Injury Control Update

A PUBLICATION OF THE NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL

Vol. 2, No. 2 ▲ Fall 1997

CDC

CENTERS FOR DISEASE CONTROL

AND PREVENTION

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

IN THIS

ISSUE

▼

FEDERAL REPORT

SUPPORTS POISON

CONTROL CENTERS ... 11

▼

PRESCHOOLERS ADOPT

HELMET HABIT ............ 2

▼

PACT HELPS YOUTHS

AVOID VIOLENCE ...... 13

▼

NRC EXAMINES VIOLENCE

AGAINST WOMEN ..... 19

▼

CALIFORNIA “HEALTHY

CITY” PROMOTES BIKE

HELMETS .................. 16

▼

RESOURCES YOU

CAN USE ................... 18

▼

CALENDAR ............... 20

Evidence builds: youth violence

prevention programs working

Violence among America’s young

people remains at historically high

levels, and both offenders and

victims are getting younger each

year. Yet aggressiveness, antisocial

behavior, and violent crimes can all be

prevented with early intervention—

and the earlier the better, according

to W. Rodney Hammond, PhD,

director of NCIPC’s Division of

Violence Prevention (DVP) and

codeveloper of the Positive Adolescent Choices Training (PACT) program

(see article, page 13).

“Youth violence is a serious problem,” he says, “but in public health,

we have found good approaches to

prevent it. The causes of youth violence lie in the way many youths

respond to negative conditions in the

environment. We now know we need a

multipronged approach in which we

not only teach youths appropriate

responses but also focus on the environments that place youths at risk.”

He is encouraged by the variety of

strategies being used by injury prevention programs across the country and

by study findings indicating that some

of these interventions are successfully

curbing youth violence.

Bicycle helmets: getting

people to use them

“The issue is not ‘proving’ that

bicycle helmets work to reduce

injuries, but motivating people to

wear them,” maintains Jeffrey J.

Sacks, MD, MPH, acting leader of

the Home and Leisure Team in

NCIPC’s Division of Unintentional

Injury Prevention (DUIP).

The facts are clear. Each year, hundreds of people die as a result of

bicycle crashes and tens of thousands

more are injured, some so severely that

they are permanently disabled. The

largest proportion of the population

affected by bicycle-related injuries are

children and adolescents. And these

injuries are largely preventable if

riders wear helmets. Some studies

suggest that wearing a helmet reduces

the likelihood of head injury by more

than 75%.

CONTINUED ON PAGE 6

CONTINUED ON PAGE 4
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▲INJURY CONTROL UPDATE ▲ Fall 1997

Preschoolers adopt the helmet habit

Tykes on trikes are the latest recruits in

the battle to reduce head injuries among

children.

Although the image of helmeted

preschoolers tooling about on their Big

Wheels may evoke chuckles, the subject is

serious. A recent review of pediatric

trauma cases nationwide found that,

although the tricycle set (those under 5

years of age) accounted for only a small

proportion of kids with bike-related

injuries, their injuries were just as severe

as those of children aged 5–14 [Powell EC,

Tanz RR, DiScala C. Bicycle-related injuries

among preschool children. Ann Emerg Med

1997; 30(3):260-5.]. The study’s authors

recommended that the young cyclists

wear helmets, both to prevent head

injuries and to instill good habits early.

An innovative program in Washington

State is demonstrating just how to do that.

“We know that bicycle-related head

injuries are a leading cause of head injury

for kids ages 5–14, so we wanted to

establish a pattern of wearing helmets for

these little kids who are on the verge of

moving into the high-risk age group,”

said Ilene Silver, MPH, coordinator of the

Washington State Injury Prevention

Program.

The project targets low-income children

who participate in Head Start and the

Early Childhood Education and Assistance Program (ECEAP) and, indirectly,

their older siblings and parents. Key

components include the following:

▲ education for the kids and their

parents about the importance of

wearing helmets

▲ extensive training for preschool staff

and family service workers

▲ a policy requiring all children to wear

helmets when they ride wheeled

vehicles at the preschool

▲ distribution of free bicycle helmets to

the Head Start/ECEAP children and

their siblings aged 5–14

By the end of the 3-year project this past

September, more than 205 Head Start and

ECEAP sites were participating, and more

than 1,500 helmets had been purchased

for use of preschoolers at these sites. In

addition, more than 28,000 helmets were

purchased for free distribution to the

preschoolers and their siblings. Supplementing the CDC grant, the project received funding from the Washington

Traffic Safety Commission, the Preventive

Health Block Grant, and the Maternal and

Child Health Block Grant to purchase the

helmets.

Program incorporates multiple

dimensions

The project involved far more than a

helmet giveaway, Ms. Silver emphasized.

Training via interactive video teleconferences helped introduce the program to

staff and provided tips for the proper

fitting of helmets and for creative safety

events. A video on how to fit a helmet was

part of the training, and copies also were

provided to each agency to show teachers
INJURY CONTROL UPDATE ▲ Fall 1997

3

▲

and parents the

correct way to

measure and fit

helmets.

The education

and helmet

giveaway efforts

culminated at

each site with a

“bicycle rodeo,”

modified from

the typical

safety event for

older riders,

which teaches

older kids how

to ride safely in

traffic. “The

little kids were

really learning

safe pedestrian activities, only on trikes,”

Ms. Silver explained. A favorite activity

was the “driveway ride-out.” The youngsters maneuvered their wheeled vehicles

down a path marked with orange safety

cones and learned to stop and look both

ways at the end before proceeding. Parents and siblings helped develop props

that represented potential hazards for kids

approaching the end of a real driveway,

such as cars or shrubs that could hide a

dog or pedestrian.

“The kids really loved these ‘rodeos,’”

said Ms. Silver, “and it provided a great

way to involve the parents and older

siblings. Moreover, the events drew good

coverage in the local press, which could

help pave the way for future funding at

the local level.”

