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Pedestrian injury and the built environment : an environmental scan of hotspots Schuurman, Nadine; Cinnamon, Jonathan; Crooks, Valorie A., 1976-; Hameed, S Morad Jul 14, 2009

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ralssBioMed CentBMC Public HealthOpen AcceResearch articlePedestrian injury and the built environment: an environmental scan of hotspotsNadine Schuurman*1, Jonathan Cinnamon1, Valorie A Crooks1 and S Morad Hameed2Address: 1Department of Geography, Simon Fraser University, Burnaby, Canada and 2Department of Surgery, University of British Columbia, Vancouver, CanadaEmail: Nadine Schuurman* - nadine@sfu.ca; Jonathan Cinnamon - jca80@sfu.ca; Valorie A Crooks - crooks@sfu.ca; S Morad Hameed - morad.hameed@vch.ca* Corresponding author    AbstractBackground: Pedestrian injury frequently results in devastating and costly injuries and accountsfor 11% of all road user fatalities. In the United States in 2006 there were 4,784 fatalities and 61,000injuries from pedestrian injury, and in 2007 there were 4,654 fatalities and 70,000 injuries. InCanada, injury is the leading cause of death for those under 45 years of age and the fourth mostcommon cause of death for all ages Traumatic pedestrian injury results in nearly 4000hospitalizations in Canada annually. These injuries result from the interplay of modifiableenvironmental factors. The objective of this study was to determine links between the builtenvironment and pedestrian injury hotspots in Vancouver.Methods: Data were obtained from the Insurance Corporation of British Columbia (ICBC) forthe 6 year period from 2000 to 2005 and combined with pedestrian injury data extracted from theBritish Columbia Trauma Registry (BCTR) for the same period. High incident locations (hotspots)for pedestrian injury in the City of Vancouver were identified and mapped using geographicinformation systems (GIS), and the characteristics of the built environment at each of the hotspotlocations were examined by a team of researchers.Results: The analysis highlighted 32 pedestrian injury hotspot locations in Vancouver. 31 of 32hotspots were situated on major roads. Likewise, the majority of hotspots were located ondowntown streets. The 'downtown eastside' was identified as an area with multiple high-incidentlocations, including the 2 highest ranked pedestrian injury hotspots. Bars were present at 21 of thehotspot locations, with 11 of these locations being judged to have high alcohol establishmentdensity.Conclusion: This study highlighted the disproportionate burden of pedestrian injury centred onthe downtown eastside area of Vancouver. The environmental scan revealed that important passivepedestrian safety countermeasures were only present at a minority of high-incident locations. Moreimportantly, bars were highly associated with risk of pedestrian injury. This study is the basis forpotential public health intervention by clearly indicating optimal locations for signalized pedestrianPublished: 14 July 2009BMC Public Health 2009, 9:233 doi:10.1186/1471-2458-9-233Received: 12 January 2009Accepted: 14 July 2009This article is available from: http://www.biomedcentral.com/1471-2458/9/233© 2009 Schuurman et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 10(page number not for citation purposes)crosswalks.BMC Public Health 2009, 9:233 http://www.biomedcentral.com/1471-2458/9/233BackgroundThe World Health Organization [1] estimates that morethan five million people around the world die annually asa result of injury. Half-a-million are in high-income coun-tries alone, where they account for 6% of all deaths. Inhigh-income countries, road traffic injuries (includingpedestrian trauma), self-inflicted injuries and interper-sonal violence are the three leading causes of deathamong people aged 15–29 years [2]. In Canada, injury isthe leading cause of death for those under 45 years of ageand the fourth most common cause of death for all ages.Collisions between motor-vehicles and pedestrians claimhundreds of lives and injure tens of thousands annually[3]. Traumatic pedestrian injury, in particular, results inaround 4000 hospitalizations in Canada each year [4].These injuries often result from the interplay of modifia-ble or preventable environmental factors [5]. Addressingthe environmental factors related to pedestrian injury thusrepresents an important public health opportunity.Active interventions to reduce the toll of pedestrian injurycentre on educating drivers and pedestrians in road safetyand enforcement of traffic safety laws, while passive inter-ventions largely involve modifications to the built-envi-ronment [6,7]. Designing pedestrian-friendly roadwayshas the potential to reduce pedestrian injury [7,8]; how-ever the movement of motorized vehicles remains the pri-mary design objective for road engineers, while