Bicyclists' Injuries and the Cycling Environment: The …docs.trb.org/prp/13-2995.pdfWinters M,...

Winters M, Harris MA, Reynolds CCO, Cripton PA, Chipman M, Cusimano MD, 1

Brubacher J,Friedman SM, Monro M, Vernich L, Shen H, Babul S, Hunte G, Teschke K.

Bicyclists’ Injuries and the Cycling Environment: The impact of route infrastructure 1

Winters M, Harris MA, Reynolds CCO, Cripton PA, Chipman M, Cusimano MD, Brubacher J, 2

Friedman SM, Monro M, Vernich L, Shen H, Babul S, Hunte G, Teschke K. 3

4 Submission date: July 31, 2012 5 6 * A version of this paper is published in the American Journal of Public Health(Oct 8, 2012). Teschke K, 7 Harris MA, Reynolds CCO, Winters M, Babul S, Chipman M, Cusimano MD, Brubacher J, Friedman SM, 8 Hunte G, Monro M, Shen H, Vernich L, Cripton PA. Route infrastructure and the risk of injuries to 9 bicyclists: A case-crossover study. American Journal of Public Health 10 (http://ajph.aphapublications.org/loi/ajph) 11 12 Word Count: 5,825 13 Number of Figures: 2 14 15 Meghan Winters **Corresponding Author 16 Faculty of Health Sciences, Simon Fraser University 17 8888 Blusson Hall, Burnaby, BC, Canada, V5A 1S6 18 T: 778.782.9325 19 F: 772.782.5927 20 [email protected] 21 22 Harris, MA 23 Occupational Cancer Research Centre, Cancer Care Ontario 24 505 University Avenue, 17th Floor Toronto, Ontario, M5G 1X3 Canada 25 T: 416-217-1849 26 [email protected] 27 28 Reynolds, CCO 29 Liu Institute for Global Issues, University of British Columbia 30 6476 NW Marine Drive Vancouver, BC Canada V6T 1Z2 31 Fax: 604-822-6966 32 [email protected] 33 34 Cripton, PA 35 Department of Mechanical Engineering, University of British Columbia 36 2054-6250 Applied Science Lane Vancouver, B.C., V6T 1Z4 37 T: 604 822-2781 38 [email protected] 39 40 Chipman, M 41 Dalla Lana School of Public Health, University of Toronto 42 155 College Street Health Science Building, 6th floor 43 Toronto, ON M5T 3M7 44 [email protected] 45 46 Cusimano, MD 47 Neurosurgery, St. Michael’s Hospital, University of Toronto 48 30 Bond Street Toronto, Ontario M5B 1W8, Canada 49 T: 416-360-4000 50

TRB 2013 Annual Meeting Paper revised from original submittal.



[email protected] 51 52 Brubacher, J 53 Department of Emergency Medicine, Faculty of Medicine, University of British Columbia 54 Vancouver General Hospital 55 855 West 12th Avenue 56 Vancouver, B.C. V5Z 1M9 57 T: (604) 875-5242 58 Fax: (604) [email protected] 59 60 Friedman, SM 61 Faculty of Medicine, University of Toronto 62 University Health Network, Toronto 63 190 Elizabeth St. Toronto, ON M5G 2C4 Canada 64 T: 416 340 3111 65 [email protected] 66 67 Monro, M 68 School of Population and Public Health, University of British Columbia 69 2206 East Mall, Vancouver, BC, Canada, V6T 1Z9 70 T: 604.822.2041 71 [email protected] 72 73 Vernich, L 74 Dalla Lana School of Public Health, University of Toronto 75 155 College Street Health Science Building, 6th floor 76 Toronto, ON M5T 3M7 77 [email protected] 78 79 Shen, H 80 School of Population and Public Health, University of British Columbia 81 2206 East Mall, Vancouver, BC, Canada, V6T 1Z9 82 T: 604.822.2041 83 [email protected] 84 85 Babul, S 86 British Columbia Injury Research and Prevention Unit L 87 408-4480 Oak St. Vancouver, BC V6H 3V4 88 T: (604) 875-3776 89 [email protected] 90 91 Hunte, G 92 Department of Emergency Medicine, University of British Columbia 93 Vancouver General Hospital 94 855 West 12th Avenue 95 Vancouver, B.C. V5Z 1M9 96 T: 604 875-5242 97 [email protected] 98 99 100




