SafetyLit Update: 16 September 2002

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16 September 2002

We are unable to provide photocopies of any the articles and reports abstracted below. Where possible, links have been provided to the publisher of the material and contact information for the corresponding author is listed. Many of the journals provide copies (usually for a fee) of reports online. Please consider asking your library to subscribe to the journals from which these abstracts have been gathered.

Sobriety tests for low blood alcohol concentrations.

McKnight AJ, Langston EA, McKnight AS, Lange JE. Accid Anal Prev 2002; 34(3):305-311.

Correspondence: James McKnight, Pacific Institute for Research and Evaluation, Calverton, MD 20705-3201, USA; jimmcknight@earthlink.net

The legal limits of blood alcohol concentration (BAC) for operators of commercial vehicles throughout the United States, and underage drivers in most states, are approximately half the 0.08-0.10% imposed on other drivers. Easily administered measures involving performance and appearance are needed to establish probable cause for requesting breath tests. Several measures showing relationships to blood alcohol were examined for their ability to distinguish BACs under and over 0.04% within the 0.00-0.08% range. Measures of heat loss. pupillary response, balance, complex tasks, and accuracy under speed were studied in controlled experiments with alcohol-dosed subjects. The only reliable index of blood alcohol was horizontal gaze nystagmus (HGN) as administered in the standardized field sobriety test (SFST), using alternative scoring criteria. Although other measures evidenced intra-individual change at low BACs, the magnitude of change was greatly exceeded by inter-individual differences, thwarting their use in detecting drivers with BACs lower than 0.08%. HGN, however, proved as valid in detecting BACs in the 0.04-0.08% range as at the higher levels of the SFST. It is also as valid when administered to a seated subject as one standing, making it of particular benefit in enforcement, where the behavior of low BAC drivers rarely provides probable cause to request that they leave a vehicle to be tested in a standing position. (Copyright © 2002 Elsevier Science)
Vehicle action: effective policy for controlling drunk and other high-risk drivers?

Voas RB, Deyoung DJ. Accid Anal Prev 2002; 34(3):263-270.

Correspondence: Robert Voas, Pacific Instittute Research and Evaluation, Calverton, MD 20705-3102, USA; (email: voas@pire.org).

License suspension effectively reduces recidivism and crash involvement of those convicted of driving while impaired (DWI). The impact of this sanction, however, is being reduced by the large number of offenders (up to 75%) who drive even though suspended. To deal with this problem. several states have enacted laws providing for vehicle impoundment, immobilization, or forfeiture for repeat DWI offenders and for driving while suspended (DWS) offenders. Although a 1992 review of vehicle sanctions for DWI and DWS offenders showed 32 states with such laws, they were infrequently applied. Further, none of those laws had been adequately evaluated. This paper reviews the studies of vehicle action programs in California, Minnesota, New York, Ohio, Oregon, and Washington that have been applied broadly enough to permit evaluation. Although none of the studies has applied random assignment to ensure equal groups. several have applied sufficient statistical controls to provide reasonably credible results. All the programs reviewed showed positive effects. including some relatively large recidivism reductions, from denying offenders the use of their vehicles for 1-6 months. Highlighted in this review are several issues that appear to be important to the effectiveness of vehicle sanctioning programs. (Copyright © 2002 Elsevier Science)
The relationship between liquor outlet density and injury and violence in New Mexico.

Escobedo LG, Ortiz M. Accid Anal Prev 2002; 34(5):689-694.

Correspondence: Luis Escobedo, New Mexico Department of Health, Las Cruces 88001, USA; (email: luise@doh.state.nm.us).

This study used an ecologic design based on data from 1990 to 1994 gathered from forensic, vital statistic, census, law enforcement and liquor licensing agencies to assess the relationship between liquor outlet density and alcohol-related health outcomes in New Mexico. Linear regression models show that suicide, alcohol-related crash, and alcohol-related crash fatality (adjusted for age, sex, and minority status) are significantly associated with liquor outlet density. Data also show that, compared with the first tertile, suicide and alcohol-related crash rates increase about 50% and the alcohol-related crash fatality rate two-fold with the third tertile of liquor outlet density. Greater availability of liquor outlets is associated with higher rates of suicide, alcohol-related crash, and alcohol-related crash fatality. Copyright © 2002 Elsevier Science)

Motor vehicle crash versus accident: a change in terminology is necessary.

Stewart AE, Lord JH. J Trauma Stress 2002; 15(4):333-335.

Correspondence: Alan E. Stewart, Department of Psychology, University of Florida, Gainesville 32611-2250, USA; (email: aestewrt@ufl.edu).

