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Contents lists available at ScienceDirect

Accident Analysis and Prevention

journal homepage: www.elsevier.com/locate/aap

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Evelyn Vingilis a, , Piotr Wilk b

a Population and Community Health Unit, Department of Family Medicine, Schulich School of Medicine and Dentistry, The University of Western Ontario London, Ontario, Canada N6A 5C1 b School of Nursing, Faculty of Health Sciences, London, Ontario, Canada N6A 5C1

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Keywords: Motor vehicle injuries Risk factors Medicinal drugs Health Alcohol

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1. Introduction

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Article history: Received 31 January 2008 Received in revised form 9 April 2008 Accepted 28 June 2008

Objective: The purpose of this study was to examine the effects of health factors and substance use on subsequent motor vehicle collision (MVC) injuries of three different age groups, using the longitudinal dataset from the Canadian National Population Health Survey (NPHS) for the years 19942002. Methods: Path analysis technique was used to determine the relations between MVC injury and four risk factors: binge drinking; health status; distress; and medication use. The three demographic variables, age at baseline, sex, and immigration status were added into the model as control variables. Three age groups were examined: young = 1229.9; middle-aged = 3059.9 and old = 6085 years of age. The total sample size was 16,093. Results: A lower percentage of males, older persons, immigrants, and non-binge drinkers reported a subsequent MVC injury, as did respondents reporting better health and lower distress scores. Medication use was associated with higher subsequent MVC injuries. Path analysis found that among younger individuals, the variable binge drinking, was the only signicant risk factor associated with subsequent injuries. In contrast, among middle-aged individuals, the variable medication use, was the only statistically signicant risk factor for subsequent injuries. No variables were signicant risk factors of injuries for older individuals. Conclusions: Various demographic and risk factors were found to inuence injuries among a nationally representative sample of Canadians. Reported binge drinking among young individuals and medication use among middle-aged individuals were found to be risk factors for subsequent MVC injury. These ndings support the need for continued focus on alcohol, drugs and trafc safety. 2008 Elsevier Ltd. All rights reserved.

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Motor vehicle collisions (MVCs) are a major cause of injuries in Canada, with recent Canadian data indicating that in 2005, 210,629 people were injured while 2923 persons died in MVCs (Transport Canada, 2007). Thus, injuries outnumber fatalities by over 70 times, making injuries a major economic burden. Interestingly, evidence indicates that MVC fatalities and injuries differ in patterns and trends. For example, the age and sex patterns of MVC injuries have been found to differ substantively from fatalities (National Highway Trafc Safety Administration, 2005; Roberts et al., 2007; Transport Canada, 2005). These differences and high economic burden support the need for research on MVC injuries. However, despite the high number of injuries due to MVCs, information is more limited

Corresponding author. Tel.: +1 519 8585063x2. E-mail address: evingili@uwo.ca (E. Vingilis). 0001-4575/$ see front matter 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.aap.2008.06.020

on risk factors of MVC injuries, particularly among large representative samples. Three main sources of data on MVC injuries include: (1) clinical, (2) ofcial police, and (3) social survey data (Gelles, 2000; Roberts et al., 2007), although the majority of studies on MVC injuries are based on clinical samples (emergency room or hospitalization data) (Cherpitel, 1988; Longo et al., 2000; Meropol et al., 1995; Stoduto et al., 1993; Tavris et al., 2001) or on police collision reports (AbdelAty and Abdelwahab, 2000; Ulfarsson and Mannering, 2004; Valent et al., 2002; Zhang et al., 2000). Because studies using clinical and police data are based on administrative databases, the risk factors that can be examined are limited to trauma- or collision-related variables and some available demographics. Studies based on social surveys can examine a wider range of risk factors. However, because MVC injuries are rare events and thus surveys to examine MVC injuries require large sample sizes, few population-based survey studies have been conducted. Those that have been conducted, have often focused on subpopulations, such as adolescent or elderly

