Trends in Elective Deliveries in California and New Jersey.

Introduction: Cesarean section deliveries in the U.S. increased from 5% of births in 1970 to 32% in 2020. Little is known about trends in cesarean sections and inductions in low-risk pregnancies (i.e., those for which interventions would not be medically necessary). This study addresses the following questions: (1) what is the prevalence of elective deliveries at the population level?, (2) how has that changed over time?, and (3) to what extent do the rates of elective deliveries vary across the population? Methods: We first documented long-term trends in cesarean sections in the U.S., California, and New Jersey. We then used linked birth and hospital discharge records and an algorithm based on Joint Commission guidelines to identify low-risk pregnancies and document trends in cesarean sections and inductions in low-risk pregnancies in California and New Jersey over a recent 2-decade period, overall and by maternal characteristics and gestational age. Results: In low-risk pregnancies in California and New Jersey, rates of cesarean sections and inductions increased sharply from the early 1990s through the mid-2000s, peaked at 33% in California and 41% in New Jersey in 2007, and then declined somewhat, and the proportions of inductions that were followed by cesarean sections increased from fewer than 1 in 5 to about 1 in 4. More education, non-Hispanic White race/ethnicity, U.S.-born status, and non-Medicaid were associated with higher rates of interventions. Trends were similar across all socioeconomic groups, but differences have been narrowing in California. Among early-term (gestational age of 37-38 weeks) births in low-risk pregnancies, the rates of elective deliveries increased substantially in both states until the mid/late-2000s, peaked at about 35% in California and over 40% in New Jersey, and then decreased in both states to about 20%. Conclusions: Given established health risks of nonmedically necessary cesarean sections, that a nontrivial share of induced deliveries in low-risk pregnancies result in cesarean sections, and that interventions in low-risk pregnancies have not substantially declined since their peak in the mid-2000s, the trends documented in this paper suggest that sustained, even increased, public health attention is needed to address the still-too-high rates of cesarean sections and inductions in the U.S.

Municipal social expenditures and maternal health disparities: a study of linked birth and hospitalisation records.

BACKGROUND: Local government expenditures provide services and benefits that can affect health but the extent to which they are associated with narrowing or widening of racial/ethnic and socioeconomic disparities in health is unknown. We examined race/ethnicity-stratified and education-stratified associations between municipal social expenditures-those on housing, transportation, education, and other society-wide needs-and serious life-threatening maternal health conditions in a large US state. METHODS: In this cross-sectional study, we used individual birth records for 1 003 974 births in the state of New Jersey from 1 January 2008 to 31 December 2018 linked to individual maternal hospital discharge records and municipality-level characteristics for 564 municipalities. Severe maternal morbidity (SMM) was identified in the discharge records using a measure developed by the US Centers for Disease Control and Prevention. Associations between municipal-level social expenditures per capita and SMM were estimated using multilevel logistic models. RESULTS: Residing in a municipality with higher social expenditures was associated with lower odds of SMM across all racial/ethnic groups and education levels. Overall, 1% higher annual social expenditures per capita was associated with 0.21% (95% CI -0.29 to -0.13) lower odds of SMM. The associations were greater for individuals with less than a high school education than for those in the other educational groups in both relative (lnOR -0.53; 95% CI -0.74 to -0.31) and absolute (ß -0.013; 95% CI -0.019 to -0.008) terms. CONCLUSION: Municipal-level spending on social services is associated with narrowing socioeconomic disparities in SMM. Narrowing racial/ethnic disparities in maternal health will likely require intervening beyond the provision of services to addressing historical and ongoing structural factors.

Racialized police use of force and birth outcomes.

OBJECTIVE: To estimate associations between police use of force (PUOF) in local jurisdictions and birth outcomes of Black women compared to White women. METHODS: Using birth records linked to municipal police department data on PUOF incidents, we estimated associations between overall and racialized PUOF and birth outcomes of 75,461 Black women and 278,372 White women across 430 municipalities in New Jersey (2012-2016). RESULTS: Overall PUOF was not associated with birth outcomes of Black or White women. A 1% increase in racialized PUOF was associated with a 0.06% increase in the odds of low birth weight (ß: 0.06; 95% CI: 0.03-0.09) and preterm birth (ß: 0.06; 95% CI: 0.03-0.10) among Black women but had no associations with birth outcomes of White women. CONCLUSIONS: Lack of associations between overall PUOF and birth outcomes coupled with significant associations between racialized PUOF and birth outcomes, among Black women only, is consistent with mounting evidence that structural racism adversely affects the health of Black people in the U.S. POLICY IMPLICATIONS: The findings point to the need to address health inequalities at the structural level.