More than fun and games

All the fun and games resulted in solid

injury prevention, too. Observed helmet

use among the preschoolers increased

from 40% to 88% in the second year of the

project (the last year for which data were

available). Moreover, parents reported

that the proportion of preschool children

who “always” wear helmets increased

from 43% at baseline to 64% after the

helmet program was implemented.

None of this success could have happened

without the creative input at the local

level and the support of the Head Start

and ECEAP directors, said Ms. Silver. The

initial idea for focusing on a preschool

population came from a county health

educator, Becky Martin from Snohomish

County. She had developed a program

with a minigrant from a previous CDC

state capacity-building grant, and the

Head Start/ECEAP project extended her

idea statewide.

“The best ideas come from people at the

local level,” said Ms. Silver. “They are

really committed and have a fountain of

good ideas. We can help by getting seed

dollars and providing a forum to share

ideas about what works.” ■

▲

Wheeling their way through makeshift intersections and obstacle courses, children from the

Burlington Head Start program in Washington State learn the importance of wearing bicycle

helmets and watching for traffic.

Photo courtesy of Scott Terrell, Skagit Valley Herald
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▲INJURY CONTROL UPDATE ▲ Fall 1997

Prevention potential

A recent study published by Dr. Sacks and

others at NCIPC found that each year in

the United States, an average of 247

children and adolescents die from traumatic brain injuries sustained in bicycle

crashes, and another 140,000 are treated

for head injuries. Had these riders worn

helmets, as many as 184 deaths and

116,000 head injuries might have been

prevented, according to the researchers,

who used surveillance information from

selected emergency rooms and national

multiple cause-of-death data. (Sosin DM,

Sacks JJ, Webb KW. Pediatric head injuries

and deaths from bicycling. Pediatrics

1996;98:868-70)

Employing such a simple, relatively lowcost intervention should be a given for the

injury prevention world. And it does

appear that helmet use is increasing,

especially in states and communities with

mandatory helmet use laws. But the

proportion of riders who regularly wear a

helmet before setting out for a bicycle ride

still is far below the national year 2000

objective of 50%. A recent telephone

survey found that only a quarter of

children 5–14 years old are reported to

wear helmets regularly. (Sacks JJ, Kresnow

M, Houston B, Russell Bolen J. Bicycle helmet

use among U.S. children. Inj Prev 1996;2:258-

62).

The same survey found that young adults

had an even more dismal record. Only

about 20% of adults said they wore a

helmet while cycling, but riders aged 18–

24, the group that had the highest proportion of bike riders for any adult age group,

had the lowest rate of helmet use: 5.1%.

(Russell Bolen J, Kresnow M, Sacks JJ. Reported bicycle helmet use among adults in the

U.S., 1994. Arch Fam Med 1998 [in press]).

Making helmet use a “norm”

With the life-saving benefits of helmets

so apparent, why don’t all bicycle riders

wear one?

“Every time you get on a bicycle, you

have to make a decision to wear a helmet,” said Dr. Sacks. Many barriers work

against that choice, especially for children

and adolescents, but the main one is that

it is not a “social norm” in most communities. In other words, it’s not the “cool”

thing to do.

Reasons that young riders give for not

wearing helmets include never thinking

about it, not perceiving a risk from bicycling, discomfort, expense, and a feeling

that helmets are unattractive. “Peer

pressure and the fear of being labeled

‘different’ are strong motivations for

nonuse,” according to a DUIP report.

No single approach is likely to overcome

these complex behavioral barriers, said

Dr. Sacks. Rather, a multifaceted approach

has shown promise in several demonstration programs. “More is better in this

case,” said the NCIPC scientist. “The more

pathways you use to motivate compliant

behavior, the more likely you are to be

successful in the long run.”

Nine states have just completed 3-year

NCIPC-funded projects to promote

bicycle helmet use and evaluate program

effectiveness. The experience of these

projects points to several elements that seem

to make a difference, according to DUIP:

▲ Mandatory helmet use legislation

appears to provide a prompt and

substantial increase in helmet use.

This approach can double the helmet

use rate in a short period of time.

BICYCLE HELMETS (continued)
INJURY CONTROL UPDATE ▲ Fall 1997

5

▲

National Bicycle Safety Network

promotes safe riding

Twenty national organizations are

working together to encourage expanded and safer bicycling. The National Bicycle Safety Network was

formed 3 years ago as a subcommittee of

the Advisory Committee for Injury

Prevention and Control. The cochairs are

Richard Schieber, MD, MPH, with

DUIP’s Home and Leisure Team, and

Maria Vegega, PhD, of the National

Highway Traffic Safety Administration.

Member organizations represent other

federal agencies, nonprofit organizations, advocacy groups, and consumer

associations.

The network has two main purposes:

▲ assist the nation in reaching the year

2000 objective of 50% bicycle helmet

use

▲ increase the safe use of bicycles as

an alternative means of transportation

The network’s first major project is

development of an Internet web page to

serve as a common starting point for

people seeking information on bicycle

safety and use. There will be Hypertext

links to partners’ web pages and contact

information for organizations without

web pages. The network’s Internet

address is www.cdc.gov/ncipc/bike.

Currently, 15 states and numerous

local communities have such legislation, suggesting substantial potential

for improvement.

▲ A sustained multifactorial approach

is more successful than any single

approach. Many effective programs

incorporate information and education, helmet giveaway programs, and

efforts to pass helmet use laws or

vigorously promote their enforcement.

Components of such an approach

include involving local coalitions and

forging public and private partnerships

between public health departments,

health care providers, schools, businesses, and community-based groups.

▲ Each community is unique, and

programs to promote helmet use

must be tailored to local concerns

and resources. There is no single

template for a successful program;

instead each local effort should take

into account its own community

needs, social norms, and characteristics.

▲

One of the big reasons that people don’t wear bike

helmets consistently says NCIPC’s Dr. Jeffrey Sacks is

that it requires a conscious decision “every time you get

on a bicycle.”

