SafetyLit Update: 2 September 2002

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2 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.

Prevalence of responsible hospitality policies in licensed premises that are associated with alcohol-related harm.

Daly JB, Campbell EM, Wiggers JH, Considine RJ. Drug Alcohol Rev 2002; 21(2): 113-120.

Correspondence: Justine B. Daly, Hunter Centre for Health Advancement, NSW, AUSTRALIA; (email: unavailable).

This study aimed to determine the prevalence of responsible hospitality policies in a group of licensed premises associated with alcohol-related harm. During March 1999, 108 licensed premises with one or more police-identified alcohol-related incidents in the previous 3 months received a visit from a police officer. A 30-item audit checklist was used to determine the responsible hospitality policies being undertaken by each premises within eight policy domains: display required signage (three items); responsible host practices to prevent intoxication and under-age drinking (five items); written policies and guidelines for responsible service (three items); discouraging inappropriate promotions (three items); safe transport (two items); responsible management issues (seven items); physical environment (three items) and entry conditions (four items). No premises were undertaking all 30 items. Eighty per cent of the premises were undertaking 20 of the 30 items. All premises were undertaking at least 17 of the items. The proportion of premises undertaking individual items ranged from 16% to 100%. Premises were less likely to report having and providing written responsible hospitality documentation to staff, using door charges and having entry/re-entry rules. Significant differences between rural and urban premises were evident for four policies. Clubs were significantly more likely than hotels to have a written responsible service of alcohol policy and to clearly display codes of dress and conditions of entry. This study provides an indication of the extent and nature of responsible hospitality policies in a sample of licensed premises that are associated with a broad range of alcohol related harms. The finding that a large majority of such premises appear to adopt responsible hospitality policies suggests a need to assess the validity and reliability of tools used in the routine assessment of such policies, and of the potential for harm from licensed premises. (Copyright © 2002 Australian Professional Society on Alcohol and Other Drugs, Published by Taylor & Francis)

See editorial under Pedestrian and Bicycle Issues.

Civil society and the state: Turkey after the earthquake.

Jalali R. Disasters 2002; 26(2):120-39.

Correspondence:Rita Jalali, Department of Sociology, Middle East Technical University, Ankara, TURKEY; (email: rita@metu.edu.tr).

On 17 August 1999 Turkey was hit by a massive earthquake. Over 17,000 lives were lost and there was extensive damage to Turkey's heartland. This paper examines how various public and private institutions, including state and civil society institutions such as NGOs and the media responded to the needs of earthquake survivors. It documents the extensive involvement of NGOs in the relief efforts immediately after the disaster and examines the impact of such participation on state-civil society relations in the country. The data show that state response to the disaster went through several phases from a period of ineptitude to effective management. The paper credits the media and the NGOs for acting as advocates for survivors and forcing changes at the state level. The paper argues that an ideal response system, which fully addresses the needs of victims, can only be based on state-civil society relations that are both collaborative and adversarial. (Copyright © 2002 Blackwell Publications)
Earthquake disasters--lessons to be learned.

Peleg K, Reuveni H, Stein M. Isr Med Assoc J 2002; 4(5): 361-365.

Correspondence: Kobi Peleg, Trauma and Emergency Medicine Research Unit, Gertner Institute for Health Policy Research, Tel Hashomer, ISRAEL; (email: kobip@gertner.health.gov.il).

Human beings do not have the ability prevent earthquakes. However, we can take measures to minimize injuries and damage by using strict building codes and constructing infrastructures in areas of less risk. A great number of buildings in Israel, including some hospitals, will not withstand a major earthquake as they were built with inadequate standards. Data collected during earthquakes show a significant rise in cardiac-related disease and stress-related medical problems in addition to conventional injuries. Public health issues are of increasing importance due to the collapse of sanitation facilities. In addition to field clinics, field hospitals should be deployed in the vicinity of the stricken area. While planning the medical response for disasters such as earthquakes, one should take into account the availability of local medical personnel. Some or most of the local staff may be unable to function. A study from the Gulf War showed that even the threat of chemical attack resulted in less staff reporting to work [33]. During the 1999 earthquakes in Turkey, many of the hospital staff opted to care for their close families instead of reporting to work at the hospital. Regular training exercises in prehospital emergency medical services for the more common multiple casualty incidents should be bolstered with additional exercises in mass casualty incidents. The basic functions in these scenarios may be quite different. Although no exercise can mimic the real event, preplanning and drills are invaluable. When an earthquake does occur, medical management includes local search and rescue teams together with emergency medical service teams if these can still function. Early deployment of local medical centers can alleviate the burden from local hospitals. Evacuation to distant medical centers is probably a major key for success. Psychological problems are abundant in such incidences, affecting also rescue and medical teams. It becomes a major issue when there are large numbers of pediatric casualties and the operations continue for more than a few days. (Copyright © 2002 Israel Medical Association)

Burns due to gunpowder explosions in fireworks factory: a 13-year retrospective study.

Chen XL, Wang YJ, Wang CR, Hu DL, Sun YX, Li SS. Burns 2002; 28(3): 245-9.

Correspondence: XL Chen, Department of Burns, The First Affiliated Hospital, Anhui Medical University, Anhui 230022, Hefei, PR CHINA; (email: xulinchen@163.net).