We assert that motor vehicle crash should replace motor vehicle accident in the clinical and research lexicon of traumatologists. Crash encompasses a wider range of potential causes for vehicular crashes than does the term accident. A majority of fatal crashes are caused by intoxicated, speeding, distracted, or careless drivers and, therefore, are not accidents. Most importantly, characterizing crashes as accidents, when a driver was intoxicated or negligent, may impede the recovery of crash victims by preventing them from assigning blame and working through the emotions related to their trauma. (Copyright © 2002 Kluwer Academic Publishers)

No reports this week

The effect of first aid training on Australian construction workers' occupational health and safety motivation and risk control behavior.

Lingard H. J Safety Res 2002; 33(2): 209-230.

Correspondence: Helen Lingard, Faculty of Architecture, Building and Planning, The University of Melbourne, Parkville, Victoria 3052, AUSTRALIA; h.lingard@architecture.unimelb.edu.au).

METHOD: A 24-week experiment was conducted to assess how first aid training affects the motivation of small business construction industry employees in avoiding occupational injuries and illnesses and its effect on their occupational health and safety behavior. A simplified multiple baseline design across workplace settings was used to evaluate the effects of first aid training. Participants' motivation to control occupational safety and health risks was explored during in-depth interviews before and after receipt of first aid training. Objective measurement of occupational safety and health behavior was conducted by a researcher directly observing the workplace before and after participants received first aid training.

RESULTS: The observations at participants' worksites suggested that, for the most part, the first aid training had a positive effect on the occupational safety and health behavior of participants. First aid training appeared to reduce participants' "self--other" bias, making them more aware that their own experience of occupational safety and health risks is not beyond their control but that their own behavior is an important factor in the avoidance of occupational injury and illness. First aid training also appeared to reduce participants' willingness to accept prevailing levels of occupational safety and health risk and increase the perceived probability that they would suffer a work-related injury or illness. Participants expressed greater concern about taking risks at work after receiving first aid training.

DISCUSSION: It appears that first aid training enhances participants' motivation to avoid occupational injuries and illnesses and improves their risk control behavior. The implications of this are that first aid training can have a positive preventive effect and could complement traditional occupational health and safety training programs. As such, there may be benefit in providing first aid training to all employees rather than limiting this training to a small number of designated "first aiders." (Copyright © 2002 Elsevier Science)
Construction workers' falls through roofs: Fatal versus serious injuries.

Kines P. J Safety Res 2002; 33(2): 195-208.

Correspondence: Pete Kines, National Institute of Occupational Health, Lersø Parkallé 105, 2100 Copenhagen, DENMARK; (email: pk@ami.dk).

BACKGROUND: The study examined risk factors for fatal versus serious injuries of construction workers' falls through roofs.

METHODS: Fatal injury falls (N=10) were matched against serious injury falls (N=10), and descriptive analyses were carried out retrospectively of investigation reports.

FINDINGS: Fatal injuries occurred predominantly on farms, in the afternoon, and without the use of passive personal fall protective equipment (PPFPE; safety net, lifeline, etc.). In contrast, serious injuries disproportionately occurred in the morning hours, and were likely due to decreased risk perceptions and less safe behavior, possibly as the result of the greater use of PPFPE.

DISCUSSION: Risk factors for fatal and serious roof fall injury incidents differ in terms of farm/nonfarm location, time of day, and use of PPFPE. Occupational injury incident surveillance systems need to collect data systematically regarding the status and role of personal protective equipment (PPE). (Copyright © 2002 Elsevier Science)

Exposure to traffic among urban children injured as pedestrians.

Posner JC, Liao E, Winston FK, Cnaan A, Shaw KN, Durbin DR. Inj Prev 2002; 8(3): 231-235.

Correspondence: Jill C Posner, Division of Emergency Medicine, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA; (email: posner@email.chop.edu).

OBJECTIVES: To explore the immediate pre-crash activities and the routine traffic exposure (street crossing and play) in a sample of urban children struck by automobiles. In particular, the traffic exposure of children who were struck while playing was compared with that of those struck while crossing streets. DESIGN: Cross sectional survey.

SETTING: Urban pediatric emergency department.

PATIENTS: A total of 139 children ages 4-15 years evaluated for acute injuries resulting from pedestrian-motor vehicle collisions during a 14 month period.

MAIN OUTCOME MEASURES: Sites of outdoor play, daily time in outdoor play, weekly number of street crossings, pre-crash circumstance (play v walking).

RESULTS: Altogether 39% of the children routinely used the street and 64% routinely used the sidewalks as play areas. The median number of street crossings per week per child was 27. There were no differences in exposures for the 29% who were hit while playing compared with the 71% who were hit while walking. Although 84% of the children walked to or from school at least one day per week, only 15% of the children were struck while on the school walking trip. The remainder were injured either while playing outdoors or while walking to other places.

