Correspondence: W. Downs, Department of Social Work, University of Northern Iowa, 30 Sabin Hall, Cedar Falls, Iowa 50614-0405, USA; (email: downs@uni.edu).
OBJECTIVE: The objective of this study is to examine the associations between mother physical abuse, mother psychological aggression, father physical abuse and father psychological aggression and women's alcohol dependence while controlling for several demographic variables, childhood sexual abuse and mother and father alcohol problems.
METHOD: Samples of women in treatment for substance use disorders (n = 225) and receiving services for domestic violence (n = 222) volunteered to be in the study. We used the Parent-Child Conflict Tactics Scales to assess retrospectively experiences of parental aggression during childhood and the Composite International Diagnostic Interview for a diagnosis of alcohol dependence based on International Classification of Diseases (ICD-10) criteria.
FINDINGS: Logistic regression applied to the data showed that being in the substance use disorder treatment sample, being unemployed and not being black were significantly related to a higher likelihood of lifetime diagnosis of alcohol dependence. Mother psychological aggression was found to be significantly associated with alcohol dependence. Father psychological aggression was found to be significantly related to alcohol dependence for nonwhite women but not for white women. Mother and father physical abuse were both found to be significantly related to alcohol dependence, but only for women who did not report childhood sexual abuse.
COMMENTS: Associations between experiences of childhood abuse and development of alcohol problems for women are complex. Experiences of mother and father abuse need to be examined separately with samples of women who are of different ethnicities and samples of women who are receiving services for different problems.
Changes in alcohol involvement, cognitions and drinking and driving behavior for youth after they obtain a driver's license.
- McCarthy DM, Brown SA. J Stud Alcohol 2004; 65(3): 289-296.
Correspondence: Denis M. McCarthy, Department of Psychological Sciences, University of Missouri, Columbia, 210 McAlester Hall, Columbia, Missouri 65211, USA; email: mccarthydm@missouri.edu).
OBJECTIVE: This study tested whether obtaining a driver's license was associated with increases in alcohol and other drug involvement and changes in alcohol-related cognitions for youth, and whether drinking and driving behavior increased with driving experience.
METHODS: Confidential, anonymous surveys were conducted at two time points (fall, spring) with students at four high schools in San Diego county (N = 2,865, 51% female). Data were collected on alcohol, cigarette and marijuana use, license status, alcohol use by peers, attitudes towards drinking and driving and drinking and driving behaviors.
FINDINGS: Nondrivers (60%), new drivers (obtained a license between Time 1 and Time 2) and experienced drivers (26%) were compared on study variables at both time points and over time. Initially obtaining a driver's license was associated with increased frequency of substance use. Results were not significant for quantity of alcohol use, frequency of heavy drinking or perceived alcohol use norms. Attitudes towards drinking and driving reflected an increase in the perceived dangerousness of this behavior for new drivers. Drinking and driving behavior during the last 30 days increased with increased driving experience.
COMMENTS: The results indicate a number of changes in substance involvement after obtaining a driver's license. However, initially this transition may also indicate a period of protection against drinking and driving. These results may have implications for the target and content of drinking and driving interventions.
Flint photovoice: community building among youths, adults, and policymakers.
- Wang CC, Morrel-Samuels S, Hutchison PM, Bell L, Pestronk RM. Am J Public Health 2004; 94(6): 911-913.
Correspondence: C. Wang, School of Public Health/HBHE, University of Michigan, 1420 Washington Heights, Ann Arbor, MI 48109-2029, USA; (email: wangc@umich.edu).
Flint Photovoice represents the work of 41 youths and adults recruited to use a participatory-action research approach to photographically document community assets and concerns, critically discuss the resulting images, and communicate with policymakers.At the suggestion of grassroots community leaders, we included policymakers among those asked to take photographs. In accordance with previously established photovoice methodology, we also recruited at the project's outset another group of policymakers and community leaders to provide political will and support for implementing photovoice participants' policy and program recommendations.Flint Photovoice enabled youths to express their concerns about neighborhood violence to policymakers and was instrumental in acquiring funding for local violence prevention. We note salutary outcomes produced by the inclusion of policymakers among adults who took photographs.
Correspondence: Gwen Keeney, University of Illinois at Chicago, UIH Rm. 404, M/C 443, 1740 W. Taylor, Chicago, IL 60612, USA; (email: gbkeeney@uic.edu).
Disasters are events that exceed the capacity of the people affected to recover from the adverse affects. Understanding types of disasters and components of disaster responses provides a basis for developing disaster preparedness plans. Disaster preparedness is a process for assessing risks and capacities for responding when disasters occur. Planning can mitigate damages and facilitate rapid and effective disaster response services. Health care workers, including midwives and women's health care providers, can access resources to be prepared as competent responders in disaster contexts to meet the needs of women and their communities.
Posttraumatic stress reactions among children following the Athens earthquake of September 1999.
- Kolaitis G, Kotsopoulos J, Tsiantis J, Haritaki S, Rigizou F, Zacharaki L, Riga E, Augoustatou A, Bimbou A, Kanari N, Liakopoulou M, Katerelos P. Eur Child Adolesc Psychiatry 2003; 12(6):273-80.
Correspondence: John Tsiantis, Department of Child Psychiatry, Athens University Medical School, Aghia Sophia Children's Hospital, Thivon & Levadias Str. 115, 27 Athens, GREECE; (email: itsianti@cc.uoa.gr).
The objective of the present study was to assess symptoms of posttraumatic stress disorder (PTSD), depression and anxiety among children 6 months after they had been exposed to an earthquake (EQ) affecting the northwestern suburbs of Athens in September 1999. A total of 115 children attending two elementary schools located at the epicentre of the EQ were assessed. A group of 48 children not affected by the EQ attending a school not affected by the EQ were used as controls. The children and their parents completed a number of questionnaires. Overall, there was a high rate (78%) of severe to mild PTSD symptoms in the EQ exposed group. Additionally, a substantial proportion of these children scored above criteria (32%) for depression compared to the control group (12.5%). Severe or moderate symptoms of PTSD were associated with high scores of depression (p = 0.002). The relationship between PTSD symptoms and anxiety was limited to the "avoidance" factor of the anxiety questionnaire (p = 0.029). Those who were most likely to be affected were children alone at the time of the EQ, and children who sustained injuries. In summary, countries where EQs are frequent should be prepared to offer psychological support to a substantial proportion of children presenting with PTSD and depressive symptoms and should educate and prepare children to cope with these events.
The Circadian Alertness Simulator (CAS) was developed as a practical tool for assessing the risk of diminished alertness at work. Applications of CAS include assessment of operational fatigue risk, work schedule optimization, and fatigue-related accident investigation. Based on the documented work schedules of employees, sleep and alertness patterns are estimated and a cumulative fatigue score is calculated. The risk assessment algorithms are based on physiological sleep/wake principles including homeostatic and circadian processes. The free parameters of the algorithms were optimized using over 10,000 d of sleep and alertness data sets collected from transportation workers performing their regular jobs. The validity and applicability of the CAS fatigue score was then tested using work/rest and accident data from three trucking operations. Heavy truck drivers involved in DOT-recordable or high-cost accidents were found to have significantly higher CAS fatigue risk scores than accident-free drivers. Implementing a risk-informed, performance-based safety program in a 500 power-unit trucking fleet, where dispatchers and managers were held accountable for minimizing driver CAS fatigue risk scores, significantly reduced the frequency and severity of truck accidents. Further examination of CAS risk assessment validity using scenarios provided in a fatigue modeling workshop indicated that the CAS Model also performed well in estimating alertness with a real-world transportation scenario of railroad locomotive engineer work/rest patterns.
Correspondence: Ngaire Kerse, Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, NEW ZEALAND; (email: kerse.n@auckland.ac.nz).
BACKGROUND: Risk factor studies for falls in residential care have not included factors related to the facilities themselves.
OBJECTIVE: To identify risk factors for falls and injury related to the individual and the facility.
METHODS: Cohort study with 1 to 17 months of followup.
SETTING: A random sample of 14 residential care homes in Auckland, New Zealand.
SUBJECTS: All residents were approached and 606 (97%) participated, mean (SD) age was 83 (11) years. 114 (19%) residents died and 64 (11%) were transferred.
MEASURES: Rate of falls and injurious falls per resident year were measured.