Communication with Kin in the Wake of the COVID-19 Pandemic.

This study investigates patterns of communication among non-coresident kin in the aftermath of the COVID-19 pandemic using data from the New York City Robin Hood Poverty Tracker. Over half of New Yorkers spoke to their non-coresident family members several times a week during the pandemic and nearly half increased their communication with non-coresident kin since March 2020. Siblings and extended kin proved to be especially important ties activated during the pandemic. New Yorkers were most likely to report increased communication with siblings. A quarter of respondents reported that they increased communication with at least one aunt, uncle, cousin, or other extended family member. While non-Hispanic White respondents reported the highest frequency of communication with kin, it was those groups most impacted by COVID-19 - foreign-born, Black, and Hispanic New Yorkers - who were most likely to report that they increased communication with kin in the wake of the pandemic.

Association Between Housing Affordability and Severe Maternal Morbidity.

Importance: The number of people living in unaffordable housing (relative to income) is projected to continue increasing as housing cost inflation outpaces incomes in the US. Although reproductive-aged women have disproportionately high housing costs, particularly around the time of childbirth, data on associations between housing costs and maternal health and the role of publicly supported affordable housing programs in mitigating those associations are lacking. Objective: To estimate associations between area-level rental housing costs and severe maternal morbidity (SMM) and assess the potential mitigating role of publicly supported affordable housing. Design, Setting, and Participants: This cross-sectional study linked New Jersey birth files from January 1, 2008, to December 31, 2018, to maternal hospital discharge records and municipal-level housing and demographic data from the state of New Jersey and the US Census Bureau. Data were analyzed from January to September 2022. The birth files contained records for all births in New Jersey, and the hospital discharge records contained information from all inpatient hospitalizations over the study period. A total of 1 004 000 birth records were matched to maternal discharge records and municipal-level data. Exposures: Municipal-level rental costs relative to income (housing cost burden), availability of publicly supported affordable housing, and housing subsidy per person with an income lower than the federal poverty level. Main Outcomes and Measures: Severe maternal morbidity was identified using diagnosis and procedure codes developed by the US Centers for Disease Control and Prevention to measure SMM. Results: Of 1 004 000 mothers (mean [SD] age at birth, 29.8 [5.9] years; 44.7% White), 20 022 (2.0%) experienced SMM. Higher municipal rental housing costs were associated with greater odds of SMM (odds ratio [OR], 1.27; 95% CI, 1.01-1.60), particularly among mothers with less than a high school education (OR, 1.81; 95% CI, 1.06-3.10), and the positive associations decreased at higher levels of affordable housing availability. Among mothers with less than a high school education, the risk of SMM was 8.0% lower (risk ratio, 0.92; 95% CI, 0.85-1.00) for each additional $1000 annual municipal-level housing subsidy per person with an income lower than poverty level after controlling for rental costs and other characteristics, which translated to a 20.7% lower educational disparity in SMM. Conclusions and Relevance: In this cross-sectional study, living in a municipality with higher rental housing costs was associated with higher odds of SMM, except when there was high availability of publicly supported affordable housing. These results suggest that greater availability of publicly supported affordable housing has the potential to mitigate the association between rental housing costs and SMM and reduce socioeconomic disparities in SMM.

Elective Deliveries and the Risk of Autism.

INTRODUCTION: Cesarean section and induced deliveries have increased substantially in the U.S., coinciding with increases in autism spectrum disorder. Studies have documented associations between cesarean section deliveries and autism spectrum disorder but have not comprehensively accounted for medical risks. This study evaluates the extent to which cesarean section and induced deliveries are associated with autism spectrum disorder in low-risk births. METHODS: In this retrospective cohort study, California's birth records (1992-2012) were linked to hospital discharge records to identify low-risk births using a stringent algorithm based on Joint Commission guidelines. Autism spectrum disorder status was based on California Department of Developmental Service data. Logistic regression models were used to estimate associations between autism spectrum disorder and induced vaginal deliveries, cesarean section deliveries not following induction, and cesarean section deliveries following induction, with noninduced vaginal deliveries as the reference category. RESULTS: A total of 1,488,425 low-risk births took place in California from 1992 to 2012. The adjusted odds of autism spectrum disorder were 7% higher for induced vaginal deliveries (AOR=1.07, 95% CI=1.01, 1.14), 26% higher for cesarean section deliveries not following induction (AOR=1.26, 95% CI=1.19, 1.33), and 31% higher for cesarean section deliveries following induction (AOR=1.31, 95% CI=1.18, 1.45) than for noninduced vaginal deliveries. Lower gestational age and neonatal morbidities did not appear to be important underlying pathways. The associations were insensitive to alternative model specifications and across subpopulations. These results suggest that, in low-risk pregnancies, up to 10% of autism spectrum disorder cases are potentially preventable by avoiding cesarean section deliveries. CONCLUSIONS: After accounting for medical risks, elective deliveries-particularly cesarean section deliveries-were associated with a substantially increased risk of autism spectrum disorder.