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drivers, or active duty army personnel (Begg et al., 1999; Bell et al., 2000; Hu et al., 1998). Moreover, most studies used cross-sectional surveys, making it impossible to assess whether the factors that correlated with the outcome measures precede or follow the outcome measures (Chipman, 1995). All three data sources are subject to validity problems. Ofcial, administrative datasets, such as clinical or police data, have been criticized for potentially having biased samples, as not all persons injured are reported to the police or present to hospitals (e.g., Alsop and Langley, 2001; Amoros et al., 2006; Aptel et al., 1999; Begg et al., 1999; Elvik and Mysen, 1999). A major critique of self-report surveys is the presumption that self-report data are subject to poor recall of events, particularly beyond a 2-month window (Jenkins et al., 2002; Mock et al., 1999), although various studies have found that memory for salient events, such as MVCs, is good (Schwarz and Oyserman, 2001; Sudman and Bradburn, 1983). For example, Begg et al. (1999) assessed the validity of self-report of MVCs and serious injuries among young adults in comparison with clinical and police data sources. They found high concordance between self-report and ofcial data, although their study was based on a small sample of young adults. The purpose of this study was to examine the effects of risk factors on subsequent MVC injuries, using the longitudinal dataset from the Canadian National Population Health Survey (NPHS). Risk factors affecting MVC injuries can be conceptualized as mechanisms through which certain factors can cause injuries. The conceptual framework of Laamme and Diderichsen (2000) was used to identify at the individual level, the two downstream mechanisms to affect injuries: (1) differential exposure and (2) differential susceptibility. The risk factors used in this study were based on our previous research ndings, the literature on variables that increased exposure (e.g., gender) and/or susceptibility (e.g., binge drinking) to MVC injury and on the availability of the measures within the survey. The strength of the longitudinal, national survey database is the representativeness and generalizability of the sample, and prospective nature of the survey. The limitation is that not all potential risk factors of subsequent MVC injuries are available in the survey instrument. Moreover, the NPHS does not include information on whether the respondent was injured as a driver or passenger or on kilometres driven per year. However, a major value of the survey is the availability of health-related variables that have not typically been examined as potential risk factors of MVC injuries. Relevant variables available in the survey, that have been found to affect MVC injuries, included control variables of age, sex, immigration status and four risk factors of binge drinking, health status, distress, and psychotropic medication use (Alvarez et al., 2001; Bell et al., 2000; Braver and Trempel, 2004; Broyles et al., 2003; Cherpitel, 1993; Chipman, 1995; Ellinwood and Heatherly, 1985; Fife et al., 1984; Koepsell et al., 1994; Kypri et al., 2002; Lagarde et al., 2004; Langley and McLoughlin, 1989; McLeod et al., 2003; Sagberg, 2006; Selzer and Vinokur, 1974; Selzer et al., 1968; Singleton et al., 2004; Tavris et al., 2001; Vaa et al., 2003; Vingilis and MacDonald, 2002; Vinglis and Wilk, 2007; Walsh et al., 2004; Zhang et al., 2000). These variables could affect exposure; for example, males drive more than females and therefore are at greater risk of being involved in a MVC (Chipman et al., 1992, 1993). Additionally, variables such as, binge drinking, distress, certain health problems, and medications can cause impairment which could increase susceptibility for MVC injuries. Research has shown that binge or heavy drinkers are more likely to drive impaired, to be passengers with drinking drivers, and to not wear seatbelts (Chipman, 1995; McKinnon et al., 2004; Van Beurden et al., 2005). Moreover, alcohol and certain health problems, such as fragility, can possibly potentiate injury and thus also increase