pedestriansafety is often an afterthought [9,10]. Research has linkedaspects of the built environment, roadway infrastructure,and types of land-use to an increase or decrease in the riskof pedestrian injury. For example, roadway design factorsincluding curb parking, long blocks, and the absence ofmarked and signalized crosswalks are associated with anincrease in the risk of collisions between pedestrians andvehicles. Certain types of land uses have been linked withincreases in pedestrian injury incidence, in particularschools and alcohol serving establishments [11-22].Lower vehicle speeds, exclusive turn phasing at intersec-tions, and medians have been shown to reduce pedes-trian-vehicle encounters [8]. These and otherenvironmental countermeasures are highly-effective, low-cost solutions that can be implemented at high-risk sitesto help reduce the burden of pedestrian injury [23].Geographic Information Systems (GIS) are a valuable toolfor epidemiological research [24]. A handful of pedestrianinjury studies have used GIS to analyze incident locations;however, few of these studies include a comprehensiveanalysis of the environmental factors that may be contrib-uting to the risk of pedestrian injury [25-27]. The goals ofthis study were (i) to use GIS to determine pedestrianinjury hotspot locations in the City of Vancouver and (ii)that should be targeted for safety interventions, and maybe useful for directing strategies to implement environ-mental countermeasures. In addition, this study intro-duces an innovative methodological advancement inusing GIS-based hot spot analysis in combination with adetailed environmental scan.MethodsIn this study, high incident locations (hotspots) for pedes-trian injury in the City of Vancouver were identified usingGIS, and the characteristics of the built environment ateach of the hotspot locations were examined. Two pedes-trian injury data sources were combined for the analysis:The Insurance Corporation of British Columbia's (ICBC)pedestrian-vehicle collision data for the 6 year periodfrom 2000 to 2005 inclusive, and the British ColumbiaTrauma Registry's (BCTR) pedestrian injury records for the6 year period 2001 to 2006 inclusive. The ICBC sourcerecords all reported incidents, while the BCTR sourcerecords all incidents that resulted in a hospital stay of twodays or more. Combined, and with duplicate recordsremoved, data from the two sources can be consideredrepresentative of the majority of injuries from pedestrian-vehicle collisions over a given 6 year period. It should benoted that each record involved one person. If a road traf-fic collision involved two people, then there would be twoincidents for that particular hotspot. For the purposes ofthis study, hotspots were determined to be locationswhere a minimum of 5 incidents were recorded in bothdatasets combined. Hotspots were then ranked accordingto the number of incidents recorded over the 6 yearperiod. More severe incidents were ranked equally with"near misses" recorded as minor injuries. The rationale forthis is that these minor incidents were as potentiallylethal.Incident locations were mapped using ArcGIS 9.2, [28]georeferenced to either an intersection or midblock loca-tion. The ICBC data were mapped according to latitudeand longitude coordinates provided in the dataset foreach incident location. The BCTR data were geocodedbased on the street address or intersection where the inci-dent occurred which was available in the dataset. The fre-quency of non-mappable records was negligible, and alldata were assumed to be accurate and complete. A kerneldensity map was created to allow for a simple visual exam-ination of incident locations and precise identification ofall hotspots. A kernel search distance of 100 m was used,as it proved to be the most appropriate distance for high-lighting unique incident locations. Elements of the built-environment and roadway design were recorded at each ofthe hotspot locations to examine their potential contribu-tion to pedestrian injury. A team of 4 researchers inde-Page 2 of 10(page number not for citation purposes)to determine key characteristics of the built-environmentthat may contribute to increased risk of pedestrian injury.Results of this study highlight important areas of the citypendently surveyed each hotspot to assess 14 pre-determined built-environment characteristics, andrecorded any other particularities observed at each loca-BMC Public Health 2009, 9:233 http://www.biomedcentral.com/1471-2458/9/233tion (e.g., changes in roadway slope). Prior to the obser-vational period the investigators met to discuss how eachvariable should be interpreted in order to enhance theconsistency of recorded data. The four investigators inde-pendently completed their observations at each intersec-tion on a standard recording sheet and then immediatelymet to compare notes and resolve any disagreements