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December 8, 2000


  • Thompson NJ, McClintock HO. Demonstrating your program's worth: A primer on evaluation for programs to prevent unintentional injury. 2nd edition. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2000. (E.07.02B)

    This book is designed to help program staff understand the processes involved in planning, designing, and implementing evaluation of programs to prevent unintentional injuries. Section 1 has general background information. Section 2 describes the four stages of evaluation: formative, process, impact, and outcome. Section 3 is devoted to the methods for conducting evaluation. Appendices include sample questions for interviews, focus groups, and questionnaires; sample forms; a checklist of tasks to make sure that evaluation steps are not omitted; a bibliography of resources, and a glossary of terms.

  • Al West T, Rivara FP, Cummings P, Jurkovich GJ, Maier RV. Harborview assessment for risk of mortality: an improved measure of injury severity on the basis of ICD-9-CM. Journal of Trauma 2000; 49(3):530-540. (E.01.02S)

    There have been several attempts to develop a scoring system that can accurately reflect the severity of a trauma patient's injuries, particularly with respect to the effect of the injury on survival. Current methodologies require unreliable physiologic data for the assignment of a survival probability and fail to account for the potential synergism of different injury combinations. The purpose of this study was to develop a scoring system to better estimate probability of mortality on the basis of information that is readily available from the hospital discharge sheet and does not rely on physiologic data. Records from the trauma registry from an urban Level I trauma center were analyzed using logistic regression. Included in the regression were Internation Classification of Diseases- 9th Rev (ICD-9CM) codes for anatomic injury, mechanism, intent, and preexisting medical conditions, as well as age. Two-way interaction terms for several combinations of injuries were also included in the regression model. The resulting Harborview Assessment for Risk of Mortality (HARM) score was then applied to an independent test data set and compared with Trauma and Injury Severity Score (TRISS) probability of survival and ICD-9-CM Injury Severity Score (ICISS) for ability to predict mortality using the area under the receiver operator characteristic curve. The HARM score was based on analysis of 16,042 records (design set). When applied to an independent validation set of 15,957 records, the area under the receiver operator characteristic curve (AUC) for HARM was 0.9592. This represented significantly better discrimination than both TRISS probability of survival (AUC = 0.9473, p = 0.005) and ICISS (AUC = 0.9402, p = 0.001). HARM also had a better calibration (Hosmer-Lemeshow statistic [HL] = 19.74) than TRISS (HL = 55.71) and ICISS (HL = 709.19). Physiologic data were incomplete for 6,124 records (38%) of the validation set; TRISS could not be calculated at all for these records. The HARM score is an effective tool for predicting probability of in- hospital mortality for trauma patients. It outperforms both the TRISS and ICD9-CM Injury Severity Score (ICISS) methodologies with respect to both discrimination and calibration, using information that is readily available from hospital discharge coding, and without requiring emergency department physiologic data.

  • Guyer B, Freedman MA, Strobino DM, Sondik EJ. Annual summary of vital statistics: trends in the health of Americans during the 20th century. Pediatrics 2000; 106(6):1307-1317. (E.45.02S)