susceptibility for MVC injuries (Li et al., 1997; Meuleners et al., 2006). 2. The National Population Health Survey The NPHS is a longitudinal, biennial study of Canadians, excluding people living on Native reserves, military bases, institutions, and some remote areas in Ontario and Quebec. The survey focuses on health and injury status, use of health services, lifestyles, psychosocial factors, and socio-demographic information (Statistics Canada, 2004). Five waves of data collected over an 8-year period (measured in 19941995 (Cycle 1); 19961997 (Cycle 2); 19981999 (Cycle 3); 20002001 (Cycle 4); and 20022003 (Cycle 5)) are available for analyses (Statistics Canada, 2005). In 1994 (Time 1), 19,600 households were selected from across Canada, using a two-staged, stratied, random sampling procedure based on the Canadian Labour Force survey. In the rst wave of the NPHS (19941995), the sample was created by rst selecting households and then within each household randomly choosing one member 12 years of age or older to be interviewed every 2 years. The NPHS longitudinal follow-up sample includes 17,276 longitudinal respondents who have completed at least the general component of the questionnaire in Time 1. In order to assess whether the self-reported injury rates in the NPHS were a valid measure of MVC injury rates in Canada, we conducted an initial study to compare the NPHS self-reported MVC injury rates with police collision reports of MVC injury rates, based on Transport Canadas Trafc Accident Information Database (TRAID) for Canadian provinces and territories (Roberts et al., 2007). Injury rates for 19941996 for both datasets were compared for males and females for seven age groups. The study found the datasets to be strikingly similar in their reports of injury trends (Roberts et al., 2007). Overall, no signicant differences were found between males and females when the two datasets were compared for any of the age categories. Both datasets indicated prevalence rates of over 1.5% for persons in the under 30 age categories, between .51.0% for persons in the 3059 age categories, and .5% or lower for the older age categories. Moreover, the rates by age were not linear. In a subsequent study, we examined predictors of subsequent MVC injuries, using the longitudinal NPHS sample for the years 19942002 (Vinglis and Wilk, 2007). The bivariate analyses found that a higher percentage of females and younger persons reported MVC injuries as did binge drinkers, persons with poor health, distress and those who reported using two or more medications. Multiple logistic regression analysis found that health status and medication use were associated with MVC injury. A medication use by binge drinking interaction effect was found with an increased probability of MVC injury among individuals taking more medication and binge drinking. Moreover, the probability of MVC injury by age demonstrated a curvilinear trend with highest probability for respondents under 30 years of age and lowest for respondents over 60 years of age. However, as age was used as a continuous variable, the analyses may not have been sensitive enough to assess risk factors that are typically associated with certain age groups. For example, younger persons are more likely to engage in binge drinking activities (Naimi et al., 2003; Serdula et al., 2004), while older persons are more likely to be using medications (Furu et al., 1997; Kaufman et al., 2002). Since age has been found to play an important role in explaining the relationship between risk factors and MVC injury (e.g. binge drinking more common among younger persons, medication use more common among older persons), we hypothesized that different risk factors would affect different age groups; namely that

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3. Measures 3.1. Dependent variable The dependent variable was derived from the outcomes of two questions: In the past 12 months, did you have any injuries that were serious enough to limit your normal activities? Participants who answered yes were then asked, What happened? Participants who cited a transportation accident as the cause of their injuries were coded as 1 (indicating an MVC) and all others were coded as a zero, i.e. 1 = injured; 0 = not injured. The survey did not query on the type of transportation accident or if the respondent was a driver or passenger in the accident. The dependent variable was included for the years 19961997 (Cycle 2); 19981999 (Cycle 3); 20002001 (Cycle 4); and 20022003 (Cycle 5). If there were repeated events (more than one MVC injury), only the rst event was taken into account. 3.2. Independent variables

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Because Laamme and Diderichsens (2000) two downstream causal mechanisms for injuries framed the conceptualization of the relations between the four risk factors and subsequent MVC injury, path analysis was used. Path analysis is a statistical technique that is an extension of the regression model and is used to examine causal relationships between two or more variables, including direct and indirect effects (although, as with other regression techniques, the technique examines correlation, not causation of variables per se). A regression is conducted for the dependent (endogenous) variable in the model on other (endogenous or exogenous) variables that the model identies as inuencing the dependent variable. The regression weights predicted by the model are compared with the observed correlation matrix for the variables, and a goodness-of-t statistic is calculated. The path coefcient is a standardized regression coefcient (beta) indicating the direct effect of an independent variable on a dependent variable in the path model. Thus, when the model has two or more causal variables, path coefcients are partial regression coefcients, which measure the extent of effect of one variable on another in the path model controlling for other prior variables, using standardized data or a correlation matrix as input. 3.3.1. Model We created a path model based on previous research to assess the relative importance of the four risk factors, Binge drinking, Health status, Distress, and Medication use on MVC injuries. In this model, Binge drinking, Health status, Distress, and Medication use are hypothesized as differential risk factors of subsequent MVC injury of different age groups. The variables of MVC injury, Binge drinking, and Distress are binary, whereas variables of Health status and Medication use are assumed to be measured on a continuous scale. The three demographic variables, Age at baseline, Sex, and Immigration status, were added into the model as control variables. Direct and indirect effects were specied from the control variables of Sex and Immigration status, to MVC injury whereas the control variable Age at baseline had only indirect effect on MVC injury through the four risk factors. 3.3.2. Multiple group analysis Binge drinking can start in early adolescence (Chassin et al., 2002; Hill et al., 2000), with the highest prevalence continuing into the late 20s (Naimi et al., 2003; Serdula et al., 2004), while the 60-year olds and older show the highest proportion of medication use (Furu et al., 1997). Based on these studies and the differential injury rates for different age groups found from the NHPS and Transport Canadas trafc collision statistics (Roberts et al., 2007; Transport Canada, 2007), three age groups were identied: (1) young individualsthose between the ages of 12 and 29.9; (2) middle-aged individualsthose between the ages of 30