The aim of this study was to evaluate the epidemiology of burns due to gunpowder explosions in fireworks factories. Three hundred and fifty-one patients having burns caused by gunpowder explosions in a fireworks factory were admitted to our center from 1 January 1987 to 31 December 1999 and the clinical notes of 339 patients were available for review. Data on age, sex, size, depth and sites of burn, incidence by month, inhalation injury, associated injuries, number of operations, length of hospital stay, morbidity, mortality, and causes of explosions were recorded. The majority of the patients were male, with a mean age of 36.7 years. The mean total burn surface area was 40.9%, mostly deep burns. The commonest areas of the body to be injured were the head and neck. One hundred and eighty-five patients (55%) were injured in December, November, and January. Sixty-five patients (19%) had an inhalation injury, 35 having tracheotomies and mechanical ventilation. Thirty-five patients (10%) had associated injuries, the commonest being the fracture of limbs (25 patients). Two hundred and thirty-two patients (68%) required operations while the number of operations including debridement and grafting, or tracheotomy, per patient were 2.7. The mean time in hospital of the survivors was 32 days with a range of 1-94 days. Acute respiratory distress syndrome (ARDS) and sepsis were the commonest complications during the early post-burn period (7 days or less) and the later period (>7 days), respectively. Forty-four patients died in this series giving a mortality rate of 13%. The commonest cause of death was sepsis (27 patients), followed by multiple organ dysfunction syndrome (MODS) (11 patients). Most accidents (71%) were caused by too much gunpowder put in at one time and accidents resulting from carelessness while making fireworks. Prevention measures are also discussed. (Copyright © 2002 Elsevier Science)
Risk Level Assessment and Occupational Insurance Expenditure: a Gender Imbalance.

Khan J and Jansson B. J Socio-Economics 2001; 30(6):539-547.

Correspondence: Jahangir Khan, Karolinska Instritutet, Department of Public Health Sciences, Division of Social Medicine, Norrbacka, 2nd floor, SE-171 76 Stockholm, SWEDEN; (email: jahangir.khan@phs.ki.se).

It is tested whether occupational risk explains differences in reimbursements from occupational-injury insurance schemes in relation to socioeconomic differences in all municipalities in Stockholm county, Sweden. An occupational risk level is formed, which considered the proportions of workers in various industrial sectors and the probability of a worker being injured in each. A regression analysis is performed, treating socioeconomic condition and risk level as predictors of reimbursement. After controlling for variation in socioeconomic factors, occupational-risk level explains the pattern of payments to men but not to women. From a gender perspective, it can be concluded that women, as a group, are not compensated for their occupational risks to the same extent as men. (Copyright © 2002 Elsevier Science)
Work-related Acute Injuries from Mandatory Fitness Training Among the Swedish Police Force.

de Loes M and Jansson B. Int J Sports Med 2002; 23(3): 212-217.

Correspondence: Marianne de Loses, Karolinska Institutet, Dept of Public Health Sciences, Division of Social Medicine, Stockholm, SWEDEN; (email: Marianne.de.Loes@phs.ki.se).

Acute injuries in the Swedish Police Force from on-duty fitness training were selected retrospectively from the Information System of Occupational Injuries (ISA) at the National Board of Occupational Safety and Health and, if having caused a sick-leave exceeding 2 weeks, to the Labour Market Insurance (AMF Insurance). The latter included injuries from 1995 only. During the seven-year period 1992 to 1998, 920 injuries (80 % in males) from fitness training involving police officers were reported to the ISA-register. The total incidence was 1.6 for policemen per 10 000 hours of exposure and 2.2 for policewomen, which is 1.4 times higher than in men. Around 50 % of the injuries occurred in team and contact sports, with a slightly higher percentage for males, 54 % versus 49 % in females. The percentage of injuries from self-defense training was twice as high as in women than in men, 29 % versus 15 %. In 1995, 42 of the 72 injuries in males and 6 of the 21 injuries in females caused more than 14 days of sick-leave and were announced to the Occupational No Fault Liability Insurance. The major part, 32 of 48 injuries, came from team or contact sports (mainly floorball and soccer). Six policemen incurred injuries that were classified with a degree of disability ranging from 2 to 5 %. The total cost for medical treatment and production loss for the 48 injuries was Euro 248 448 and 99 336, respectively. Team and contact sports accounted for 89 % of the costs and 77 % of the production loss through sick-leave. (Copyright © 2002 Georg Thieme Verlag)

Estimates of the incidence and costs associated with handlebar-related injuries in children.

Winston FK, Weiss HB, Nance ML, Vivarelli-O'Neill C, Strotmeyer S, Lawrence BA, Miller TR. Arch Pediatr Adolesc Med 2002; 156(9): 922-928.

TraumaLink, The Children's Hospital of Philadelphia, 10th Floor, 34th Street and Civic Center Blvd, Philadelphia, PA 19104; USA (email: ).

BACKGROUND: The US Consumer Product Safety Commission is considering handlebar regulation regarding impact performance to address the risk of abdominal and pelvic organ injuries in bicyclists.

OBJECTIVE: To provide national estimates of incidence and costs of handlebar-related abdominal and pelvic organ injuries.

DESIGN AND SETTING: Censuses of hospital discharge data from 19 states were extrapolated to determine national estimates. The percentage of abdominal and pelvic injuries associated with handlebars was estimated based on a case series from a pediatric trauma center. Costs were estimated using standard methods.

PARTICIPANTS: All subjects younger than 20 years treated as inpatients and discharged from acute care hospitals for non-motor vehicle bicycle-related injury in 19 states in 1997 and at a pediatric trauma center located in one of the states between January 1, 1996, and December 31, 2000.