Kay Teschke 101 School of Population and Public Health, University of British Columbia 102 2206 East Mall, Vancouver, BC, Canada, V6T 1Z9 103 T: 604.822.2041 104 F: 604.822.4994 105 [email protected] 106




ABSTRACT 107

Introduction. Safety concerns have contributed to low bicycling rates in North America. Injury rates are 108 lower and cycling is more common in northern European countries where route infrastructure is designed 109 for cyclists, yet few studies have examined the relationship between the cycling environment and injuries. 110

Methods. 690 people injured while cycling were recruited via emergency departments in Toronto and 111 Vancouver, Canada. Conditional logistic regression compared route infrastructure at each injury site to 112 that of a randomly selected control site from the same trip. The case-crossover design controlled for 113 exposure to risk and for personal and trip characteristics that are stable within a trip. 114

Results. Of 15 route types, cycle tracks (physically separated lanes alongside city streets) had the lowest 115 risk, about 9 times lower than the reference (arterials and collectors with parked cars and no bike 116 infrastructure). Bike lanes on arterials and collectors with no parked cars, local streets, and off street bike 117 paths had 2-fold risk reductions. Risks on arterials and collectors were lower when parked cars were not 118 present. Other infrastructure characteristics were associated with increased risks: downhill grades; 119 streetcar or train tracks; and construction. 120

Conclusions. These results indicate that the design approach used in countries in northern Europe with 121 high cycling rates is effective in North America. The following route types are the best choices for 122 common urban transportation locations and would lower injury risks to cyclists: alongside arterials and 123 collectors – cycle tracks; on local streets – designated bikeways with traffic diversion; and off-street – 124 bike paths. 125

126

127




INTRODUCTION 128

Bicycling is an active mode of transportation that integrates physical activity into daily life. It has a range 129 of individual and public health benefits, including improved physical and mental health, decreased 130 obesity, reduced risk of cancer, cardiovascular and other diseases, and reduced motor vehicle noise, air 131 pollutants and greenhouse gases (1-5). However, bicycling is underused for transportation in North 132 America, comprising an estimated 1 to 3% of trips, compared to 10 to 27% of trips in Denmark, Germany, 133 Finland, the Netherlands, and Sweden (6-8). The reasons for low bicycle share of trips are multifaceted, 134 but safety is one of the most frequently cited deterrents (9-11). These concerns are well founded: 135 bicycling injuries rates in North America are higher than in northern European countries (8,12,13). 136

To reduce bicycling injuries, the first step is to understand the determinants of risk. Studies in 137 many English-speaking countries have focused on head injury reductions afforded by helmets (14-17). 138 However, helmet use cannot explain the risk difference, since helmets are rarely used in the European 139 countries with lower injury rates (8,18,19). Typical route infrastructure (physical transportation structures 140 and facilities) in countries with low bicycle share of trips differs from that in countries with high trip 141 shares. In Germany, Denmark and the Netherlands, bicycle-specific infrastructure is frequently available 142 (20), so this is a promising avenue for investigating injury risks. In a review of route infrastructure and 143 injury risk (21), we found evidence that bicycle-specific infrastructure was associated with reduced risk. 144 However, the studies reviewed had problems that have compromised confidence in the results: grouping 145 of route categories that may have different risks; unclear definitions of route infrastructure; and difficulty 146 controlling for characteristics of cyclists and for exposure to various route types. Debate continues about 147 the contribution of route design to safety and about the safety of various route types (12,13,20,21). 148

We conducted a study designed to overcome these limitations (22). It examined injury risk of 15 149 route types using a case-crossover design in which injured participants served as their own controls. It 150 compared route characteristics at the location where the injury event occurred to those at a randomly 151 selected point on the same trip route where no injury occurred. By randomly selecting the control site in 152 this way, the probability that a specific infrastructure type would be chosen was proportional to its 153 relative length on the trip (i.e., on a 4-km trip, there would be a 25% chance of selecting a control site on 154 a 1-km section that was on a bike path). Because comparisons were within-trip, personal characteristics 155 such as age, sex, and propensity for risk-taking behaviour were matched, as were trip conditions such as 156 bicycle, clothing visibility, helmet use, weather, and time of day. This allowed the comparisons to focus 157 on between-site infrastructure differences. 158

