income countries experience among the highest rates of traumatic brain injury in the world. Much of this burden may be preventable with faster intervention, including reducing the time to definitive care. This study examines the relationship between traumatic brain injury severity and time to definitive care in major trauma hospitals in three low-middle-income countries. METHODS: A prospective traumatic brain injury registry was implemented in six trauma hospitals in Armenia, Georgia and the Republic of Moldova for 6 months in 2019. Brain injury severity was measured using the Glasgow Coma Scale (GCS) at admission. Time to definitive care was the time from injury until arrival at the hospital. Cox proportionate hazards models predicted time to care by severity, controlling for age, sex, mechanism, mode of transportation, location of injury and country. RESULTS: Among 1135 patients, 749 (66.0%) were paediatric and 386 (34.0%) were adults. Falls and road traffic were the most common mechanisms. A higher proportion of adult (23.6%) than paediatric (5.4%) patients had GCS scores indicating moderate (GCS 9-11) or severe injury (GCS 0-8) (p<0.001). Less severe injury was associated with shorter times to care, while more severe injury was associated with longer times to care (HR=1.05, 95% CI 1.01 to 1.09). Age interacted with time to care, with paediatric cases receiving faster care. CONCLUSIONS: Implementation of standard triage and transport protocols may reduce mortality and improve outcomes from traumatic brain injury, and trauma systems should focus on the most severe injuries.

Farm Vehicle Following Distance Estimation Using Deep Learning and Monocular Camera Images.

This paper presents a comprehensive solution for distance estimation of the following vehicle solely based on visual data from a low-resolution monocular camera. To this end, a pair of vehicles were instrumented with real-time kinematic (RTK) GPS, and the lead vehicle was equipped with custom devices that recorded video of the following vehicle. Forty trials were recorded with a sedan as the following vehicle, and then the procedure was repeated with a pickup truck in the following position. Vehicle detection was then conducted by employing a deep-learning-based framework on the video footage. Finally, the outputs of the detection were used for following distance estimation. In this study, three main methods for distance estimation were considered and compared: linear regression model, pinhole model, and artificial neural network (ANN). RTK GPS was used as the ground truth for distance estimation. The output of this study can contribute to the methodological base for further understanding of driver following behavior with a long-term goal of reducing rear-end collisions.

The prevalence of work-related suicides varies by reporting source from the National Violent Death Reporting System.

INTRODUCTION: Both suicides overall and work-related suicides are increasing in the United States, and efforts to reduce suicide risk will require an understanding of the frequency and role of work in suicides. This study examines the incidence of occupational suicides using the National Violent Death Reporting System (NVDRS), which identified the role of work in suicides using the traditional death certificate as well as from death investigations. METHODS: NVDRS suicides among those aged 16 through 65 from 2013 through 2017 were examined to determine if the death certificate identified the death as work-related, if the death investigation identified a job problem as a suicide circumstance, and if the death investigation indicated that the job problem was a crisis at the time of the suicide. RESULTS: Overall, 1.13% of death certificates identified the suicides as work-related, 2.34% of suicides included a job crisis, and 11.2% a job problem, and proportions did not vary over the years of the study. Overlap between the death certificate and death investigation was very low, with only 0.21% of suicides identified as related to work by both sources. Identification of work-relatedness varied by source for demographic characteristics, mechanism of suicide, and occupation. For example, the death certificate identified 2.1% of suicides among those working in protective services as work-related, but death investigations identified 15.2% as having a job problem. CONCLUSION: Work-related factors may be associated with a far higher proportion of suicides than previously documented.

Determining occupation for National Violent Death Reporting System records: An evaluation of autocoding programs.