MAIN OUTCOME MEASURES: Incidence of bicycle-related handlebar abdominal and pelvic organ injury, total hospital charges, lifetime medical payments, lifetime productivity loss, and lifetime monetized quality-adjusted life-years.

FINDINGS: An estimated 1147 subjects (95% confidence interval, 1082-1215; 1.49 per 100 000 subjects 19 years and younger) in the United States had serious non-motor vehicle-involved bicycle-related abdominal or pelvic organ injury leading to hospitalization in 1997, and 886 (95% confidence interval, 828-944; 1.15 per 100 000 subjects 19 years and younger) of these injuries likely were associated with handlebars. The estimated national costs associated with handlebar-related abdominal and pelvic organ injuries were $9.6 million in total hospital charges, $10.0 million in lifetime medical costs (including claims processing), $11.5 million in lifetime productivity losses, and $503.9 million in lifetime monetized quality-adjusted life-years.

DISCUSSION: Handlebar-related abdominal and pelvic organ injuries pose a serious health risk to children and result in substantial health care costs. Requirements for safer handlebar designs may provide one avenue to achieve a health and economic benefit. (Copyright © 2002 American Medical Association)
Effect of legislation on the use of bicycle helmets.

Leblanc JC, Beattie TL, Culligan C. CMAJ 2002; 166(5):592-595.

Correspondence: John C. LeBlanc, Dalhousie University, Department of Pediatrics, IWK–Grace Health Centre, Halifax, NS, CANADA (email: John.LeBlanc@Dal.Ca).

BACKGROUND: About 50 Canadian children and adolescents die each year from bicycle-related injuries, and 75% of all bicycle-related deaths are due to head injuries. Although the use of helmets can reduce the risk of head injury by 85%, the rate of voluntary helmet use continues to be low in many North American jurisdictions. We measured compliance before, during and after 1997, when legislation making the use of helmets mandatory for cyclists was enacted in Nova Scotia. METHODS: In the summers and autumns of 1995 through 1999, trained observers who had a direct view of oncoming bicycle traffic recorded helmet use, sex and age group of cyclists in Halifax on arterial, residential and recreational roads. Sampling was done during peak traffic times of sunny days. We abstracted data from the Canadian Hospitals Injury Reporting and Prevention Program database on bicycle-related injuries treated during the same period at the Emergency Department of the IWK Health Centre, Halifax. RESULTS: The rate of helmet use rose dramatically after legislation was enacted, from 36% in 1995 and 38% in 1996, to 75% in 1997, 86% in 1998 and 84% in 1999. The proportion of injured cyclists with head injuries in 1998/99 was half that in 1995/96 (7/443 [1.6%] v. 15/416 [3.6%]) (p = 0.06). Police carried out regular education and enforcement. There were no helmet-promoting mass media education campaigns after 1997. INTERPRETATION: Rates of helmet use rose rapidly following the introduction of legislation mandating the use of helmets while bicycling. The increased rates were sustained for 2 years afterward, with regular education and enforcement by police. (Copyright © 2002 Canadian Medical Association)
Hats off (or not?) to helmet legislation.

Chipman ML. CMAJ 2002; 166(5): 602.

Correspondence: Mary L. Chipman, 12 Queen's Park Cres. W, Toronto ON M5S 1A8, CANADA; (email: mary.chipman@utoronto.ca).

A preventive measure is most likely to succeed when 3 conditions are met: 1) it is population based, rather than requiring individual initiatives; 2) it is passive, rather than requiring active participation; and 3) it is accomplished with a single action, rather than requiring repeated reinforcement. Thus, we install water treatment systems in every community, rather than ask people to boil their own drinking water (condition 1). We require that cars have passive air bags installed in addition to seat belts (condition 2). We prefer vaccines that provide lifetime immunity to those that require booster shots (condition 3).

A law that requires cyclists to wear helmets does not incorporate any of these conditions — individual riders must actively purchase a helmet and remember to wear it every time they cycle — and should have a low chance of success. It is therefore reassuring to see that, despite these theoretical drawbacks, the helmet law in Nova Scotia appears to be working (see report above). Not only has the proportion of riders wearing helmets increased since the legislation was passed, but the incidence of head injuries among cyclists has decreased in the same period, and these changes are persistent.

Nova Scotia is among only 5 provinces in Canada to have such laws in place, and John LeBlanc and colleagues1 urge physicians in other provinces to lobby actively for comparable legislation. Before doing so, however, one might ask why legislation appears to work so well.

Legislation can have any of the following effects: cyclists comply by buying helmets for themselves and their children and wearing them consistently; cyclists comply by not cycling or forbidding their children to cycle; or cyclists fail to comply (i.e., they do not wear a helmet) and cycle less than before.

On the basis of the data presented by LeBlanc and colleagues, all 3 effects may have occurred in Halifax. Certainly some cyclists will have responded by wearing helmets that they would not have bothered with before the legislation was passed. But there is troubling evidence that less positive responses have also occurred. The number of cyclists observed per day dropped from nearly 90 in 1995/96 to 34 in 1997 and 52 in 1998/99. Also, the proportion of the child cyclists observed decreased, from 8.1% before the legislation to 6.1% in the year it was introduced to 3.7% 2 years afterward. These results may be due in part to changes in observation sites or to bad weather in some years that discouraged all but the most dedicated cyclists. They are, however, exactly what one would expect if people were complying with the legislation by cycling less themselves and discouraging their children from cycling. Moreover, these figures reflect a pattern observed in New South Wales and Victoria, Australia, before and after legislation was introduced.2 Although the numbers of helmeted cyclists went up, the total numbers of cyclists dropped by larger amounts in the 2 years after the law took effect. These observations were made in good weather and in a country that had had a lengthy campaign to promote bike safety before the legislation was introduced.