Photo from Digital Stock
6

▲INJURY CONTROL UPDATE ▲ Fall 1997

EVIDENCE BUILDS (continued)

Injury control experts agree that the

problem of youth violence is too involved

to be solved with any one approach. A

child’s tendency toward violence is

affected not only by families, peers, and

the school environment, but also by social

factors such as access to drugs and a lack

of job training and opportunities for

employment. “Because the problem is

complicated, it’s going to take a lot of

different types of interventions, each of

which will make a small contribution,”

explains Kenneth E. Powell, MD, former

associate director for science at DVP. “We

don’t want to miss an opportunity to put

all of these small contributions together

and use them to make a larger impact.”

Early childhood interventions—for example, programs to improve adults’

parenting skills or activities to help preschool children overcome problems with

persistent antisocial behavior—are promising because they lay a foundation that

will help deter violence during adolescence. Moreover “We’ve got to do more to

make homes a safer place, and we need to

help parents deal with relationship issues

that kids observe in the home that can

promote violence or detract from kids’

ability to avoid it,” Dr. Hammond says.

“Violence prevention also has to take

place in many other settings,” adds Dr.

Hammond. “To deal with violence in the

population, you have to have interventions

in the schools and out in the community—

for example, in youth development

programs, recreational centers, church

groups, and wherever kids are,” he explains. “We also need to get out into the

broader community by dealing with issues

such as unemployment, high crime areas,

and the need for partnerships between

law enforcement and community members.”

NCIPC activities promote bicycle

helmet use

Grants to support state programs yield

rich results. (Examples of how two statebased programs carved out unique

approaches are included in the stories

beginning on pages 2 and 17.) NCIPC has

just awarded funds to support five new

3-year programs promoting helmet use

among children 5–12 years of age. The

newly funded states are California,

Colorado, Florida, Oklahoma, and Rhode

Island.

In addition to supporting state and

community demonstration projects,

NCIPC has funded both biomechanical

research on bicycle helmets and evaluation of various aspects of bicycle safety,

including the impact of helmet laws.

Several of the NCIPC-funded injury

control research centers, including

Harborview Medical Center in Seattle and

Johns Hopkins University in Baltimore,

have focused on bicycle-related injuries.

NCIPC also conducts surveillance on

bicycle-related injuries, carries out special

studies, and develops and disseminates

related information. Underscoring the

importance of well-conducted evaluation,

the center is in the process of developing

a manual to help local programs conduct

observational studies on helmet use.

Altogether, Dr. Sacks is encouraged by

various signs of improvement in the

efforts to prevent bicycle-related deaths

and injuries. “We are moving in the right

direction.” he said. “Helmet use is up,

and programs are showing success. A

number of challenges remain, but we

have a good sense of what to do. The issue

is one of getting enough resources to do

the job.” ■
INJURY CONTROL UPDATE ▲ Fall 1997

7

▲

It is not enough, though, just to put

different types of programs in place.

They need to be scientifically evaluated to

determine whether they are working,

what positive outcomes they have produced, whether they are cost-effective,

and what circumstances are needed for

them to succeed.

NCIPC has supported 18 evaluation

projects, the latest of which are to be

completed in 1999. Four of these projects

are evaluating programs that aim to create

positive social environments for young

children and their families. Other projects

are evaluating interventions to prevent

and reduce aggressive and violent behavior

among youths. The following three

projects, past recipients of NCIPC funding,

have undergone full or partial evaluation,

with encouraging results.

PeaceBuilders

PeaceBuilders is a school-based program

described by Dennis D. Embry, PhD,

whose research led to the program’s

creation, as more “a way of life” than a

curriculum. It was designed for children

in grades K–5, and its activities are built

into the school environment and into

daily interactions among students, teachers, and other staff. PeaceBuilders is based

on scientific evidence that children who

grow up to commit acts of violence exhibit

cognitive, social, and imitative differences

from their peers—differences that can best

be ameliorated at an early age, says Dr.

Embry, who serves as chief executive

officer of Tucson-based Heartsprings, Inc.

The program teaches the children, their

peers, and adults at school and at home

specific ways to reduce aggression and

hostility in their lives. At PeaceBuilders

schools, children learn five principles:

praise people, avoid put-downs, seek wise

people as advisors and friends, notice and

correct hurts we cause, and right wrongs.

The young students are given plenty of

opportunities to rehearse positive behavior and rewards for practicing such behavior, Dr. Embry explains. For example,

during recess children may take turns

being Peace Coaches who praise other

children for sharing or inviting other

students to play with them. After the last

recess, children can write each other

praise notes for display on the school’s

Peace Board.

According to an evalution conducted by

Daniel J. Flannery, PhD, of Kent State

University, the program has had some

positive results. Three to five months into

the program, nine Tucson PeaceBuilders

schools showed a 10% decline in fightingrelated injuries. During the same period,

fighting-related injuries increased 56% in

control schools. Another good example of

the program’s success, says Dr. Embry, is

an elementary school in San Bernardino,

California, where in the year before

PeaceBuilders began, 120 children were

Photo courtesy of Heartsprings, Inc.

Being recognized as PeaceBuilder of the Day instills

pride in schoolchildren and is just one example of how

the PeaceBuilders program reinforces positive behavior

at school.

▲
8

▲INJURY CONTROL UPDATE ▲ Fall 1997

suspended and about 30 were arrested for

crimes in the community. Two years into

PeaceBuilders, the number of suspensions

had dropped to five, and there were no

arrests for community crimes.

The strength of PeaceBuilders is that it is

based on scientific research, yet it is

accessible and easy for children, teachers,

and parents to understand, according to

Dr. Embry. “And it’s very portable. We

started PeaceBuilders in 1993 in nine

elementary schools. It’s now in about 400

schools nationally. It grows at a rate of

five to ten schools a week. And it’s poised

to become a national program in Australia.”

Second Step

Evaluation of a program in Seattle

schools, Second Step: A Violence Prevention

Curriculum, showed modest success in

reducing aggressive behavior and increasing positive social behavior among second

and third graders. At the same time, it

showed that school-based programs can

be evaluated using randomized controlled

trials, which are generally considered the

most scientifically rigorous method of

testing.