BACKGROUND: Suicide is a leading cause of death for working-age adults. Suicide risk varies across occupations. The National Violent Death Reporting System (NVDRS) collects information about violent deaths occurring in the United States. Occupation can be determined using autocoding programs with NVDRS data. The objective of this analysis is to determine the accuracy of autocoding programs for assigning occupations in the NVDRS. METHODS: Deaths from suicide were identified in NVDRS for individuals age 16 and older from 2010 to 2017. Occupations were assigned after processing job description free text with autocoding programs. Job assigned by autocoding program were compared with the occupation code recorded on the death certificate. RESULTS: Assignment of major occupation group had substantial agreement (Cohen's kappa > 0.7) for the two autocoding programs evaluated. Agreement of assigned code varied across race/ethnicity and occupation type. CONCLUSIONS: Autocoding programs provide an efficient method for identifying the occupation for decedents in NVDRS data. By identifying occupation, circumstances of suicide and rates of suicide can be studied across occupations.

Racial disparities in pedestrian-related injury hospitalizations in the United States.

BACKGROUND: Racial/ethnic disparity has been documented in a wide variety of health outcomes, and environmental components are contributors. For example, food deserts have been tied to obesity rates. Pedestrian injuries are strongly tied to environmental factors, yet no studies have examined racial disparity in pedestrian injury rates. We examine a nationally-representative sample of pedestrian-related hospitalizations in the United States to identify differences in incidence, severity, and cost by race/ethnicity. METHODS: Patients with ICD diagnosis E-codes for pedestrian injuries were drawn from the United States Nationwide Inpatient Sample (2009-2016). Rates were calculated using the United States Census. Descriptive statistics and generalized linear regression were used to examine characteristics (age, sex, severity of illness, mortality rates, hospital admissions, length of stay, total costs) associated with hospitalizations for pedestrian injuries. RESULTS: The annual average of pedestrian-related deaths exceeded 5000 per year and hospitalizations exceeded 47,000 admissions per year. The burden of injury from pedestrian-related hospitalizations was higher among Black, Hispanic, and Multiracial/Other groups in terms of admission rates, costs per capita, proportion of children injured, and length of stay compared to Whites and Asian or Pacific Islander race/ethnicities. Compared to Whites, hospital admission rates were 1.92 (95% CI: 1.89-1.94) and 1.20 (95% CI: 1.19-1.21) times higher for Multiracial/Other and Blacks, respectively. Costs per capita ($USD) were $6.30, $4.14, and $3.22 for Multiracial/Others, Blacks, and Hispanics, compared to $2.88 and $2.32 for Whites and Asian or Pacific Islanders. Proportion of lengths of stay exceeding one week were larger for Blacks (26.4%), Hispanics (22.6%), Asian or Pacific Islanders (23.1%), and Multiracial/Other (24.1%), compared to Whites (18.6%). Extreme and major loss of function proportions were also highest among Black (34.5%) and lowest among Whites (30.2%). CONCLUSIONS: Results from this study show racial disparities in pedestrian injury hospitalization rates and outcomes, particularly among Black, Hispanic, and Multiracial/Other race/ethnicity groups and support population and system-level approaches to prevention. Access to transportation is an indicator for health disparity, and these results indicate that access to safe transportation also shows inequity by race/ethnicity.

Contributors to pedestrian distraction and risky behaviours during road crossings in Romania.

OBJECTIVE: Pedestrian fatalities due to collisions with motor vehicles are a large public health problem in Romania, ranking them among the highest in Eastern Europe. The purpose of this study was to gain a better understanding of crash factors by examining how roadway and environmental characteristics contribute to pedestrian distraction and risky behaviours at pedestrian MVC (PMVC) locations in Cluj County, Romania. METHODS: A sample of PMVC locations was selected from the 2010 Cluj County police reported crash database for on-site examination. A total of 100 sites were visited to collect details on site characteristics and typical pedestrian and driver behaviours. Variable distributions were examined and rate ratios of pedestrian distraction and risky behaviours were calculated. RESULTS: Pedestrian distraction and risky behaviours were observed at rates of 6.3 and 24.3 per 100 observed pedestrians. The majority of distractions were related to electronic device use. Risky behaviours were evenly split between unpredictable, partial use of a crosswalk and midblock illegal crossings. Distractions and risky behaviours decreased as the number of pedestrians and average vehicle speeds at a site increased. RR of distraction was higher at intersections and locations with crosswalks. CONCLUSIONS: Pedestrian distraction was highly correlated with pedestrian risky behaviours at PMVC locations in Romania. Higher pedestrian volume was protective against pedestrian distraction and risky behaviours. Locations with painted crosswalks had increased distraction. Targeted distraction prevention, particularly at intersections and crosswalk locations, may contribute to the prevention of PMVCs.