If legislation has discouraged people, particularly children, from cycling, this is a negative effect that requires both acknowledgement and response. With an increasing prevalence of obesity3 and continued low levels of physical activity among children and youth,4 the benefits of cycling cannot easily be dismissed. Legislation is not the only means to encourage safer cycling, and we may be foolish to rely on it so heavily. Legislation cannot provide the positive feedback often necessary to change behaviour. I am reminded of a colleague who wears her seat belt when driving because it makes her feel comfortable; she says, "It's like getting a hug from your car." It is hard to imagine similar positive reinforcement for wearing a bicycle helmet. But there are other changes that will promote safety, such as dedicated bicycle paths, better education of motorists about sharing the road with cyclists, improved visibility and other safety gear. Physicians and others need to promote these changes, because legislation cannot do enough. Together, such measures can meet the 3 conditions for successful preventive measures: population based (e.g., helmet legislation that applies to all ages), passive (e.g., the development of safer environments for cyclists, such as bike paths) and not requiring repeated reinforcement (e.g., a bike of the right size for the rider).

Much of what is said to justify helmet legislation suggests that promotion alone does not work. The data from Australia and now Nova Scotia1 suggest that legislation increases helmet use but also reduces the numbers of cyclists. We need to develop and evaluate a combined approach to achieve the true benefits of safe cycling. (Copyright © 2002 Canadian Medical Association)
Butting heads over bicycle helmets.

DeMarco TJ. CMAJ 2002; 337-338.

Correspondence: Thomas J. DeMarco, Physician, Whistler, BC, CANADA; (email and postal addresses are unavailable).

Ten years after publishing an article in CMAJ1 about the negative implications of bicycle helmet legislation, I continue to be dumbfounded by the broad consensus within our profession in favour of such laws.

A fundamental problem with emphasizing and legislating helmet use is that it reinforces the popular misconception that road bicycling is dangerous. The predictable result of such a message is decreased ridership, as Mary Chipman astutely warns. Thanks to superior cardiovascular fitness, the average cyclist outlives the average noncyclist, helmet or no helmet. Ultimately, helmet laws save a few brains but destroy many hearts.

Observations in several countries over the past 30 years have demonstrated how road cycling safety is consistently related to the numbers of riders. The converse is also true: individual risk rises as ridership declines, a pattern well documented in the US over the past decade. As helmet laws there have become widespread, and as road cycling has become less popular, the rate of injury per active cyclist has risen by 50%.

Fatal cyclist head injuries represent far less than 10% of all road-related deaths. Instead of fixating on protection for a small minority of road users, why don't physicians champion prevention of crashes and support measures that make roads safer for everyone? A priority should be to lower urban speed limits, especially on residential streets where traffic-calming devices should be standard. We should also support the elimination of all free parking, both public and commercial. By reducing both the speed and convenience of driving, we'd instantly witness dramatic declines in fatalities and everyone would benefit from model shifts to healthier, safer and more environmentally friendly forms of transport, such as walking, bicycling and public transit. (Copyright © 2002 Canadian Medical Association)
Butting heads over bicycle helmets.

Wardlaw M. CMAJ 2002; 167(4): 337-338.

Correspondence: Malcolm Wardlaw, Transport Safety Analyst, UK92 Drymen Road, Bearsden, Glasgow G61 2SY, UK (email: unavailable)

The data presented by LeBlanc and colleagues (see above) show that the risk of head injury per cyclist did not change as a result of the law, but rather the risk of other injuries approximately doubled. Their bicycle count data show a 40%–60% fall in the number of cyclists after the law was passed, from 88 per day down to 33 or 52 per day. Their injury data show a sharp fall in total injuries in 1997, but for 1998/99 the number of injuries was higher than before the law (443 v. 416). The absolute number of head injuries has fallen by half, but so has the number of cyclists, although the total number of injuries has increased. Likewise, the claim of a doubling in the rate of helmet use omits the more telling point that the absolute number of cyclists using helmets did not materially change.

The Nova Scotia helmet law experience strengthens the arguments against helmet laws. No reduction has occurred in the risk of head injury per cyclist, relative to this study's loose definition of head injury. However, a big increase has occurred in the risk of non-head injury per cyclist. Furthermore, there has been no material increase in the number of helmeted cyclists. Rather, cycling on a substantial scale has been deterred. The deterrence of the safest mode of urban transport will not contribute to overall road safety or public health. (Copyright © 2002 Canadian Medical Association)
Butting heads over bicycle helmets: A reply to the critics.

LeBlanc JC. CMAJ 2002; 167(4):337-338.

Correspondence: John C. LeBlanc, Dalhousie University, Department of Pediatrics, IWK–Grace Health Centre, Halifax, NS, CANADA (email: John.LeBlanc@Dal.Ca).