    The overall improvement in the health of Americans over the 20th century is best exemplified by dramatic changes in 2 trends: 1) the age-adjusted death rate declined by about 74%, while 2) life expectancy increased 56%. Leading causes of death shifted from infectious to chronic diseases. In 1900, infectious respiratory diseases accounted for nearly a quarter of all deaths. In 1998, the 10 leading causes of death in the United States were, respectively, heart disease and cancer followed by stroke, chronic obstructive pulmonary disease, accidents (unintentional injuries), pneumonia and influenza, diabetes, suicide, kidney diseases, and chronic liver disease and cirrhosis. Together these leading causes accounted for 84% of all deaths. The size and composition of the American population is fundamentally affected by the fertility rate and the number of births. From the beginning of the century there was a steady decline in the fertility rate to a low point in 1936. The postwar baby boom peaked in 1957, when 123 of every 1000 women aged 15 to 44 years gave birth. Thereafter, fertility rates began a steady decline. Trends in the number of births parallel the trends in the fertility rate. Beginning in 1936 and continuing to 1956, there was precipitous decline in maternal mortality from 582 deaths per 100 000 live births in 1935 to 40 in 1956. Since 1950 the maternal mortality ratio dropped by 90% to 7.1 in 1998. The infant mortality rate has shown an exponential decline during the 20th century. In 1915, approximately 100 white infants per 1000 live births died in the first year of life; the rate for black infants was almost twice as high. In 1998, the infant mortality rate was 7.2 overall, 6.0 for white infants, and 14.3 for black infants. For children older than 1 year of age, the overall decline in mortality during the 20th century has been spectacular. In 1900, >3 in 100 children died between their first and 20th birthday; today, <2 in 1000 die. At the beginning of the 20th century, the leading causes of child mortality were infectious diseases, including diarrheal diseases, diphtheria, measles, pneumonia and influenza, scarlet fever, tuberculosis, typhoid and paratyphoid fevers, and whooping cough. Between 1900 and 1998, the percentage of child deaths attributable to infectious diseases declined from 61.6% to 2%. Accidents accounted for 6.3% of child deaths in 1900, but 43.9% in 1998. Between 1900 and 1998, the death rate from accidents, now usually called unintentional injuries, declined two-thirds, from 47.5 to 15.9 deaths per 100 000. The child dependency ratio far exceeded the elderly dependency ratio during most of the 20th century, particularly during the first 70 years. The elderly ratio has gained incrementally since then and the large increase expected beginning in 2010 indicates that the difference in the 2 ratios will become considerably less by 2030. The challenge for the 21st century is how to balance the needs of children with the growing demands for a large aging population of elderly persons.

  • Bar-on ME. The effects of television on child health: implications and recommendations. Archives of Disease in Childhood 2000; 83(4):289-292. (E.78.06S)

    The exposure of American children and adolescents to television continues to exceed the time they spend in the classroom - 15,000 hours vs. 12,000 hours by the time they graduate. Based on surveys of what children watch, the average child annually sees about 12,000 violent acts, 14,000 sexual references and innuendos, and 20,000 advertisements. Although there have been studies documenting some prosocial and educational benefits from television viewing, significant research has shown that there are negative health effects resulting from television exposure in areas such as: violence and aggressive behavior, sex and sexuality, nutrition and obesity, and substance use and abuse patterns. To help mitigate these negative health effects, pediatricians need to become familiar with the consequences of television and begin providing anticipatory guidance to their patients and families. In addition, pediatricians need to continue their advocacy efforts on behalf of more child appropriate television. This article reviews the effects of television on children and adolescents and makes recommendations for pediatricians and parents to help address this issue.


  • Division of Unintentional Injury Prevention, NationalCenter for Iinjury Prevention and Control. A toolkit to prevent senior falls. 1999. Atlanta, GA, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. (E.55.06S)

    The purpose of this Took Kit is to provide health professionals with current technical information and materials about falls and fall-related injuries that can be incorporated into new or existing activities to reduce falls among older adults. The kit contains a variety of fact sheets, research findings, graphics, a brochure, and a safety checklist. Camera-ready copies of the brochure and checklist can be used for photocopying. Space has been designed into these materials to add an agency/organization name and/or stock number.

  • Cote A, Gerez T, Brouillette RT, Laplante S. Circumstances leading to a change to prone sleeping in sudden infant death syndrome victims. Pediatrics 2000; 106(6):e86. (E.55.04S)