The study was conducted in the cities of Toronto and Vancouver, Canada. At the time of the 159 study, Toronto had a population of about 2.5 million, 1.7% of trips by bicycle, 11 km of bike lanes and 160 paths per 100,000 population, snowy winter weather and warm summer weather; Vancouver had a 161 population of about 0.6 million, 3.7% of trips by bicycle, 26 km of bike lanes and paths per 100,000 162 population, rainy winter weather and mild summer weather (7). Although these cities did not have the 163 entire range of cycling infrastructure in place in European settings, together they included most route 164 designs available in North America at the time. 165

166

METHODS 167

The study population consisted of adults (≥ 19 years) who were injured while riding a bicycle and treated 168 within 24 hours in the emergency departments of the following hospitals between May 18, 2008 and 169 November 30, 2009: St. Paul’s or Vancouver General in Vancouver; St. Michael’s, Toronto General or 170 Toronto Western in Toronto. All are teaching hospitals based either in the downtown core or a major 171 business district; one hospital in each city was also a regional trauma centre. The study methods were 172 reviewed and approved by the human subjects ethics review boards of the University of British Columbia, 173 the University of Toronto, and the participating hospitals. 174




Research staff at each hospital identified injured cyclists and provided contact information to 175 study coordinators in each city. The coordinator sent an introductory letter to each potential participant, 176 conducted a screening phone interview for eligibility one to two weeks later, and arranged an interview if 177 the individual was eligible and willing to participate. Eligibility criteria were designed primarily to ensure 178 that participants could retrace their injury trip, and that they were riding in the city using a cycling mode 179 for which urban cycling infrastructure is designed. They excluded the following: those who lived or were 180 injured outside of Toronto or Vancouver or who had no known address or phone number; those who were 181 fatally injured, unable to communicate either because of their injuries or because of language difficulties, 182 or unable to remember the injury trip; those injured while riding on private property or during a trip in 183 which they were trick riding, racing, mountain biking, or participating in a critical mass ride; those who 184 were riding a motorized bike, unicycle or tandem bike; and those who had already participated in the 185 study after an earlier injury. 186

Participants were interviewed as soon as possible after the injury incident to maximize recall 187 (50% completed within 4.9 weeks, 75% within 7.7). In-person interviews were conducted by trained 188 interviewers, using a structured questionnaire that took 25 to 45 minutes to complete. The questionnaire 189 was pretested on 22 cyclists to ensure that the questions were clearly worded, respondents were willing to 190 answer them, and trip routes could be mapped to locate injury and control sites for subsequent 191 observations. 192

The primary purpose of the interview was to trace the route of the injury trip on a city map (scale 193 1:31,250) and note the injury site. Distance travelled was measured using a digital map wheel (Calculated 194 Industries ScaleMaster 6020 Classic, Carson City, NV). A control site on the same route was identified by 195 multiplying a randomly generated proportion by the trip distance, then tracing the resulting distance along 196 the route using the map wheel. The interviews queried the following: where the participant was riding at 197 the injury and control sites (e.g., street or sidewalk); temporary features (e.g., construction) at each site; 198 characteristics of the trip (e.g., time of day and circumstances of the injury event); and personal 199 characteristics (e.g., age, sex, education, household income, cycling frequency). 200

Data about route infrastructure at the injury and control sites were collected during structured site 201 observations by trained personnel blinded to site status. Observations were done at a time that conformed 202 as closely as possible to the time of the injury trip (i.e., season; weekday vs. weekend; morning rush, mid-203 day, afternoon rush, evening, night). The following details were recorded: type of street or path; whether 204 the site was at an intersection; presence of junctions, street lighting, streetcar or train tracks; slope of the 205 surface (measured using a Suunto PM-5 clinometer, Vantaa, Finland); distance visible along the direction 206 of travel (measured using a Rolatape Measure Master MM-12 trundle wheel, Watseka, IL); counts of 207 motor vehicle, cyclist and/or pedestrian traffic volume in 5 minutes; and average motor vehicle traffic 208 speed (5 vehicles measured at normal traffic speeds, using a Bushnell Velocity Speed Gun, Overland Park, 209 KS). The site observation method underwent pretesting and revision at 16 sites, then reliability testing at 210 25 sites by 3 observers. Variables presented in this analysis had raw agreements (all three observers) of 211 0.74 to 1.0 and Fleiss’ kappa (23) for agreement beyond chance of 0.73 to 1.0. 212