FINDINGS: The mean rate of falls and injurious falls was 2.75 and 1.75 per resident year respectively. Factors independently associated with increased falls included: increased mobility (IRR 1.25; 95% CI 1.14-1.37), and less problematic behaviours (IRR 1.09, 95% CI 1.02-1.17), while unexpectedly digoxin use (IRR 0.56, 95% CI 0.33-0.97) was associated with decreased falls. Factors associated with increased risk of injury included being born in the UK (IRR 2.89, 95% CI 1.24-7.19) and being more mobile (OR 1.15, 95% CI 1.06-1.25), whereas wearing soft-soled shoes compared with slippers (IRR 0.50, 95% CI 0.28-0.90) and unexpectedly visual impairment (IRR 0.52, 95% CI 0.33-0.80) was associated with decreased injury. No significant factors related to the facility were identified.
COMMENTS: Falls are frequent in residential care facilities and risk factors related to footwear are potentially reversible. Residents should be encouraged to wear shoes rather than slippers.
This study used national survey data of working adults (aged 33-41) to identify factors associated with the occurrence of occupational injuries and illnesses. Data from the National Longitudinal Survey of Youth were used to compare selected employment and personal characteristics for respondents who reported experiencing a work-related injury or illness with those who did not. Multivariate analyses were performed to calculate nationally representative odds ratios reflecting the likelihood for specific individual attributes and job characteristics to be associated with the reporting of a work-related injury or illness, while controlling for relevant covariates. In this study the incidence of occupational injuries was related to several demographic factors, including low family income and rural residence, and several job characteristics, including working in a high-hazard occupation, job dissatisfaction, and exposure to six specific hazardous job activities: (1) performing lots of physical effort on the job, (2) lifting or carrying more than 10 lbs, (3) using stairs and inclines, (4) kneeling or crouching, (5) reaching, and (6) hearing special sounds. These results suggest targeted prevention strategies for decreasing the incidence of work-related injuries and illnesses, such as worker self-assessment of the total physical effort demanded by a job and periodic monitoring of workforce job satisfaction.
Costs of occupational injury and illness across industries.
Correspondence: J. Leigh, Center for Health Services Research in Primary Care, UC Davis Medical Center, Sacramento, CA 95817, USA; (email: pleigh@ucdavis.edu).
OBJECTIVES: This study has ranked industries using estimated total costs and costs per worker.
METHODS: This incidence study of nationwide data was carried out in 1993. The main outcome measure was total cost for medical care, lost productivity, and pain and suffering for the entire United States (US). The analysis was conducted using fatal and nonfatal injury and illness data recorded in large data sets from the US Bureau of Labor Statistics. Cost data were derived from workers' compensation records, estimates of lost wages, and jury awards. Current-value calculations were used to express all costs in 1993 in US dollars.
FINDINGS: The following industries were at the top of the list for average cost (cost per worker): taxicabs, bituminous coal and lignite mining, logging, crushed stone, oil field services, water transportation services, sand and gravel, and trucking. Industries high on the total-cost list were trucking, eating and drinking places, hospitals, grocery stores, nursing homes, motor vehicles, and department stores. Industries at the bottom of the cost-per-worker list included legal services, security brokers, mortgage bankers, security exchanges, and labor union offices.
COMMENTS: Detailed methodology was developed for ranking industries by total cost and cost per worker. Ranking by total costs provided information on total burden of hazards, and ranking by cost per worker provided information on risk. Industries that ranked high on both lists deserve increased research and regulatory attention.
Childhood lead poisoning from commercially manufactured French ceramic dinnerware--New York City, 2003.
- Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep 2004; 53(26): 584-586.
Lead poisoning adversely affects children worldwide. During 1999-2000, an estimated 434,000 children aged 1-5 years in the United States had elevated blood lead levels (BLLs) >/=10 microg/dL. Glazes found on ceramics, earthenware, bone china, and porcelain often contain lead and are a potential source of lead exposure. Children are especially vulnerable to the neurotoxic effects of lead. Exposures to lead in early childhood can have adverse effects on the developing nervous system, resulting in decreased intelligence and changes in behavior. In addition, certain behaviors (e.g., thumb sucking) place children at greater risk for exposure to lead. In 2003, the New York City Department of Health and Mental Hygiene's Lead Poisoning Prevention Program (LPPP), and the Mount Sinai Pediatric Environmental Health Specialty Unit (PEHSU) investigated a case of lead poisoning in a boy aged 20 months. This report summarizes that case investigation, which identified ceramic dinnerware imported from France as the source of lead exposure. This case underscores the susceptibility of children to a toxic exposure associated with 1) the high proportion of time spent in the home and 2) dietary habits that promote exposure to lead leached from ceramic ware.
Snakebites in the State of Goias, Brazil.
-Pinho FM, Oliveira ES, Faleiros F. Rev Assoc Med Bras 2004; 50(1): 93-96.
Correspondence: F. Pinho, Universidade Catolica de Goias, Goiania, GO, BRAZIL; (email: pfabia@bol.com.br).
BACKGROUND: Ophidic accidents are a serious health problem for tropical countries, because are responsible for the high incidence of morbidity and mortality.
OBJECTIVE: This article describes aspects of snakebite epidemiology in the State of Goias, Brazil.
METHODS: Notifications about the accidents caused by poisonous snakes have been analysed for Government of the State of Goias (Brazil), Health Department, from 1998 to 2000.
FINDINGS: In this period, 3261 accidents caused by poisonous snakes have been notified, which represented the average annual incidence rate of 20 to 23/100,000 persons. The vast majority of cases occurred from October to April. The classification of the snake genus had been possible in 2350 cases and the distribution was: Bothrops (78.6%), Crotalus (20.8%) and Micrurus (6%). The age distribution shows that the accidents had been suffered by 20 to 39 year old people with great predominance in males (78%). The anatomical areas more frequently bitten were feet (43.6%), legs (23.2%) and hands (20.1%). At the health center 80% of the patients had been treated within sixth hour after the accident. The distribution according to the severity of poisoning was: light (31.6%), moderate (47.5%) and severe (9.6%). The most common complications were necrosis bite site (31.8%) in bothropic envenoming and acute renal failure (1.2%) in crotalic envenoming. The case fatality rate was 0.46%, been the most rate observed in crotalic envenoming (1%).
COMMENTS: Accidents owing to poisonous snakes are frequent in the State of Goias, the young male population is more often attacked and they are an important cause of death.
Identification of injuries and their risk factors is required in order to develop risk controls within the context of sports injury prevention. The Australian Football Injury Prevention Project (AFIPP) was a randomised controlled trial (RCT) examining the effects of protective equipment on injury rates in Australian Rules Football. The aim of this paper is to describe the general injury profile of community level Australian Football players over one season, as recorded during this RCT. Players were recruited from the largest community football league in Victoria, Australia, during the 2001 playing season. A total of 301 players participated (64% response rate) and all injuries occurring during training and games were recorded. The overall injury incidence rate was 12.1/1000 player hours. Bruises/soft tissue injuries made up more than a quarter of all injuries (28%) and the leg (lower leg, ankle, thigh/hamstring and knee) was the most commonly injured body region. Most injuries occurred at the beginning of the season (April-May, 53% of injuries), during competition (77%) and through body contact (49.9%). Midfielders (OR = 3.39, 95% CI: 1.13, 10.14) and players aged at least 25 years (OR = 2.15, 95% CI: 1.06, 4.34) were significantly more likely to experience an injury than other playing positions and younger players. Although the injury rate in this study was lower than that in previous studies, the results are consistent with the finding that injuries tend to occur earlier in the season and more commonly during competition. Injury prevention efforts should be particularly targeted at midfielders and older players.
Children should wear helmets while ice-skating: a comparison of skating-related injuries.
Correspondence: Jennifer McGeehan, Department of Pediatrics, Ohio State University College of Medicine and Public Health, Center for Injury Research and Policy, Columbus Children's Research Institute, Children's Hospital, 700 Children's Drive, Columbus, Ohio 43205-2664, USA; (email: mcgeehaj@pediatrics.ohio-state.edu).
OBJECTIVE: This study compares injuries, especially head injuries, among ice-skaters with those among skateboarders, rollerskaters, and in-line skaters, to determine the need for helmet use during recreational ice-skating by children.
DESIGN: A comparative study of a consecutive series of patients.
SETTING: The emergency department of a large, urban, academic, children's hospital.
PARTICIPANTS: Children treated for injuries related to recreational ice-skating, skateboarding, rollerskating, and in-line skating.