Epidemiology of pedestrian-MVCs by road type in Cluj, Romania.

OBJECTIVE: Pedestrian-motor vehicle (PMV) crash rates in Romania are among the highest in all of Europe. The purpose of this study was to examine the characteristics of pedestrian-MVCs in Cluj County, Romania, on the two major types of roadways: national or local. METHODS: Cluj County police crash report data from 2010 were used to identify pedestrian, driver and crash characteristics of pedestrian-MVCs. Crashes with available location data were geocoded and road type (national or local) for each crash was determined. Distributions of crash characteristics were examined by road type and multivariable logistic regression models were built to determine predictors of crash road type. RESULTS: Crashes occurring on national roads involved more teenagers and adults, while those on local roads involved more young children (0-12) and older adults (65+) (p<0.01). Crashes on national roads were more likely to have marked pedestrian crossings and shoulders compared with local crashes. Pedestrian-MVCs that involved a moving violation by the motorist were more likely to occur on national roadways (adjusted OR=1.93, 95% CI 1.07 to 3.49). CONCLUSIONS: Pedestrian-MVCs pose a considerable health burden in Romania. Results from this study suggest that factors leading to PMV crashes on national roads are more likely to involve driver-related causes compared with local roads. Intervention priorities to reduce pedestrian crashes on national roads should be directed towards driver behaviour on national roads. Further examination of driver and pedestrian behaviours related to crash risk on both national and local roads, such as distraction and speeding, is warranted.

ProjectDRIVE: study protocol for a randomized controlled trial to improve driving practices of high-risk teen drivers with a traffic violation.

BACKGROUND: Teen drivers with a traffic violation are at increased risk for crashes and crash-related injuries; however, most parent-focused interventions target teen drivers with supervised learner's permits. Very few interventions are implemented at the probationary driver's license stage or target high-risk teen drivers, such as those with traffic violations. This paper describes the protocol of ProjectDRIVE, A Randomized Controlled Trial to Improve Driving Practices of High-Risk Teen Drivers with a Traffic Violation, which targets improving parent-teen communication about safe driving practices to reduce unsafe driving behaviors and traffic violation recidivism of teen drivers cited for traffic violation. METHODS: Teen drivers (ages 16 or 17) cited for a moving violation and the parent/legal guardian most involved with the teen's driving are recruited from juvenile traffic courts following their required court hearing. After completing informed consent/assent, enrolled dyads are randomized into one of three groups using stratified block randomization: control, device feedback only, or device feedback plus parent communication training. Participating dyads are followed for 6 months with 3 months of active intervention. Using in-vehicle device and smartphone application technology, the study provides real-time and cumulative driving feedback to intervention teens and collects continually recorded, objectively measured driving outcome data throughout the teen's study participation. Primary outcomes include rates of risky driving events and unsafe driving behaviors per 1000 miles driven. Secondary outcomes include traffic violation recidivism up to 12 months following study completion and frequency and quality of parent-teen communication about safe driving practices. DISCUSSION: Through partnership with the local juvenile traffic courts, this study integrates recruitment and randomization into existing court practices. Successfully completing this study will significantly impact juvenile traffic court's practices and policies by informing judges' decisions regarding the driving safety programs they refer to teens to prevent motor vehicle crashes and crash-related injuries and deaths. Trial registration The study was registered on ClinicalTrials.gov Registry (NCT04317664) on March 19, 2020, https://clinicaltrials.gov/study/NCT04317664 and updated on April 27, 2021. This protocol was developed per the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) Checklist.

Rates and predictors of teen driver crash culpability.