ordifferences in interpretation. Overall there was very littledisagreement in the data recorded on the standard sheetacross investigators and any that did occur was easilyresolved through discussion at the intersection. Finally, allinvestigators reviewed and agreed with the data shared inthe summative table produced (see Table 1).The environmental scan was conducted between 10 amand 3 pm to avoid encountering high traffic volume andassociated congestion. Factors that have been shown toincrease risk that were included in the assessment werelong blocks, presence of bus stops, curb parking, absenceof controlled crosswalks, and visual obstructions. Protec-tive factors assessed were the presence of traffic calmingmeasures, medians or pedestrian refuge islands, andexclusive turn signals at intersections. Factors that contrib-ute to location complexity were the number of signs,number of approach lanes, and whether a vehicle turningban was in effect. Also recorded were the densities of bars,retail establishments, and schools in proximity to thehotspot locations. Privacy was protected both use of thekernel density method and by the clustering of incidentsinto hotspots of greater than 5 collisions.Ethics approval for this study was granted from the Officeof Research Services at Simon Fraser University (file#37437).ResultsA total of 2358 pedestrian-vehicle collisions wererecorded within the City of Vancouver over the 6 yearperiod, for an average annual pedestrian injury incidencerate of 66.6/100,000 residents. Intersections – rather thanmidblock locations – accounted for 61% of all incidents.Our analysis highlighted 32 pedestrian injury hotspotlocations in the City of Vancouver for this time period.Figure 1 shows the intersections and midblock locationswhere pedestrian injuries were recorded and illuminatesthe high density locations. The darkest shades indicate thehigher density hotspots. Of the 32 hotspots, 21 (66%)were at intersections while 11 were at midblock locations.Thirty-one of 32 hotspots were situated on either majorcollector or major arterial roads, with just one at a mid-block location of a minor traffic-restricted street. Overall,most hotspots were located on downtown streets. Thedowntown eastside (DTES) area was particularly high-Also of interest is the east-west Broadway corridor – aretail intensive commercial stretch.Results of the hotspot environmental scan are shown inTable 1. The results of primary interest are highlighted inthe table, indicating the presence of demonstrated risk fac-tors for pedestrian injury, or lack of pedestrian safetycountermeasures in place at the location. For a majority ofmidblock and intersection hotspots, long blocks, busstops, and curb parking were recorded. Only 1 of the 11midblock locations had a marked and signalized pedes-trian crosswalk. Regarding visual obstructions, a minorityof locations had advertising or flora which was deemed tobe intrusive. Complex signage was observed at just 3hotspots. The number of approach lanes varied from 2 to6 for midblock locations with 6 being the most common,and from 6 to 14 for intersections, with 12 the most com-mon. Just 4 of 21 intersections had a turning banimposed. Almost all (26) locations had retail establish-ments nearby, with 9 considered to be in high retail den-sity areas. Only 2 locations were situated near schools,and only 1 had traffic-calming measures in place. Nine of32 hotspots had medians or traffic refuge islands, and 12of 21 intersections had exclusive turning signals. Bars werepresent at 21 of the hotspot locations, with 11 of theselocations judged to have high alcohol serving establish-ment density.DiscussionThe mapping of Vancouver's pedestrian injury hotspotsrevealed an intriguing spatial pattern. As may be expected,there were more high-incident locations in downtownareas compared with outer areas of the city; however, thedisproportionate number of hotspots in a small area ofthe DTES is conspicuous. Nine of 32 hotspots, and fully10 per cent of total pedestrian injuries in Vancouver, wererecorded within this small part of the downtown core.This area is notorious as the epicentre of homelessness inVancouver in which large numbers of homeless and othermarginalized individuals congregate along Hastings andadjacent streets. It is also where a large number of servicesaimed at homeless, drug addicted, and/or mentally ill per-sons are located. It is also likely that the number of alco-hol-serving retail establishments within the DTES was astrong factor with respect to the number of hotspots in thearea. This is consistent with the existing literature [11-18].The authors hypothesize that a combination of mental ill-ness, despondency associated with homelessness andhigh alcohol and substance abuse contributed to the con-centration of pedestrian injury in the DTES.The scan of roadway infrastructure and