FINDINGS: During a 31-month period, 419 consecutive children were evaluated in the emergency department for skating-related injuries. Children were predominantly male (53.9%), with a mean age of 10.0 years (SD: 3.0 years; median: 10.0 years; range: 1-18 years). The most frequent mechanism of injury was a fall. Overall, 76.5% of children (215 of 281 children) were reported to be wearing no protective equipment, such as a helmet or padding on the elbows or knees, at the time of injury. Ice-skaters were more likely to have adult supervision than were skateboarders (relative risk [RR]: 5.16; 95% confidence interval [CI]: 2.13-12.46), rollerskaters (RR: 1.21; 95% CI: 1.09-1.35), and in-line skaters (RR: 2.08; 95% CI: 1.72-2.51). Ice-skaters were at greater risk of injury to the head (20.0%) than were in-line skaters (4.9%) (RR: 4.09; 95% CI: 1.81-9.23); a weak difference was noted between ice-skaters and rollerskaters (9.9%) (RR: 2.18; 95% CI: 1.04-4.57), with no significant difference in head injuries between ice-skaters and skateboarders (15.9%) (RR: 1.60; 95% CI: 0.54-2.93). Ice-skaters demonstrated lacerations to the head in 68.8% of abnormal head examinations, compared with 37.0% for rollerskaters (RR: 1.86; 95% CI: 1.08-3.20) and 50.0% for in-line skaters (RR: 2.06; 95% CI: 1.35-3.16); however, there was no significant difference in lacerations to the head between ice-skaters and skateboarders (53.3%) (RR: 1.29; 95% CI: 0.76-2.19). Injuries to ice-skaters occurred more often in an indoor skating facility (92.9%, 52 of 56 cases), compared with injuries to skateboarders (3.6%, 1 of 28 cases) (RR: 13.96; 95% CI: 2.01-96.76), rollerskaters (63.4%, 59 of 93 cases) (RR: 1.46; 95% CI: 1.23-1.74), and in-line skaters (10.9%, 15 of 137 cases) (RR: 8.48; 95% CI: 5.23-13.75).
COMMENTS: The proportion of head injuries among ice-skaters in this study was greater than that observed for participants in other types of skating, for which helmet use is recommended and often required. Children should wear a helmet during recreational ice-skating. Mandatory helmet use by pediatric ice-skaters at indoor rinks should be implemented. Use of other types of protective equipment, such as wrist guards, knee pads, and elbow pads, should be considered for prevention of injuries to the extremities during ice-skating. Caution should be used when allowing young children to participate in recreational ice-skating. Additional research should be conducted in other populations, to corroborate these findings and to evaluate ice-skating safety recommendations for children.
BACKGROUND: Injuries represent an important public health problem but their incidence is difficult to estimate.
METHODS: We conducted a population-based household survey in Greece covering 4079 interviewed individuals. The interviewees reported, for themselves and for cohabitating adults (age 15 years and older; n = 7157), injuries that occurred during the preceding year. Major injuries were defined as those requiring contact with a health institution. We compared these survey data with data obtained through a national Emergency Department Injury Surveillance System (EDISS).
FINDINGS: For the month closest to the survey interview, the incidence reported for the responders was 5.9 per 100 person-year, whereas the incidence for cohabitating adults was 3.7 per 100 person-years. These incidence rates declined for months more remote to the interview. Comparison of survey and EDISS data suggested that survey reporting was less accurate for nontraffic-related injuries. Taking into account possible recall and telescoping biases, the best survey estimate of the national annual number of major injuries is 525,000 (5.9 per 100 person-year), whereas the EDISS data yielded an estimate of 1,150,000 major injuries (12.9 per 100 person-years)
COMMENTS: Comparison of survey and EDISS data systems provides quantitative assessment of accuracy of the survey data in relation to time of injury before report date, to severity of injury, and to whether the injury is to the interviewee or to a cohabitant. The 2 systems could be used in a complementary way, although EDISS generates information that is medically more accurate and is a more cost-effective data collection system.
Characteristics and circumstances of falls in a hospital setting.
- Hitcho EB, Krauss MJ, Birge S, Claiborne Dunagan W, Fischer I, Johnson S, Nast PA, Costantinou E, Fraser VJ. J Gen Intern Med 2004; 19(7): 732-739.
Correspondence: Melissa Krauss, Washington University School of Medicine, Department of Internal Medicine, Division of Infectious Diseases, Campus Box 8051, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (email: mkrauss@im.wustl.edu).
OBJECTIVE: To describe the epidemiology of hospital inpatient falls, including characteristics of patients who fall, circumstances of falls, and fall-related injuries.
DESIGN: Prospective descriptive study of inpatient falls. Data on patient characteristics, fall circumstances, and injury were collected through interviews with patients and/or nurses and review of adverse event reports and medical records. Fall rates and nurse staffing levels were compared by service.
SETTING: A 1,300-bed urban academic hospital over 13 weeks.
PATIENTS: All inpatient falls reported for medicine, cardiology, neurology, orthopedics, surgery, oncology, and women and infants services during the study period were included. Falls in the psychiatry service and falls during physical therapy sessions were excluded.
MEASUREMENTS AND MAIN FINDINGS: A total of 183 patients fell during the study period. The average age of patients who fell was 63.4 years (range 17 to 96). Many falls were unassisted (79%) and occurred in the patient's room (85%), during the evening/overnight (59%), and during ambulation (19%). Half of the falls (50%) were elimination related, which was more common in patients over 65 years old (83% vs 48%; P <.001). Elimination-related falls increased the risk of fall-related injury (adjusted odds ratio, 2.4; 95% confidence interval 1.1 to 5.3). The medicine and neurology services had the highest fall rates (both were 6.12 falls per 1,000 patient-days), and the highest patient to nurse ratios (6.5 and 5.3, respectively).
COMMENTS: Falls in the hospital affect young as well as older patients, are often unassisted, and involve elimination-related activities. Further studies are necessary to prevent hospital falls and reduce fall injury rates.
Unintentional drowning in Finland 1970-2000: a population-based study.
- Lunetta P, Smith GS, Penttila A, Sajantila A. Int J Epidemiol 2004; Epub ahead of print).
Correspondence: Philippe Lunetta, Department of Forensic Medicine, PO Box 40 (Kytosuontie 11), University of Helsinki, 00300 Helsinki, FINLAND; (email: philippe.lunetta@helsinki.fi).
BACKGROUND: While standard data on drowning reported by the World Health Organization (WHO) fails to provide a reliable picture of the burden of drowning in Finland, they suggest that the rates are much higher than those of other industrialized countries.
OBJECTIVE: To determine the true burden of drowning in Finland and factors related to its high rates. Design Descriptive, retrospective, population-based analysis of all deaths by drowning, among residents of all ages. Setting Finland, 1970-2000.
METHODS: Mortality and population data furnished by Statistics Finland (SF) were used to determine age- and sex-specific drowning mortality rates using both nature- and cause-of-injury codes. Individual-level data from the death certificates were analysed and cross-linked to a nationwide postmortem toxicology database.
FINDINGS: From 1970 to 2000, 9279 unintentional drownings occurred (mean: 299.3/year SD 84.3, rate 6.1/100 000/year; M:F ratio = 8.6:1), accounting for 11.7% of all unintentional injury deaths. Drowning rates overall have decreased from 9.9/100 000/year in 1970-1972, to 4.5 in 1998-2000 (-2.7%/year; 95% CL: -3.0; -2.5). The most frequent activities related to drowning included boating (29.8%), falling (26.1%), swimming (25.0%), and activities on ice (12.4%). In non-boating-related drownings, 74.5% of males and 67.4% of females tested had a blood alcohol concentration (BAC) >/=50 mg/dl, while in boating-related drownings, the respective values were 78.1% and 71.4%.
COMMENTS: WHO statistics underestimate the true burden of drowning in Finland by up to 40-50%. Drowning rates and alcohol involvement in drowning are much higher than in other comparable developed countries. Broad-based countermeasures to reduce alcohol use in water activities are needed as part of any strategy to reduce drowning rates.
The ability to communicate effectively the degree or magnitude of public exposures or health risks is essential for risk assessors and risk managers. Various guidelines exist for communicating environmental and public health risks, including recommended approaches for putting risk data into proper context. Although it remains unclear as to which approach is the most useful or appropriate under different circumstances, risk comparisons are a popular choice for conveying the significance of or providing a better perspective on a particular chemical exposure or health risk. In this paper, several different types of risk comparisons are described that are frequently used in the private and public sectors, and these are illustrated using a variety of examples from the literature. These approaches include: (1) intrachemical comparisons, (2) interchemical comparisons, (3) comparisons to background levels of risk, (4) comparisons to theoretical risks or safety levels, and (5) comparisons to other actions or activities. The primary purpose of this paper is to summarize and briefly discuss the advantages and limitations of these risk communication approaches. The evolving field of risk communication is also discussed, including ongoing research on public risk perceptions and alternative methods for communicating risk magnitudes and data uncertainties.
