CHARACTERISTICS OF INITIAL AND REPEAT ALCOHOL DRIVING WHILE IMPAIRED (ALCOHOL-DWI) LICENSE SUSPENSIONS AND IMPACTS ON RECIDIVISM AND FUTURE CRASH EVENTS IN NORTH CAROLINA, 2007 - 2016

Alcohol-related driving-while-impaired (alcohol-DWI) represents a significant public health problem, with more than 10,000 traffic-related deaths annually in the US. While license suspensions are commonly used to deter this behavior, several gaps exist in understanding the application and impacts of suspensions over time. This dissertation sought to fill key gaps by examining: 1) trends in and personal and contextual characteristics of alcohol-DWI suspensions and 2) associations between alcohol-DWI suspension duration and future license and crash events. To achieve these aims, we used an open cohort of North Carolina drivers from 2007 to 2016. Data included personal-level NC administrative licensing and crash data linked with contextual data from several sources. In Aim 1, we calculated suspension rates (per 1,000 person-years) and examined annual trends by race/ethnicity, sex, and suspension duration (initial vs. repeat suspensions). In Aim 2, we produced Kaplan-Meier survival curves and used Cox proportional hazards models to estimate hazard ratios (HRs) with corresponding 95% confidence intervals (CIs). We found that 21-24-year-olds (6.9 per 1,000 person-years for initial; 1.5 for repeat) and Black individuals (4.1 for initial; 1.0 for repeat) had the highest suspension rates. Annual suspension rates decreased for most groups of race/ethnicity, with the largest decreases among Hispanic individuals. High suspension rates were observed in counties with higher proportions of individuals without health insurance and high Black/White residential segregation indices. Analyses estimating associations between suspension duration and license and crash events revealed that individuals with repeat, versus initial, suspensions had a lower incidence of both future license (adjusted HR [aHR]: 0.49; 95% CI: 0.42, 0.57) and crash outcomes (aHR: 0.67; 95% CI: 0.60, 0.75). Estimates varied when stratified by race/ethnicity, where estimates among Black individuals (license aHR: 0.38, 95% CI: 0.26, 0.55; crash aHR: aHR: 0.64, 95% CI: 0.50, 0.83) were further from the null compared to White individuals (license aHR: 0.54, 95% CI: 0.45, 0.64; crash aHR: 0.72; 95% CI: 0.63, 0.81). Future research should examine underlying mechanisms contributing to trends and disparities in alcohol-impaired driving, as well as convictions and safety-related outcomes, to inform holistic public health interventions that equitably address root causes and mechanisms.Doctor of Philosoph

Qualitative Evaluation of High School Implementation Strategies for Youth Sports Concussion Laws

Context: All 50 states and the District of Columbia have enacted laws governing concussion management and education. These concussion laws, featuring common tenets regarding removal from play, return to play, and concussion education, have shaped school and district policies. Objective: To evaluate the strategies commonly used to implement concussion laws at the school and district levels, as reported by certified athletic trainers (ATs). Design: Qualitative study. Setting: High schools. Patients or Other Participants: We interviewed 64 ATs from high schools (1 per school) participating in High School Reporting Information Online. Data Collection and Analysis: Interviews were conducted with participants between April and October 2015 regarding implementation of the 3 core tenets of concussion laws. Research team members independently evaluated the interview transcripts and field notes to identify common themes in implementation strategies. Results: Of the 64 schools represented, 90.6% were public schools, 89.1% sponsored more than 15 sports, and all schools employed at least 1 AT and had a written concussion policy. Four commonly used strategies to implement removal from play were reliance on coaches, immediate response, referral and guidance after injury, and notification of key individuals. Use of assessment or baseline tests, communication among parties involved, reliance on AT assessments, and return-to-learn policies were 4 frequent strategies to implement return to play. Finally, 3 major implementation strategies to effectuate concussion education were use of existing educational tools, timing of education, and concussion training for school professionals. Conclusions: Although concussion laws were passed at different times and varied in content across states, common themes in implementation strategies emerged across jurisdictions. The identification of strategic approaches to implementation will help ensure proper concussion management and education, reducing negative health outcomes among youths with concussions

Racial and ethnic disparities in motor vehicle crash-related outcomes in North Carolina surrounding the COVID-19 pandemic

Long-term impacts of the COVID-19 pandemic on racial and ethnic disparities in motor vehicle crash (MVC) injuries and death are poorly understood. This study aimed to characterize trends and investigate the heterogeneity of MVC-related disparities in North Carolina across several data sources. Crash reports, emergency department visit records, and death certificates from 2018 to 2021 were used to calculate monthly population-rates of MVC-related public health outcomes. We estimated trendlines using joinpoint regression and compared outcomes across racial and ethnic classifications. MVC and MVC-related injury rates declined in conjunction with NC’s stay-at-home order, while rates of severe outcomes remained unimpacted. By December 2021 rates of MVC-related outcomes met or exceeded pre-pandemic levels, with the highest rates observed among non-Hispanic Black individuals. Racial and ethnic disparities in MVC-related outcomes remained prevalent throughout the COVID-19 pandemic. These results highlight the importance of a holistic approach to traffic injury surveillance when assessing the impact of MVCs