CONCLUSIONS: Urban children who are victims of pedestrian crashes have a high level of traffic exposure from a variety of circumstances related to their routine outdoor playing and street crossing activities. The distributions of traffic exposures were similar across the sample, indicating that the sample as a whole had high traffic exposure, regardless of the children's activity preceding the crash. Future pedestrian injury programs should address the pervasive nature of children's exposure to traffic during their routine outdoor activities. (Copyright © 2002 BMJ Publications Group)

Pediatric and young adult exposure to chemiluminescent glow sticks.

Hoffman RJ, Nelson LS. Arch Pediatr Adolesc Med 2002; 156(9): 901-904.

Correspondence: Robert J. Hoffman, Maimonides Medical Center, 455 First Ave, Room 123, New York, NY 10016, USA; (email: rjhoffman@pol.net).

BACKGROUND: Although chemiluminescent plastic rods, commonly called "glow sticks" or "light sticks," are typically considered to be minimally toxic or nontoxic, published data about exposure to these products are scarce. OBJECTIVES: To test our hypothesis that exposure to chemiluminescent products is unlikely to result in significant morbidity or mortality and to describe factors associated with exposure by reviewing reports to our urban poison control center of human exposure to chemiluminescent products.

METHODS: Pediatric and young adult exposure to chemiluminescent products reported between January 1, 2000, and April 1, 2001, to our poison control center were evaluated with regard to demographic group, type of product involved, circumstances of exposure, symptoms, and management.

RESULTS: Reported routes of exposure (n = 118) included ingestion (n = 108), ocular (n = 9), and dermal exposure (n = 1). Only patients exposed to chemiluminescent fluid from a leaking container reported symptoms (n = 27). Symptoms were limited to transient irritation of the exposure site, and no systemic toxicity occurred. All adults (n = 4) inadvertently ruptured or swallowed intact light sticks while at a dance club or dance party. Most exposure and all adult exposure occurred on holidays or weekends.

CONCLUSIONS: Most incidences of exposure to chemiluminescent products involve asymptomatic ingestion of fluid that leaks from glow sticks or ingestion of an intact glow stick. Symptoms occur after exposure to chemiluminescent fluid and consist of transient irritation at the site of exposure. The clustering of reported exposure on weekends and in dance clubs and parties coupled with a lack of occupational or workplace exposure suggest that recreational use is a major contributory factor. Exposure to chemiluminescent products infrequently resulted in symptoms and the symptoms reported were minor. Exposure to chemiluminescent products as described is unlikely to cause significant morbidity or mortality. (Copyright © 2002 American Medical Association)

Gradients in risk for youth injury associated with multiple-risk behaviours: a study of 11,329 Canadian adolescents.

Pickett W, Garner MJ, Boyce WF, King MA. Soc Sci Med 2002; 55(6): 1055-1068.

Correspondence: Will Pickett, Department of Emergency Medicine, Queen's University, Kingston General Hospital, ON, CANADA; (email: PickettW@post.queensu.ca).

This study used the Canadian version of the World Health Organization-Health Behaviour in School-Aged Children (WHO-HBSC) Survey to examine the role of multiple risk behaviours and other social factors in the etiology of medically attended youth injury. 11,329 Canadians aged 11-15 years completed the 1997-1998 WHO-HBSC, of which 4152 (36.7%) reported at least one medically attended injury. Multiple logistic regression analyses failed to identify an expected association between lower socio-economic status and risk for injury. Strong gradients in risk for injury were observed according to the numbers of multiple risk behaviours reported. Youth reporting the largest number (7) of risk behaviours experienced injury rates that were 4.11 times (95% CI: 3.04-5.55) higher than those reporting no high risk behaviours (adjusted odds ratios for 0-7 reported behaviours: 1.00, 1.13, 1.49, 1.79, 2.28, 2.54, 2.62, 4.11; p(trend) < 0.001). Similar gradients in risk were observed within subgroups of young people defined by grade, sex, and socio-economic level, and within restricted analyses of various injury types (recreational, sports, home, school injuries). The gradients were especially pronounced for severe injury types and among those reporting multiple injuries. The analyses suggest that multiple risk behaviours may play an important role in the social etiology of youth injury, but these same analyses provide little evidence for a socio-economic risk gradient. The findings in turn have implications for preventive interventions. (Copyright © 2002 Elsevier Science)

A note on the variance of paired comparisons estimates.

Hertz ES.Accid Anal Prev 2002; 34(3):401-404.

Correspondence: ES Hertz, National Highway Traffic Safety Administration, Washington, DC 20590, USA; (email: ehertz@nhtsa.dot.gov).