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binge drinking would be a risk factor for the younger respondents and health status and medication use would be risk factors for older respondents. Various studies have documented highest rates of self-reported, binge drinking for younger persons (e.g. 12 years of age through adolescence and young adulthood) (Chassin et al., 2002; Hill et al., 2000; Naimi et al., 2003; Wechsler et al., 2000). Indeed, Rehm et al. (2005) write heavy drinking occasions are particularly important for this group [adolescents] and young adults (p. 569). Yet, medication use shows the reverse trend with highest use among those 60 years and older (Furu et al., 1997; Kaufman et al., 2002). Moreover, the oldest are most likely to use multiple medications. For example, Kaufman et al. (2002) found that 44% of men and 57% of women 65 years of age and older reported using ve or more medications in the preceding week, with 19% of men and 23% of women reporting using ve or more prescription medications in the past week.

Medication use: included pain relievers; tranquillizers; antidepressants; codeine; Demerol; morphine; and sleeping pills in the past month. The original variables were added together to form a single score which was coded as 0 = no medication; 1 = one medication; 2 = two medications and 3 = three medications or more. The four risk factors were measured at the baseline (a wave previous to the cycle when the MVC injury was recorded); that is, there is 2-year lag between the time of the report of MVC injury and the measurement of the risk factors. Control variables, Sex and Immigration status, were measured at Cycle 1 (19941995) whereas Age was measured at baseline. 3.3. Path analysis

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Sociodemographic variables: included age, sex and immigrant status. Sex was coded as a categorical variable with 1 = male; 0 = female. Age was coded continuously from 12 to 85 years of age. Immigrant status was coded as 1 = immigrant and 0 = born in Canada. Binge drinking: was assessed using a derived frequency measure of consumption of ve or more alcoholic beverages in one sitting in the past 12 months to assess frequency of bingeing behaviour, with 1 = yes and 0 = no. Health status: was assessed by a single question that asks: in general, would you say your health is excellent, very good, good, fair or poor? The question was coded as 1 = poor; 2 = fair; 3 = good; 4 = very good; 5 = excellent. This question has been found to be one of the best predictors of health care utilization, morbidity and mortality (Vingilis et al., 2002, 2007). Psychological distress: is a composite of six items included in the NPHS that is a subset of a generalized distress scale (Composite International Diagnostic Interview (CIDI)) developed at the University of Michigan (Robins et al., 1988). The items asked respondents to indicate the frequency of times in the previous month when the respondent felt nervous, restless, sad, hopeless, worthless, or that everything in life was an effort. The index ranged from 0 to 24 with higher scores indicating greater distress. Previous research has indicated an internal consistency of this six-item subscale to be = 0.79 (Wade and Cairney, 1997). The original variables were recoded into a binary variable; score 7 and above on a 24 point scale indicates that a participant is distressed where 1 = yes and 0 = no.