In her editorial, (see above) Mary Chipman states that the introduction of bicycle helmet legislation in Nova Scotia may have reduced cycling activity and the proportion of child cyclists. However, our study design precludes drawing this conclusion. We sought to maximize the number of cyclists observed in a fixed observation period. Due to availability of observers, we could not standardize observation times from year to year. Not surprisingly, we observed large variations in the number of cyclists per unit time, depending on the time of day, the day of the week, or the month. For example, during 1998 and 1999 we collected data almost exclusively during weekdays, which largely reflected adult commuter traffic. These variations in collection methods are a far more plausible explanation for the variation in cycling rates and proportion of child cyclists than the legislation. In support of this view, the owners of 3 major Halifax bicycle shops informed me that although bicycle helmet sales surged after the introduction of the legislation, there was no reduction in the sale of bicycles and no discernable impact on cycling activity.

Chipman refers to an Australian report by Dorothy Robinson that revealed cycling by children under 12 fell by 36% after the introduction of helmet legislation. However, Robinson did not discuss whether the decline persisted or whether those who stopped cycling substituted other equally beneficial activities. Chipman did not cite the study conducted by her colleagues who directly assessed the impact of helmet legislation on cycling behaviour in Toronto.4 They found that the rate of child cyclists before and after the introduction of bicycle helmet legislation actually increased from 4.3 cyclists per hour in the preceding year to 6.8 cyclists per hour in the year following the introduction of a law similar to the Nova Scotia legislation.

Thomas DeMarco continues to be dumbfounded by the widespread support of the medical profession for helmet legislation. Without offering any evidence, he concludes that "ultimately, helmet laws save a few brains but destroy many hearts." Such a conclusion cannot be drawn without knowing about the habits of those who abandoned cycling, and what activities if any they substituted in their quest for freedom from the burden of helmets.

Finally, based on calculations not warranted by our study design, Malcolm Wardlaw comes to the remarkable conclusion that cycling activity in Halifax has been cut in half. In addition, he ignores published literature that shows cycling rates continue to increase after the introduction of legislation as well as accumulating evidence, summarized in a Cochrane review and a subsequent able defence against its critics, that has already shown that helmets are effective in preventing head injuries. This evidence cannot be dismissed by inappropriate secondary analysis of our data.

In summary, opponents of helmet legislation speculate that helmet legislation leads to increased cardiovascular deaths by discouraging exercise. First, is there clear evidence that the introduction of helmet legislation is followed by reduced cycling? Although our study cannot be used to address this question, the Australian study shows reduced cycling following legislation. However, the Canadian study indicates cycling continued to increase after the introduction of legislation. Second, do cyclists who oppose legislation and decide to stop become inactive and obese, or do they substitute other physical activity? No empirical evidence exists to respond to this question scientifically. Policy debate concerning the benefits and risks of helmet legislation must be rooted in evidence, not in speculation or strongly held views that ignore evidence to the contrary. (Copyright © 2002 Canadian Medical Association)

No reports this week

See reports under Pedestrians and Bicycles

No reports this week

Multiple risk behavior and injury: an international analysis of young people.

Pickett W, Schmid H, Boyce WF, Simpson K, Scheidt PC, Mazur J, Molcho M, King MA, Godeau E, Overpeck M, Aszmann A, Szabo M, Harel Y. Arch Pediatr Adolesc Med 2002; 156(8): 786-93.

Department of Community Health and Epidemiology, Queen's University, c/o Emergency Medicine Research, Angada 3, Kingston General Hospital, 76 Stuart St, Kingston, Ontario, K7L 2V7 CANADA;PickettW@post.queensu.ca).

BACKGROUND: Multiple risk behavior plays an important role in the social etiology of youth injury, yet the consistency of this observation has not been examined multinationally.

OBJECTIVE: To examine reports from young people in 12 countries, by country, age group, sex, and injury type, to quantify the strength and consistency of this association.

SETTING: World Health Organization collaborative cross-national survey of health behavior in school-aged children.

PARTICIPANTS: A multinational representative sample of 49 461 students aged 11, 13, and 15 years.

MAIN EXPOSURE MEASURES: Additive score consisting of counts of self-reported health risk behaviors: smoking, drinking, nonuse of seat belts, bullying, excess time with friends, alienation at school and from parents, truancy, and an unusually poor diet.

MAIN OUTCOME MEASURE: Self-report of a medically treated injury.

FINDINGS: Strong gradients in risk for injury were observed according to the numbers of risk behaviors reported. Overall, youth reporting the largest number (>/=5 health risk behaviors) experienced injury rates that were 2.46 times higher (95% confidence interval, 2.27-2.67) than those reporting no risk behaviors (adjusted odds ratios for 0 to >/=5 reported behaviors: 1.00, 1.22, 1.48, 1.73, 1.98, and 2.46, respectively; P<.001 for trend). Similar gradients in risk for injury were observed among youth in all 12 countries and within all demographic subgroups. Risk gradients were especially pronounced for nonsports, fighting-related, and severe injuries.

DISCUSSION: Gradients in risk for youth injury increased in association with numbers of risk behaviors reported in every country examined. This cross-cultural finding indicates that the issue of multiple risk behavior, as assessed via an additive score, merits attention as an etiological construct. This concept may be useful in future injury control research and prevention efforts conducted among populations of young people. (Copyright © 2002 American Medical Assocation)
International comparison of costs of a fatal casualty of road accidents in 1990 and 1999.

Trawen A, Maraste P, Persson U. Accid Anal Prev 2002; 34(3): 323-332.

Correspondence: Anna Trawen, Department of Technology and Society, Lund Institute of Technology, Lund University, SWEDEN; (email: anna.trawen@tft.lth.se).