Risk taking in adolescence: what changes, and why?
Extant studies of age differences in cognitive processes relevant to risk taking and decision making, such as risk perception and risk appraisal, indicate few significant age differences in factors that might explain why adolescents engage in more risk taking than adults. The present analysis suggests that the greater propensity of adolescents to take risks is not due to age differences in risk perception or appraisal, but to age differences in psychosocial factors that influence self-regulation. It is argued that adolescence is a period of heightened vulnerability to risk taking because of a disjunction between novelty and sensation seeking (both of which increase dramatically at puberty) and the development of self-regulatory competence (which does not fully mature until early adulthood). This disjunction is biologically driven, normative, and unlikely to be remedied through educational interventions designed to change adolescents' perception, appraisal, or understanding of risk. Interventions should begin from the premise that adolescents are inherently more likely than adults to take risks, and should focus on reducing the harm associated with risk-taking behavior.
Survey on injury in four rural communities in China.
- Yang GH, Ma JM, Wang LJ. Zhonghua Liu Xing Bing Xue Za Zhi. 2004; 25(3): 204-208.
[Article in Chinese]
Institute of Basic Medicine Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100005, CHINA.
OBJECTIVE: To understand the incidence and prevalence by causes of injury, and the proportion of different causes of deaths, as well as occurrence of disability due to injuries. METHODS: 200,000 families were randomly sampled in 4 rural communities. Questionnaire on occurrence, disability, death of injury and related risk factors for all family members living at home from Feb. 12, 2002 to Aug. 12, 2002 were studied. RESULTS: The incidence rate and prevalence rate in the observed population were 65.1/1000 and 69.2/1000, respectively. In every 100 cases of injury there were one death and 6 disabled. Fall, animal bites, striking or crushing, cutting and piercing, road accidents, fire and poisoning were the common causes in injury. Animal bites was the leading cause while drawing appeared the highest in children aged 0 - 14. Rate of road accident was the highest in adults aged 15 - 34, while falls causing higher proportion of disability in population aged over 60. CONCLUSIONS: Based on the report of National Disease Surveillance Points System, there were 592,000 death cases of injury in Chinese rural areas every year, meaning 59.2 million cases of injury and 3,490,000 disabled cases every year. Since injury causes serious social and economic loss with different orders of incidence and mortality, it is necessary to develop different preventive strategies on different target populations and different causes accordingly.
Violent behaviour among Turkish high school students and correlates of physical fighting.
- Alikasifoglu M, Erginoz E, Ercan O, Uysal O, Kaymak DA, Iiter O. Eur J Public Health 2004; 14(2): 173-177.
Correspondence: Mujgan Alikasifoglu, Istanbul University, Cerrahpasa Medical Faculty, Department of Paediatrics, TURKEY; (email: kasif@kablonet.com.tr).
BACKGROUND: The purpose of this study was to provide data about the prevalence of violent behaviour among high school students living in Istanbul and to determine the correlates of physical fighting.
METHODS: This study involved the completion of a modified version of 'Health Behaviour in School Age Children (HBSC) 1997/1998' survey questionnaire by 4153 grade 9-11 students. Chi square tests and forward stepwise multiple logistic regression models were used for statistical analyses.
FINDINGS: During the last 12 months preceding the survey 42% of students (n=1720) reported that they had been in a physical fight; 7% (n=274) reported that they were involved in a fight which required medical treatment. During the last school term 19% (n=768) bullied others at school; 30% (n=1255) reported having been bullied at school; 7% (n=309) reported that they had been bullied with a weapon on school grounds; 8% (n=346) reported that they carried a weapon on school grounds. In logistic regression analyses being male, poor mental health score, being sexually active, current cigarette use, illicit drug use, not using seat belts, bullying, being bullied with a weapon, carrying a weapon, spending more time with friends, poor school image and physical abuse were found to be associated with fighting.
COMMENTS: Violent behaviour is common in high school students. There is a strong need for violence prevention programmes in schools.
Spatial and temporal regularities commonly exist in natural visual scenes. The knowledge of the probability structure of these regularities is likely to be informative for an efficient visual system. Here we explored how manipulating the spatio-temporal prior probability of stimuli affects human orientation perception. Stimulus sequences comprised four collinear bars (predictors) which appeared successively towards the foveal region, followed by a target bar with the same or different orientation. Subjects' orientation perception of the foveal target was biased towards the orientation of the predictors when presented in a highly ordered and predictable sequence. The discrimination thresholds were significantly elevated in proportion to increasing prior probabilities of the predictors. Breaking this sequence, by randomising presentation order or presentation duration, decreased the thresholds. These psychophysical observations are consistent with a Bayesian model, suggesting that a predictable spatio-temporal stimulus structure and an increased probability of collinear trials are associated with the increasing prior expectation of collinear events. Our results suggest that statistical spatio-temporal stimulus regularities are effectively integrated by human visual cortex over a range of spatial and temporal positions, thereby systematically affecting perception.
Correspondence: Karl-Heinz Ladwig, Institut und Poliklinik für Psychosomatische Medizin, Psychotherapie und Med. Psychologie des Klinikums rechts der Isar der Technischen Universitat Munchen, (email: kh.ladwig@lrz.tu-muenchen.de).
BACKGROUND: As a basis for preventive strategies to reduce subway suicides, an investigation was undertaken to determine if there was a distinct pattern of subway suicidal behaviour.
METHODS: Data were taken from the Municipal Munich Subway System case registry (southern Germany) for all suicidal incidents on the track: purposely inflicted; date, time and location of incident, sex of victim, outcome. The analysis covered a 20 year observation period between 1980 and 1999, for which the Munich Municipal Office for Statistics also provided data of all deaths due to suicides within the city area of Munich. Suicide mortality was classified by the International Classification of Diseases, Ninth revision (codes E950-E959).
FINDINGS: A total of 306 incidents were documented with an annual mean of 16.5 cases. Case fatality was 66% (n=202). It was highest in winter and in higher aged groups. No significant time trend for incidences was observed. Median age of suicide attempters was 38 years. Most incidences (24.2%) were recorded for persons aged 20-29 years. The male: female ratio was 1.15 : 1. The peak time of day for incidences in women was during the late morning hours while significantly more men committed subway suicides during evening hours (p=0.001). No consistent seasonal variation was observed.
COMMENTS: In comparison to average suicide attempters, subjects committing subway suicides are markedly younger and they follow to a lesser extent established seasonal or circadian time patterns. More women are involved in subway suicides than would be expected. However, similarities to reports on behavioural patterns of subway suicides in other communities are striking.
Deliberate self-harm in children and adolescents: association with social deprivation.
- Correspondence: Agnes Ayton, West End Child and Family Service, 2062-68 Hessle Road, Hessle HU13 9NW, North Humberside, UK; (email: a.k.ayton@hull.ac.uk).
BACKGROUND: It has been demonstrated that adult suicidal behaviour is associated with unemployment and social deprivation. The association between self-harm and social deprivation in young people is less clear. AIMS: To examine the relationship between social deprivation and deliberate self-harm in children and adolescents in an UK district. METHOD: Computer records of patients under 18 years of age presenting with self-harm at the district casualty department were analysed in Hull and East Yorkshire. The relationship with social deprivation was examined using Townsend scores. RESULTS: 730 young people presented with self-harm during a period of two years. Socio-economic deprivation was associated with overdose, self-injury, and poisoning by illicit substances. After controlling for the proportion of single parent households, moving households with children, and adult long-term sickness in each ward, partial correlations remained significant between overdose, self-injury, and Townsend scores. CONCLUSIONS: The results highlight the importance of socio-economic deprivation in the aetiology of deliberate self-harm in young people. Primary and secondary prevention programs cannot be successful without taking this into consideration.
Predicting repeat self-harm in children--how accurate can we expect to be?
Correspondence: Prathiba Chitsabesan, The University Department of Child and Adolescent Psychiatry, Central Manchester and Manchester Children's University Hospitals, Hospital Road, Pendlebury, Manchester, M27 4HA, UK; (email: unavailable).