Second Step is based in the classroom and

teaches empathy—students learn to

identify their feelings and those of others;

impulse control—they learn behavioral

skills and a strategy for solving problems;

and anger management—they learn a

strategy for coping with anger and behavioral skills to help them in tense situations. Although the program is designed

to be implemented schoolwide, limited

funding dictated that only a few classrooms in each of the 12 participating

schools take part.

Teachers from these classrooms underwent two days of training before the

program began in December 1993. The

children in the Second Step group received

one or two 35-minute lessons each week,

totaling 30 lessons. These children and

those in the control group were then

observed by teachers, parents, and trained

observers, with varying results.

Parents and teachers noticed little change

in the children’s behavior in the classroom

or at home, whereas the trained observers,

who were not told the study’s purpose,

noticed significant changes in behavior on

the playground and in the cafeteria. The

trained observers saw physically aggressive behavior decrease significantly more

and neutral and positive social behavior

increase significantly more among children receiving the curriculum than among

those in the control group. Most of these

effects were evident six months after the

intervention ended.

The principal investigator David C.

Grossman, MD, MPH, of Harborview

Injury Prevention and Research Center,

offers several possible explanations for

these differing observations: Teachers may

have been less aware of aggressive behavior outside the classroom and, therefore,

less likely to notice changes. Parents may

have noticed little change because the

children may have been better behaved at

school than at home.

Another possible explanation is that the

instruments that evaluators used to

measure changes in behavior may not

have been sensitive to change. “Or parents

and teachers may have fixed impressions

that are slow to change,” he suggested. Dr.

Grossman also wonders how the results

would have differed if the program had

included the parent’s component, which

was not yet available; if the Second Step

curriculum could have been implemented

in the whole school; and if students had

received continued reinforcement.
INJURY CONTROL UPDATE ▲ Fall 1997

9

▲

SAGE

African American boys 12–16 years of age

were the focus of the Supporting Adolescents with Guidance and Employment

(SAGE) program in Durham, North

Carolina. The community-based program

included an eight-month African-American Rites of Passage program, which

consists of adult mentoring, culture and

history lessons, and manhood and conflict-resolution training; a six-week

summer employment component; and a

12-week entrepreneurial experience.

SAGE was based on the assumption that

various risk factors—such as blocked

educational and employment opportunities, a lack of ethnic pride, single-parent

families, and low household income—

may increase an African-American teenagers’ likelihood of engaging in violent

behavior. SAGE was developed in 1992 by

the Durham Business and Professional

Chain (The Chain), the City of Durham

Employment and Training Office, and the

Durham County Health Department.

The program is undergoing a process and

outcome evaluation, conducted by staff

from the Research Triangle Institute,

University of North Carolina, and North

Carolina State University. The preliminary findings are somewhat promising,

reports project evaluator Mallie J.

Paschall, PhD. “In three areas—carrying

weapons, selling illicit drugs, and using

alcohol—our program seems to have

made a difference. But we are seeing no

effect on fighting behavior,” he notes.

Dr. Paschall adds that youths participating in the Rites of Passage program have

shown minimal improvement in four

areas: increased ethnic pride, improved

self-esteem, a more optimistic outlook on

the future, and a lessening of the belief

that aggression is socially acceptable and

expected behavior.

Community support was essential to

evaluating the intervention, says Dr.

Paschall. But gaining the community’s

trust and support was not easy. After

sitting down and talking with members of

the community to answer their questions

and address their fears, the level of acceptance increased. “They realized,” says Dr.

Paschall, “that we were listening to people

and not just crunching numbers—that the

results would be important to improving

and continuing SAGE.”

Advice for program planners

When developing a strategy to prevent

youth violence, planners should consider a

wide array of issues before investing in a

curriculum or program. Injury Control

Update staff asked Dr. Powell and two

other NCIPC experts in youth violence

prevention for their views on these considerations:

▲ First, carefully consider what you

really want to accomplish. “Start with

a realistic framework and be fairly

specific to keep focused. Don’t just say,

‘We’re going to prevent youth violence,’” advises Dr. Powell.

▲ Before purchasing curriculum or

program materials, make sure the

intervention has been evaluated and

shown to be effective. “Teachers,

school administrators, and other

decision makers need to know what

works,” emphasizes James A. Mercy,

PhD, DVP’s associate director for

science. “This is the information that

will help them make rational decisions

about what types of interventions will

most likely reduce violence.”

▲ Next, consider how easily a curriculum or program will translate to the

target population, recommends Lloyd

B. Potter, PhD, MPH, leader of DVP’s

Youth Violence/Suicide Prevention

CONTINUED ON PAGE 11
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▲INJURY CONTROL UPDATE ▲ Fall 1997

Seven Characteristics of Promising School Violence Prevention Programs

After extensively reviewing school-based programs to prevent violence, the U.S.

General Accounting Office identified the following seven characteristics as being

associated with the most promising interventions:

▲ Comprehensive approach. These programs recognize violence as a complex

problem that requires a multifaceted response. Consequently, they address more

than one problem area and involve a variety of services that link schools to the

community.

▲ Early start and long-term commitment. There is a focus on (1) reaching young

children to shape attitudes, knowledge, and behavior while they are still open to

positive influences, and (2) sustaining the intervention over multiple years (for

example, from kindergarten through 12th grade).

▲ Strong leadership and disciplinary policies. Leadership is strong at the school

level. Principals and school administrators need to sustain stable funding, staff,

and program components, and, most important, they must collaborate with others

to reach program goals. In addition, student disciplinary policies are clear and

consistently applied.

▲ Staff development. Key school administrators, teachers, and staff are trained to

handle disruptive students and mediate conflict as well as understand and

incorporate prevention strategies into their school activities.

▲ Parental involvement. The schools seek to increase parental involvement in

reducing violence by providing training on violence prevention skills, making

home visits, and enlisting parents as volunteers.

▲ Interagency partnerships and community linkages. The schools seeks community support in making school antiviolence policies and programs work. To

accomplish this, they develop collaborative agreements in which school personnel, local businesses, law enforcement officers, social service agencies, and private

groups work together to address the multiple causes of violence.