    In addition to usual prone sleeping, unaccustomed prone sleeping represents a significant risk factor for sudden infant death syndrome (SIDS). However, little information is available regarding the circumstances leading caretakers to change the infant's sleep position to prone position in SIDS victims. The purpose of this studay wa to determine, in a population of SIDS victims, the timing of a change to prone sleeping and the reason for that change in infants who were originally nonprone sleepers. A case series analysis was conducted from a questionnaire administered between 1991 and 1997 to parents and other caretakers of SIDS victims in the province of Quebec (Canada). The subjects were 157 SIDS cases occurring in the province during the study. Of the 157 SIDS cases studied, 139 were found in the prone position, although only 93 infants usually slept prone. Of the 64 nonprone sleepers, 34 had been changed to prone by the parents or another caretaker before death, and 18 had apparently turned to prone for the first time. In the 34 cases changed to prone, the change occurred <1 week before death for 21 infants; for 16 of those infants, death occurred the first or second time that they slept prone. In 56% of the cases changed from a nonprone to prone sleeping position, a caretaker other than the parents had precipitated the change. Ongoing campaigns to decrease the risk of SIDS should emphasize the risk of unaccustomed prone sleeping to both parents and secondary caretakers.


  • Hakamies-Blomqvist L, Henriksson P. Cohort effects in older drivers' accident type distribution: are older drivers as old as they used to be? Transportation Research Part F: Psychology and Behaviour 1999; 2(3):131-138. (E.52S)

    Accident type distributions were compared in successive cohorts of older drivers, with focus on intersection accidents. It was thought that if the increasing share of intersection accidents is a truly age-related phenomenon, as opposed to cohort-related or time-related, it would remain fairly constant over time in different cohorts. The data consisted of Finnish traffic insurance data on private car accidents of drivers aged 60 yr or more who were legally responsible for causing the accident, and covered the years 1987-1995 ( N=56,481). Some changes in accident type distributions were found across cohorts. Among male drivers aged 60-79 yr, the portion of intersection accidents decreased in successive cohorts, so that the younger cohorts showed the age-typical accident picture at a somewhat later age than the older cohorts. In contrast, for male drivers aged 80 yr or more, there was an increase in the share of intersection accidents in more recent cohorts. Among female drivers, a decrease in intersection accidents only reached statistical significance for drivers aged 60-69 yr, and for the oldest age group (75+ yr) no change was observed. For both male and female drivers, the tendency to incur accidents at intersections increased with age in all cohorts. The occurrence of intersection accidents thus is both an age-related and a cohort-related phenomenon: age-related in the sense that it will emerge eventually, but with cohort-related variance in timing

  • van Winsum W, de Waard D, Brookhuis KA. Lane change manoeuvres and safety margins. Transportation Research Part F: Psychology and Behaviour 1999; 2(3):139-149. (E.52S)

    The relation between perceptual information and the motor response during lane-change manoeuvres was studied in a fixed-based driving simulator. Eight subjects performed 48 lane changes with varying vehicle speed, lane width and direction of movement. Three sequential phases of the lane change manoeuvre are distinguished. During the first phase the steering wheel is turned to a maximum angle. After this the steering wheel is turned to the opposite direction. The second phase ends when the vehicle heading approaches a maximum that generally occurs at the moment the steering wheel angle passes through zero. During the third phase the steering wheel is turned to a second maximum steering wheel angle in opposite direction to stabilize the vehicle in the new lane. Duration of the separate phases were analysed together with steering amplitudes and Time-to-Line Crossing in order to test whether and how drivers use the outcome of each phase during the lane change manoeuvre to adjust the way the subsequent phase is executed. During the first phase the time margin to the outer lane boundary was controlled by the driver such that a higher speed was compensated for by a smaller steering wheel amplitude. Due to this mechanism the time margin to the lane boundary was not affected by vehicle speed. During the second phase the speed with which the steering wheel was turned to the opposite direction was affected by the time margins to the lane boundary at the start of the second phase. Thereafter, smaller minimum time margins were compensated for by a larger steering wheel amplitude to the opposite direction. The results suggest that steering actions are controlled by the outcome of previous actions in such a way that safety margins are maintained. The results also suggest that visual feedback is used by the driver during lane change manoeuvres to control steering actions, resulting in flexible and adaptive steering behaviour. Evidence is presented in support of the idea that temporal information on the relation between the vehicle and lane boundaries is used by the driver in order to control the motor response.