Inferential analyses (SAS 9.2; SAS Institute, Cary, NC) examined associations between the 213 cycling environment and the binary dependent variable (1 = injury site or 0 = control site), using the 214 following logistic regression model: 215

log(πij /(1- πij)) = αi + xij1 β1+ xij2 β2 +… + xijp βp , 216

where πij is the probability of injury for ith subject and j

th site, given the covariates xij1, xij2, … , xijp. i=1, 217

… , N; j=1 for injury site, j=0 for control site. N is the number of subjects and p is the number of 218 covariates. The conditional likelihood method in Proc Logistic was used to estimate parameters β1, …, βp. 219

The primary analysis examined the association of injuries with route type. Site observations were 220 used to classify routes into 15 categories corresponding to those used in a survey of route preferences 221 conducted in Metro Vancouver in 2006 (24). Secondary analyses examined associations with other 222 infrastructure features. Each was initially examined separately then offered in a single model with route 223




type. Based on results of the Wald test for each variable, the variable with the highest non-significant p-224 value was removed and the model refit with the remaining variables until all variables in the model were 225 significant (p<0.05). 226

227

RESULTS 228

Participants and Trips 229

Of 2,335 injured cyclists who attended one of the five hospital emergency departments during the 18-230 month study period, 927 were ineligible, 741 were eligible, and 690 agreed to participate (93.1% of 231 known eligible), 414 from Vancouver and 276 from Toronto. There were 667 with unknown eligibility. 232 Assuming that the proportion eligible in this group was the same as among those with known eligibility, 233 we estimated the participation rate as 66.5%. Those potentially eligible who did not participate were 234 similar in age to those who did (mean age = 37 vs. 36 years, respectively), but were more likely to be 235 male (69% vs. 59%). 236

Most participants were men (59.4%), younger than 40 (62.3%), well educated (75.1% with post-237 secondary education), employed (79.1%), regular cyclists (88.1% cycled ≥ 52 times / year), and earned 238 more than $50,000 a year (55.9%). Most of the injury trips were utilitarian in nature (74.3%), on 239 weekdays (77.0%), during daylight hours (77.5%), and short (68.1% < 5 km). Most cyclists wore helmets 240 on the trip (69.3%), but less than half wore high visibility clothing on their torso (39.6%). Most of the 241 injury events were collisions (72%, mainly with motor vehicles, surfaces or infrastructure) rather than 242 falls. About a third of all events were direct collisions with motor vehicles; another 14% involved motor 243 vehicles indirectly (e.g., avoidance manoeuvres). 244

Route Characteristics 245

The following were notable characteristics related to the 15 route types: 246 median motor vehicle speeds on the 6 arterial and collector route types were higher (38 – 44 247

km/h) than on the 3 local street route types (27 – 32 km/h); 248

median motor vehicle traffic counts on the arterial and collector route types (708 – 1584 h-1

) 249

were much higher than on local street route types (48 – 72 h-1

); 250

median bike traffic counts were highest on cycle tracks (114 h-1

), bike lanes on arterials and 251

collectors with no parked cars (78 h-1

), and paved multi-use paths (72 h-1

); 252

designated bike routes on local streets and shared lanes on arterials and collectors were rarely 253

flat (< 20% of observations); 254

streetcar or train tracks were most frequently located on arterials and collectors without bike 255

infrastructure and almost all were in Toronto (98%); and 256

construction was more frequently observed on shared lanes, paved multi-use paths and bike 257

paths (>14% of observations on these route types vs. < 8% of other route observations). 258

Infrastructure and Injury Risk 259

Figure 1 shows the odds ratios (the estimator of relative risk) and 95% confidence intervals comparing 260 injury sites to randomly selected control sites within the same trips, for the 15 route types, grouped into 261 four categories. We designated the most frequently observed route type as the reference category: arterials 262 and collectors with parked cars and no bike infrastructure. All other route types had lower injury risks. 263 The following route types had statistically significantly lower odds ratios, starting with the lowest risk 264 route type: 265

cycle tracks (bike lane alongside arterial or collector, but separated by a curb or other 266

physical barrier); 267




local street designated bike routes (with bike signage and usually cyclist-operated traffic 268

lights at intersections with arterials and collectors); 269

local streets with no bike infrastructure; 270

bike lanes on arterials and collectors with no parked cars; and 271

arterials and collectors with no parked cars and no bike infrastructure. 272

Two other route types had notably low risks though not statistically significant: 273 local street bike routes with traffic diversion had the lowest risk of all local street types; and 274

bike paths had lower risks than multi-use paths and sidewalks shared with pedestrians. 275

It is also important to note that local street bike routes with traffic slowing devices (speed bumps, speed 276 humps, traffic circles, corner bulges) were not as safe as other local street route types. 277