▲ Culturally sensitive and developmentally appropriate materials and activities.

Program materials and activities are designed to be compatible with (1) students’

cultural values and norms by using bilingual materials and culturally appropriate

program activities, role models, and leaders, and (2) participants’ age and level

of development.

From: U.S. General Accounting Office. School safety: promising initiatives for addressing

school violence. Washington, DC: US General Accounting Office, 1995.
INJURY CONTROL UPDATE ▲ Fall 1997

11

▲

Team. For example, is the curriculum

culturally appropriate for the target

group? Will it work in your setting and

environment, whether it be a school,

church, or the home?

▲ Make sure your institution is ready to

conduct the intervention. Are the

necessary funds available? Do you

have the necessary staff? Do you have

the time required to develop and

conduct the intervention? “When

institutional readiness isn’t there, you

can have the best curriculum, but the

program just won’t work,” Dr. Potter

cautions.

▲ Make sure all of the appropriate

people and organizations support

the project and want to be involved.

“For example,” says Dr. Powell, “if

the intervention has a summer job

component, you will need the support

of local employers.”

▲ Finally, gather as much information

that is available about the type of

approach you plan to use. “Draw

upon the experiences of others, but

also recognize the unique characteristics of your own community,” Dr.

Powell suggests. ■

Federal report urges support

for poison control centers

[LATE BREAKER: On October 28, as

Injury Control Update went to press,

Secretary Shalala approved and forwarded

to Congress the report of the Advisory

Committee for Injury Prevention and

Control.]

In December 1993, members of an Oregon

family suffered severe respiratory symptoms after using a new type of leather

cleaning spray. An alert poison control

center director notified colleagues nationally and set in motion a response to the

potential crisis. Within four hours, the

manufacturer had voluntarily recalled the

aerosol cleaner, and stores throughout the

country were directed to remove the

product from their shelves. During that

same period, 550 reports of lung injury and

illness attributable to the leather spray had

come in from 17 other states around the

country.

Poison control centers—linked through the

Toxic Exposure Surveillance System (TESS)

of the American Association of Poison

Control Centers (AAPCC)—have prevented or restricted public health catastrophes such as the leather spray episode

for a long time now. Perhaps the best

remembered incident took place some

years ago when tamper-proof packaging

was instituted after a poisoning was

traced to TylenolTM laced with cyanide.

Every day, poison control centers are

only a phone call away for a frantic

parent or caregiver seeking help after a

child swallows a toxic substance.

However, dwindling funds have jeopardized the capacity of poison control

centers to provide adequate coverage to

the U.S. population. This funding crisis

was the catalyst for a report, developed

by the Secretary’s Advisory Committee

for Injury Prevention and Control, that

chronicles the precarious and haphazard

funding history of poison control centers

over the past two decades.

EVIDENCE BUILDS (continued)
12

▲INJURY CONTROL UPDATE ▲ Fall 1997

Injury Control Update is a

publication of the Centers for Disease Control and

Prevention (CDC), National Center for Injury Prevention

and Control (NCIPC).

DIRECTOR, CDC

David Satcher, MD, PhD

DIRECTOR, NCIPC

Mark L. Rosenberg, MD, MPP

EDITOR

Gwen Ingraham

MANAGING EDITOR

Katie Baer, MPH

WRITER-EDITORS

Katie Bauer, MPH

Valerie Johnson

LAYOUT ARTIST

Leslie Parker

Direct editoral correspondence to:

Gwen Ingraham, Director, Office of

Communication Resources, NCIPC, CDC,

MS K-65

4770 Buford Hwy. NE • Atlanta, GA 30341-3724

Internet: gni@cipcod1.em.cdc.gov

According to Dr. Richard Weisman, past

president of the AAPCC, poison control

centers are customarily “unwanted stepchildren” with no single organization

taking ownership or responsibility for

them within the public health system. The

number of centers in the United States has

declined steadily over the last two decades, and the remaining centers are in a

constant budget crunch. Prevention

activities especially have been slashed

from centers’ budgets, even though many

preventive measures are quite inexpensive.

Although a public health program

strapped for money is not a new story,

this particular funding crisis has drawn

attention because cutbacks at poison

control centers seem certain to push

medical costs even higher. The average

cost from a poisoning exposure call is

$31.28, while the average cost if other

parts of the medical care system are

involved is $932, according to Dr. Toby

Litovitz, executive director of the AAPCC.

Every dollar spent on poison control

center services saves an estimated $7 in

medical spending, mainly by eliminating

the need for emergency department care

for cases that can be managed safely at

home.

The advisory group report recommends

that the federal government pay 25% of

costs, or its “fair share” according to the

benefits derived by the federal government, to stabilize the present system

Long-range planning is underway

through a study by Dr. Ann Zuvekas of

George Washington University and

sponsored by the Robert Wood Johnson

Foundation to better streamline services

offered by the U.S. poison control system

and make them even more cost-effective.

Meanwhile, the advisory group calls for

immediate federal funding to enact

certain initiatives. These include a

national 800 number (see sidebar, page

13), a national public education campaign,

standard protocols for commonly encountered toxic exposures, and an improved

electronic surveillance system.

Jean Athey, PhD, of the Bureau of Maternal and Child Health, Health Resources

and Services Administration, says, “This

important report highlights the contribution to health care made by poison control

centers—the lives they save and the cost

savings they generate.” The report is

expected to lead to an enhanced and

improved system for poison prevention.

For a copy of the report, contact Paul

Burlack at NCIPC, MS F-41, 4770 Buford

Hwy, NE, Atlanta, GA 30341-3724. ■
INJURY CONTROL UPDATE ▲ Fall 1997

13

▲

PACT helps

youths express

anger, disagree

without violence

African-American youths, particularly

boys, are far more likely than other young

people to be victims or perpetrators of

violence. The Positive Adolescent Choices

Training (PACT) program developed at

Wright State University is teaching

African-American children and teens how

to express anger constructively, listen to

negative feedback, and negotiate with

peers when disagreements persist. Students are discovering that they can replace violence-provoking actions with

behaviors that create less antagonism and

lead to more satisfying and safer results.