Generational Shifts in Young Adult Cardiovascular Health? Millennials and Generation X in the United States and England.

OBJECTIVES: To compare cardiovascular (CV) risks/conditions of Millennials (born 1981-1996) to those of Generation X (Gen X; born 1965-1980) at ages 20-34 years, across 2 countries (United States, England), by gender. METHODS: Using data from the National Health and Nutrition Examination Survey (United States) and Health Survey for England, we estimated weighted unadjusted and adjusted gender-specific proportions of CV risk factors/conditions, separately for Millennials and Generation X in each country. We also further calculated sex-specific generational differences in CV risk factor/conditions by income tercile and for individuals with normal body weight. RESULTS: Millennials in the United States were more obese compared to their Gen X counterparts and more likely to have diabetes risk but less likely to smoke or have high cholesterol. Millennials in England had higher diabetes risk but similar or lower rates of other CV risk/conditions compared to their Gen X counterparts. Generational changes could not be fully attributed to increases in obesity or decreases in income. DISCUSSION: We expected that Millennial CV risk factors/conditions would be worse than those of Gen X, particularly in the United States, because Millennials came of age during the Great Recession and a period of increasing population obesity. Millennials generally fared worse than their Gen X counterparts in terms of obesity and diabetes risk, especially in the United States, but had lower rates of smoking and high cholesterol in both countries. Secular trends of increasing obesity and decreased economic opportunities did not appear to lead to uniform generational differences in CV risk factors.

Municipality-Level Variation in Severe Maternal Morbidity and Association With Municipal Expenditures in New Jersey.

Importance: Severe maternal morbidity (SMM) is a major risk factor for maternal mortality, yet little is known about geographic variation in SMM or factors associated with geographical variation at the local level. Municipal governments incur substantial expenditures providing services that are an essential part of residents' lives, but associations between municipal expenditures and SMM have not been previously examined. Objective: To investigate variation in rates of SMM across municipalities in New Jersey, the contributions of individual-level characteristics and municipal expenditures to that variation, and associations between municipal expenditures and SMM. Design, Setting, and Participants: This cross-sectional study analyzed 2008 to 2018 New Jersey birth files linked to maternal hospital discharge records and US Census municipal expenditures data. The birth files contain all birth records for New Jersey, and hospital discharge records contain information from all in-patient hospitalizations in New Jersey over the study period. Birth records were matched to maternal discharge records and expenditures data. Data were analyzed from August 2020 to August 2021. Exposures: Individual-level characteristics and per capita municipal expenditures on education; public health; fire and ambulance; parks, recreation, and natural resources; housing and community development; public welfare; police; transportation; and libraries. Main Outcomes and Measures: SMM was identified using diagnosis and procedure codes developed by the Centers for Disease Control and Prevention to measure SMM. Results: Of 1 001 410 individuals (mean [SD] age, 29.8 [5.9] years; 108 665 Asian individuals [10.9%]; 147 910 Black individuals [14.8%]; 280 697 Hispanic individuals [28.0%]; 447 442 White individuals [44.7%]) who gave birth in New Jersey hospitals from 2008 to 2018, 19 962 individuals (2.0%) had SMM. There was substantial municipality-level variation in SMM that was not fully explained by demographic characteristics. Municipal expenditures on fire and ambulance, transportation, health, housing, and libraries were negatively associated with SMM; $1000 higher annual expenditures per capita in these categories were associated with 35.4% to 67.3% lower odds of SMM (odds ratios, 0.33 [95% CI, 0.15-0.72] to 0.65 [95% CI, 0.46-0.91]). Expenditures on police were positively associated with SMM (odds ratio, 1.15 [95% CI, 1.04-1.28]). Conclusions and Relevance: The findings in this study regarding associations between spending on various types of services at the municipal level and SMM, holding constant overall spending, population size, and socioeconomic status at the municipal level, indicate that municipal budget allocation decisions were associated with SMM rates and point to the importance of future research investigating potential causal connections.