built-environmentcharacteristics at pedestrian injury hotspots in VancouverPage 3 of 10(page number not for citation purposes)lighted as an area with multiple high-incident locations,including the 2 highest ranked pedestrian injury hotspots.produced two findings of interest. The most striking find-ing was the frequent presence of demonstrated environ-BMC Public Health 2009, 9:233http://www.biomedcentral.com/1471-2458/9/233Page 4 of 10(page number not for citation purposes)Table 1: ReLOCATIO Land Use Safety MeasuresMIDBLOC R ban bars retail school calming median excl. turnE Hastings bColumbia &N/A H M N N N N/AE Hastings bJackson & DN/A M M N N N N/AE Hastings bMain & GorN/A H M N N N N/ABurrard btwNelson & CN/A N L N N N N/AE Hastings bKamloops &PentictonN/A N H N N N N/AGranville btGeorgia & DunsmuirN/A L H N Y N N/AE Hastings bHeatley & HN/A M M N N N N/AGranville btNelson & HelmckenN/A H H N N N N/AMain btw N& TerminalN/A H L N N Y N/AW Georgia Howe & GrN/A N N N N N N/AW Hastings Carrall & AbN/A H M N N N N/Asults of the hotspot environmental scanN Incidents Contribute to Risk ComplexityK total rank long blockbus stopcurb parkX walk obstruction sign- age # lanes L/tw  Main49 1 Y Y Y N N L 6tw unlevy10 5 Y Y Y N Y-AD L 6tw e9 6 Y Y Y N Y-FL L 6 omox8 7 Y Y Y N N L 6tw  8 7 Y N Y N N L 6w 8 7 Y Y N N Y-FL L 2tw awks7 8 Y N Y N N L 6w 7 8 N Y Y N N L 4ational 6 9 N Y N N N L 7btw anville5 10 N Y Y* N Y-FL L 6btw bott5 10 N N Y Y N L 5BMC Public Health 2009, 9:233http://www.biomedcentral.com/1471-2458/9/233Page 5 of 10(page number not for citation purposes)INTE H H M N N N YE BComN H N N Y YE BFrasN L N N Y YW GBurN H N N N NW HCarH M N N N NE HComN N N N Y YE H H M N N N NE 49 N M N N N NHow M L N N N NComAveM H N N N YE 41 N M Y N Y YW BMacM H N N N NE HRenN N N N N YMai L L N N Y YThu H H N N N NW HAbbH M N N N NClaBroN N Y N Y YE H L N N N Y YKinBroL H N N Y YBur H M N N N NW GHowL L N N N Ybtw  low, Y = yes, N = no.TabERSECTIONastings & Main 18 2 Y Y-A Y Y Y-FL L 12 Nroadway & mercial12 3 Y Y-B&A Y Y N M 10 Yroadway & er12 3 Y Y-A N Y N M 10 Neorgia & rard12 3 Y Y-A N Y N M 12 Yastings & rall12 3 Y Y-A Y Y Y-FL L 9 Nastings & mercial11 4 Y Y-B&A Y Y N M 13 Nastings & Gore 10 5 Y Y-B&A Y Y N L 9 Nth & Victoria 9 6 Y Y-B&A N Y N L 8 Ne & Davie 9 6 N Y-A Y Y N H 8 Nmercial & 1st 8 7 N Y-A Y Y N L 13 Nst & Fraser 8 7 Y Y-B&A Y Y N M 14 Nroadway & donald8 7 N Y-B&A Y Y Y-FL M 11 Nastings & frew7 8 Y Y-B&A N Y Y-AD H 12 Nn & Terminal 7 8 Y Y-B&A N Y N L 16 Nrlow & Davie 7 8 N Y-A Y Y N L 6 Nastings & ott7 8 Y Y-B Y Y Y-FL, AD L 9 Nrk & E adway6 9 Y Y-A N Y N L 13 Nastings & Clark 6 9 Y Y-A Y Y N L 12 Ngsway & E adway6 9 Y Y-B&A Y Y N H 11 Yrard & Davie 5 10 Y Y-B&A Y Y Y-FL M 10 Yeorgia & e5 10 N N Y* Y Y-FL M 10 N = between, B = before, A = after, FL = flora, AD = advertising, N/A = not applicable, * = illegal, H = high, M = medium, L =le 1: Results of the hotspot environmental scan (Continued)BMC Public Health 2009, 9:233 http://www.biomedcentral.com/1471-2458/9/233mental risk factors, coupled with a scarcity of traffic-calming and passive pedestrian safety countermeasures atmany of the high-incident locations. A second importantfinding from the environmental scan was that bars wereclosely situated to many of the hotspots.The Absence of Pedestrian Safety CountermeasuresRoad safety research has highlighted the influential rolesthat road infrastructure and the local environment at col-lision sites contribute to the occurrence of pedestrianinjury [29]. Passive safety measures including the devel-opment of safe road infrastructure have been successful inreducing the burden of pedestrian injury [30]. Road-divid-ing medians were absent from a majority of high-incidentlocations, despite nearly all of the hotspots occurring onstreets and a slight reduction in vehicle speeds [31].Implementation of medians or refuge islands is likely pos-sible at many of the hotspot locations in which they areabsent. The highest-ranked intersection location at Hast-ings and Main Streets (Figure 2) is a good candidate forinstallation of a roadway-dividing median which willallow for a two stage crossing if needed, and will likelyreduce vehicle speeds in this pedestrian-congested area.Another roadway modification designed with the pedes-trian in mind (and endorsed by the City of Vancouver) iscorner sidewalk bulges to reduce crossing times for pedes-trians [32]. Figure 3 shows a location with a corner bulgein place. Medians and bulges at this hotspot location mayrequire lane narrowing, or a possible lane removal whichmay result in reduced vehicle flow on this thoroughfare;The intersections and midblock locations where pedestrian injuries were recorded, illuminating the high density locationsFigure 1The intersections and midblock locations where pedestrian injuries were recorded, illuminating the high den-sity locations.Page 6 of 10(page number not