The purpose of this study is to assemble information of costs per fatal casualty in traffic accidents, adopted by authorities in different countries. analyse and compare these figures as well as the methods used for estimating these values. A questionnaire was sent to 19 countries from which 11 gave information on cost per fatality and methods of valuation. The costs per fatality, usually defined as direct and indirect costs plus a value of safety per se, are compared both between countries and over time, 1990 and 1999, for each country. The average cost per fatality has increased between 1990 and 1999 (fixed prices) due to both changes in the methodology and changes of valuations. Great Britain, New Zealand, Sweden and the US conduct own willingness-to-pay (WTP) surveys, while the Netherlands and Norway make reviews of these studies. In Finland, the cost per fatality is a combination of the value of lost productivity and the cost of care for an institutionalised disabled person. In Australia, Austria, Germany and Switzerland, the cost per fatality is estimated as a value of lost productivity and an addition of a human cost based on compensation payments or insurance payments. Estimates from recently conducted WTP surveys or meta-analyses are considered in Austria, Finland and Sweden, however, not yet adopted as official values for use in road traffic planning. (Copyright © 2002 Elsevier Science)

No reports this week

See several reports under Violence.

Suicide classification-clues and their use. A study of 122 cases of suicide and undetermined manner of death.

Lindqvist P, Gustafsson L. Forensic Sci Int 2002; 128(3): 136-140.

Correspondence: Per Lindqvist, Department of Community Medicine and Rehabilitation, Section of Forensic Medicine, Umea University, P.O. Box 7642, SE-907 12, Umea, SWEDEN; (email: per.lindqvist@spo.sll.se).

In order to identify clues to forensic pathologist's classification of suicide, the forensic files of 100 consecutive cases of suicide, and 22 cases of undetermined manner of death, were analysed. Some specific causes of death, suicidal communication and other circumstantial evidence suggesting suicidal intent explained all but three classifications. Problematic cases concerned death by poisoning and by submersion, alcohol-dependent persons and subjects with positive blood alcohol concentration at autopsy. Guidelines to support the police investigation as well as the medico-legal examination can probably reduce the number of undetermined cases in cases of possible suicide. (Copyright © 2002 Elsevier Science)
Suicide in children, adolescents and young adults.

Schmidt P, Muller R, Dettmeyer R, Madea B. Forensic Sci Int 2002; 127(3): 161-167.

Correspondence: P. Schmidt, Institute of Forensic Medicine, Rheinische Friedrich-Wilhelms-Universitat, Stiftspatz 12, D 53111, Bonn, GERMANY; (email: unavailable).

As suicides of children, adolescents and young adults occur very seldom and only few case reports and more comprehensive studies are available in forensic literature, the autopsy records of the Bonn Institute of Forensic Medicine and the database of the Bonn police authorities from 1989 to 1998 were retrospectively analysed for this phenomenon. This search revealed 37 respective suicides involving 23 male (62%) and 14 female (38%) victims. The ages ranged from 10 to 21 years with the prevalence sharply increasing in adolescents and young adults. Independent from sex, the victims almost unexceptionally applied hard suicide methods like hanging, running over by a train or jump from the height. As for the psychological background, current conflicts with a sweetheart, within the family or at school on the background of mental illness or chronically disturbed family structures were encountered as prevailing factors. (Copyright © 2002 Elsevier Science)

Multidisciplinary in-depth investigations of head-on and left-turn road collisions.

Larsen L, Kines P. Accid Anal Prev 2002; 34(3):367-80.

Danish Transport Research Institute, Lyngby, DENMARK; (email: dtf@dtf.dk).

To enhance traffic safety, a multidisciplinary Road Accident Investigation Team was established in Denmark for a 2-year trial period. The objective was to conduct in-depth investigations of specific types of accidents, and to identify effective preventive measures. The team consisted of a road engineer, a vehicle inspector, a police superintendent, a psychologist and a physician. Seventeen serious head-on collisions as well as 17 left-turn collisions were analysed. In collecting data, police reports were supplemented by the team's investigation of accident sites and vehicles involved, and interviews were carried out with the involved road users and witnesses. The drivers, to whom the accident factors were primarily related in the head-on collisions, were characterised by their conscious risk-taking behaviour. They were all males; several of them were under age 40 and had earlier traffic and/or drug convictions. The main accident factors were excessive speed, drunk driving and driving under the influence of illegal drugs. In the left-turn accidents, the most common accident factors were attention errors, and it was also noted that elderly drivers (> 74) were over-represented. The synergy effect of working as a multidisciplinary team proved fruitful. It resulted in a more precise knowledge of the road accident circumstances and of contributing factors leading up to the accidents. Due to the great demand on resources, only a limited number of accidents could be analysed, but the results provide a basis for further and more targeted research. (Copyright © 2002 Elsevier Science)
Toll road crashes of commercial and passenger motor vehicles.

Braver ER, Solomon MG, Preusser DF. Accid Anal Prev 2002; 34(3):293-303.

Correspondence: ER Braver, Insurance Institute for Highway Safety, Arlington, VA 22701-4751, USA; (email: ebraver@iihs.org).