Racial-ethnic inequality in cardiovascular health in the United States: Does it mirror socioeconomic inequality?

PURPOSE: To document gender-specific racial-ethnic disparities in cardiovascular (CV) conditions and risk factors net of socioeconomic status (SES) across the lifespan. METHODS: Using pooled data from the 1999 to 2016 U.S. National Health and Nutrition Examination Survey, we document gender-specific proportions of non-Hispanic Whites, non-Hispanic Blacks, and Hispanics ages 12-69 years with various socioeconomic characteristics and CV conditions. We then further disaggregate into 10-year age groups and present unadjusted and SES-adjusted prevalence of each CV condition for each gender/racial-ethnic/age group. RESULTS: Racial-ethnic differences in the prevalence of CV conditions are large for some conditions, emerge early in adulthood, and remain relatively constant though age 69. Only small proportions of the differences can be attributed to differences in SES across groups; attenuation after adjusting for income, education, and available measures of wealth ranged from 0 to 2.3 percentage points. Black-White differences in prevalence of CV conditions differ substantially and systematically by gender; White females have larger advantages or smaller disadvantages (depending on indicator) relative to Black females than White males do relative to Black males. CONCLUSIONS: Racial-ethnic disparities in CV conditions are rooted early in the life course, do not mirror socioeconomic disparities, and vary considerably by gender. Explanations likely involve early life experiences such as racial discrimination and entrenched inequality.

Using universal kriging to improve neighborhood physical disorder measurement.

Ordinary kriging, a spatial interpolation technique, is commonly used in social sciences to estimate neighborhood attributes such as physical disorder. Universal kriging, developed and used in physical sciences, extends ordinary kriging by supplementing the spatial model with additional covariates. We measured physical disorder on 1,826 sampled block faces across 4 US cities (New York, Philadelphia, Detroit, and San Jose) using Google Street View imagery. We then compared leave-one-out cross-validation accuracy between universal and ordinary kriging and used random subsamples of our observed data to explore whether universal kriging could provide equal measurement accuracy with less spatially dense samples. Universal kriging did not always improve accuracy. However, a measure of housing vacancy did improve estimation accuracy in Philadelphia and Detroit (7.9 and 6.8% lower root mean square error, respectively) and allowed for equivalent estimation accuracy with half the sampled points in Philadelphia. Universal kriging may improve neighborhood measurement.

Elective Deliveries and Neonatal Outcomes in Full-Term Pregnancies.

Cesarean and induced delivery rates have risen substantially in recent decades and currently account for over one-third and one-fourth of US births, respectively. Initiatives to encourage delaying deliveries until a gestational age of 39 weeks appear to have slowed the increases but have not led to declines. The rates are at historic highs and the consequences of these interventions when not medically necessary have not been systematically explored at the population level. In this study, we used population-level data on births in New Jersey (1997-2011) to document trends in elective deliveries (induced vaginal delivery, cesarean delivery with no labor trial, and cesarean delivery after induction) and estimate logistic and linear regression models of associations between delivery method and neonatal morbidities and cost-related outcomes in low-risk pregnancies. We found that elective deliveries more than doubled during the observation period and were associated with neonatal morbidities and cost-related outcomes even at gestational ages of 39 and 40 weeks. Findings suggest that delaying beyond 39 weeks and avoiding delivery interventions when not medically necessary would improve infant health and reduce health-care costs.

Darker days? Recent trends in depression disparities among U.S. adults.

Depression is the most prevalent mood disorder in the United States, and disparities in depressive symptoms and treatment by socioeconomic status have been well-documented. Recent evidence suggests the prevalence of depression is increasing, but less is known about time trends in disparities. Using nationally representative data from the National Health and Nutrition Examination Survey, we examined patterns of depressive symptoms (Patient Health Questionnaire-9) and treatment (self-reported psychotherapy and psychopharmacology). We assessed time trends in depression disparities by educational attainment among U.S. adults 2005-2014 using logistic regression models. Among the least educated groups, the odds of moderate to severe depressive symptoms increased; for the most educated, they remained stable (women) or decreased (men). At the same time, odds of receiving treatment, conditional on being depressed, declined (women) or remained stable (men) for the least educated group, whereas treatment rates stayed steady (women) or increased (men) for the most educated. Between 2005 and 2014, overall depression prevalence increased. Despite recent policies designed to improve mental health care coverage, depression treatment rates were unable to keep pace. The least educated consistently had the highest rates of moderate to severe depressive symptoms and the lowest rates of treatment. Disparities in depression by educational attainment have persisted or worsened. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Ethnic enclaves and birth outcomes of immigrants from India in a diverse U.S. state.