The main objective of the study was to find which variables predict repetition of deliberate self-harm in children. The study is based on a group of children who took part in a randomized control trial investigating the effects of a home-based family intervention for children who had deliberately poisoned themselves. These children had a range of baseline and outcome measures collected on two occasions (two and six months follow-up). Outcome data were collected from 149 (92 %) of the initial 162 children over the six months. Twenty-three children made a further deliberate self-harm attempt within the follow-up period. A number of variables at baseline were found to be significantly associated with repeat self-harm. Parental mental health and a history of previous attempts were the strongest predictors. A model of prediction of further deliberate self-harm combining these significant individual variables produced a high positive predictive value (86 %) but had low sensitivity (28 %). Predicting repeat self-harm in children is difficult, even with a comprehensive series of assessments over multiple time points, and we need to adapt services with this in mind. We propose a model of service provision which takes these findings into account.
Correspondence: David Grabowski, Lister Hill Center for Health Policy, School of Public Health, University of Alabama, Birmingham, USA; (email: grabowsk@uab.edu).
BACKGROUND: Little is known about how state-level driver licensure laws, such as in-person renewal, vision tests, road tests, and the frequency of license renewal relate to the older driver traffic fatality rate.
OBJECTIVE: To determine whether state driver's license renewal policies are associated with the fatality rate among elderly drivers.
DESIGN, SETTING, AND POPULATION: Retrospective, longitudinal study conducted January 1990 through December 2000 of all fatal crashes in the contiguous United States identified in the Fatality Analysis Reporting System, which involved either an older (ages 65-74 years, 75-84 years, and > or =85 years) or middle-aged (ages 25-64 years) driver. Two regression approaches were used to study the effect of state laws mandating in-person renewal, vision tests, road tests, and frequency of license renewal on driver fatalities, controlling for state-level factors including the number of licensed elderly drivers, primary and secondary seatbelt laws, maximum speed limit laws, blood alcohol level of 0.08, and administrative license revocation drinking and driving laws, per capita income, and unemployment rate. The first regression approach examined only elderly driver fatalities and the second approach examined daytime elderly driver fatalities and used daytime fatalities among middle-aged drivers as a general control for unobserved variation across states and over time.
MAIN OUTCOME MEASURES: Older driver fatalities and older and middle-aged daytime driver fatalities.
FINDINGS: Among individuals aged 85 years or older, there were a total of 4605 driver fatalities and 4179 daytime driver fatalities during the study period. For this age cohort, after controlling for middle-aged daytime driver deaths, states with in-person license renewal were associated with a lower driver fatality rate (incident rate ratio [RR], 0.83; 95% confidence interval [CI], 0.72-0.96). This was the only policy related to older drivers that was significantly associated with a lower fatality risk across both regression models. Thus, state-mandated vision tests, road tests, more frequent license renewal, and in-person renewal (for individuals aged 65-74 years and 75-84 years) were not found to be independently associated with the fatality rate among older drivers in the 2 models.
COMMENTS: In-person license renewal was related to a significantly lower fatality rate among the oldest old drivers. More stringent state licensure policies such as vision tests, road tests, and more frequent license renewal cycles were not independently associated with additional benefits.
Correspondence: Phyllis Agran, University of California, Center for Health Policy and Research, Child Injury and Traffic Safety Research Group, Irvine, California 92697-5800, USA; (email: pagran@uci.edu).
BACKGROUND: Nonuse of child car safety seats (CSSs) remains significant; in 2000, 47% of occupant fatalities among children <5 years of age involved unrestrained children. Nonusers and part-time users of CSSs represent small proportions of the US population that have not responded to intervention efforts. Our study examined the factors contributing to nonuse or part-time use of CSSs and the effects of exposure to a class for violators of the California Child Passenger Safety (CPS) law.
METHODS: Focus groups (in English and Spanish) were conducted with individuals cited for violation of the law (N = 24). A thematic analysis of notes made by an observer, supplemented by audiotapes of the sessions, was conducted. In addition, a study of the effects of exposure to a violator class on knowledge and correct CSS use was conducted among violators. Certified CPS technicians conducted the classes and interviews. Subjects were parents cited as the driver with a child of 20 to 40 pounds, between 12 and 47 months of age. One hundred subjects recruited from the class were compared with 50 subjects who did not attend a class. Follow-up home interviews, with inspection of CCS use, were conducted 3 months after payment of the fine and completion of all court requirements. Fisher's exact test was used for 2 x 2 tables, because some of the tables had small cell sizes. The Mann-Whitney rank sum test was used for child restraint use, knowledge, and correct use scales, because some of these variables were not normally distributed. Linear and logistic regression models were used to examine the effects of several variables on these parameters.
RESULTS: Factors influencing CSS nonuse were 1) lifestyle factors, 2) transportation and trip circumstances, 3) nonparent or nondriver issues, 4) parenting style, 5) child's behavior, and 6) perceived risks of nonuse. Violator subjects were mostly Hispanic and female, with incomes of less than 30,000 dollars per year. Those exposed to the class (citation and education group) scored 1 point higher on a knowledge test and had 1 more item correct on a CSS use instrument than did the group not exposed to the class (citation only group). In the logistic model, the citation and education group scored higher on the 2 items that were corrected by the instructor during the class.
CONCLUSION: Our focus group study of CPS law violators revealed that multiple complex factors influence consistent use of a CSS. The interplay of the particular vehicle, the trip circumstances, and family/parent/child factors affected the use of a CSS at the time of parent citation. Addressing transportation issues and parenting skills in CPS programs is necessary. Among parents who had been ticketed for not restraining their children, exposure to a violator class demonstrated some benefit, compared with a fine alone. Correct CSS use improved most on items corrected by the instructor. Violator classes that include "hands-on" training show promise for improving rates of correct use of CSSs.
Types and characteristics of ramp-related motor vehicle crashes on urban interstate roadways in Northern Virginia.
BACKGROUND: Freeway entrance and exit ramp interchanges are the sites of far more crashes per mile driven than other segments of interstate highways, but the characteristics and circumstances of ramp crashes have been the subject of relatively little recent research.
METHODS: This study examined a sample of 1,150 crashes that occurred on heavily traveled urban interstate ramps in Northern Virginia. Based on a review of diagrams and narrative descriptions from police crash reports, the most common crash types were identified and examined for different roadway locations and ramp designs and by whether at-fault drivers were entering or exiting the freeway.
FINDINGS: About half of all crashes occurred when at-fault drivers were in the process of exiting interstates, 36% occurred when drivers were entering, and 16% occurred at the midpoints of access roads or on ramps connecting two interstate freeways. Three major crash types--run-off-road, rear-end, and sideswipe/cutoff--accounted for 95% of crashes in the study. The crash type most frequently associated with exiting was run-off-road, and the types most common with entering drivers were rear-end or sideswipe/cutoff. Crashes most common on ramps--run-off-road crashes--frequently occurred when vehicles were exiting interstates at night, in bad weather, or on curved portions of ramps. Speed was often a factor. Crashes occurring on ramp margins (where ramps or access roads enter or exit) were most commonly of the sideswipe/cutoff type. These often involved at-fault passenger vehicles merging from entrance ramps into the sides of large trucks already on the freeway. The predominant crash type on access roads was rear-end crashes; congestion was a factor in these crashes. Alcohol was a reported factor in a sizeable proportion of run-off-road crashes occurring on ramps (14%) and ramp margins (30%).
COMMENTS: Candidate countermeasures for run-off-road crashes include geometric design changes to increase ramp design speed such as increasing curve radii. Speed-related crashes may be reduced by the use of speed cameras accompanied by publicity. Rear-end crash countermeasures could include surveillance systems that quickly detect unexpected congestion, incident response programs, and variable message signs to alert drivers to traffic congestion ahead. Countermeasures for sideswipe/cutoff crashes could include extending the length of acceleration lanes.
Factors related to seat belt use among fatally injured teenage drivers.
- McCartt AT, Northrup VS. J Safety Res 2004; 35(1): 29-38.
Correspondence: A. McCartt, Preusser Research Group, Trumball, CT 06111, USA; (email: amcartt@iihs.org).
BACKGROUND: In the United States, teenage drivers have a higher crash risk and lower observed seat belt use than other age groups.
METHODS: Seat belt use was examined for teenage (16-19 years) drivers who were fatally injured in traffic crashes occurring in the United States during the years 1995-2000. Vehicle, driver, and crash factors potentially related to belt use were examined. State differences in belt use rates among fatally injured teenage drivers were related to states' observed belt use rates for all ages and other state-level variables.