  • Rimmo P, Aberg L. On the distinction between violations and errors: sensation seeking associations. Transportation Research Part F: Psychology and Behaviour 1999; 2(3):151-166. (E.52S)

    In this study about 700 young adult Swedish drivers aged 18-27 yr responded to a questionnaire on sensation seeking, the tendency to engage in risky behaviours, four types of aberrant driving behaviour (violations, mistakes, inattention and inexperience errors), traffic offences and accident involvement. These results suggest, not unreasonably, a differential relationship between different aspects of sensation seeking and aberrant driving behaviour. Whereas sensation seeking explained a large part of the variation in the violations factor, it accounted for very little of the variance in the other aberrant driving behaviour factors. This finding corresponds reasonably well with a hypothesis calling for a distinction between violations and errors. Still after controlling for the effect of exposure the self-reported accidents was associated with self-reported violations and driving mistakes. Self-reported traffic offences was associated with violations. Consequently, the violations and mistakes factors proved to be stable predictors of offences and accidents. The hierarchical approach taken in this study also shows how the construct of sensation seeking may be associated with aberrant driving behaviour.

  • Berg HY, Eliasson K, Palmkvist J, Gregersen NP. Learner drivers and lay instruction - how socio-economic standing and lifestyle are reflected in driving practice from the age of 16. Transportation Research Part F: Psychology and Behaviour 1999; 2(3):167-179. (E.52.04S)

    On September 1st 1993, a new law came into effect in Sweden, permitting instructor-supported driving practice from the age of 16 instead of 17 years and 6 months. The intention was to enable young people to gain more experience of driving a car before they acquire a driver's permit and thereby to reduce their accident risk. The study was conducted by means of a questionnaire posted to 601 17-year-olds throughout Sweden. The participants were analysed concerning gender, socio-economic standing (blue-collar and white-collar), and lifestyle (friend-oriented, externally-oriented and parent-oriented). The results show that men obtain a learner's permit more often than women (67.4% vs 57.2%) and that youngsters in white-collar families acquire a learner's permit in more cases than those in blue-collar families (67.4% vs 52.4%). One of the reasons for the latter group not acquiring a permit is that they cannot afford it, while children in white-collar families state that they have neither the time nor the desire. No significant difference was found between the three lifestyle groups. When it comes to the amount of practice, the men have been out on the road on average 39.9 h during their first 13 months, compared to 19.9 h for the women. In the lifestyle groups, those who belong to the so-called externally-oriented lifestyle have practised most. They have reported 39.2 h compared to the parent-oriented group with the least amount of training, 27.9 h on average. The friend-oriented group has 22.2 h of practice. When both lifestyle and socio-economic standing were considered, even greater differences were found. The white-collar group of the externally-oriented lifestyle reported as much as 51.5 h, compared to the blue-collar group of the parent-oriented lifestyle with only 18.4 h of practising. The above result is important because it is not in accordance with the intentions of the new driving practice system. The idea behind the new system was that all young people should have the opportunity for a longer period of driving practice in order to reduce the high accident risk during the first year with a driver's license. If it is impossible for certain groups of youngsters to start their driving practice at the age of 16, the situation will become socially unjust and measures must be taken to remedy this situation.


  • Thornton TN, Craft CA, Dahlberg LL, Lynch BS, Baer K. Best Practices of Youth Violence Prevention: A Sourcebook for Community Action. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2000. (E.80.06B)

    This sourcebook presents the best knowledge available about several strategies designed to prevent youth violence. Chapter 1 reviews general principals of intervention planning, implementation, and evaluation. Chapter 2 builds on the experiences of others who have worked to prevent violence by children and adolescents. It discusses in depth the best practices of four key youth prevention strategies and documents the science behind those best practices. Also in this chapter are resources for more information about programs that have used these practices. The appendices include a fact sheet on the problem of youth violence and an overview of the public health approach to youth violence prevention and the underlying reason for why this sourcebook was developed.

