1. 3 rd Conference of the International Society for Child Indicators July 29, 2011 University of York Jim McDonell Tracy Waters Institute on Family and Neighborhood Life Clemson University Clemson, SC USA This research was sponsored in part by a grant from The Duke Endowment

2. Child injuries emerged as a relevant issue in the field of prevention and public policy in 1980s Advances in medicine led to fewer child deaths from disease (polio, measles, etc) Shift in thinking and terminology ◦ Accidents = random, caused by chance or fate, unpreventable ◦ Unintentional injuries = explicable and preventable

3. In the United States, unintentional injuries are the leading cause of child mortality and morbidity [Centers for Disease Control and Prevention (CDC), 2008] ◦ 12,000 child fatalities annually ◦ 9 million initial visits to the emergency department ◦ Fatal child injury rate: 15 per 100,000 ◦ Nonfatal child injury rate: 11,272 per 100,000

4. Falls are the leading cause of nonfatal childhood injury in the United States (CDC, 2008)  2.8 million children injured  Injury rate: 3,420 per 100,000 children Falls account for a large proportion of child injuries throughout the world:  United Kingdom, 40% (Haynes et al, 2003)  New Zealand, 40% (Kypri et al, 2001)  USA, 38% (CDC, 2007)

5. Transportation related injuries are the leading cause of unintentional child fatalities in the United States (CDC, 2008) ◦ Transportation-related death rate = 9.8 per 100,000  Motor vehicle crash (occupant) = 4.6 per 100,000  Pedestrian death rate = 1.2 per 100,000 Recent decline in child pedestrian injuries (Doukas et al., 2010)

6. Childhood injuries are related to a number of population and environmental factors (Freisthler et al., 2008) ◦ Number of female headed households ◦ Adult to child ratio ◦ Neighborhood disadvantage ◦ Residential instability ◦ Child care burden ◦ Social capital

7. As many child injuries occur in or near the home, the context of neighborhood has received increased attention ◦ 24% of child injuries occurred on the street ◦ 15% of child injuries occurred at a park, playground, or sports facility (Haynes et al., 2003) ◦ Schools and parks are the most common sites of child injuries leading to litigation (Frost, 1995)

8. During middle childhood (5 – 9 years of age), children are at increased risk of falls, especially falls at the playground (Kypri et al., 2001) Children have greater independent mobility starting between 7 – 9 years of age (Soori & Bhopal, 2001) But how do neighborhood physical and social characteristics contribute to these child injuries?

9. Neighborhood characteristics are also important for understanding motor vehicle and child pedestrian injuries ◦ Number of parked cars on the street ◦ Multi-family dwellings ◦ Number of pedestrians observed (Agran et al., 1996) On school days, 71% of child pedestrian injuries occur between 3 – 7 pm (Newbury et al., 2008)

10. Traffic calming techniques, such as speed humps, are effective in reducing child pedestrian injury (Tester et al., 2004) ◦ Children living on a street with a speed hump were significantly less likely to have a pedestrian injury ◦ Speed humps and other physical structures do not require policing and appear to be more effective than conventional deterrents Again, more research is needed on the influence of neighborhood characteristics on child injuries

11. This study attempts to fill a gap in the literature by exploring the relationship between both physical and social characteristics of neighborhoods and unintentional child injuries. After an overview of the methodology, this presentation will highlight the resulting path models and conclude with implications for research, policy, and practice.

12. The sample consisted of 244 neighborhoods in 132 census block groups. The neighborhoods were located in the Upstate and Midlands regions of South Carolina. Convenience sample of neighborhoods Neighborhoods were defined using GIS software. ◦ Aggregations of roads having an apparent geographic relationship ◦ Limited through road or arterial intersection ◦ Bounded by natural or constructed features ◦ Isolated from other road aggregations by distance

13. Illustration of sampled neighborhood

14. Three independent observations per neighborhood ◦ One weekday afternoon/evening observation ◦ One weekend day morning/early afternoon observation ◦ One “anytime” observation Observations completed during warm weather months by driving and/or walking through neighborhood

15. Neighborhood Observation Scale ConstructFactor# itemsAlpha Physical appearance Neighborhood physical appearance 7.94 School/park/public space physical appearance 5.89 Social appearance Neighborhood social appearance5.55 Indicated social engagement4.63 Observed social engagement3.56 Park/public space social engagement 3.63 SafetyResident watchfulness3.66 Neighborhood safety risk4.68 Initial results indicate acceptable reliability and validity (McDonell & Waters, 2010)

16. Items measured on 10 point Likert-type scale Example: Yards are poorly kept Yards are well kept 1 2 3 4 5 6 7 8 9 10 Poorly kept = Lawn overgrown; property is dirty and unkempt; does not appear that attention is given to upkeep Well kept = Clean; property apparently maintained; grass is cut; stairs/porch swept and clean.