for citation purposes)major arterial and collector roads. It has been shown thatmedians or pedestrian refuge islands can reduce pedes-trian injury as they promote a two-stage crossing on busyhowever, the potential to increase pedestrian safety at thishigh-incident location should be paramount.BMC Public Health 2009, 9:233 http://www.biomedcentral.com/1471-2458/9/233The absence of marked and signalized pedestrian cross-ings at all but one midblock location is of particular con-cern. Well-marked crosswalks with a pedestrian-controlled signal can reduce pedestrian-vehicle conflicts[33]. Another option that has been shown to be effectiveat midblock locations are non-signalized crosswalks within-pavement lights that flash when a pedestrian is present[34]. These were not present at any of our hotspot loca-tions. The midblock location on Hastings St. betweenColumbia and Main was by far the highest ranked inci-dent location (Figure 4). This is one of the main areas ofthe DTES where large groups of homeless people congre-gate, and is also the precise location of Insite, the govern-ment-sponsored controlled safe drug injection facility.These are likely factors in the disproportionately largenumber of pedestrian-vehicle collisions at this location;however, no crosswalk, traffic-calming measures, orpedestrian safety interventions are in place at this mid-block location. The City of Vancouver has committed toproviding midblock crossings on downtown streets near"significant pedestrian generators that create highdemands for pedestrian crossing at mid-block" [32]. Fig-ure 5 shows a signalized crosswalk and median at a mid-block location on Expo/Pacific Blvd. This type of roadwaydesign/traffic calming measure could potentially improvepedestrian safety at this very high-incident location onHastings St. Indeed, this study is the basis for concertedand directed intervention on the part of public safety offi-cials. Moreover, it provides a protocol for determiningand studying hotspot locations in other cities.The Presence of Bars and Alcohol Serving EstablishmentsAlcohol consumption by pedestrians is a recognized fac-tor influencing their risk of collision with a vehicle; how-ever it is often overlooked as an issue in comparison withalcohol consumption by drivers. Recent consumption ofalcohol is common in injured pedestrians, and it has beenshown that the severity of injuries is frequently greater forthis group [35]. The high incidence of injury in alcohol-affected pedestrians may in part be due to the effects ofalcohol on the pedestrian's ability to judge gaps in thetraffic for safe road-crossing [36]. Pedestrian injuryhotspot locations are often in areas with a high density ofbars and other alcohol serving establishments. In a spatialanalysis of pedestrian injury in San Francisco, LaScala etal. [37] discovered that pedestrian injury was highest inareas with the greatest density of alcohol serving establish-ments, for incidents where the pedestrian had been con-suming alcohol. The results of the present study indicatethat bars were located immediately proximal to two-thirdsof the hotspots, with almost one-third located in highdensity bar and alcohol serving establishment areas. Sincepedestrian injury patients' alcohol levels are not consist-ently included in the BCTR, we were unable to gaugeIntersection at Hastings and Main StreetsFigur  2Intersection at Hastings and Main Streets.A location with a corner bulge in placeFigure 3The midblock location on Hastings St. between Columbia and MainFigure 4The midblock location on Hastings St. between Page 7 of 10(page number not for citation purposes)A location with a corner bulge in place. Columbia and Main.BMC Public Health 2009, 9:233 http://www.biomedcentral.com/1471-2458/9/233whether alcohol was a definitive explanation for the cor-relation between bars and injuries. However, there isample reason to suspect that this is the case and policyshould proceed accordingly.Active interventions such as educating the customer andservice establishment in safe drinking guidelines havebeen used to varying success [14]; however, more effectivecountermeasures may involve modifying the roadwayenvironment or calming traffic to increase the safety ofalcohol-affected pedestrians. Results of a study by Lenné etal. [38] suggest that modifying traffic signals at high-risktimes (late evening and early morning) could help reduceinjury in this group. Specifically, if traffic signals in areasof high alcohol establishment density were set to 'dwell-on-red' in all directions when no vehicles were present,then the average speed of vehicles would drop, thus creat-ing a safer pedestrian environment. An Australian studyproposed that environmental countermeasures such asenhanced street lighting, medians, skid-resistant surfaces,and highly responsive pedestrian operated signals shouldbe implemented in areas with