BACKGROUND: Motor-vehicle crash risk is highest among teen drivers. Despite a wealth of research on the topic, there are still many contributors to these crashes that are not well understood. The current study sought to examine the contribution of graduated driver licensing (GDL) restrictions, sex, age, roadway circumstances, and citation history to teen drivers' crash culpability. METHOD: Crash system data from the Iowa Department of Transportation were linked with traffic-related charges from the Iowa Court Information System. Crashes involving teens aged 14 to 17 years between 2016 and 2019 were analyzed (N = 19,847). Culpability was determined using the driver contributing circumstances from the crash report. Moving and non-moving traffic citations issued prior to the date of each crash were considered. A multivariable logistic regression model was constructed to examine predictors of crash culpability. RESULTS: Teen drivers were determined to be culpable for more than two thirds of crashes (N = 13,604, 68.54%). Culpability was more prevalent among males, younger teens, in rural areas, in the presence of reported roadway contributing circumstances, during hours of restricted nighttime driving, and among teens with citation histories that included both moving and non-moving citations. Similarly, multivariable model results indicated that the likelihood of culpability was higher among males, in rural areas, and at each stage of GDL compared to teen drivers with unrestricted licenses. While drivers with a history of both moving and non-moving violations were more likely to be culpable, those with a history of only moving or only non-moving violations were less likely to be culpable compared to those with no violation history. CONCLUSION: Sex, crash location, and GDL stage were associated with teen driver crash culpability. A singular prior moving or non-moving violation may play a protective role in teen crash culpability.

Informing traffic enforcement leniency and discretion: Crash culpability and the effectiveness of written warnings versus citations.

OBJECTIVES: Deterrence of risky driving behavior is important for the prevention of crashes and injuries. Traffic law enforcement is a key strategy used to decrease risky driving, but there is little evidence on the deterrent effect of issuing warnings versus citations to drivers regarding the prevention of future crashes. The purpose of this study was to 1) investigate the difference between citations and written warnings in their association with future crash culpability and 2) investigate whether drivers who were issued written warnings or citations have different associations with future crash culpability likelihood than those without prior citations or written warnings. METHODS: Data for this study included Iowa Department of Transportation crash data for 2016 to 2019 linked to data from the Iowa Court Case Management System. A quasi-induced exposure method was used based on driver pairs involved in the same collision in which one driver was deemed culpable and one was non-culpable. Conditional logistic regression models were constructed to examine predictors of crash culpability. The main independent variable was traffic citation and warnings history categorized into moving warning, non-moving warning, moving citation, non-moving citation, or no citation or warning in the 30 days prior to the crash. RESULTS: The study sample included a total of 152,986 drivers. Among drivers with moving violations, previously cited drivers were more likely to be crash culpable than previously warned drivers (OR = 1.64, 95% CI = 1.29-2.08). Drivers with prior non-moving citations were less likely to be the culpable party in a crash than a driver who had no recent warnings or citations (OR = 0.72, 95% CI = 0.58-0.89). Drivers with prior warnings (moving or non-moving) did not appreciably differ in crash culpability relative to drivers who had not received any citations or warnings in the previous 30 days. CONCLUSIONS: Drivers with prior moving citations were more likely to be culpable in a future crash than drivers with prior moving warnings, which may relate to overall driving riskiness as opposed to effectiveness of citations in deterring risky driving behaviors. Results from this study also suggest that officer discretion was being appropriately applied by citing the riskiest drivers, while giving lower risk drivers warnings. Results from this study may be useful to support strengthening of state driver improvement programming.

Traumatic head injuries in Moldova: a cross-sectional analysis of medical registry data.

AIM: The aims of this study were to evaluate the demographics and crash profiles of road traffic-related traumatic brain injury (TBI) patients treated at two emergency departments in the Republic of Moldova, and to identify areas for prevention.

Predictors of rural driver self-reported passing behaviors when interacting with farm equipment on the roadway.