Trends and Insights from Transportation Congestion Pricing Policy Research: A Bibliometric Analysis

Toll-based congestion pricing (CP) policies are increasingly implemented globally for alleviating road traffic congestion. Several interconnected factors affecting or induced by CP implementation include air quality/emissions, travel time, and road user safety. We sought to examine and characterize research output and patterns across several domains (e.g., health, policy acceptability) surrounding toll-based CP policies, in order to identify where research has focused and where gaps exist. We conducted a structured review and identified 2333 relevant publications, using semi-supervised and machine learning strategies combined with manual review. Annual publication counts peaked in 2015 (n = 122). Themes identified from title and abstract terms included policy implementation characteristics, advanced transportation modeling methods and approaches, and public perception and acceptability. Authorship networks indicated a lack of interdisciplinary research. Country analyses identified the US, China, and the UK as the most frequently represented countries, and underrepresentation from low-income countries. Findings indicate that research focused on specific road user types (e.g., pedestrians) and safety impacts, and equity considerations were relatively sparse compared to other topics (e.g., policy economics, public perception). Additional research on these critical topics is necessary to ensure that such policies are designed to promote positive and equitable effects on road user health and safety

Driving Simulator Performance in the Acute Post-Injury Phase Following a Mild Traumatic Brain Injury Among Young Drivers

While mild traumatic brain injury (mTBI) can lead to cognitive and functional impairments, little is known about how mTBI may affect driving, especially among young drivers who are at an increased risk of mTBI and motor vehicle collisions compared to other age groups. The objective of this multisite, pilot study was to examine the feasibility of assessing driving performance acutely post-injury (i.e., mTBI sustained < 2 weeks at assessment) among young drivers with and without mTBIs (N=42; nmTBI= 21; ncontrol=21) using high-fidelity driving simulators. Driving performance was hypothesized to be significantly degraded, especially under conditions of high cognitive load, among drivers with mTBI compared to matched controls. Neurocognitive measures used in clinical assessment of mTBI (i.e., Cogstate Brief Battery) were hypothesized to correlate with driving simulator performance metrics. Risk management protocols were successful (i.e., no participants withdrew due to simulator sickness) and no significant increase in post-concussion symptoms was found from pre-assessment to immediately following driving assessment. Group differences on key driving variables did not emerge; however, drivers with mTBI showed a differential pattern of driving under high cognitive load. Neurocognitive correlates of simulated driving performance suggested processing speed, attention, and working memory are important functions for driving. Implications and future directions discussed

Trends and Insights from Transportation Congestion Pricing Policy Research: A Bibliometric Analysis

Toll-based congestion pricing (CP) policies are increasingly implemented globally for alleviating road traffic congestion. Several interconnected factors affecting or induced by CP implementation include air quality/emissions, travel time, and road user safety. We sought to examine and characterize research output and patterns across several domains (e.g., health, policy acceptability) surrounding toll-based CP policies, in order to identify where research has focused and where gaps exist. We conducted a structured review and identified 2333 relevant publications, using semi-supervised and machine learning strategies combined with manual review. Annual publication counts peaked in 2015 (n = 122). Themes identified from title and abstract terms included policy implementation characteristics, advanced transportation modeling methods and approaches, and public perception and acceptability. Authorship networks indicated a lack of interdisciplinary research. Country analyses identified the US, China, and the UK as the most frequently represented countries, and underrepresentation from low-income countries. Findings indicate that research focused on specific road user types (e.g., pedestrians) and safety impacts, and equity considerations were relatively sparse compared to other topics (e.g., policy economics, public perception). Additional research on these critical topics is necessary to ensure that such policies are designed to promote positive and equitable effects on road user health and safety

Rest Evaluation for Active Concussion Treatment (ReAct) Protocol: a prospective cohort study of levels of physical and cognitive rest after youth sports-related concussion

Introduction: Although current guidelines for the early clinical management of sports-related concussion (SRC) call for a gradual return-to-activity, the optimal level of rest needed to promote recovery remains unknown. This paper describes the protocol of the Rest Evaluation for Active Concussion Treatment (ReAct) study which objectively measures physical and cognitive rest following SRC and its relation to recovery among youth athletes. Methods and analysis: Youth athletes aged 11–17 years are recruited preinjury and enrolled within 72 hours following a physician-diagnosed concussion. Injury information and acute clinical presentation are assessed at the time of injury. Youth participants are prospectively followed to objectively monitor daily physical and cognitive rest using two electronic devices: ActiGraph (to measure physical rest and sleep) and Narrative Clip (to measure cognitive rest), along with self-reported postconcussive symptoms using daily surveys. Other concussion outcomes, including functional outcomes, are assessed by surveying youth and their parents at three time points: (1) within 72 hours of injury, (2) at day 7 postenrolment and (3) at symptom resolution (or a maximum of 45 days postconcussion)