Sociological theory suggests that ethnic enclaves promote immigrant health. Existing studies of ethnic enclaves and immigrant birth outcomes have generally focused on blacks and Hispanics, while few have focused on immigrants from India - the second largest immigrant group in the U.S., after Mexicans. Paradoxically, this group generally exhibits worse birth outcomes than non-Hispanic whites, despite their high levels of education. This study investigates associations between residence in South Central Asian ethnic enclaves and both birth outcomes and prenatal behaviors of immigrant mothers from India, using population-level birth record data from the state of New Jersey in the U.S. (1999-2012; n = 64,375). Results indicate that residence in a South Central Asian enclave is associated with less prenatal smoking and earlier prenatal care, but not with birthweight- or gestational-age related outcomes, among immigrant mothers from India. These findings are consistent with theory suggesting that social support, social capital, and social norms transmitted through the social networks present in ethnic enclaves foster health-promoting behaviors. Notably, the prenatal behaviors of non-Hispanic white mothers were not associated to a large degree with living in South Central Asian enclaves, which is also consistent with theory and bolsters our confidence that the observed associations for immigrant mothers from India are not spurious.

Low birthweight among immigrants in Australia, the United Kingdom, and the United States.

Immigrant women are less likely than their native-born counterparts to give birth to a low birthweight infant in the United States, and length of U.S. residence shrinks nativity differences in rates of low birthweight. Yet, we know little about how the U.S. context compares to immigrant low birthweight patterns in other countries. Using nationally representative data, we examine variations in the association between nativity and low birthweight in Australia, the United Kingdom, and the United States-three economically developed countries with long immigrant traditions, but different admission regimes. This study uses birth cohort data from these three destination countries to compare low birthweight between immigrant and native-born residents and then investigates how immigrant low birthweight varies by country of origin and duration in the host country. We find no significant difference in low birthweight between immigrants and native Australians, but for the United Kingdom, we find patterns of low birthweight by duration consistent with those found in the United States. Specifically, foreign-born status protects against low birthweight, though not uniformly across racial groups, except for new arrivals. The results suggest that low birthweight among immigrants is a product of several country-specific factors, including rates of low birthweight in sending countries, access to health services in host countries, and immigrant admission policies that advantage skilled migrants.

Street Audits to Measure Neighborhood Disorder: Virtual or In-Person?

Neighborhood conditions may influence a broad range of health indicators, including obesity, injury, and psychopathology. In particular, neighborhood physical disorder-a measure of urban deterioration-is thought to encourage crime and high-risk behaviors, leading to poor mental and physical health. In studies to assess neighborhood physical disorder, investigators typically rely on time-consuming and expensive in-person systematic neighborhood audits. We compared 2 audit-based measures of neighborhood physical disorder in the city of Detroit, Michigan: One used Google Street View imagery from 2009 and the other used an in-person survey conducted in 2008. Each measure used spatial interpolation to estimate disorder at unobserved locations. In total, the virtual audit required approximately 3% of the time required by the in-person audit. However, the final physical disorder measures were significantly positively correlated at census block centroids (r = 0.52), identified the same regions as highly disordered, and displayed comparable leave-one-out cross-validation accuracy. The measures resulted in very similar convergent validity characteristics (correlation coefficients within 0.03 of each other). The virtual audit-based physical disorder measure could substitute for the in-person one with little to no loss of precision. Virtual audits appear to be a viable and much less expensive alternative to in-person audits for assessing neighborhood conditions.

Prematurity and Sudden Unexpected Infant Deaths in the United States.