The method of paired comparisons to estimate treatment effectiveness was introduced by Evans (Evans L. Double pair comparison--a new method to determine how occupant characteristics affect fatality risk in traffic crashes. Accident Analysis and Prevention 1985;12:217-27). It is similar in form to other effectiveness estimates based on odds ratios using independent groups. Therefore, it has been generally assumed that the variance is computed in the same way. In this note, it is demonstrated. using a simple binomial model and linear approximation, that the variance is lower for paired comparisons estimates than for odds ratios estimates based on independent groups. In order to use odds ratios, there must be a treated group and an untreated group. Within each group there are occurrences of an event against which treatment effectiveness is being estimated and, also, occurrences of different event that is considered unamenable to the treatment. The treatment effectiveness, e, is estimated by 1-R where R is the ratio of amenable type events to unamenable ones in the treated group, divided by the same ratio for the untreated group. A distinction is made between 'real' paired comparisons and odds ratios based on independent data. An example of the independent case is. x is the number of fatalities in frontal crashes without air bags; y the number of fatalities in non-frontal crashes without air bags; s the number of fatalities in frontal crashes with air bags, and t the number of fatalities in non-frontal crashes with air bags. While fatalities in non-frontal crashes serve as denominators in R, a particular frontal crash is not paired with one particular non-frontal crash. In this case, in which all the data are independent, the variance of e is approximately R2(1/x + 1/y + 1/s + 1/t), a result which is consistent with well known results about the log odds ratio. For an example of real paired comparisons, we consider fatalities in cars that have a driver and exactly one unbelted right front seat passenger. Suppose there were x driver fatalities and y passenger fatalities in the cars in which the driver was also unbelted and s driver fatalities and t passenger fatalities in the cars in which the driver was belted. Since the fate of the passenger would not be amenable to 'treating' the driver, the same estimate of belt effectiveness based on these data. 1 - (s/t)/(x/y), is reasonable. In this case, x and y, and s and t are not independent. This is due to the fact that while the overall probability of fatality in a crash is very low, the conditional probability of fatality given that someone else in the car died is greater than the unconditional probability of fatality. Under these circumstances, the variance of the paired comparisons estimate is reduced. (Published by Elsevier Science)
Driver injury severity: an application of ordered probit models.

Kockelman KM, Kweon YJ.Accid Anal Prev 2002; 34(3):313-321.

Correspondence: Kara M. Kockelman, Department of Civil Engineering, The University of Texas at Austin, TX 78712-1076, USA; (email: kkockelm@mail.utexas.edu).

This paper describes the use of ordered probit models to examine the risk of different injury levels sustained under all crash types, two-vehicle crashes, and single-vehicle crashes. The results suggest that pickups and sport utility vehicles are less safe than passenger cars under single-vehicle crash conditions. In two-vehicle crashes, however, these vehicle types are associated with less severe injuries for their drivers and more severe injuries for occupants of their collision partners. Other conclusions also are presented; for example. the results indicate that males and younger drivers in newer vehicles at lower speeds sustain less severe injuries. (Copyright © 2002 Elsevier Science)

No reports this week

See abstract under Suicide

School-based violence prevention programs: systematic review of secondary prevention trials.

Mytton JA, DiGuiseppi C, Gough DA, Taylor RS, Logan S. Arch Pediatr Adolesc Med 2002; 156(8):752-762.

Corrspondence: Julie A. Mytton, Department of Public Health, Oldham Primary Care Trust,Westhulme Avenue, Oldham OL1 2UL, UK; (email: jmytton@doctors.org.uk).

OBJECTIVE: To quantify the effectiveness of school-based violence prevention programs for children identified as at risk for aggressive behavior.

DESIGN: Systematic review and meta-analysis of randomized controlled trials. Electronic databases and bibliographies were systematically searched and authors and organizations were contacted to identify randomized controlled trials. Standardized, weighted mean effect sizes were assessed by meta-analysis.

SETTING: Elementary, middle, and high schools.

PARTICIPANTS: Children at risk for aggressive behavior.

MAIN OUTCOME MEASURES: Violent injuries, observed or reported aggressive or violent behaviors, and school or agency responses to aggressive behaviors.

RESULTS: Of the 44 trials identified, none reported data on violent injuries. For the 28 trials that assessed aggressive behaviors, the pooled difference between study groups was -0.36 (95% confidence interval, -0.54 to -0.19) in favor of a reduction in aggression with intervention. For the 9 trials that reported data on school or agency responses to aggression, the pooled difference was -0.59 (95% confidence interval, -1.18 to 0.01). Subgroup analyses suggested greater effectiveness in older students and when administered to mixed-sex groups rather than to boys alone.

CONCLUSIONS: School-based violence prevention programs may produce reductions in aggressive and violent behaviors in children who already exhibit such behavior. These results, however, need to be confirmed in large, high-quality trials. (Copyright © 2002 American Medical Association)

Rural-urban differences in reasons for living.

McLaren S, Hopes LM. Aust N Z J Psychiatry 2002; 36(5): 688-692.

Correspondence: Suzanne McLaren, School of Behavioural & Social Sciences & Humanities, University of Ballarat, PO Box 663, Ballarat 3353, Victoria, AUSTRALIA; (email: s.mclaren@ballarat.edu.au).