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E. Vingilis, P. Wilk / Accident Analysis and Prevention xxx (2008) xxxxxx Table 1 Weighted frequencies and percentages of respondents reported involvement in subsequent MVC injuries by demographic and risk factors from the Canadian National Population Health Survey Number Age 1229.9 3059.9 6085 Total Gender Female Male 288,704 323,862 40,957 653,523 365,818 287,705 Percentage (%) 3.4 2.9 1.1 2.8 3.1 2.5 2.9 2.5 2.3 3.6 3.4 5.5 3.8 6.2 4.9 3.5 2.8 2.9 2.4 2.7 3.6 2.0 3.3 2.8 3.4 2.7 6.6 2.6 6.9 2.8 4.3 2.1 2.8 6.5 5.8

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and 59.9; and (3) older individualsthose between the ages of 60 and 85. 3.3.3. Analysis Mixture modelling techniques, offered in Mplus 4 (Muthn and Muthn, 2006), were used to conduct the statistical analysis. Mixture modelling analysis refers to models with categorical latent variables that represent subpopulations, where population membership is not known but is inferred from the data (Muthn and Muthn, 2006). Multiple-group path analysis is a special case of a mixture model, where class membership for the categorical latent variable representing a subpopulation is known. In our analysis, class membership corresponds to the three age groups; i.e., young individuals, middle-aged individuals, and older individuals. A maximum likelihood estimator with robust standard errors (MLR) employing a numerical integration algorithm (Monte Carlo integration) was used. The MLR standard errors are computed using a sandwich estimator. The total sample size (all individuals between the ages of 12 and 85 in the data set) was 16,093. Listwise deletion for all cases with the missing data points would reduce the available sample by 2821 cases. We addressed the issue of missing data explicitly by modelling the missing data as a function of observed covariates and observed outcomes (missing at random (MAR) assumption). In the end, we were able to retain most of the cases with missing values, except for 134 cases that either had missing data points on the exogenous variables and/or on all the endogenous variables. Estimation was conducted using the sampling weights that were calculated by post-stratifying the Cycle 1 stripped weight to the 19941995 population estimates, based on 1996 Census counts by age group and sex within each province. 4. Results

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Immigration status Born in Canada Immigrant

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The distribution of the sample by the three age groups, based on participants age at baseline were: 1229.9 years of age = 36.5%; 3059.9 years of age = 47.3% and 6085 years of age = 16.1%. Table 1 shows the weighted frequencies and percentages of those who did and did not report a subsequent MVC injury between 1996 and 2002, indicating lower percentage of males, older and immigrant persons reporting a subsequent MVC injury. Moreover, a lower percentage of non-binge drinkers reported a subsequent MVC injury, as did respondents reporting better health and lower distress scores. Medication use was associated with higher subsequent MVC injuries. Three times the percentage of respondents indicating use of two or more medications reported subsequent MVC injuries, compared to respondents indicating no medication use. Table 2 presents the estimates of path coefcients, standard errors, and the corresponding odds ratios for the three age groups. Among younger individuals, the variable Binge drinking, was the only signicant risk factor of MVC injuries, with a path coefcient of 0.851. A logit weight of 0.851 suggests that individuals between the ages of 12 and 29.9 who engaged in binge drinking were 2.341 times more likely to experience a subsequent MVC injury, when compared to individuals who did not engage in such a behaviour. In contrast, among middle-aged individuals, the variable Medication use, was the only statistically signicant contributor to the outcome variable MVC injuries (path coefcient = 0.509). A logit weight of 0.509 suggests that, among individuals between the ages of 30 and 59.9, an increase in the number of medications used by one, increases the odds of experiencing MVC injury 1.664 times. Among the older drivers, no variables were signicant risk factors of MVC injuries.

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Frequency of having 5 or more drinks Never <Once/month Once/month 23 times/month Once/week >Once/week Self perceived health Poor Fair Good Very good Excellent

Use of pain relievers No Yes Use of tranquillizers No Yes Use of antidepressants No Yes

Use of codeine, Demerol, and morphine No 570,643 Yes 61,812 Use of sleeping pills No Yes Use of medications 0 1 2 3 607,569 24,886 167,935 348,326 95,145 21,049