Background: Crashes involving farm equipment (FE) are a major safety concern for farmers as well as all other users of the public road system in both rural and urban areas. These crashes often involve passenger vehicle drivers striking the farm equipment from behind or attempting to pass, but little is known about drivers' perceived norms and self-reported passing behaviors. The objective of this study is to examine factors influencing drivers' farm equipment passing frequencies and their perceptions about the passing behaviors of other drivers. Methods: Data were collected via intercept surveys with adult drivers at local gas stations in two small rural towns in Iowa. The survey asked drivers about their demographic information, frequency of passing farm equipment, and perceptions of other drivers' passing behavior in their community and state when approaching farm equipment (proximal and distal descriptive norms). A multinomial logistic regression model was used to estimate the relationship between descriptive norms and self-reported passing behavior. Results: Survey data from 201 adult drivers showed that only 10% of respondents considered farm equipment crashes to be a top road safety concern. Respondents who perceived others passing farm equipment frequently in their community were more likely to report that they also frequently pass farm equipment. The results also showed interactions between gender and experience operating farm equipment in terms of self-reported passing behavior. Conclusions/Implications: Results from this study suggest local and state-level norms and perceptions of those norms may be important targets for intervention to improve individual driving behaviors around farm equipment.

Trends in pediatric passenger restraint use by rurality and age in Iowa, 2006-2019.

OBJECTIVE: Pediatric restraint use has increased over time in the United States, but motor vehicle crashes remain a leading cause of death for children under age 18. Age-appropriate use of safety restraints (safety seats, booster seats, seat belt) and statewide child restraint laws can greatly reduce injury or death in the event of a crash. Surveillance of pediatric restraint use and compliance with policy can inform prevention efforts. This study aims to examine time trends in pediatric restraint use and compliance with pediatric passenger laws in Iowa by rurality and age. METHODS: Fourteen years of Iowa observational pediatric restraint use data (2006-2019) are included in this cross-sectional study. Proportions of restrained youth by year, age, and rurality (rural, urban) were calculated. Log-linear models were used to compute the Annual Percent Change (APC) by year to explore trends in restraint use over time by rurality and by age group. RESULTS: A total of 42,007 observed pediatric passengers with complete data from 2006 to 2019 were included in this study. Restraint use increased across all years and all age groups observed, with the largest increases among the older pediatric age groups. However, restraint use was consistently highest among the youngest child passengers. With all study years combined, the odds of being compliantly restrained were 13% lower in rural areas (OR = 0.87, 95% CI = 0.80, 0.95) compared to urban areas. CONCLUSIONS: Restraint use was lower in rural areas and among older pediatric passengers, suggesting targeted efforts to increase restraint use among these groups may have the greatest impact on overall occupant protection.

A Naturalistic Study Assessing the Impact of Daytime Running Lights and Vehicle Passing events on Cyclist's Physiological Stress.

Bicyclists are vulnerable road users who are at a greater risk for injury and fatality during crashes. Additionally, the "near-miss" incidents they experience during regular trips can increase the perceived risk and deter them from riding again. This paper aims to use naturalistic bicycling data collected in Johnson County, Iowa to: 1) study the effect of factors such as road surface type, parked vehicles, pavement markings and car passing events on cyclists' physiological stress and 2) understand the effect of daytime running lights (DRL) as an on-bicycle safety system in providing comfort to cyclists and highlight of their presence on the road to other vehicles. A total of 37 participants were recruited to complete trips over two weekends, one weekend with DRL and the other without DRL. Recruitment was specifically targeted toward cyclists who expressed discomfort riding in traffic. Data were collected using a front forward facing camera, GPS, and a vehicle lateral passing distance sensor mounted on the bicycle and a Empatica E4 wrist band (providing physiological data such as electrodermal activity; EDA) worn by the cyclist. Data from those sources were cleaned, processed, merged, and aggregated into time windows depicting car passing and no car passing events. Mixed effects models were used to study the cyclists' skin conductance response (phasic EDA) and baseline skin conductance level (tonic EDA). Car passing, parked vehicles, and roads with dashed centerline markings were observed to increase the cyclists stress. The use of DRL had negligible impact on cyclist stress on roads.

Farm vehicle crashes on public roads: Analysis of farm-level factors.