OBJECYIVE: The suicide rate in Australia is cause for concern, especially the increase in attempted and completed suicides in rural and regional locations. The present study examined reasons for choosing not to commit suicide as a function of residential location.

METHODS: The study involved 655 Victorian residents from four population-based strata; urban, regional city, regional town, and rural.

FINDINGS: Results from the Reasons for Living Inventory revealed significant differences as a function of residential location. Overall, residents in rural locations reported having significantly more to live for than their urban counterparts. Further analysis of six reasons for living (child, family, moral, social, coping and death-related concerns) showed a pattern whereby residents in rural locations reported having the most to live for, followed by regional residents, and urban residents who reported having the least to live for.

DISCUSSION: These findings are in contrast to increase of suicide rates in rural areas, and highlight the need for a greater understanding of the mechanisms underlying suicidal behaviour. (Copyright © 2002 Blackwell Publications)
Impact of an empowerment-based parent education program on the reduction of youth suicide risk factors.

Toumbourou J, Gregg M. J Adolesc Health 2002; 31(3): 277

Correspondence: John W. Toumbourou, Centre for Adolescent Health, Murdoch Children's Research Institute and Department of Pediatrics, University of Melbourne, Victoria, AUSTRALIA; (email:jwt@unimelb.edu.au). ).

PURPOSE: To evaluate the impact of parent education groups on youth suicide risk factors. The potential for informal transmission of intervention impacts within school communities was assessed.

METHODS: Parent education groups were offered to volunteers from 14 high schools that were closely matched to 14 comparison schools. The professionally led groups aimed to empower parents to assist one another to improve communication skills and relationships with adolescents. Australian 8th-grade students (aged 14 years) responded to classroom surveys repeated at baseline and after 3 months. Logistic regression was used to test for intervention impacts on adolescent substance use, deliquency, self-harm behavior, and depression. There were no differences between the intervention (n = 305) and comparison (n = 272) samples at baseline on the measures of depression, health behavior, or family relationships.

RESULTS: Students in the intervention schools demonstrated increased maternal care (adjusted odds ratio [AOR] 1.9), reductions in conflict with parents (AOR.5), reduced substance use (AOR.5 to.6), and less delinquency (AOR.2). Parent education group participants were more likely to be sole parents and their children reported higher rates of substance use at baseline. Intervention impacts revealed a dose-response with the largest impacts associated with directly participating parents, but significant impacts were also evident for others in the intervention schools. Where best friend dyads were identified, the best friend's positive family relationships reduced subsequent substance use among respondents. This and other social contagion processes were posited to explain the transfer of positive impacts beyond the minority of directly participating families.

CONCLUSIONS: A whole-school parent education intervention demonstrated promising impacts on a range of risk behaviors and protective factors relevant to youth self-harm and suicide. (Copyright © 2002 Elsevier Science)

See abstract under Commentary
Characteristics of traffic crashes in Maryland (1996-1998): differences among the youngest drivers.

Ballesteros MF, Dischinger PC.Accid Anal Prev 2002; 34(3):279-284.

Correspondence: Michael Ballesteros, National Study Center for Trauma and EMS, University of Maryland, Baltimore 21201, USA; (email: mick_ballesteros@yahoo.com).

Motor vehicle crashes (MVCs) are the leading cause of death among teenagers in the US. The present study examines how crash rates and crash characteristics differed among drivers aged 16-21 in the state of Maryland from 1996 to 1998. The results show that, based on police reports. the youngest drivers have the highest rate of MVCs per licensed driver and per annual miles driven. Furthermore, crash characteristics suggest that inexperience rather than risky driving may account for the differing rates. Drivers closer to the age of 16 had their crashes under the safest conditions: during the day in clear weather while drinking less. (Copyright © 2002 Elsevier Science)
The relationship between body weight and risk of death and serious injury in motor vehicle crashes.

Mock CN, Grossman DC, Kaufman RP, Mack CD, Rivara FP. Accid Anal Prev 2002; 34(2):221-228.

Correspondence: Charles N. Mock, Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, WA 98104, USA; (email: cmock@u.washington.edu).

We sought to investigate the effect of increased body weight on the risk of death and serious injury to occupants in motor vehicle crashes. We employed a retrospective cohort study design utilizing data from the National Automotive Sampling System, Crashworthiness Data System (CDS), 1993-1996. Subjects in the study included occupants involved in tow-away crashes of passenger cars, light trucks, vans and sport utility vehicles. Two outcomes were analyzed: death within 30 days of the crash and injury severity score (ISS). Two exposures were considered: occupant body weight and body mass index (BMI; kg/m2). Occupant weight was available on 27263 subjects (76%) in the CDS database. Mortality was 0.67%. Increased body weight was associated with increased risk of mortality and increased risk of severe injury. The odds ratio for death was 1.013 (95% CI: 1.007, 1.018) for each kilogram increase in body weight. The odds ratio for sustaining an injury with ISS > or = 9 was 1.008 (95% CI: 1.004, 1.011) for each kilogram increase in body weight. After adjustment for potentially confounding variables (age, gender, seatbelt use, seat position and vehicle curbweight), the significant relationship between occupant weight and mortality persisted. After adjustment, the relationship between occupant weight and ISS was present, although less marked. Similar trends were found when BMI was analyzed as the exposure. In conclusion, increased occupant body weight is associated with increased mortality in automobile crashes. This is probably due in part to increased co-morbid factors in the more overweight occupants. However, it is possibly also due to an increased severity of injury in these occupants. These findings may have implications for vehicle safety design, as well as for transport safety policy. (Copyright © 2002 Elsevier Science)