“In America, where kids face so much

danger and there are so many risks associated with relationships, it’s much more

dangerous for today’s kids not to have

these social skills than it was for previous

generations,” notes director of NCIPC’s

Division of Violence Prevention

W. Rodney Hammond, PhD, who worked

with psychology professor Betty R. Yung,

PhD, to develop PACT and the companion

curriculum Dealing with Anger. “We

understand from the research that kids

with poor social skills are very vulnerable

to violence, and kids with good social

skills tend to be protected from violence.

So PACT gives children—particularly

those most at risk—the skills they need to

avoid becoming victims and perpetrators

of violence,” he explains.

The program cannot prevent instrumental

violence, such as armed robbery, advises

1–800–POISON–1

A national 800 number for public

access to poison control services is an

idea whose time has come, according

to Dr. Steven Marcus, director of the

New Jersey Poison Control Center. He

and the Texas poison control centers

have spearheaded an arrangement

with AT&T to respond with toxicological advice to calls directed to 1-800-

POISON-1.

Dr. Marcus sees many benefits to a

single 800 number, which will route

callers to the center designated to cover

in their region. For one thing, a common number may make promoting the

service easier. He suggested that

private industry is often willing to

print a nationwide number on their

own materials, thus saving costs for

poison control centers.

Some poison control center directors

are more cautious. Toby Litovitz,

executive director of the AAPCC, said

that, since many centers now handle

most of their calls over local telephone

lines, implementation of an 800 number would involve an added expense.

The AAPCC at their annual meeting

this past September, passed a resolution supporting “the immediate move

to a single national toll free telephone

number for poison emergencies,

controlled by the AAPCC, provided

that adequate and sustained funding is

assured such that the institution of this

service does not adversely impact

already financially-strained poison

control centers.”

Although logistical problems still

remain, the initiative is gathering

speed, with the 800 number being

adopted in Florida, Michigan, Minnesota, Oklahoma, Oregon, South

Dakota, and Texas.
14

▲INJURY CONTROL UPDATE ▲ Fall 1997

Dr. Hammond, but it can help significantly

with expressive violence, such as a fight

that erupts during an angry conversation

between teenagers on the street. Students

learn that in such situations, they have the

power to make choices and each choice

has a different consequence. For instance,

if a teenage boy steps on another student’s

foot, that student can choose to walk

away, to shout at the boy, or to shoot him.

Givin’ it, takin’ it, workin’ it out

PACT began in 1989 as a pilot project of

Wright State University’s School of Professional Psychology in cooperation with

public schools in Dayton, Ohio. PACT

serves as a preprofessional training

program, because it is staffed by students

enrolled in the university’s doctoral

program in clinical psychology. A parent

component, staffed in the same way, has

been developed and refined. A Wright

State train-the-trainer program supported

by funding from CDC, the Bureau of

Maternal and Child Health, and the

Department of Education has increased

the potential for widespread growth.

Forty people from fifteen states have been

through the PACT trainers program.

Students participating in PACT attend at

least 10 sessions, each lasting 60 to 90

minutes. Groups usually include six to

eight kids of about the same age (PACT is

most appropriate for adolescents, but the

curriculum can be adapted for younger

and older students). Groups can include

boys only, girls only, or both boys and

girls. The curriculum was designed for

urban minority youths and works best

with multiethnic or predominantly

African-American groups. Each group has

a leader with the same ethnical and

cultural background as the members.

In the program’s first component, students learn about the risks associated with

violence and about street survival skills

and ways to gauge potentially harmful

situations. In the second component, they

learn techniques for managing anger and

gain an understanding of actions that can

trigger anger as well as how their consequences will differ, depending on how

they respond to anger. In the third component, students learn three social skills—

known as Givin’ It, Takin’ It, and Workin’ It

Out—that have been shown to be effective

in preventing violence.

▲ Givin’ It. How to express criticism,

disappointment, anger, or displeasure

calmly and vent strong emotions

constructively.

▲ Takin’ It. How to listen, understand,

and react appropriately to the criticism

or anger of other people.

▲ Workin’ It Out. How to listen to other

people, identify problems and potential solutions, propose alternatives

when disagreements persist, and

compromise.

PACT students learn how to express anger constructively,

listen to negative feedback, and negotiate with peers to

avoid becoming victims or perpetrators of violence.

▲ Photo courtesy of Wright State University/the PACT program
INJURY CONTROL UPDATE ▲ Fall 1997

15

▲

PACT is based on sound principles

One of the strengths of the PACT program,

says Dr. Hammond, is that it is based on

social learning and anger control theory

and on research findings, which show that

people learn social behavior by observing

what other people do and what consequences their actions bring. Translating

this theory and research into real life

situations was challenging for program

planners. “We knew that to be effective,

the program had to be engaging and take

into account how hard it is to do these

skills in the real world,” he recalls.

Therefore, PACT foregoes class lectures

and instead uses interactive strategies that

allow students to observe and practice

positive behaviors in group meetings and

at home:

▲ Modeling. During the training sessions, group leaders can set a good

example for students by demonstrating appropriate behaviors that make

up the skill being taught, and they can

show videos depicting such behaviors.

Modeling also can occur naturally

when conflicts erupt at the group

meetings. For example, if members of

the group want to participate in an

activity not on the day’s agenda, they

might use negotiation skills to lobby

for what they want.

▲ Role play. Most students find that role

play is awkward at first, so the group

leader may introduce role play

through games such as charades or

have students talk through the steps

or practice privately before the actual

role play. The group leader also may

assume the role of the main actor to

ensure that early role plays are successful. All group members have the

opportunity to play the main actor,

and role play partners are mixed up to

avoid repeatedly pairing the same two

individuals.

▲ Coaching. During role play, the group

leader gives youths verbal

coaching (instructions, reminders,

demonstrations, encouragement, and

praise) as well as nonverbal cues

(pointing to a skill step written on the

chalkboard or raising a hand to signal

that a step is being left out).