278

279

280 281

FIGURE 1 Relative risks for 15 route types; adjusted odds ratios and 95% confidence intervals 282 estimated using multiple logistic regression. 283

284

Figure 2 shows the odds ratios and 95% confidence intervals for other infrastructure 285 characteristics that were significantly associated with injury risk in the final logistic regression model 286 (with route type). Downhill grades, streetcar or train tracks and construction were all associated with 287 increased risk of injuries. The following infrastructure elements were not significantly associated with 288 injury risk and were not included in the final model: intersection location; presence of junctions (e.g., 289 driveways, lanes) in the previous 100 m; presence of bike signage on arterials and collectors; number of 290 marked traffic lanes; distance visible along the route. 291




292

293

294 295

FIGURE 2 Relative risks for other infrastructure components, including grade, rail tracks and 296 construction; adjusted odds ratios and 95% confidence intervals estimated using multiple logistic 297 regression; same model as routes types (results in Figure 1). 298

299

DISCUSSION 300

In this study, bike-specific infrastructure was associated with lower injury risk. Cycle tracks had the 301 lowest injury risk, about one-ninth the risk of the reference route type. Bike lanes on arterials and 302 collectors with no parked cars and off-street bike paths had nearly half the risk of the reference. Route 303 characteristics other than bike infrastructure were also associated with risk reductions: local streets 304 (except with traffic slowing devices); and no car parking on arterials and collectors. Shared bike 305 infrastructure (shared lanes, multi-use paths) and pedestrian infrastructure had only small risk reductions, 306 and none were significant. 307

These findings reinforce some conclusions of our prior review of the literature: that busy streets 308 are associated with higher risks than quiet streets; and that bicycle-specific facilities are associated with 309 lower risks (21,25-32). Many, though not all, of the previously reviewed studies found higher risks on 310 off-street route types (27,29-34), but this was not the case in the present study. Our study did not include 311 injury events that occurred while mountain biking; this may account for at least some of the difference. 312




Most previous studies grouped off-street routes into only one or two categories, typically sidewalks and 313 other off-street routes. Our study was able to differentiate within these categories. In our study, sidewalks 314 and multi-use paths had among the highest risks, but bike-only paths and especially cycle tracks had 315 lower risks. 316

The higher risk estimates for undifferentiated off-street routes observed in previous studies have 317 been used to recommend against bike-specific infrastructure in Canada and the United States (35). This 318 point of view has had a dominant influence on bike transportation facilities in North America for the last 319 40 years, and has resulted in the very different infrastructure available compared to continental European 320 countries with higher cycling rates (20,36). Cycle tracks highlight the difference: they are common 321 alongside arterials and collectors in the Netherlands and Denmark, but rare in North America, Australia 322 and the UK. Cycle tracks had the lowest risk in this study. Most studies of cycle tracks elsewhere have 323 shown risk reductions: in Montreal (relative risk = 0.72, compared to nearby streets); in Copenhagen 324 (0.59, compared to before cycle track installation (our calculation) and 1.10, compared to estimates of 325 expected injury rates); and in the Netherlands and Belgium (0.10 and 0.83, respectively, compared to 326 roundabout designs without cycle tracks) (25,26,36,37). Relative risk estimates likely vary because of 327 differences in study design (particularly methods of adjusting for traffic volumes and exposure to risk) 328 and differences in comparison infrastructure. 329

An important question is whether safer route types are routes that cyclists would prefer to use. 330 Many route types with positive preference ratings in our early study of route preferences were also among 331 the safest: cycle tracks; local streets; bike only paths; and arterials and collectors with bikes lanes and no 332 parked cars (24). These provide a range of options with potential to both lower injury rates and increase 333 cycling. This in turn may create a positive feedback cycle, since increased ridership has been associated 334 with increased safety (12,38-40). 335

In addition to route type, three infrastructure components were associated with injury risk: 336 downhill slopes; streetcar or train tracks; and construction. Two studies have shown increased injury 337 severity with increased grades (41,42). Route grades may not seem modifiable, but routes can be located 338 where grades are low (e.g., along abandoned rail beds). This would also improve route preference, since 339 steep slopes are a deterrent to cycling (11). Streetcar or train tracks were found to be particularly 340 hazardous to cyclists, a finding that does not appear to have been reported elsewhere. There is renewed 341 interest in streetcars for urban transportation, so this result deserves consideration in broader 342 transportation planning. The higher risk for construction also has not been reported elsewhere; it suggests 343 that when construction sites impact transportation corridors, safe detours need to be provided for cyclists. 344 Other infrastructure factors examined in this study did not have statistically significant associations with 345 injuries, though most had associations in the expected directions and deserve to be evaluated in future 346 studies. 347