FINDINGS: During 1995-2000, mean belt use was 36% among fatally injured teenage drivers and 23% among fatally injured teenage passengers. One of the strongest predictors of higher belt use for both drivers and passengers was whether the crash occurred in a state with a primary seat belt law. Belt use rates for 1995-2000 for fatally injured teenage drivers ranged from 20% or less in six states to more than 60% in two states. States with the highest use rates were those with strong primary belt use laws and those with high rates of observed belt use for all ages. Lower belt use among fatally injured teenage drivers was associated with increasing age; male drivers; drivers of SUVs, vans, or pickup trucks rather than cars; older vehicles; crashes occurring late at night; crashes occurring on rural roadways; single vehicle crashes; and drivers with BACs of 0.10 or higher. Teenage driver belt use declined as the number of teenage passengers increased, but increased in the presence of at least one passenger 30 years or older.
COMMENTS: It is suggested that to increase teenage belt use, states should enact strong primary belt use laws and mount highly publicized efforts to enforce these laws. Graduated driver licensing systems should incorporate strong provisions that require seat belt use by teenage drivers and passengers.
Pattern of injuries in helmeted motorcyclists in Singapore.
- Tham KY, Seow E, Lau G. Emerg Med J 2004; 21(4): 478-482.
Correspondence: Kum Ying, Department of Emergency Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, SINGAPORE; (email: kum_ying_tham@ttsh.com.sg).
BACKGROUND: Singapore has a mandatory helmet law for motorcyclists. This study aimed to determine the injuries sustained by helmeted motorcyclists presenting to the emergency Department (ED).
METHODS: Adult victims of motor vehicular incidents (MVI) who presented to an urban public hospital ED from 1 December 1998 to 31 May 1999 were interviewed. Chart reviews were done for those hospitalised. Data collected were demographic, nature of injury, ambulance care, ED and hospital care, outcome and final diagnoses.
FINDINGS: Motorcyclists formed 49.1% (1018) of all MVI victims, of whom 96.1% were men. The mean age was 32.5 years (SD 13.1), significantly younger (p<0.0001) than the mean age of 36.4 years (SD 16.4) among other MVI victims. The proportions of motorcyclists and other MVI patients admitted to the hospital were not different. Among those admitted, significantly fewer (p = 0.001) motorcyclists (32.2%) sustained head injury compared with other MVI victims (46.8%) but among the motorcyclists with head injury, more than one third (34.2%) had severe head injury. The proportion of patients with thoracic injury was not different (p = 0.93) between motorcyclists (10.2%) and other MVI victims (9.9%). However, among those with thoracic injury, 79.2% of motorcyclists had severe thoracic injury, significantly more (p = 0.04) than 50% of other MVI patients. Wounds, fractures, and/or dislocations of the limbs (p<0.001) were significantly more among motorcyclists compared with other MVI patients.
COMMENTS: Compared with other MVI victims, fewer helmeted motorcyclists sustained head injury. When head injury occurs in helmeted motorcyclists, it tends to be more severe. Motorcyclists remain vulnerable to extremity injury and to severe chest injury.
Posttraumatic stress disorder following road traffic accidents: a second prospective study.
Correspondence: Paul Stallard: Dept. of Child and Family Psychiatry, Royal United Hospital, Combe Park, Bath, BA1 3NG, UK; (email: paul.stallard@awp.nhs.uk).
OBJECTIVE: The aim of this prospective study was to determine the psychological effects of everyday road traffic accidents (RTAs).
METHODS: A community follow-up study was made of children (75 boys and 83 girls aged 7-18)-attending an Accident and Emergency Department after being involved in an RTA. Diagnostic clinical interview and self-completed psychometric assessments were performed.
FINDINGS: Four weeks post-accident diagnostic interviews revealed that 46 (29.1 %) children fulfilled the diagnostic criteria for posttraumatic stress disorder (PTSD). Screening questionnaires identified 20.3% with significant levels of anxiety and 17.7% with scores above threshold levels for possible clinical depression. Type of accident, nature and severity of injury and age were not related to the development of PTSD. Gender was significant, with girls being more likely than boys to develop PTSD.
COMMENTS: Significant psychological distress following RTAs is common. The need to raise awareness of the possible psychological sequelae of everyday RTAs is highlighted.
Estimation of AIS3+ thoracic injury risks of belted drivers in NASS frontal crashes.
Real-world field data from the 1988-2001 National Automotive Sampling System (NASS ) - Crashworthiness Data System of the United States were examined. The abbreviated injury scale (AIS) was used to relate the injuries. Specifically, the AIS3+ thoracic injury rates of belted drivers in real-world frontal crashes in the United States were investigated. The research consisted of five steps. Firstly, aggregate NASS data (i. e. the total number of AIS3+ injured drivers across the entire crash speed domain) were collected for numerous frontal crash categories. These categories included: primary direction of force (11 o'clock, 12 o'clock and 1 o'clock), crash severity (barrier-like and not barrier-like), gender (men and women), age groups (13-49 and 50-97 years) and level of restraint (belt-only and belt+ airbag). Secondly, to control for the effect of these categories and to introduce the effect of crash speed change (D V), a statisticalmodel was constructed to fit the field data. The outcome variable was AIS3+ thoracic injury rate; the predictor variables were DV and the aforementioned categories. Thirdly, the resulting logistic fit was compared with the original (unfitted) field data. Conclusions derived from the logistic fit of the field data were consistent with the aggregate NASS data, i. e. for like events: higher-speed crashes were associated with a higher injury risk than lower-speed crashes; higher-severity crashes were associated with a higher injury risk than lowerseverity crashes; female drivers exhibited a higher risk than male drivers; older drivers exhibited a higher risk than younger drivers; age effects were more pronounced than the gender effects (e. g. aggregate risk ratios between men and women were about 1.5, whereas ratios between older and younger drivers ranged from 4.2 to 5.5); and belt-only drivers exhibited a higher risk than belted drivers with airbags. Fourthly, the fidelity of the logistic model was evaluated against numerous, published, point estimates of AIS3+ thoracic field injury rates. The correlations were deemed acceptable. Finally, as an example of the utility of the logistic fit results, a set of empirical AIS3+ thoracic risk curves for differing ages (13-49 versus 50-97 years) and genders (male versus women) were derived for belt-only drivers.
Each year, 3.3 to 10 million children are exposed to domestic violence/abuse (DV). Providers' reporting obligations for these children are unclear. The child maltreatment statutes available on state's web sites (through August 2003) were reviewed. Only Alaska defines DV in the presence of a child as child abuse within its juvenile code. Within their child abuse definition and reporting statutes, many states include language such as "substantial risk" or"imminent danger" of "physical harm" or "mental injury." Although knowledge of the state law is an important first step, abiding by it may be challenging because most statutes are open to wide interpretation. As a result, providers are encouraged to seek advice from local child maltreatment specialists who understand the local legal interpretations and resources.
Mechanisms of pediatric trauma deaths in Canada and the United States: the role of firearms.
BACKGROUND: This study aimed to determine whether firearms are a more prevalent cause of pediatric death in the United States than in Canada.
METHODS: All pediatric trauma deaths from 1991 to 1996 in Ontario and Missouri were reviewed. Socioeconomic data were compiled for the two jurisdictions.
FINDINGS: During the period reviewed, there were 1,146 pediatric trauma deaths in Ontario (10.4 per 100,000 population) and 1,782 in Missouri (32.4 per 100,000 population). Firearm injuries accounted for 19% of the trauma deaths in Missouri and 0.5% of such deaths in Ontario. Overall, a child was 100 times more likely to die of firearm injury in Missouri (6 per 100,000 population) than in Ontario (0.06 per 100,000 population). The incidences of violent acts unrelated to firearms were similar between the two groups. Both populations were similar in terms of socioeconomic and education parameters, but differed in their rates for guns carried.
COMMENTS: The significantly higher death rate from firearm injuries in Missouri likely reflects differing gun control attitudes and legislation, and provides a rationale for prevention and future investigation.
Gun control law (Bill C-17), suicide, and homicide in Canada.
Correspondence: F. Bridges, Division of Health, Leisure, and Exercise Science, The University of West Florida, 11000 University Parkway, Pensacola, FL 32514-5750, USA; (email: fbridges@uwf.edu).