high alcohol-related pedes-trian-vehicle collisions [39].Our findings did not implicate schools as a type of landuse associated with Vancouver's pedestrian injuryhotspots, despite the various other studies that havedescribed the risk of pedestrian injury to children at ornear schools as an important public health problem[21,40]. Road safety engineering is common in Vancouveron streets surrounding schools; particularly traffic-calm-ing measures such as speed humps, road narrowing, andreduced speed limits designed to prevent pedestrian inju-ries among school children. These passive interventionsin sensitive areas [41]. Traffic-calming and environmentalcountermeasures should also be aggressively pursued inother parts of the city, especially in areas of elevatedpedestrian use such as Vancouver's DTES and streets witha high density of alcohol serving establishments. There arefewer options available to calm traffic and improve pedes-trian safety on arterial roads; however reducing the widthof vehicle lanes can reduce the overall speed of vehicles onbusy thoroughfares [42]. Also, a simple reduction ofspeed limits in high-risk areas is likely to be effective.Measures such as this, coupled with engineering modifica-tions including medians or refuge islands, corner bulges,and controlled midblock crosswalks could be imple-mented with probable benefits for pedestrian safety.LimitationsThis study has several limitations. The socio-demographiccharacteristics of the location of injury (average income,age of the population), and of the injured pedestrian (age,income, etc.) were not addressed. We focused on the con-tribution of the built-environment to pedestrian injurybecause much less is known about the relationshipbetween roadway design and land-use type with pedes-trian injury, compared with its social correlates. Also, it ispossible that aspects of the built-environment not consid-ered (or overlooked) in our analysis may be associatedwith pedestrian injury at these hotspot sites. For instance,we did not examine land use in detail nor did we accountfor weather or traffic volumes. Another limitation may bethat the characteristics of a whole area could potentiallyhave a greater effect on pedestrian injury than those ofindividual incident locations. For example, there is likelyan area effect behind the clustering of multiple high-inci-dent locations in the DTES. Also, while our designation ofa pedestrian injury hotspot as a location with 5 or moreincidents over the time period was done in order to setparameters on the scope of the analysis, there are nofirmly established precedents in the literature regardinghotspot determination.Another potential limitation of this research is the reli-ance on raw numbers of incidents rather than using adenominator population. We did this for several reasons.First, many of the incidents occurred in high traffic areasthat were not particularly high population density regions(e.g. the DTES). Thus residential population densitywould not be a good indicator of pedestrian or road traf-fic. Second, many of the incident locations were not coin-cident with the home residence of the victims. Third, ourchief focus was the examination of urban design that facil-itates greater rates of injury.ConclusionA signalized crosswalk and median at a midblock location on Expo/Pacific BlvdFigure 5A signalized crosswalk and median at a midblock location on Expo/Pacific Blvd.Page 8 of 10(page number not for citation purposes)can reduce the toll of paediatric pedestrian injury nearschools through a reduction of speed and traffic volumesThis study highlighted the disproportionate burden ofpedestrian injury centred on the DTES area of VancouverBMC Public Health 2009, 9:233 http://www.biomedcentral.com/1471-2458/9/233through undertaking a spatial analysis of pedestrianinjury and subsequent environmental scan of hotspots.The environmental scan revealed that some importantpassive pedestrian safety countermeasures were onlypresent at a minority of high-incident locations. Our find-ings support those of other studies which associate den-sity of bars with pedestrian injury; however, there was nosuch association with schools. These results provide afoundation for extending pedestrian injury research aswell as instituting passive intervention efforts. Futurestudies should analyze the effectiveness of built-environ-ment modifications on reducing rates of pedestrian injuryin areas such as those highlighted in this study.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsNS conceptualized and designed the study, participated inthe environmental scan as well as in writing the paper. JCconducted the spatial analysis, participated in the envi-ronmental scan and contributed substantially to writingthe paper. VC participated in the environmental scan andin writing the paper. 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