A strength of this study is its case-crossover design. It allowed a direct focus on the route 348 environment, while controlling for personal characteristics and other factors that are stable within a trip. 349 The design also controlled for exposure to the various types of infrastructure by randomly selecting 350 control sites from each cyclist’s route. 351

Another feature of the study is that it used detailed and objective site observations to delineate a 352 much wider array of cycling infrastructure than previous injury studies. However, even with 15 route 353 types, there were types not observed in this study (e.g., rural roads), and others that were grouped here, 354 but could be separated into finer categories in cities where they are more common (e.g., bidirectional vs. 355 unidirectional cycle tracks). Because the cycling infrastructure was observed after the injury event, we 356 cannot be certain the infrastructure was exactly as occurred on the injury trip. We expect this to most 357 greatly affect the results for temporary features, like construction, and at sites where the infrastructure 358 changed within a short distance (within a block), such that potential errors in site location would be 359 consequential. Because site observations were made in the identical way for injury and control sites, and 360 observers were blind to site status, we expect any misclassification to be non-differential and to be more 361




likely to bias risk estimates to the null. 362

The results on the 15 detailed route types are new and merit investigation in other settings. If 363 confirmed, they should be generalizable to cities with comparable route infrastructure and urban 364 environments. Features of the Toronto and Vancouver cycling environments were described earlier. The 365 infrastructure that the injured cyclists encountered was weighted towards the urban core of each city, 366 since the participating hospitals were in or near downtown. 367

The study participants had very similar sex, age, and trip distance distributions to population-368 based samples of cyclists in the two cities and in other North American cities (7,24,33,43). Our sample 369 had a high proportion of regular cyclists (88% vs. ~ 13% of all cyclists in Vancouver), likely because 370 more frequent cycling provides more opportunity for injury events (24). 371

As in all injury studies, only a segment of those injured were included, in this case those whose 372 injuries were serious enough to result in a visit to a hospital emergency department, but not to cause death 373 or a head injury so severe that the trip could not be recalled. Two potential participants were fatally 374 injured and 26 of those contacted could not remember their route; it is possible that others who were not 375 successfully contacted may have been in the latter category. By recruiting injured cyclists from hospital 376 records, we were able to include injuries caused by all kinds of crashes, whether motor vehicles were 377 involved or not, thus encompassing a broad array of injury circumstances faced by cyclists. By excluding 378 mountain biking, racing, and trick riding incidents, the study focused on the utilitarian and recreational 379 cycling for which urban bicycle route infrastructure is designed. 380

381

CONCLUSIONS 382

This study reinforces previous evidence that the cycling environment can be designed for primary 383 prevention of injuries to cyclists. Bike-specific facilities, quiet streets, gentle slopes, and absence of 384 streetcar tracks were all associated with lower risks to cyclists. As a public health approach, safer route 385 infrastructure offers many advantages: it is population-based and therefore benefits everyone, it does not 386 require active initiatives by individual cyclists, it does not require repeated reinforcement, and it prevents 387 crashes from occurring rather than preventing injuries after a crash has occurred (17). 388

389

ACKNOWLEDGMENTS 390

We thank the study participants for generously giving their time. We appreciate the many contributions of 391 study staff (Evan Beaupré, Niki Blakely, Jill Dalton, Vartouji Jazmaji, Martin Kang, Kevin McCurley, 392 Andrew Thomas), hospital personnel (Barb Boychuk, Jan Buchanan, Doug Chisholm, Nada Elfeki, 393 Kishore Mulpuri), city personnel (Peter Stary, David Tomlinson, Barbara Wentworth) and community 394 collaborators (Jack Becker, Bonnie Fenton, David Hay, Nancy Smith Lea, Fred Sztabinski). The study 395 was funded by the Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research 396 (Institute of Musculoskeletal Health and Arthritis, and Institute of Nutrition, Metabolism and Diabetes). 397 J.R. Brubacher, M.A. Harris, and M. Winters were supported by awards from the Michael Smith 398 Foundation for Health Research. M.A. Harris, C.C.O. Reynolds, and M. Winters were supported by 399 awards from the Canadian Institutes of Health Research. 400

401

402




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