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The ndings of this study provide important information on risk factors for subsequent MVC injuries among a nationally representative sample of Canadians. Overall, in examining the three age groups, persons aged 6085 have the lowest percentage of reported MVC injuries (i.e. one third the percentage of MVC injuries compared to 1229.9 years old), which could reect a complex interplay of exposure and susceptibility differences. Evidence suggests that both younger and older persons drive less. For example, Chipman et al. (1992) found that drivers under 20 years of age drove approximately 23% less in distance and time, while drivers aged 6069 drove about 33% less distance and 19% less time than drivers 2559 years of age. However, younger persons are more exposed as pas-

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Table 2 Path analysis results for risk factors for subsequent MVC injury by age group Variables 1229.9 years Male Immigration Alcohol bingeing* Health status Distress Medication use 3059.9 years Male Immigration Alcohol bingeing Health status Distress Medication use* 6085 years Male Immigration Alcohol bingeing Health status Distress Medication use
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Logit weights 0.378 0.481 0.851 0.124 0.148 0.295 0.173 0.354 0.222 0.118 0.048 0.509 0.147 0.364 0.332 0.180 0.490 0.418

S.E. 0.209 0.411 0.208 0.146 0.258 0.173 0.217 0.231 0.198 0.098 0.292 0.194 0.477 0.577 0.599 0.199 0.591 0.307

Est./S.E. 1.808 1.171 4.099 0.853 0.576 1.710 0.797 1.532 1.126 1.202 0.165 2.626 0.308 0.631 0.555 0.906 0.829 1.362

Odds ratios 0.685 0.618 2.341 0.883 0.862 1.344 0.841 1.424 1.249 0.889 0.953 1.664 0.863 0.695 1.394 0.835 1.633 1.519

Signicant predictor.

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sengers, compared to other age groups (Jelalian et al., 2000). This has been reected in injury rates. For example, Braver and Trempel (2004) found that for non-fatal driver injuries, rate ratios were 3.72 for 1619-year olds, 2.53 for 2024-year olds and 1.67 for 2529year olds, while for non-fatal passenger injuries, rate ratios were 5.30 for passengers riding with drivers aged 1619, 2.84 for passengers riding with drivers aged 2024 and 1.81 for passengers riding with drivers aged 2529. For all other age groups, except drivers older than 75 years of age injuring themselves, drivers and passengers had rate ratios of 1. Thus, previous research has shown that young persons are more exposed as drivers and passengers, while older persons are more exposed as drivers, although we can only speculate on the differences found with the NPHS data, as information on whether the respondents were passengers or drivers in their transportation accidents was not available to us. Young persons are also more susceptible to MVC injuries, as young persons who had ridden with impaired drivers were more likely to drink, to drink and drive themselves, to not wear seat belts, to drive faster than other drivers, to leave less distance between their vehicles and the vehicles in front of them, and to engage in other risky driving behaviours, such as speeding, particularly when driving with peer passengers (Petridou et al., 1997; Simons-Morton et al., 2005). Additionally, adolescents, but not adults, decreased driver belt use with increasing number of passengers, with driver belt use lowest when adolescent drivers were driving with passengers in their 20s, and highest when they were driving with passengers over 30 years of age (Williams and Shabanova, 2002). Passenger belt use also decreased among adolescents as the number of passengers in the vehicle increased. Consistent with other studies (Broyles et al., 2003; Jonah, 1990; Langley and McLoughlin, 1989; Naimi et al., 2003; Powell et al., 2002; Singleton et al., 2004; Williams and Shabanova, 2002), young persons were found to engage in higher levels of binge drinking and a greater percentage of females reported MVC injuries compared to males. The bivariate analyses showed that all risk factors signicantly inuenced MVC injuries, with binge drinking, and medication use, specically use of antidepressants, codeine, Demerol and morphine, showing a higher percentage of MVC injury. Alcohol and various medications have been found in experimental and other studies to cause impairment in driving skills and thus could