▲ Feedback. Following role play, the

main actor comments on his own

performance and how well he followed the skill steps. The rest of the

group then responds, taking care to

always provide positive feedback

before giving any negative comments.

Feedback must be detailed and constructive, not hostile or sarcastic. As a

final step, the group leader critiques

the feedback, helping members improve their ability to comment constructively.

▲ Reinforcement. Youths who exhibit

appropriate behavior—either during

the training sessions or in real life

situations—are rewarded with reinforcements that can be verbal (praise),

physical (smiles or pats on the back),

or material (tokens that can be redeemed for goods or privileges).

▲ Homework. Members are asked to

watch for opportunities to practice

their skills at home and then report

back to the group. If a student reports

that he was unsuccessful at home,

group members can talk about what

he might have done differently.

Proof that PACT is working

Evaluations of PACT show that the program is helping youths avoid violence. An

evaluation of the 1989–1990 school year
16

▲INJURY CONTROL UPDATE ▲ Fall 1997

California program targets

“Healthy City”

showed that PACT helped youths give

and accept negative feedback, solve

problems, and resist peer pressure. The

results of a 1992–1993 case-control study

revealed just how much PACT students

had reduced violence in their lives:

▲ They had a 50% reduction in

physical aggression at school, and

they showed a greater reduction in

levels of physical aggression than

control group students.

▲ They had more than 50% fewer overall

and violence-related juvenile court

charges and a lower per-person rate of

offending than control group students.

▲ Their behavior improvements were

maintained 2–3 years after PACT

training ended.

The program’s success depends on numerous factors, advises Dr. Yung, who has

served as program research evaluator

coordinator for PACT since 1989. For

example, schools must select group

leaders who have a natural ability to

communicate with youths and who are

comfortable around them. “With some

people, relating to kids is awkward. Kids

can see through that and know if you’re

being sincere,” she says.

To encourage student participation in the

program, staff must give young people

positive reasons for wanting to participate,

Dr. Yung recommends. For instance, PACT

is designed as a leadership club, and

students are asked to join because their

peers consider them highly influential

leaders and look up to them.

When recruiting adults for the parent

component of a program, appeal to their

concerns about violence, she suggests.

When you cast it that way—not in a way

that implies a deficit on the part of parents—

they want to get involved,” says Dr. Yung.

She also recommends making it as easy as

possible for parents to attend training

sessions: provide child care for parents

with small children; meet at locations that

are convenient for parents or offer them

bus tokens if they have no vehicle; and

provide snacks, because food gives the

meetings a feeling of “just folks coming

together to talk about a common concern”

rather than “we’re here for training.” ■

The Golden State would seem to be

heaven for bicycle riders. The mild climate means virtually year-round opportunities for cycling, and there is growing

support for cycling as recreation and a

commuting option.

The numbers confirm this assumption:

Californians own 20 million bicycles,

about 30% of all bicycles owned in the

United States, and ridership is increasing.

Unfortunately, this trend also puts the

state’s citizens at higher risk for injuries.

Californians compose 12% of the nation’s

population, but account for 18% of

bicycle-related fatalities. Typically, children

are over-represented in bicycle injuries; in

1994, children aged 5–12 years made up

12% of the state’s population, but accounted for 25% of serious bicycle injuries.
INJURY CONTROL UPDATE ▲ Fall 1997

17

▲

The statewide Bicycle Head Injury Prevention (BHIP) Program has responded to

this situation by coordinating multiple

strategies to (1) encourage law enforcement officials to promote and enforce

California’s bicycle helmet law and (2)

foster efforts to reduce bicycle-related

injuries, death, and related disability

and costs.

Moreover, BHIP has focused intense

efforts on a single community, the city of

Pittsburg in northern Contra Costa

County, to ensure that virtually every

school-aged youngster receives education

about the importance of wearing a helmet

and has the opportunity to obtain one.

The program’s success—increasing the

rate of helmet use among grade schoolers

from 22% to 64%—demonstrates how

concerted community effort and the

commitment of key local leaders can make

a difference, according to Valodi Foster,

MPH, health education consultant for the

California Department of Health Services,

Emergency Preparedness and Injury

Control.

A “Healthy City” gets healthier

Pittsburg was an ideal site to initiate a

“saturation approach,” said Ms. Foster. A

blue-collar community of about 50,000

residents, the city had joined another

community-based health program, the

Healthy Cities Program, in 1992. This

statewide project promotes a positive

physical environment, vital economy, and

supportive social climate by aiding in the

planning and implementation of innovative programs. Thus, Pittsburg was already poised to recognize the value of a

communitywide injury prevention project.

Further, Pittsburg was geographically

suitable. Somewhat isolated from surrounding communities, it provided an

ideal “laboratory” setting to measure the

impact of an intensive intervention and

contrast that with helmet use in comparable cities without such an intervention.

And not least, the local program coordinator, Nick Carr, was a former teacher with

strong ties to the school system and a

committed cyclist whose enthusiasm

helped launch and sustain the community

effort.

Community partners central to the Bicycle

Head Injury Prevention in Pittsburg

(BHIPP) Project were the school and the

local law enforcement agency. Certainly, it

makes sense to target an intervention on

the schools—that’s where the kids are. But

it’s not as easy as it might sound to institutionalize a bicycle safety program in the

schools, Ms. Foster noted. “Understandably, schools have mandates to address

multiple subjects and issues, and some

people tend to rank other social and

health issues as more important.” Developing personal relationships with teachers

and principals helped shift awareness to

the importance of preventing bicyclerelated injuries, and coordinator Nick Carr

was invaluable in forging those links.

Once the school system signed on, the

BHIPP project provided training for every

teacher at all seven city elementary

schools and distributed packets containing

information on the project, curriculum

and resource information, and suggestions on how to promote bicycle helmet

use. In addition, the project distributed

more than 5,700 helmets and, in collaboration with the Pittsburg Police Department

and the John Muir Medical Center’s

Injury Prevention Project, made presentations on bicycle and traffic safety to

almost 5,000 children between the ages of

3 and 11.