Revenue-collection data from toll roads allow for accurate estimates of miles driven by vehicle type and, when combined with crash data, valid estimates of crash involvements per mile driven. Data on vehicle-miles traveled and collisions were obtained from toll road authorities in Florida. Kansas, and New York. In addition, state crash files and published vehicle-miles of travel were obtained for toll roads in Illinois. Indiana, Ohio, and Pennsylvania. Large commercial motor vehicles were significantly underinvolved in single-vehicle crashes on all state toll roads. In five states, commercial motor vehicles were significantly overinvolved in multiple-vehicle crashes relative to passenger vehicles; the exceptions were Kansas, where they had significantly lower multiple-vehicle involvement rates, and Indiana. where there were no significant differences in multiple-vehicle involvements by vehicle type. The risk of commercial motor vehicle involvement in multiple-vehicle crashes resulting in deaths or serious injuries was double that of passenger vehicles in the two states (Ohio and Pennsylvania) that identified serious injuries. Whether crash rates, on toll roads of commercial motor vehicles are higher or lower than those of passenger vehicles appears to depend on the type of crash, specific toll road. and traffic density. (Copyright © 2002 Elsevier Science)
A comparison of safety belt use between commercial and noncommercial light-vehicle occupants.

Eby DW, Fordyce TA, Vivoda JM. Accid Anal Prev 2002; 34(3):285-91.

Correspondence: DW Eby, Transportation Research Institute, University of Michigan, UMTRI-SBA, Ann Arbor 48109-2150, USA; (email: eby@umich.edu).

The purpose of this study was to conduct an observational survey of safety belt use to determine the use rate of commercial versus noncommercial light-vehicle occupants. Observations were conducted on front-outboard vehicle occupants in eligible commercial and noncommercial vehicles in Michigan (i.e.. passenger cars, vans/minivans, sport-utility vehicles, and pickup trucks). Commercial vehicles that did not fit into one of the four vehicle type categories, such as tractor-trailers, buses, or heavy trucks, were not included in the survey. The study found that the restraint use rate for commercial light-vehicle occupants was 55.8% statewide. The statewide safety belt use rate for commercial light-vehicles was significantly lower than the rate of 71.2% for noncommercial light-vehicles. The safety belt use rate for commercial vehicles was also significantly different as a function of region, vehicle type, seating position, age group, and road type. The results provide important preliminary data about safety belt use in commercial versus noncommercial light-vehicles and indicate that further effort is needed to promote safety belt use in the commercial light-vehicle occupant population. The study also suggests that additional research is required in order to develop effective programs that address low safety belt use in the commercial light-vehicle occupant population. (Copyright © 2002 Elsevier Science)
An exploratory study of the relationship between road rage and crash experience in a representative sample of US drivers.

Wells-Parker E, Ceminsky J, Hallberg V, Snow RW, Dunaway G, Guiling S, Williams M, Anderson B. Accid Anal Prev 2002; 34(3): 271-278.

Correspondence: Elisabeth N. Wells-Parker, Social Science Research Center, Mississippi State University, MS 39762, USA; (email: bwparker@ssrc.msstate.edu).

The phenomenon of road rage has been frequently discussed but infrequently examined. Using a representative sample of 1382 US adult drivers, who were interviewed in a 1998 telephone survey, exploratory analyses examined the relationship between self-reported measures of road rage, generally hazardous driving behaviors, and crash experience. Regarding specific road rage behaviors, most respondents reported having engaged in verbal expressions of annoyance; however only 2.45% reported ever having been involved in direct confrontation with another car or driver. After controlling for gender, age. driving frequency, annual miles driven and verbal expression, an angry/threatening driving subscale of road rage was significantly associated with hazardous driving behaviors that included frequency of driving over the legal blood alcohol limit, receipt of tickets in the past year. and habitually exceeding the speed limit as well as crash experience. However, the verbal/frustration expression subscale was not associated with crash experience or hazardous driving indicators, except for number of tickets, after controlling for other crash-related factors such as gender and age. Direct confrontation by deliberately hitting another car or leaving the car to argue with and/or injure another driver was rarely reported. Results suggest that angry/threatening driving is related to crash involvement; however, after controlling for exposure and angry/threatening and hazardous driving the relationship of milder expressions of frustration while driving and crash involvement was not significant. (Copyright © 2002 Elsevier Science)

See Also final abstract under Transportation (above)
Definitions of bullying: a comparison of terms used, and age and gender differences, in a fourteen-country international comparison.

Smith PK, Cowie H, Olafsson RF, Liefooghe AP, Almeida A, Araki H, del Barrio C, Costabile A, Dekleva B, Houndoumadi A, Kim K, Olafsson RP, Ortega R, Pain J, Pateraki L, Schafer M, Singer M, Smorti A, Toda Y, Tomasson H, Wenxin Z. Child Dev 2002; 73(4): 1119-1133.

Correspondence: Peter K. Smith, Department of Psychology, Goldsmiths College, New Cross, SE14 6NW, London, UK; (email: p.smith@gold.ac.uk).

The study of school bullying has recently assumed an international dimension, but is faced with difficulties in finding terms in different languages to correspond to the English word bullying. To investigate the meanings given to various terms, a set of 25 stick-figure cartoons was devised, covering a range of social situations between peers. These cartoons were shown to samples of 8- and 14-year-old pupils (N = 1,245; n = 604 at 8 years, n = 641 at 14 years) in schools in 14 different countries, who judged whether various native terms cognate to bullying, applied to them. Terms from 10 Indo-European languages and three Asian languages were sampled. Multidimensional scaling showed that 8-year-olds primarily discriminated nonaggressive and aggressive cartoon situations; however, 14-year-olds discriminated fighting from physical bullying, and also discriminated verbal bullying and social exclusion. Gender differences were less appreciable than age differences. Based on the 14-year-old data, profiles of 67 words were then constructed across the five major cartoon clusters. The main types of terms used fell into six groups: bullying (of all kinds), verbal plus physical bullying, solely verbal bullying, social exclusion, solely physical aggression, and mainly physical aggression. The findings are discussed in relation to developmental trends in how children understand bullying, the inferences that can be made from cross-national studies, and the design of such studies. (Copyright © 2002 Society for Research in Child Development)
Alternative strategies for school violence prevention.