increase susceptibility to MVC injuries among drivers (Vingilis and MacDonald, 2002) and passengers since, binge drinking passengers are more likely to ride with drinking drivers who could crash (Jelalian et al., 2000). Health status was also found to be associated with MVC injuries with poor health and distress associated with subsequent MVC injuries, possibly by increasing susceptibility to injuries. However, in the analyses of risk factors among the three age groups, only one hypothesis was conrmed. When the data were subjected to path analyses with age, sex, and immigration status as control variables, only binge drinking was a signicant predictor for those aged 1229.9 years as hypothesized, while medication use was a signicant risk factor for those aged 3059.9 years, but not for the older persons as was hypothesized. Thus, these ndings do conrm the role of heavy drinking in MVC injuries, particularly for the under-30 age cohort, reinforcing the need to engage in impaired driving interventions for this age cohort. However, this study suggests that medication use is a risk factor for middle-aged persons and not older persons, although it is not possible to assess whether the medication use, per se, or the medical conditions for which the medications are being used, increases susceptibility of MVC injuries. The unique nding regarding the lack of risk factors found to inuence subsequent MVC injuries among the older respondents may be a statistical power issue as the older age group comprised only 16.1% of the entire sample. Moreover, some of this nationally representative sample of elderly may not be driving and among those who do, they may be driving less as they also reported the lowest percentage of MVC injuries. This small sample of older individuals involved in MVC injuries could explain why the odds ratio for medication use predicting injuries was 1.519, but not signicant. These ndings are incongruent with some other studies that have found a higher crash rate in regard to vehicle kilometre travelled (Braver and Trempel, 2004). Thus, there may be a complex interplay of exposure and susceptibility with the elderly driving less per capita, although, if they do crash, they may be susceptible to a greater probability of mortality for a given crash. For example, Meuleners et al. (2006) found that fragility was a contributing factor to serious injury risk for older drivers. This may explain some of the difference found between MVC mortality and injury trends, whereby young persons show higher mortality and injury for MVCs, while elderly persons show higher mortality but lower injury for MVCs. Interestingly, medication use and health status were not associated with signicantly increased MVC injury risk. This could be due to the above mentioned reasons of sample size and mortality susceptibility, or possibly because elderly drivers tend to reduce or stop driving because of health and vision problems (Ball et al., 1998; Chipman et al., 1998; Hakamies-Blomqvist and Wahlstrom, 1998; Rudman et al., 2006). Yet, others have suggested that the higher MVC risk among older drivers found in various studies is due to the different nature of driving of many elderly drivers. For example, Keall and Frith (2004) found in their case-control study, that older drivers had daytime risks comparable to 25-year olds, while the night-time risks were at the same low level as any other age groups, as were the risks of elderly drivers highway driving. However, given that the elderly are much less likely to drive at night or on highways compared to other age groups, the higher crash rate of elderly drivers was argued to be an artifact of the different nature of driving undertaken by elderly drivers. It is important to point out some limitations of this study. As this study was based on secondary data analyses of a pre-constructed population-based survey, the study is limited in the variables that could be included. In particular, information on driving exposure, type of collision injury, whether the respondent was a driver or passenger, etc., was not available. Thus, the study is limited in its

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Acknowledgements This research was supported by a grant from AUTO21, a member of the Networks of Centres of Excellence (NCE) program, which is administered and funded by the Natural Sciences and Engineering Research Council (NSERC), the Canadian Institutes of Health Research (CIHR) and the Social Sciences and Humanities Research Council (SSHRC), in partnership with Industry Canada. Access to the National Population Health Survey microdata les was granted through an application to the CISS-ACCESS to the Research Data Centre Program. While the research and analysis are based on data from Statistics Canada, the opinions expressed do not necessarily represent the views of Statistics Canada. References

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Please cite this article in press as: Vingilis, E., Wilk, P., The effects of health status, distress, alcohol and medicinal drug use on subsequent motor vehicle injuries. Accid. Anal. Prev. (2008), doi:10.1016/j.aap.2008.06.020

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ability to examine directly the effects of exposure on injury or accident causality per se. Moreover, other factors, such as illicit drugs, other lifestyle or personality factors were also not available. That said, this study expands our understanding of the inuences of health-related factors on subsequent MVC injuries among a large representative sample. In summary, this study found that various demographic and risk factors were associated with MVC injuries; binge drinking among young persons, and medication use among middle-aged persons were risk factors for subsequent MVC injury, controlling for demographic variables. These ndings suggest that among a nationally representative sample of Canadians, alcohol and drugs are important risk factors for subsequent MVC injuries and support the need for continued research and interventions to reduce alcohol, drug use and driving.

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