Caretaker-Child Concordance for Child's Exposure to Violence in a Preadolescent Inner-City Population.

Thomson CC, Roberts K, Curran A, Ryan L, Wright RJ. Arch Pediatr Adolesc Med 2002; 156(8):818-823.

Correspondence: Rosalind Wright, Channing Laboratory, 181 Longwood Ave, Boston, MA 02115, USA; (email: rosalind.wright@channing.harvard.edu).

BACKGROUND: Effective screening for exposure to violence (ETV) in the pediatric setting depends on informant reliability and recognition of patients at increased risk. Pediatricians screening for children's ETV often rely on parent reporting.

HYPOTHESIS: That there would be poor caretaker-child concordance given that children would report events occurring outside the home not witnessed by the caretaker and that ETV would be higher among immigrant families.

OBJECTIVES: To examine concordance between caretaker and child self-report of the child's ETV in a preadolescent population and to explore factors related to increased risk. DESIGN: Community-based survey.

SETTING: Urban community health center.

PARTICIPANTS: One hundred sixty-five caretaker-child pairs. METHODS: The ETV was assessed by means of a standardized interview questionnaire on location and frequency of ETV. A Rasch model was used to develop summary scores of ETV (frequency and severity).

RESULTS: Caretaker-child concordance on reports of child's ETV was poor. The kappa statistics ranged from -0.04 for seeing someone knifed to 0.39 for witnessing a shooting. Children reported ETV more often in their neighborhood or at school, whereas caretakers reported more events near or at home. Univariate predictors of child's self-reported ETV were female sex (beta +/- SE, -10.1 +/- 4.6; P =.03) and caretaker being divorced (beta +/- SE, 12.6 +/- 6.0; P =.04). In multivariate analyses, country of origin predicted child's ETV, adjusting for child's age and sex, and caretaker educational status and marital status.

CONCLUSIONS: Caretakers and their children have poor agreement on reports of the child's ETV. Intervention strategies around ETV should include assessment of the child independent of caretaker report for preadolescents. Screening may be more effective if pediatricians are aware of factors related to increased risk, including immigration status and caretaker marital status. (Copyright © 2002 American Medical Association)
Implementation of a program to teach pediatric residents and faculty about domestic violence.

Berger RP, Bogen D, Dulani T, Broussard E. Arch Pediatr Adolesc Med 2002; 156(8):804-810.

Correspondence: Rachel P. Berger, Department of Pediatrics, Pittsburgh Child Advocacy Center, Children's Hospital of Pittsburgh, 3705 Fifth Ave, Pittsburgh, PA 15213, USA; (email: rberger@pitt.edu).

OBJECTIVES: To obtain information about pediatric resident and staff knowledge, attitudes, and screening practices related to domestic violence (DV), to implement a domestic violence education program, and to evaluate whether the program resulted in changes in these 3 domains. DESIGN: Interventional with before and after survey evaluation. SETTING: A hospital-based, pediatric residency continuity clinic that serves families in Pittsburgh, Pa. PARTICIPANTS: Pediatric residents (n = 51), medicine-pediatric residents (n = 6), continuity clinic faculty (n = 22), and certified-registered nurse practitioners (n = 5). RESULTS: Prior to implementation of the DV education program, respondents correctly answered questions about the prevalence of DV (74 participants [90%]), the racial distribution of DV victims (66 participants [80%]), and the significant overlap between child abuse and DV (75 participants [91%]). Seventy-nine participants (96%) believed that screening for the presence of DV was part of their role as pediatric health care providers. At baseline, 17 (21%) of the 82 participants reported that they were routinely screening for signs of DV during well-child care visits compared with 39 (46%) after attending the education program (P =.005).Among participants who attended both educational session 25% (9/36) were routinely screening for the presence of DV prior to the intervention, compared with 46% (16/35) after the intervention (P =.008). At baseline, 33 (40%) of the 82 participants had identified at least 1 case of DV in the prior 6 months compared with 45 (53%) after training. Prior to training, 18 participants (22%) were aware of resources for DV victims compared with 45 (53%) after training (P <.001). CONCLUSIONS: To our knowledge, this is one of the first pediatric studies to demonstrate that using a short, multifaceted educational module, it is possible to change DV screening practices and to increase identification of DV victims among pediatric residents, continuity clinic faculty, and certified-registered nurse practitioners at a pediatric teaching hospital. (Copyright © 2002 American Medical Association)
The association of handgun ownership and storage practices with safety consciousness.