17. Child injury rates were calculated using ICD-9 CM coded hospital inpatient and emergency room discharge diagnoses. Injury codes were provided by the South Carolina Office of Research and Statistics (ORS) at the census block group level. Injury codes corresponded to the same time period in which neighborhood observations occurred.

18. 21 categories of injuries were collapsed into 9 categories: ◦ Road vehicle injuries ◦ Other vehicle injuries ◦ Poisonings ◦ Falls ◦ Other accidents ◦ Medical intervention ◦ Suicide ◦ Homicide ◦ Other injuries

19. Child injury codes were calculated at rates per 1,000 children Rates were also calculated for children by gender and by age group

20. Path analysis models were created using AMOS 19.0 Measures of neighborhood physical and social characteristics were previously validated using confirmatory factor analysis. These 8 factors were treated as observed endogenous variables. Child injury rates were also treated as observed endogenous variables.

21. Goodness of fit indices utilized: ◦ Non-significant chi square ◦ Comparative Fit Index (CFI) > 0.9 ◦ Root Mean Square Error of Approximation (RMSEA) < 0.05 Initial models included all 8 neighborhood constructs. Theory and modification indices guided adjustments to models.

22. Neighborhood type69.3% residential only 16.8% predominately residential 6.1% commercial only 5.7%predominately commercial 2.0% mixed Housing type53.3%single family detached 16.4%duplex or row house 3.6%apartment/multiple occupancy 14.3%mobile homes 12.3%other

23. People in 11.9%none neighborhood56.6% fewer than 5 25.0% 5 to 12 6.6% more than 12 Age distribution11.3%under 12 8.2%13 to 17 12.0%18 to 24 37.5%25 to 44 20.7%45 to 64 8.7%65 and older Gender37.7%female 61.8%male

24. VariableMeanSD Rate of road vehicle injuries7.493.50 Rate of injuries due to falls11.015.04 Resident watchfulness.46.20 Neighborhood social appearance1.04.12 Observed resident engagement1.35.15 Condition of sidewalks6.901.04 Indicated resident engagement4.221.18 Neighborhood safety risk1.00.09 Park/Public space social appearance1.76.22

25. χ 2 (13) = 20.48, p =.08 CFI =.99 RMSEA =.049 The model explains 26% of the variance in child injuries from road vehicle accidents.48.16 -.29.48.18.32.25.00 Neighborhood watchfulness e1.39.75 e4 Condition of sidewalks.00.56 Neighborhood social appearance e2 Road vehicle injuries e8.15 Observed resident engagement e3.19 Indicated resident engagement e5 Park/public space social engagement e7.00.43 e6.00 -.24 -.17.02 -.22 -.12 -.10 Neighborhood safety

26. χ 2 (13) = 20.48, p =.08 CFI =.99 RMSEA =.049.48.16 -.29.48.18.32.25.00 Neighborhood watchfulness e1.39.75 e4 Condition of sidewalks.00.56 Neighborhood social appearance e2.26 Road vehicle injuries e8.15 Observed resident engagement e3.19 Indicated resident engagement e5 Park/public space social engagement e7.00.43 Neighborhood safety e6.00 -.17.02 -.12 Neighborhood social characteristics accounted for most of the explained variance Road vehicle injuries are lower in neighborhoods having a better social appearance and more resident social engagement.

27. χ 2 (13) = 20.48, p =.08 CFI =.99 RMSEA =.049.48.16 -.29.48.18.32.25.00 Neighborhood watchfulness e1.39.75 e4 Condition of sidewalks.00.56 Neighborhood social appearance e2.26 Road vehicle injuries e8.15 Observed resident engagement e3.19 Indicated resident engagement e5 Park/public space social engagement e7.00.43 Neighborhood safety e6.00 -.24 -.17 -.22 -.12 -.10 However, observed resident engagement had a marginal direct effect in the opposite direction

28. χ 2 (13) = 20.48, p =.08 CFI =.99 RMSEA =.049.48.16 -.29.48.18.32.25.00 Neighborhood watchfulness e1.39.75 e4 Condition of sidewalks.00.56 Neighborhood social appearance e2.26 Road vehicle injuries e8.15 Observed resident engagement e3.19 Indicated resident engagement e5 Park/public space social engagement e7.00.43 e6.00 -.24.02 -.22 -.12 -.10 Neighborhood safety The condition of sidewalks, a single item measure, was the only physical appearance factor having a significant effect Road vehicle injuries were lower when sidewalks were in better condition