PURPOSE: Rural public roads experience higher crash fatality rates than other roadways, with agricultural equipment adding greater risk of injury and fatality. This study set out to describe farmers' experiences with farm equipment crashes and predictors of crashes at the farm level. METHODS: A survey of farm operators was conducted in 9 Midwestern states (IL, IA, KS, MN, MO, NE, ND, SD, and WI) in collaboration with the US Department of Agriculture's National Agricultural Statistical Service. FINDINGS: From 1,282 farms operating equipment on public roads in 2013, 7.6% of farmers reported that equipment from their farm had ever been in a crash (n = 97). Crashes occurred most often in June-August (44.0%) and were most often reported as being during the daytime (71.3%), on dry roads (79.4%), or in clear weather (71.4%). While most farmers responded that they were driving the farm equipment at the time of the crash (52.0%), nearly half of crashes involved their employees as the driver (48.0%). Crashes often went unreported to law enforcement (28.6%). CONCLUSION: To illustrate crash probabilities for farms with different profiles, we included farm acreage, crop farming, vehicle horsepower, annual miles driven, and the total number of farm vehicles driven on public roads in a predictive model. Large crop farms of 241+ acres, those who drove farm vehicles 1,430+ miles per year, and those with 20 or more farm vehicles had the highest probability of crash of 0.14.

Should we throw the book at 'em? Charge combinations and conviction rates among alcohol-influenced drivers involved in motorcycle crashes.

INTRODUCTION: Motorcycle fatality rates are increasing, and impaired driving is a major contributing factor. Impaired driving laws are a main component of state efforts to reduce drunk driving, but motorcycle crash charge and conviction outcomes have yet to be studied. The purpose of this study was to evaluate driver charge and conviction outcomes following alcohol-related motorcycle crashes. METHODS: Data for this study were drawn from Iowa crash, charge, and conviction data from 2011 to 2018. The study sample included 480 alcohol-influenced drivers (428 motorcyclists and 52 other vehicle drivers) involved in motorcycle crashes. Driver crash-related charges were categorized by type: Alcohol, Moving Violations, and Administrative/Miscellaneous. Factors associated with convictions were determined and estimated with multivariable logistic regression models. The main factor of interest was charge combination. RESULTS: Over three-quarters (78.5%) of the 480 alcohol-influenced drivers in crashes received any charge type and 68.1% received an alcohol-related charge. Among drivers with any charge, 88.6% were convicted, and among drivers with alcohol charges, 87.2% were convicted on an alcohol charge. After adjusting for BAC, drivers with a combination of Alcohol, Administrative, and Moving Violation charges had more than three times the odds of conviction of any charge compared to drivers with alcohol only charges (OR = 3.21, 95% CI = 1.00-10.26). However, charge combinations had little impact on alcohol-related convictions. CONCLUSIONS: Convictions were more likely when the impaired driver was charged with multiple types of offenses than with a single offense. An increased variety of charges was not associated with greater rates of conviction on alcohol-specific charges, which had high conviction rates overall. PRACTICAL APPLICATIONS: Law enforcement officers should be informed that lesser infractions impact driver conviction outcomes in alcohol-related crashes and procedures for issuing charges should be evaluated to assure equitable enforcement and to hold drivers accountable for unsafe driving behaviors.

Association between driver and child passenger restraint: Analysis of community-based observational survey data from 2005 to 2019.

INTRODUCTION: Crash data suggest an association between driver seatbelt use and child passenger restraint. However, community-based restraint use is largely unknown. We examined the association between driver seatbelt use and child restraint using data from a state-wide observational study. METHODS: Data from Iowa Child Passenger Restraint Survey, a representative state-wide survey of adult seat belt use and child passenger safety, were analyzed. A total of 44,996 child passengers age 0-17 years were observed from 2005 to 2019. Information about driver seatbelt use and child restraint was directly observed by surveyors and driver age was reported. Logistic regression was used to examine the association between driver seatbelt use and child restraint adjusting for vehicle type, community size, child seating position, child passenger age, and year. RESULTS: Over the 15-year study period, 4,114 (9.1%) drivers were unbelted, 3,692 (8.2%) children were completely unrestrained, and another 1,601 (3.6%) children were improperly restrained (analyzed as unrestrained). About half of unbelted drivers had their child passengers unrestrained (51.8%), while nearly all belted drivers had their child passengers properly restrained (92.3%). Compared with belted drivers, unbelted drivers had an 11-fold increased odds of driving an unrestrained child passenger (OR = 11.19, 95%CI = 10.36, 12.09). The association between driver seatbelt use and child restraint was much stronger among teenage drivers. Unbelted teenage drivers were 33-fold more likely (OR = 33.34, 95%CI = 21.11, 52.64) to have an unrestrained child passenger. CONCLUSION: These data suggest that efforts to increase driver seatbelt use may also have the added benefit of increasing child restraint use. Practical applications: Enforcement of child passenger laws and existing education programs for new drivers could be leveraged to increase awareness of the benefits of seatbelt use for both drivers themselves and their occupants. Interventions aimed at rural parents could emphasize the importance of child safety restraints.