Coyne-Beasley T, McGee KS, Johnson RM, Bordley WC. Arch Pediatr Adolesc Med 2002; 156(8):763-768.

Correspondence:Tamera Coyne-Beasley, Department of Pediatrics, Division of Community Pediatrics, University of North Carolina at Chapel Hill, Campus Box 7225, Wing C, Medical School, Chapel Hill, NC 27599-7225, USA; (email: coybea@med.unc.edu).

BACKGROUND: As with other injury prevention practices, education about safe firearm storage is recommended to prevent injuries to children. OBJECTIVE: To assess whether parents who are safety conscious in other respects also practice firearm safety. METHODS: Data come from responses to a baseline survey administered as part of an intervention study. Participants were consenting adults who brought a child into an emergency department. These analyses were restricted to those parents who had young children (< 7 years) and who kept a firearm in their house. A safety consciousness score was developed; participants earned a point for each of 7 home and car safety behaviors they reported practicing. The relationship between safety consciousness with handgun ownership and firearm storage practices was assessed with Wilcoxon-Mann-Whitney test. RESULTS: Of the 221 participants, most reported that they keep poisonous substances out of children's reach (92%), always keep children restrained when in cars (90%), have the telephone number for a poison control center (82%), change smoke alarm batteries annually (73%), keep electrical outlets capped (72%), and keep their tap water temperature at 120 degrees F (49 degrees C) or less (65%). Only 22% reported checking smoke alarm batteries monthly. The median safety score was 4 (mean [SD], 3.99 [1.4]). Fifty-six percent said there was a handgun in their home, 27% reported an unlocked gun, 20% reported a loaded gun, and 7% reported a loaded and unlocked gun. Results were not consistent with safety consciousness being associated with safe firearm storage practices or the absence of a handgun. CONCLUSION: Compliance with safety practices may not be associated with safe firearm storage. (Copyright © 2002 American Medical Association)
Underestimates of unintentional firearm fatalities: comparing Supplementary Homicide Report data with the National Vital Statistics System.

Barber C, Hemenway D, Hochstadt J, Azrael D. Inj Prev 2002; 8(3): 252-256.

Correspondence: Catherine Barber, Harvard Injury Control Research Center, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA; (email: cbarber@hsph.harvard.edu).

OBJECTIVE: A growing body of evidence suggests that the nation's vital statistics system undercounts unintentional firearm deaths that are not self inflicted. This issue was examined by comparing how unintentional firearm injuries identified in police Supplementary Homicide Report (SHR) data were coded in the National Vital Statistics System.

METHODS: National Vital Statistics System data are based on death certificates and divide firearm fatalities into six subcategories: homicide, suicide, accident, legal intervention, war operations, and undetermined. SHRs are completed by local police departments as part of the FBI's Uniform Crime Reports program. The SHR divides homicides into two categories: "murder and non-negligent manslaughter" (type A) and "negligent manslaughter" (type B). Type B shooting deaths are those that are inflicted by another person and that a police investigation determined were inflicted unintentionally, as in a child killing a playmate after mistaking a gun for a toy. In 1997, the SHR classified 168 shooting victims this way. Using probabilistic matching, 140 of these victims were linked to their death certificate records.

RESULTS: Among the 140 linked cases, 75% were recorded on the death certificate as homicides and only 23% as accidents.

CONCLUSION: Official data from the National Vital Statistics System almost certainly undercount firearm accidents when the victim is shot by another person. (Copyright © 2002 BMJ Publications Group)
Violence-related content in the nursing curriculum: a follow-up national survey.

Woodtli MA, Breslin ET. J Nurs Educ 2002; 41(8):340-348.

Correspondence: Margaret A. Woodtli, College of Nursing, University of Arizona, Tucson 85721, USA; (email: awoodtli@nursing.arizona.edu).

BACKGROUND: Appropriate educational preparation about violence prevention, assessment, and treatment provides critical knowledge and skills that enable nurses to provide competent care to violence survivors.

METHODS: This follow-up national survey examined changes in the extent, placement, and faculty responsible for violence-related content in baccalaureate nursing curricula since the original 1995 survey was conducted. This national study used a 31-item mailed questionnaire that requested demographic information; data related to course content, clinical experiences, curriculum and faculty development, and curriculum evaluation; and recommendations. Usable questionnaires were returned from 395 (61%) of 648 programs surveyed.