  • Webster DW, Starnes M. Reexamining the association between child access prevention gun laws and unintentional shooting deaths of children. Pediatrics 2000; 106(6):1466-1469. (E.96.04S)

    A previous study estimated that child access prevention (CAP) laws, which hold adults criminally liable for unsafe firearm storage in the environment of children, were associated with a 23% decline in unintentional firearm mortality rates among children. The purpose of this study was to reassess the effects of CAP laws and more fully examine the consistency of the estimated law effects across states. A pooled time-series study of unintentional firearm mortality among children from 1979 through 1997 was conducted, using data from the 50 states and the District of Columbia. Participants were all children <15 years. Main Outcome Measures were rates of unintentional deaths attributable to firearms. When the effects of all 15 state CAP laws enacted before 1998 were aggregated, the laws were associated with a 17% decline in unintentional firearm death rates among children. The laws' effects were not equal across states. Florida's CAP law was associated with a 51% decline; however, there were no statistically significant aggregate or state-specific law effects in the other 14 states with CAP laws. Florida's CAP law -1 of only 3 such laws allowing felony prosecution of violators - appears to have significantly reduced unintentional firearm deaths to children. However, there is no evidence of effects in the other 14 states with CAP laws.

Alcohol/Drug use:

  • Warner M, Smith GS, Langley JD. Drowning and alcohol in New Zealand: what do the coroner's files tell us? Australian and New Zealand Journal of Public Health 2000; 24(4):387-390. (E.60.06S)

    The purpose of this study was to provide a systematic review of the details on alcohol involvement available in the coronial files to determine if there is enough evidence to estimate the role of alcohol in drowning. The authors reviewed the coroner's files of persons 10 years or older who drowned in New Zealand between 1992-1994 inclusive. A total of 320 coroner's files were examined. Blood Alcohol Concentrations (BACs) were taken in 115 cases (36%) and positive for 50% of these. When accounting for the incomplete testing by using all the information on alcohol involvement collected, between 30-40% of the cases were estimated to have a positive BAC and between 17-24% to have a BAC 100 mg/dL or higher. The quality and completeness of current coronial information on alcohol involvement in drowning is insufficient to arrive at an accurate estimate of the percentage of drownings where alcohol was a factor. Coroners should test drowning victims 10 years and older for BAC. These data should be systematically recorded and processed with the goal of determining who should be targeted in drowning and alcohol prevention programs.


  • Wassell JT, Gardner LI, Landsittel DP, Johnston JJ, Johnston JM. A Prospective Study of Back Belts for Prevention of Back Pain and Injury. Journal of the American Medical Association 2000; 284(21):2727-2732. (E.74.08S)

    Despite scientific uncertainties about effectiveness, wearing back belts in the hopes of preventing costly and disabling low back injury in employees is becoming common in the workplace. The purpose of this study was to evaluate the effectiveness of using back belts in reducing back injury claims and low back pain. A prospective cohort study was conducted from April 1996 through April 1998. The authors identified material-handling employees in 160 new retail merchandise stores (89 required back belt use; 71 had voluntary back belt use) in 30 states (from New Hampshire to Michigan in the north and from Florida to Texas in the south); data collection ended December 1998, median follow-up was 6(1/2) months. Participants were a referred sample of 13,873 material handling employees who provided 9377 baseline interviews and 6311 (67%) follow-up interviews; 206 (1.4%) refused baseline interview. The main outcome measures were the incidence rate of material-handling back injury workers' compensation claims and 6-month incidence rate of self-reported low back pain. Neither frequent back belt use nor a belt-requirement store policy was significantly associated with back injury claim rates or self-reported back pain. Rate ratios comparing back injury claims of those who reported wearing back belts usually every day and once or twice a week vs those who reported wearing belts never or once or twice a month were 1.22 (95% confidence interval [CI], 0.87-1.70) and 0.95 (95% CI, 0.56- 1.59), respectively. The respective odds ratios for low back pain incidence were 0.97 (95% CI, 0.83-1.13) and 0.92 (95% CI, 0.73-1.16). In the largest prospective cohort study of back belt use, adjusted for multiple individual risk factors, neither frequent back belt use nor a store policy that required belt use was associated with reduced incidence of back injury claims or low back pain.

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