29. χ 2 (13) = 20.48, p =.08 CFI =.99 RMSEA =.049.48.16 -.29.48.18.32.25.00 Neighborhood watchfulness e1.39.75 e4 Condition of sidewalks.00.56 Neighborhood social appearance e2.26 Road vehicle injuries e8.15 Observed resident engagement e3.19 Indicated resident engagement e5 Park/public space social engagement e7.00.43 Neighborhood safety e6.00 -.24 -.17.02 -.22 -.12 -.10 Of the two safety measures, neighborhood watchfulness had an indirect effect while neighborhood safety risk had both a direct and an indirect effect

30. Neighborhood safety χ 2 (13) = 20.48, p =.08 CFI =.99 RMSEA =.049.48.16 -.29.48.18.32.25.00 Neighborhood watchfulness e1.39.75 e4 Condition of sidewalks.00.56 Neighborhood social appearance e2.26 Road vehicle injuries e8.15 Observed resident engagement e3.19 Indicated resident engagement e5 Park/public space social engagement e7.00.43 e6.00 -.24 -.17.02 -.22 -.12 -.10 Road vehicle injuries are lower in neighborhoods with greater watchfulness and safety The total effect of watchfulness was -.17 while the total effect of safety was -.21

31. χ 2 (5) = 4.66, p =.46 CFI = 1.00 RMSEA =.000.37.73 Neighborhood social appearance e2.53 Observed resident engagement e3.14 Unintentional falls e6 Park/public space social engagement e5.00 Park/public space physical appearance e4.00 Neighborhood watchfulness e1 -.28.30.01 -.20.13 -.36.33.43 -.38 The model explains 34% of the variance in child injuries from unintentional falls

32. χ 2 (5) = 4.66, p =.46 CFI = 1.00 RMSEA =.000.37.73 Neighborhood social appearance e2.53 Observed resident engagement e3.14 Unintentional falls e6.34 Park/public space social engagement e5.00 Park/public space physical appearance e4.00 Neighborhood watchfulness e1 -.28.01 -.20.13 -.36.33.43 -.38 Interestingly, injuries due to unintentional falls increased when parks and public spaces had a more pleasing physical appearance This likely indicates higher use of parks and public spaces creating more opportunities for injuries from falls

33. χ 2 (5) = 4.66, p =.46 CFI = 1.00 RMSEA =.000.37.73 Neighborhood social appearance e2.53 Observed resident engagement e3.14 Unintentional falls e6.34 Park/public space social engagement e5.00 Park/public space physical appearance e4.00 Neighborhood watchfulness e1.30.13 -.36.33.43 -.38 Again, factors related to neighborhood social appearance account for most of the variance Observed resident engagement has a small direct effect on injuries due to falls.

34. χ 2 (5) = 4.66, p =.46 CFI = 1.00 RMSEA =.000.37.73 Neighborhood social appearance e2.53 Observed resident engagement e3.14 Unintentional falls e6.34 Park/public space social engagement e5.00 Park/public space physical appearance e4.00 Neighborhood watchfulness e1 -.28.30.01 -.20.13 -.36.33.43 -.38 Again, neighborhood watchfulness had an indirect effect on unintentional falls. The total effect of watchfulness was -.14 Injuries due to unintentional falls are lower in neighborhoods with higher levels of resident watchfulness

35. This research further demonstrates the importance of neighborhood context to children’s safety This suggests that environmental modification is key to improving child safety However, the typical approach to improving children’s safety is by modifying the physical neighborhood This study shows that attending to neighborhood physical features alone is not sufficient to improve children’s safety

36. Neighborhood characteristics, social characteristics in particular, are significant indicators of the risk of injuries to children  In socially cohesive settings, caregivers are more likely to watch over neighbor children, perhaps taking action to protect children from harm  In addition, social activity increases surveillance opportunities; residents are more likely to notice dangers  Too, when residents know and spend time with each other, they are more likely to talk about potential threats to children’s safety.

37. Strategies to increase social exchange among neighbors are likely to go a long way to improving children’s safety.  Such strategies as family activity groups, resident buying clubs, communal meals, and the like are low cost and easy to implement  A neighborhood watch group is a good way to foster resident engagement while simultaneously increasing watchfulness. Finally, more research is needed to better understand the effect of neighborhood social and physical characteristics across a broader range of child injuries.