FINDINGS: The results indicated content related to women, children, and suicide and self-destructive behavior was taught primarily in 2 to 4 hours; 46% of schools presented sexual and elder abuse content in 1 hour or in readings only; and related clinical experiences were primarily coincidental. The majority of schools (63%) reported no violence-related faculty development activities during the past 4 years despite previous indication of need. More than two thirds of programs (68%) did not systematically evaluate violence content, and 75% had not developed violence-focused student competencies. Although small gains were found in hours of presentation in some content, little has changed in the nursing curriculum overall.

DISCUSSION: The significance of this study is related to the relevance of nursing education to preparing students and faculty to address the social and health problems of increasing violence and abuse.
Violence in adolescents' romantic relationships: findings from a survey amongst school-going youth in a South African community.

Swart L, Seedat M, Stevens G, Ricardo I. J Adolesc 2002; 25(4): 385-395.

Correspondence: Lu-Anne Swart, Institute for Social and Health Sciences, University of South Africa, 1087, Lenasia, 1820, SOUTH AFRICA; (email: swartl@unisa.ac.za).

This paper reports on a study of heterosexual adolescent dating violence among secondary school students in a South African community. Approximately half of the surveyed males, and just over half of the surveyed females reported involvement in a physically violent dating relationship either as a perpetrator and/or victim. The study found significant associations between the beliefs about violence in a romantic relationship, the witnessing of physical violence in friendship contexts, the use of alcohol and adolescent dating violence. A significant association between familial variables and adolescent dating violence was only found for male participants. No significant association was found between religious participation and adolescent dating violence. The implications for prevention are discussed in an attempt to demonstrate the potential of local information that identifies risk factors for the development of appropriate community- andschools-based intervention programmes.Copyright 2002 The Association for Professionals in Services for Adolescents. (Published by Elsevier Science Ltd.)
Policing guns and youth violence.

Fagan J. Future Child 2002; 12(2):132-151.

Correspondence: Jeffrey Fagan, Columbia University Law School,722 W 168TH St., New York, NY, USA; (email: jaf45@columbia.edu).

To combat the epidemic of youth gun violence in the 1980s and 1990s, law enforcement agencies across the United States adopted a variety of innovative strategies. This article presents case studies of eight cities' efforts to police gun crime. Some cities emphasized police-citizen partnerships to address youth violence, whereas others focused on aggressive enforcement against youth suspected of even minor criminal activity. Still others attempted to change youth behavior through "soft" strategies built on alternatives to arrest. Finally, some cities used a combination of approaches. Key findings discussed in this article include: Law enforcement agencies that emphasized police-citizen cooperation benefited from a more positive image and sense of legitimacy in the community, which may have enhanced their efforts to fight crime. Aggressive law enforcement strategies may have contributed to a decline in youth gun violence, but they also may have cost police legitimacy in minority communities where residents felt that the tactics were unfair or racially motivated. Approaches that emphasize nonarrest alternatives and problem-solving strategies offer an intriguing but unproven vision for addressing youth gun violence. None of the initiatives presented in the case studies has been shown conclusively to reduce youth gun crime over the long term. The author suggests that policing alone cannot contain youth gun violence, but by carefully balancing enforcement with community collaboration, police departments can help shift social norms that contribute to youth gun violence. (The Future of Children is a publication of the David and Lucile Packard Foundation.)
Behavior-oriented approaches to reducing youth gun violence.

Hardy MS. Future Child 2002; 12(2):100-117.

Correspondence: Marjorie S. Hardy, Department of Psychology, Eckerd College, 4200 54 Avenue South, St Petersburg, FL 33711, USA; (email: hardyms@eckerd.edu).

Advocacy groups on both sides of the guns issue frequently point to changing personal behavior--of both parents and children--as a key element in reducing gun violence among youth. Efforts to bring about these changes range from community-based campaigns, to laws and programs that encourage parents to store their guns safely, to educational initiatives that focus on keeping young children away from guns and encouraging youth to resolve disputes without violence. Unfortunately, these behavior-oriented programs have not shown great success in reducing youth gun violence. This article reviews the research surrounding behavioral approaches to gun violence prevention and highlights obstacles that hamper the effectiveness of these programs. Supportive communities can play a key role in protecting youth from violence in general, but the few community-based violence prevention programs that focus on youth have not been shown to decrease youth access to or use of guns. By and large, behavioral programs and legal interventions aimed at parents have not been proven to reduce youth gun violence. This may be due in part to parental misperceptions about children's risk of injury and ability to protect themselves. Children and youth are particularly difficult targets for behavioral change programs. Cognitive immaturity among younger children and perceptions of invulnerability among adolescents may be part of the reason. Most programs that seek to persuade youth to stay away from guns have not been proven effective. The author concludes that, although behavioral programs could be improved, overall they hold only limited promise for reducing youth gun violence. (The Future of Children is a publication of the David and Lucile Packard Foundation.)

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Rev. 15-Sep-2002.