Gagnon JC, Leone PE. New Dir Youth Dev 2001; 92: 101-125.

Correspondence: Joseph C. Gagnon, Department of Special Education, University of Maryland, College Park, USA; (email: jgagnon@umd.edu).

A number of programs with empirical evidence of effectiveness in addressing problems of aggression and disruption have emerged in schools. This report discusses the alternatives. (Copyright © 2002 Josey-Bass)
Pediatric residents' attitudes and behaviors related to counseling adolescents and their parents about firearm safety.

Solomon BS, Duggan AK, Webster D, Serwint JR. Arch Pediatr Adolesc Med 2002; 156(8): 769-775.

The Johns Hopkins University School of Medicine, Division of General Pediatrics and Adolescent Medicine, 600 N Wolfe St, Children's Medical and Surgical Center 149, Baltimore, MD 21287, USA; (email: bsolomo@jhmi.edu).

BACKGROUND: Firearms continue to be a major cause of mortality in adolescence. Although the American Academy of Pediatrics strongly encourages pediatricians to counsel adolescents and their parents on firearm safety, few residency programs educate their trainees in this area. More in-depth information is needed to design effective educational interventions.

OBJECTIVES: To determine the attitudes, beliefs, and practices of pediatric residents regarding firearm safety counseling and to compare their counseling practices for adolescents and parents of adolescents during health maintenance visits.

DESIGN: Cross-sectional survey.

PARTICIPANTS: Pediatric residents from 9 programs in the mid-Atlantic region.

FINDINGS: Of the 322 respondents (76% response rate), few believed that it is not a pediatrician's responsibility to counsel, that their patients are not at risk for firearm injury, and that children are safer with a gun in the home. However, only 50% reported routine counseling, and more than 20% reported almost never counseling adolescents and their parents on firearm safety. Barriers included inadequate training (38%), insufficient time (26%), and a lack of preceptor expectation (13%). The strongest predictors for counseling adolescents included the belief that gun-related media coverage influences counseling practice, level of training, and personal experience with guns in the home. The strongest predictors for counseling parents of adolescents were the belief in the media's influence on counseling practice, perceived counseling effectiveness, and discomfort with firearm safety counseling.

DISCUSSION: To increase counseling practices, clinical preceptors should aim to strengthen residents' comfort in counseling and to develop specific ways to enhance their perceived effectiveness in counseling parents. (Copyright © 2002 American Medical Association)
The costs of gun violence against children.

Cook PJ, Ludwig J. Future Child 2002; 12(2): 86-99.

Sanford Institute of Public Policy, Duke University, USA.

Gun violence imposes significant costs on children, families, and American society as a whole. But these costs can be difficult to quantify, as much of the burden of gun violence results from intangible concerns about injury and death. This article explores several methods for estimating the costs of gun violence. One method is to assess how much Americans would be willing to pay to reduce the risk of gun violence. The authors use this "willingness-to-pay" framework to estimate the total costs of gun violence. Their approach yields the following lessons: Although gun violence has a disproportionate impact on the poor, it imposes costs on the entire socioeconomic spectrum through increased taxes, decreased property values, limits on choices of where to live and visit, and safety concerns. Most of the costs of gun violence--especially violence against children--result from concerns about safety. These are not captured by the traditional public health approach to estimating costs, which focuses on medical expenses and lost earnings. When people in a national survey were asked about their willingness to pay for reductions in gun violence, their answers suggested that the costs of gun violence are approximately $100 billion per year, of which at least $15 billion is directly attributable to gun violence against youth. The authors note that in light of the substantial costs of gun violence, even modestly effective regulatory and other interventions may generate benefits to society that exceed costs. (The Future of Children is a publication of the David and Lucile Packard Foundation.)
Product-oriented approaches to reducing youth gun violence.

Teret SP, Culross PL. Future Child 2002; 12(2):118-131.

Center for Law and the Public's Health, Johns Hopkins University, USA; (email: steret@jhsph.edu).

Injury prevention experts have suggested that gun manufacturers could reduce youth violence by changing the design of guns. Product safety features could make guns more difficult for children to fire unintentionally and more difficult to use if stolen or obtained illegally. This article gives a brief history of efforts to make safer, smarter guns and assesses the potential of the product safety approach for reducing youth gun violence. Among the article's key findings: Research from the injury prevention field suggests that changing product design may be more effective in preventing injuries than trying to change personal behaviors; Existing product safety technologies for guns could reduce unintentional gun injuries, especially to young children. In addition, emerging technologies will enable gun manufacturers to "personalize" guns, which could prevent unauthorized users of any age from firing the weapons. Personalization could decrease access to guns by adolescents; Gun manufacturers have been slow to incorporate safety features into their products; but legislative, regulatory, and litigation efforts are under way to mandate safer guns. The authors envision a future when the law requires product safety features--including personalization--on all new firearms. These product safety features have the potential to reduce both intentional and unintentional firearm injury and death. (The Future of Children is a publication of the David and Lucile Packard Foundation.)

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Rev. 21-Jun-2002 at 23:16 hours.