Configurational pathways to pediatric e-bike injury severity: an fsQCA study of global evidence

Background: E-bike use among children and adolescents has surged worldwide, raising concerns about injury severity and safety management. While prior research has identified multiple risk factors, the complex interplay among study and contextual characteristics influencing injury outcomes remains poorly understood. Objective: This study seeks to uncover the configurational pathways that contribute to increased severity in pediatric e-bike injuries. It employs fuzzy-set qualitative comparative analysis (fsQCA) to integrate both methodological and contextual factors drawn from global evidence. Methods: Twenty-two case was calibrated across seven conditions: research quality, study design, use of quantitative severity indicators, head injury focus, multisystem injury perspective, child or adolescent sample, and inclusion of risk behavior variables. The fsQCA was applied to explore necessary conditions and sufficient configurations explaining the presence or absence of severe injury outcomes. Cases were calibrated into fuzzy sets based on the presence or absence of these conditions, and the algorithm was employed to identify parsimonious and intermediate solutions for both the presence and absence of severe injury outcomes. Results: The necessity analysis revealed that high-quality research, robust study design, and child-focused samples were common among cases reporting significant injury severity differences. The configurational analysis revealed three sufficient pathways leading to increased pediatric e-bike injury severity. Across these configurations, the absence of behavioral risk analysis combined with rigorous design consistently contributed to low-severity outcomes, while multi-system perspectives and pediatric-focused samples played complementary roles. Robustness analyses confirmed the stability of the identified causal structures across analytical thresholds. Conclusion: Pediatric e-bike injury severity is shaped by multidimensional interactions among methodological rigor, injury focus, and population characteristics rather than single risk factors. The fsQCA approach provides a novel analytical framework for disentangling heterogeneous evidence and offers new insights into designing effective injury prevention and safety policies for children.