Canadian Bill C-17 was implemented in 1991 to restrict the use of firearms, providing a chance to investigate the effect of firearm control laws in the use of firearms for suicide and homicide. Following Lester and Leenaars' comprehensive studies, the present study examined the use of firearms for suicide and homicide during the period prior to the bill and during the period after the passing of Bill C-17 to assess the association of the bill with rates of suicide and homicide by method. Analysis showed a significant decrease after passage of Bill C-17 in the rates of suicides and homicides involving firearms and the percentage of suicides using firearms. The analysis provides support for the position that restricting the availability of firearms as a lethal means of committing suicide and homicide may help reduce the numbers of suicides and homicides.
Experiences of harassment, discrimination, and physical violence among young gay and bisexual men.
- Huebner DM, Rebchook GM, Kegeles SM. Am J Public Health 2004; 94(7): 1200-1203.
Correspondence: D. Huebner, Center for AIDS Prevention Studies, 74 New Montgomery, Suite 600, San Francisco, CA, USA; (email: dhuebner@psg.ucsf.edu).
OBJECTIVE: We examined the 6-month cumulative incidence of anti-gay harassment, discrimination, and violence among young gay/bisexual men and documented their associations with mental health.
METHODS: Gay/bisexual men from 3 cities in the southwestern United States completed self-administered questionnaires.
FINDINGS: Thirty-seven percent of men reported experiencing anti-gay verbal harassment in the previous 6 months; 11.2% reported discrimination, and 4.8% reported physical violence. Men were more likely to report these experiences if they were younger, were more open in disclosing their sexual orientation to others, and were HIV positive. Reports of mistreatment were associated with lower self-esteem and increased suicidal ideation.
COMMENTS: Absent policies preventing anti-gay mistreatment, empowerment and community-building programs are needed for young gay/bisexual men to both create safe social settings and help them cope with the psychological effects of these events.
Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.
- Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. N Engl J Med. 2004 Jul 1;351(1):13-22.
Correspondence: Charles W. Hoge, Department of Psychiatry and Behavioral Sciences, Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command, Silver Spring, Md 20910, USA; (email: charles.hoge@na.amedd.army.mil).
BACKGROUND: The current combat operations in Iraq and Afghanistan have involved U.S. military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans.
METHODS: We studied members of four U.S. combat infantry units (three Army units and one Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or three to four months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and post-traumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments.
FINDINGS: Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care.
COMMENTS: This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care.
Culturally competent responses for identifying and responding to domestic violence in dental care settings.
Correspondence: Vibhuti Mehra, Family Violence Prevention Fund, National Health Resource Center on Domestic Violence, San Francisco, California 94103-5133, USA; (email: manavi@worldnet.att.net).
Dental care providers can play an important role in identifying and preventing intimate partner violence. Many victims of domestic violence interact with dental care providers, including dentists, dental hygienists, and dental assistants, thus placing dental professionals in a unique position to screen for early identification and even primary prevention of abuse. An effective and successful response to intimate partner violence in a dental care setting involves creating a safe and culturally competent environment for screening and disclosure, giving supportive messages to victims, educating patients about abuse and connection to health, offering strategies to promote safety, and informing clients about relevant community resources.
Therapeutic Foster Care for the Prevention of Violence: A Report on Recommendations of the Task Force on Community Preventive Services.
- Hahn RA, Lowy J, Bilukha O, Snyder S, Briss P, Crosby A, Fullilove MT, Tuma F, Moscicki EK, Liberman A, Schofield A, Corso PS. MMWR Recomm Rep 53(RR10); 1-8.
In therapeutic foster care programs, youths who cannot live at home are placed in homes with foster parents who have been trained to provide a structured environment that supports their learning social and emotional skills. To assess the effectiveness of such programs in preventing violent behavior among participating youths, the Task Force on Community Preventive Services conducted a systematic review of the scientific literature regarding these programs. Reported and observed violence, including violent crime, were direct measures. Proxy measures were externalizing behavior (i.e., behavior in which psychological problems are acted out), conduct disorder, and arrests, convictions, or delinquency, as ascertained from official records, for acts that might have included violence. Reviewed studies assessed two similar interventions, distinguished by the ages and underlying problems of the target populations. Therapeutic foster care for reduction of violence by children with severe emotional disturbance (hereafter referred to as cluster therapeutic foster care) involved programs (average duration: 18 months) in which clusters of foster-parent families cooperated in the care of children (aged 5--13 years) with severe emotional disturbance. The Task Force found insufficient evidence to determine the effectiveness of this intervention in preventing violence. Therapeutic foster care for the reduction of violence by chronically delinquent adolescents (hereafter referred to as program-intensive therapeutic foster care) involved short-term programs (average duration: 6--7 months) in which program personnel collaborated closely and daily with foster families caring for adolescents (aged 12--18 years) with a history of chronic delinquency. On the basis of sufficient evidence of effectiveness, the Task Force recommends this intervention for prevention of violence among adolescents with a history of chronic delinquency. This report briefly describes how the reviews were conducted, provides additional information about the findings, and provides information that might help communities in applying the intervention locally.
Physical aggression during early childhood: trajectories and predictors.
- Tremblay RE, Nagin DS, Seguin JR, Zoccolillo M, Zelazo PD, Boivin M, Perusse D, Japel C. Pediatrics 2004; 114(1): e43-50.
Correspondence: Research Unit on Children's Psychosocial Maladjustment, University of Montreal, Montreal, Quebec, CANADA; (email: tremblar@grip.umontreal.ca).
OBJECTIVES: Physical aggression in children is a major public health problem. Not only is childhood physical aggression a precursor of the physical and mental health problems that will be visited on victims, but also aggressive children themselves are at higher risk of alcohol and drug abuse, accidents, violent crimes, depression, suicide attempts, spouse abuse, and neglectful and abusive parenting. Furthermore, violence commonly results in serious injuries to the perpetrators themselves. Although it is unusual for young children to harm seriously the targets of their physical aggression, studies of physical aggression during infancy indicate that by 17 months of age, the large majority of children are physically aggressive toward siblings, peers, and adults. This study aimed, first, to identify the trajectories of physical aggression during early childhood and, second, to identify antecedents of high levels of physical aggression early in life. Such antecedents could help to understand better the developmental origins of violence later in life and to identify targets for preventive interventions.
METHODS: A random population sample of 572 families with a 5-month-old newborn was recruited. Assessments of physical aggression frequency were obtained from mothers at 17, 30, and 42 months after birth. Using a semiparametric, mixture model, distinct clusters of physical aggression trajectories were identified. Multivariate logit regression analysis was then used to identify which family and child characteristics, before 5 months of age, predict individuals on a high-level physical aggression trajectory from 17 to 42 months after birth.
RESULTS: Three trajectories of physical aggression were identified. The first was composed of children who displayed little or no physical aggression. These individuals were estimated to account for approximately 28% of the sample. The largest group, estimated at approximately 58% of the sample, followed a rising trajectory of modest aggression. Finally, a group, estimated to comprise approximately 14% of the sample, followed a rising trajectory of high physical aggression. Best predictors before or at birth of the high physical aggression trajectory group, controlling for the levels of the other risk factors, were having young siblings (odds ratio [OR]: 4.00; confidence interval [CI]: 2.2-7.4), mothers with high levels of antisocial behavior before the end of high school (OR: 3.1; CI: 1.1-8.6), mothers who started having children early (OR: 3.1; CI: 1.4-6.8), families with low income (OR: 2.6; CI: 1.3-5.2), and mothers who smoked during pregnancy (OR: 2.2; CI: 1.1-4.1). Best predictors at 5 months of age were mothers' coercive parenting behavior (OR: 2.3; CI: 1.1-4.7) and family dysfunction (OR: 2.2; CI: 1.2-4.1). The OR for a high-aggression trajectory was 10.9 for children whose mother reported both high levels of antisocial behavior and early childbearing.
COMMENTS: Most children have initiated the use of physical aggression during infancy, and most will learn to use alternatives in the following years before they enter primary school. Humans seem to learn to regulate the use of physical aggression during the preschool years. Those who do not, seem to be at highest risk of serious violent behavior during adolescence and adulthood. Results from the present study indicate that children who are at highest risk of not learning to regulate physical aggression in early childhood have mothers with a history of antisocial behavior during their school years, mothers who start childbearing early and who smoke during pregnancy, and parents who have low income and have serious problems living together. All of these variables are relatively easy to measure during pregnancy. Preventive interventions should target families with high-risk profiles on these variables. Experiments with such programs have shown long-term impacts on child abuse and child antisocial behavior. However, these impacts were not observed in families with physical violence. The problem may be that the prevention programs that ion programs that were provided did not specifically target the parents' control over their physical aggression and their skills in teaching their infant not to be physically aggressive. Most intervention programs to prevent youth physical aggression have targeted school-age children. If children normally learn not to be physically aggressive during the preschool years, then one would expect that interventions that target infants who are at high risk of chronic physical aggression would have more of an impact than interventions 5 to 10 years later, when physical aggression has become a way of life.
Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma.
- Bechtel K, Stoessel K, Leventhal JM, Ogle E, Teague B, Lavietes S, Banyas B, Allen K, Dziura J, Duncan C. Pediatrics 2004; 114(1): 165-168.
Correspondence: Kirsten Bechtel, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA; kirsten.bechtel@yale.edu).
OBJECTIVE: To describe the clinical features that distinguish accidental from abusive head injury in hospitalized children <24 months of age.
METHODS: Prospective study of children <24 months of age hospitalized for head injury between August 1, 2000, and October 31, 2002. During hospitalization, children had computed tomographic scans of the brain, serial neurologic examinations, dilated ophthalmoscopic eye examinations, evaluation by a social worker, and, in some cases, a child abuse specialist.
OUTCOME MEASURES: The main outcome measure was the proportion of children in each group with retinal hemorrhages (RHs). Secondary outcome measures were the proportion of children in each group who had vitreous hemorrhage; abnormal mental status on presentation; seizures; scalp hematomas; need for anticonvulsants; and operative procedures such as subdural tap, craniotomy, ventriculostomy, tracheostomy, and gastrostomy.
FINDINGS: Eighty-seven children were prospectively enrolled. Fifteen children were classified as having abusive head injury, and 72 were classified as having accidental head injury. Five children, all in the accidental head injury group, were excluded from statistical analysis, because they did not have a dilated ophthalmoscopic examination during their hospitalization. Thus 82 children were included in the statistical analysis. There were no significant differences between the 2 groups with respect to mean age, gender, or ethnicity. RHs were more likely to be seen in children with abusive head injury (60% vs 10%) and were more likely to be bilateral (40% vs 1.5%). Pre-RHs were more likely to be seen in children with abusive head injury (30% vs 0%). Premacular RHs and RHs that extended to the periphery of the retina were also more likely to be seen in children with abusive head injury (20% vs 0% and 27% vs 0%, respectively). Of the 7 children with accidental head injury who had RHs, 6 had unilateral RHs. Children with abusive head injury were more likely to have seizures (53% vs 6%) and an abnormal mental status on initial presentation (53% vs 1%). Children with accidental head injury were more likely to have scalp hematomas (6.7% vs 49%).
COMMENTS: RHs are seen more often in abusive head injury and often are bilateral and involve the preretinal layer. Children with abusive head injury were more likely to have RHs that cover the macula and extend to the periphery of the retina. Unilateral RHs can be seen in children with accidental head injury. Children with abusive head injury were more likely to present with abnormal mental status and seizures, whereas children with accidental head injury were more likely to have scalp hematomas. Such characteristics may be useful to distinguish accidental from abusive head trauma in children <24 months of age.
Effect of parental R-rated movie restriction on adolescent smoking initiation: a prospective study.
Correspondence: James D. Sargent, Department of Pediatrics, Dartmouth Medical School, Lebanon, New Hampshire 03756, USA; (email: james.d.sargent@hitchcock.org).
OBJECTIVE: To determine if young adolescents who report that their parents restrict viewing R-rated movies have a lower risk of trying smoking in the future. DESIGN: Prospective observational study. Students from 15 schools in New Hampshire and Vermont, randomly selected from all middle schools with >150 students, were surveyed in 1999. Baseline never-smokers were surveyed again by telephone 13 to 26 months later to determine smoking status. OUTCOME MEASURE: Trying smoking during the follow-up period. RESULTS: The majority of the 2596 students were white, with ages ranging from 10 to 14 years. Nineteen percent reported that their parents never allowed them to view R-rated movies, 29% were allowed once in a while, and 52% were allowed sometimes or all the time. Ten percent of students tried smoking during the follow-up period. Smoking-initiation rates increased as parental restriction of R-rated movies decreased (2.9% for adolescents reporting that their parents never allowed them to view R-rated movies, 7.0% for those allowed to view them once in a while, and 14.3% for those allowed to view them sometimes or all the time). There was a strong and statistically significant effect of parental R-rated movie restriction on adolescent smoking even after controlling for sociodemographics, social influences (friend smoking, receptivity to tobacco promotions), parenting style (maternal support and control, parental disapproval of smoking), and characteristics of the adolescent (school performance, sensation seeking, rebelliousness, self-esteem). Compared with adolescents whose parents never allowed them to view R-rated movies, the adjusted relative risk for trying smoking was 1.8 (95% confidence interval [CI]: 1.1, 3.1) for those allowed to watch them once in a while and 2.8 (95% CI: 1.6, 4.7) for those allowed to watch them sometimes or all the time. The effect was especially strong among adolescents not exposed to family (parent or sibling) smoking, among whom the adjusted relative risk for smoking was 4.3 (95% CI: 1.4, 13) for those allowed to view R-rated movies once in a while and 10.0 (95% CI: 3.6, 31) for those allowed to view them sometimes or all the time. CONCLUSIONS: Parental restriction from watching R-rated movies strongly predicts a lower risk of trying smoking in the future. The effect is largest among adolescents not exposed to family smoking. By exerting control over media choices and by not smoking themselves, parents may be able to prevent or delay smoking in their children.
Children's violent television viewing: are parents monitoring?
Correspondence: Tina L. Chang, Department of General Pediatrics and Adolescent Medicine, Children's National Medical Center, Washington, DC, USA; (email: tcheng2@jhmi.edu).
OBJECTIVE: Violent media exposure has been associated with aggressive behavior, and it has been suggested that child health professionals counsel families on limiting exposure. Effective violence prevention counseling requires an understanding of norms regarding parental attitudes, practices, and influencing factors. Both theories of reasoned action and planned behavior emphasize that subjective norms and attitudes affect people's perceptions and intended behavior. Few data exist on violent television viewing and monitoring from a cross-section of families. By understanding the spectrum of parental attitudes, community-sensitive interventions for violence prevention can be developed. The objective of this study was to assess attitudes about and monitoring of violent television viewing from the perspective of parents.
METHODS: An anonymous self-report assisted survey was administered to a convenience sample of parents/guardians who visited child health providers at 3 sites: an urban children's hospital clinic, an urban managed care clinic, and a suburban private practice. The parent questionnaire included questions on child-rearing attitudes and practices and sociodemographic information.
FINDINGS: A total of 1004 adults who accompanied children for health visits were recruited for the study; 922 surveys were completed (participation rate: 92%). A total of 830 (90%) respondents were parents and had complete child data. Of the 830 respondents, 677 had questions on television viewing included in the survey and were the focus of this analysis. Seventy-five percent of families reported that their youngest child watched television. Of these, 53% reported always limiting violent television viewing, although 73% believed that their children viewed television violence at least 1 time a week. Among television viewers, 81% reported usually or always limiting viewing of sexual content on television and 45% reported usually or always watching television with their youngest child. Among children who watched television, parents reported that they spent an average of 2.6 hours per day watching television. Limitation of television violence was associated with female parents and younger children.
COMMENTS: There was variability in attitudes and practices regarding television violence viewing and monitoring among parents. Attitudes and practices varied on the basis of the age of the child and the gender of the parent.
Prevalence and determinants of PTSD among Palestinian children exposed to military violence.
The prevalence and determinants of PTSD were assessed among 121 Palestinian children (6-16 years; 45% girls and 55% boys) living in the area of bombardment. The mothers (21-55 years) and the children themselves reported their exposure to military violence (being personally the target of violence or witnessing it towards others) and symptoms of posttraumatic stress disorders (PTSD: intrusion, avoidance and hypervigilance). The results showed that 54% of the children suffered from severe, 33.5 % from moderate and 11 % from mild and doubtful levels of PTSD. Girls were more vulnerable; 58% of them suffered from severe PTSD, and none scored on the mild or doubtful levels of PTSD. The child's gender and age, mother's education and PTSD symptoms were significant, and the exposure to traumatic experiences marginally significant determinants of children's PTSD symptoms. The most vulnerable to intrusion symptoms were younger girls whose mothers showed a high level of PTSD symptoms, whereas those most vulnerable to avoidance symptoms were children who had personally been targets of military violence and whose mothers were better educated and showed a high level of PTSD symptoms. The results are discussed in the context of military violence interfering with the protective function of family and home.