Instilling community norms

The California effort is aimed at nothing

less than making the wearing of bicycle

helmets a community norm, said Ms.
18

▲INJURY CONTROL UPDATE ▲ Fall 1997

Foster. “Realistically, we know that

changing behavior—and maintaining it—

takes time, so we in public health have to

take the long view. It helps to look at

changes in norms related to other issues,

like tobacco use and drinking and driving.”

Part of the BHIP approach is matching

the message to the developmental stage

and abilities of the target audience. Kids

want factual information, Ms. Foster said,

but they also need help in relating the

information to their own experience and

practicing skills to help cement their

theoretical knowledge. Hence, the bicycle

“rodeo” where kids have an opportunity

to test their abilities to ride bicycles safely

in a controlled but challenging setting.

The statewide project also adapted basic

bicycle safety information into easy-toread brochures for parents with lowliteracy skills. The brochures are available

in English and Spanish versions.

With the success of the Pittsburg project

established, the California BHIP plans to

expand the Pittsburg model to three additional communities in the coming year. ■

Resources you can use

Two new publications are available from the National Center for Injury Prevention

and Control. They can be ordered through NCIPC’s Internet home page: http://

www.cdc.gov/ncipc/ncipchm.htm or by writing to NCIPC, Attention: Library

Desk, MS K-65, 4770 Buford Highway, NE, Chamblee, GA 30341-3724.

Prevention of Motor-Vehicle-Related Injuries is a compilation of articles that

appeared in CDC’s Morbidity and Mortality Weekly Report (MMWR) from 1985-1996.

A rich source of data and insights on prevention efforts, this publication organizes

the reports according to topics: an overview of motor vehicle-related injuries as a

public health problem, the economic impact of such injuries, drinking and driving,

child occupant restraints and air bags, safety belts, bicycle and motorcycle helmets,

pedestrian safety, and motor vehicle-related injuries in rural areas. A brief summary

precedes each article. This compendium was edited by Julie Russell Bolen, PhD, MPH;

David A. Sleet, PhD; and Valerie R. Johnson.

Data Elements for Emergency Department Systems, Release 1.0 (DEEDS) is a set of

recommendations for standard data elements to be used as part of a record-keeping

system in hospital emergency departments (EDs). Increasingly, EDs are the source

of public health surveillance data for injuries, both intentional and unintentional.

To foster consistency of information, CDC coordinated the national effort to develop an ED record system that led to these recommendations and involved representatives from dozens of organizations and agencies from the fields of emergency

medicine, information management, and health care policy and research. Viewed as

the starting point for such a system, this initial release of DEEDS serves as a technical reference on automating ED data as well as a compendium of data elements. The

committee was chaired by Daniel A. Pollock, MD, leader of the Acute Care Team in

NCIPC’s Division of Acute Care, Rehabilitation Research, and Disability Prevention.
INJURY CONTROL UPDATE ▲ Fall 1997

19

▲

NRC Examines

Violence Against

Women

Violence against women is a significant

social problem. Few people would dispute

that statement—but many would argue

about the scope of the problem, its causes,

and, most important, approaches for

prevention.

To address such information gaps in this

relatively young field, Congress directed

the National Research Council (NRC) to

develop a research agenda to increase the

understanding and control of violence

against women. An expert panel examined published research findings on rape,

sexual assault, and battering of intimate

partners and also elicited the views of

practitioners and researchers in the field.

Understanding Violence Against Women

summarizes the panel’s findings and

recommendations. Published in 1996 by

the National Academy Press, the 225-page

book highlights the following areas:

▲ Preventing violence against women.

More research is needed to better

illuminate the causes of violent behavior against women. There is also a

need for more rigorous evaluation of

existing preventive interventions.

▲ Improving research methods. Many

studies suffer from methodological

flaws, resulting in inconclusive or

conflicting findings. The panel called

for development of tools to measure

multiple types of violence against

women, for consistency in definitions,

and for improved studies that recognize the context in which women

experience violence.

▲ Building knowledge. Noting that

most theories on the “causes” of

perpetrating violence against women

are too narrow, the panel encouraged

researchers to use multifactorial

models. Another key recommendation

is to develop national and communitylevel survey studies to measure incidence and prevalence of violence

against women, with particular attention to surveys of racial and ethnic

minorities, and other underrepresented

population subgroups.

▲ Developing a research infrastructure.

The panel made two main recommendations in this areas: (1) a coordinated

federal funding and research strategy

that focuses on primary prevention of

violence against women and intervention with perpetrators and victims,

and (2) establishment of at least three

research centers within academic or

other appropriate settings to support

training programs, foster collaboration

between researchers and practitioners,

and provide technical assistance.

Guiding this NRC project were Nancy A.

Crowell, study director, and Rosemary

Chalk, senior project officer.

In response to the panel’s recommendations, CDC and the National Institute of

Justice have developed a joint initiative to

address funding and programmatic

priorities, according to Pamela McMahon,

PhD, a researcher on NCIPC’s Family and

Intimate Violence Prevention Team,

Division of Violence Prevention.

Understanding Violence Against Women is

available from the National Academy

Press, 2101 Constitution Avenue, NW,

Washington, DC 20318. ■
20

▲INJURY CONTROL UPDATE ▲ Fall 1997

CALENDAR

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta, GA 30333

Official Business

Penalty for Private Use $300

Return Service Requested

First Classs Mail

Postage & Fees Paid

PHS/CDC

Permit No. G-284

May 17-20, 1998 The Fourth World Conference on Injury Prevention & Control:

Building Partnerships for Safety Promotion and Accident

Prevention will be held in Amsterdam, The Netherlands. The

deadline for early registration is January 15, 1998. For

information, contact the conference web site at http://

www.consafe.nl/conference/ or write Van Namen &

Westerlaken Congress Organization Services, P.O. Box 1558,

6501 BN Nijmegen, The Netherlands. Phone: +31 24 323

4471. E-mail: reg.fowoco.nw@prompt.nl