Medical referral and license disposition for drivers in Iowa.

INTRODUCTION: Driver retirement and determination of fitness-to-drive are important aspects of reducing the risk of motor-vehicle collision for an older driver. A lack of information about the review process may lead to poor evaluation of drivers or an increased testing burden to referred drivers. METHODS: This paper evaluates the license review process for the state of Iowa. We evaluated data from January 2014 to January 2018 and described the source of referral, testing process, and ultimate license disposition. Cox proportional hazards for competing risk were used to determine the risk of having a change in restrictions on the license and the risk of license denial. RESULTS: 20,742 individuals were followed through the medical referral process. The most common source of referrals was licensing officials (39.7%). Drivers referred by licensing officials were less likely to be denied their license when compared to drivers from other sources (HR = 0.92 95%CI: 0.87-0.98); however, licensing official referrals were more likely to result in license restrictions compared to other sources (HR = 1.91, 95%CI: 1.82-2.00). Drivers referred by either law enforcement or a physician were more likely to ultimately have their license denied. CONCLUSIONS: Physician and law enforcement referred the drivers most likely to have their license denied. A smaller proportion of drivers were referred by physicians and law enforcement compared to licensing officials. Practical Applications: Licensing agencies should work with physicians and law enforcement to identify drivers who may need a review of their license. Comprehensive tracking of all medical referrals for a driver's license review is important for individual states to understand the burden of their driver referral process and for identifying referral sources with a high proportion of referrals with no licensing change for targeted outreach and education.

Community engagement in the development and implementation of a rural road safety campaign: Steps and lessons learned.

Introduction: Rural crashes result in fatality rates twice as high as urban, after accounting for vehicle miles traveled, and those involving farm vehicles tend to be the most severe. Farm vehicle crash interventions have focused on the farm equipment (e.g., lighting and marking) or the farm vehicle operator (e.g., training), despite crashes being most frequently caused by other vehicle driver actions. Community-based campaigns focused on rural drivers have potential to influence driver behavior. The objective of this study was to describe the role, formation, and lessons learned from a community advisory board (CAB) in the development and dissemination of a community-based rural roadway safety campaign. Methods: The CAB provided campaign input through quarterly meetings and email. The campaign had three main CAB and crash data-informed messages: 1) Slow Down, 2) Leave More Space, and 3) Avoid Passing. The CAB led campaign activities to publicize the message, distribute swag, and organize event logistics. To evaluate CAB effectiveness and inform future community engagement efforts, we conducted in-depth, semi-structured telephone interviews with CAB members in July 2020. Interviews were transcribed, coded, and codes were categorized into five main themes. Results: Overall, CAB membership was described as an overwhelmingly positive experience in terms of the CAB structure, culture fostered among the group, responsibilities, and time commitment. Board members reported successful campaign implementation, gave positive feedback regarding the research team's engagement efforts, and provided valuable recommendations for future campaigns (e.g., adding social media components, expansion of CAB age and industry diversity, and increasing group bonding activities). Conclusions: Results from this study demonstrate the instrumental role and logistics involved in engagement of community advisors for the development and implementation of a rural roadway safety campaign. Steps and lessons from this study can be applied to other community-level injury and violence prevention topics, with a particular focus on rural communities.