BACKGROUND AND OBJECTIVES: Prematurity, a strong risk factor for sudden unexpected infant death (SUID), was addressed in recommendations by the American Academy of Pediatrics in 2011 for safe sleep education in NICUs. We documented associations between gestational age (GA) and SUID subsequent to these guidelines. METHODS: Using the 2012-2013 US linked infant birth and death certificate period files, we documented rates per live births of sudden infant death syndrome, ill-defined and unspecified causes, accidental suffocation and strangulation in bed, and overall SUID by GA in postneonatal, out-of-hospital, and autopsied cases; compared survivors and cases; and estimated logistic regression models of associations between GA and SUID. RESULTS: SUID cases were more likely than survivors to be <37 weeks' GA (22.61% vs 10.79%; P < .0001). SUID rates were 2.68, 1.94, 1.46, 1.16, 0.73, and 0.51 per 1000 live births for 24 to 27, 28 to 31, 32 to 33, 34 to 36, 37 to 38, and 39 to 42 weeks' GA, respectively. Logistic regression models additionally indicated declines in the risk for SUID as GA increased. Prenatal smoking, inadequate prenatal care, and demographics associated with poverty were strongly associated with SUID. CONCLUSIONS: Despite the 2011 American Academy of Pediatrics recommendations for increased safe sleep education in the NICUs, SUID rates were inversely associated with GA in 2012 to 2013, suggesting that risk of SUID associated with prematurity has multiple etiologies requiring continued investigation, including biological vulnerabilities and the efficacy of NICU education programs, and that strategies to reduce SUID should be multifaceted.

Neighborhood Physical Disorder in New York City.

Neighborhood physical disorder, or the deterioration of urban environments, is associated with negative mental and physical health outcomes. Eleven trained raters used CANVAS, a web-based system for conducting reliable virtual street audits, to collect data on nine indicators of physical disorder using Google Street View imagery of 532 block faces in New York City, New York, USA. We combined the block face indicator data into a disorder scale using item response theory; indicators ranged in severity from presence of litter, a weak indicator of disorder, to abandoned cars, a strong indicator. Using this scale, we estimated disorder at the center point of each sampled block. We then used ordinary kriging to interpolate estimates of disorder levels throughout the city. The resulting map condenses a complex estimation process into an interpretable visualization of the spatial distribution of physical disorder in New York City.

Beyond Income Poverty: Measuring Disadvantage in Terms of Material Hardship and Health.

The New York City (NYC) Longitudinal Study of Wellbeing, or "Poverty Tracker," is a survey of approximately 2300 NYC residents. Its purpose is to provide a multidimensional and dynamic understanding of economic disadvantage in NYC. Measures of disadvantage were collected at baseline and a 12-month follow-up, and include 3 types of disadvantage: 1) income poverty, using a measure on the basis of the new Supplemental Poverty Measure; 2) material hardship, including indicators of food insecurity, housing hardship, unmet medical needs, utility cutoffs, and financial insecurity; and 3) adult health problems, which can drain family time and resources. In this article initial results for NYC families with children younger than the age of 18 years are presented. At baseline, 56% of families with children had 1 or more type of disadvantage, including 28% with income poverty, 39% with material hardship, and 17% with an adult health problem. Even among nonpoor families, 33% experienced material hardship and 14% reported an adult health problem. Two-thirds of all families faced disadvantage at either baseline or follow-up, with 46% experiencing some kind of disadvantage at both time points. Respondents with a college education were much less likely to face disadvantage. Even after adjusting for educational attainment and family characteristics, the families of black and Hispanic respondents had increased rates of disadvantage. Considering income poverty alone the extent of disadvantage among families with children in NYC is greatly understated. These results suggest that in addition to addressing income poverty, policymakers should give priority to efforts to reduce material hardship and help families cope with chronic physical or mental illness. The need for these resources extends far above the poverty line.

Use of Google Street View to Assess Environmental Contributions to Pedestrian Injury.

OBJECTIVES: To demonstrate an information technology-based approach to assess characteristics of streets and intersections associated with injuries that is less costly and time-consuming than location-based studies of pedestrian injury. METHODS: We used imagery captured by Google Street View from 2007 to 2011 to assess 9 characteristics of 532 intersections within New York City. We controlled for estimated pedestrian count and estimated the relation between intersections' characteristics and frequency of injurious collisions. RESULTS: The count of pedestrian injuries at intersections was associated with the presence of marked crosswalks (80% increase; 95% confidence interval [CI] = 2%, 218%), pedestrian signals (156% increase; 95% CI = 69%, 259%), nearby billboards (42% increase; 95% CI = 7%, 90%), and bus stops (120% increase; 95% CI = 51%, 220%). Injury incidence per pedestrian was lower at intersections with higher estimated pedestrian volumes. CONCLUSIONS: Consistent with in-person study observations, the information-technology approach found traffic islands, visual advertising, bus stops, and crosswalk infrastructures to be associated with elevated counts of pedestrian injury in New York City. Virtual site visits for pedestrian injury control studies are a viable and informative methodology.