Pegg oat

Training of alternative providers
to be studied

The project will now turn to evaluating
an approach in which calls are answered
by advice nurses from health mainte-
nance organizations or 911 operators,
who will triage the calls and handle
nontoxic exposures themselves. For this
phase of the study, the San Francisco
center will work with the Institute for
Health Policy Studies at the University
of California at San Francisco.

Using a system developed by the project
staff, operators will lead callers through
a series of questions about the sub-
stance, route, and amount of poison that
may have been ingested. Depending on
the answers, people will either be

able to handle 5% to 10% of calls to the
poison center, resulting in greater effi-

ciency and freeing toxicologists to con-
centrate on more urgent cases. ll

For more information, contact Patty Hiatt,
Project Coordinator, at (415) 206-6878.

NCIPC home page:
Correct address

The NCIPC home page is now available
on the Internet. Users can find general
information on the injury center, publica-
tions, research grants and funding
opportunities, surveillance data, and a
“what's new” section. The correct

helped directly by the operator or trans-
ferred to a poison center specialist. The
San Francisco investigators estimate that
advice nurses and 911 operators will be

address is: http://www.cde.gov/ncipc/
ncipchm.htm.

(Please note that the address printed in the
winter 1996 issue of Injury Control
Update was incorrect.)

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A L EN D A R

NOveEMBER 10-12 National Conference on Shaken Baby Syndrome, Salt Lake City, UT.
Sponsored by the National Network on Shaken Baby Syndrome and
other groups, the conference will bring together national experts in
medicine, law, social services, psychology, and prevention. Sessions
will focus on diagnostic techniques, litigation, victim and perpetrator
profiles, impact on families, and prevention programming. Contact:
Child Abuse Prevention Council at (801) 399-8430 or the “Don’t Shake
the Baby” Campaign at (719) 583-2000.

November 17-21 American Public Health Association’s 124th Annual Meeting,
New York, NY. More than 12,000 national and international physicians,
administrators, educators, epidemiologists, nurses, and related health
specialists will attend this meeting, which will feature public health
issues. This year’s conference theme is social justice in public health.
Contact: APHA, 1015 15th Street, NW, Washington, DC 20005,
phone (202) 789-5600, or request a registration form via fax by calling
(202) 274-4577 (request document no. 201).



TM 4

The Milwaukee Women’s Center “Safe at Home” posters may soon be appearing on buses
across the country. States from coast to coast are ordering the posters, reported Terri
Strodthoff, project manager for Safe at Home.

SOON APPEARING ON A BUS NEAR YOU....

The posters and the public awareness campaign against domestic violence have been so
successful that they have attracted the attention of the Office of the Secretary at the U.S.
Department of Health and Human Services (DHHS), which is considering ways to create
new messages about domestic violence at the national level.

“The Milwaukee Women’s Center campaign is powerful and beautifully designed and
executed,” said Peter Edelman, Assistant Secretary for Planning and Evaluation for
DHHS. “We need to find ways to get messages like these out in every community.”

The center’s public awareness campaign has drawn praise from the advertising industry
as well, garnering the prestigious Gold World Medal for the best transit advertising cam-
paign entered in the New York Festivals competition. The center’s Safe at Home poster
campaign and two of the posters were among the winners, which were selected from more
than 5,000 entries representing 56 countries. The center also won six Milwaukee Advertis-

ing Club ADDY awards.

help. Women were encouraged to seek
support from community groups and
not remain victims; men were encour-
aged to seek help before their feelings
turn violent.

A series of six print images capturing
these ideas was developed for the bus
campaign and for 11,000 posters that
will be distributed to businesses, med-
ical and social service agencies, and
other organizations throughout the com-
munity. Radio and television public ser-
vice announcements incorporating the
same visual and verbal themes will
begin later this year.

Another important piece of the commu-
nications campaign is the Safe at Home
brochure, developed with funding from
the Department of Social Services and
Aurora Health Care, Wisconsin’s largest
not-for-profit health care system in the

state. The brochure highlights key facts
about family and intimate violence,
describes early warning signs of an abu-
sive relationship, and lists community
resources for help.

Evaluating different treatment
models for batterers

Another facet of the Milwaukee pro-
gram focuses on what makes an impact
on men with a history of family and inti-
mate violence. Increasingly, courts man-
date that batterers participate in educa-
tional and counseling programs. The
Milwaukee project supports three differ-
ent treatment models aimed at reducing
the incidence and severity of violence
against women. Ms. Strodthoff
explained that each of the three pro-
grams will be evaluated against its own
goals. “We are not trying to make a com-
parison across groups. The programs

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INJURY CONTROL UPDATE & Spring/Summer 1996

TM 4

NCIPC has recently funded research projects that examine various facets of biomechan-
ics. The first two projects listed below address injuries related to motor vehicle crashes,
and the following seven emphasize other types of unintentional injury. The name and

affiliation of the principal investigator, plus a contact number, are included in brackets.

CDC-FUNDED BIOMECHANICS RESEARCH PROJECTS

The Mechanics and Biomechanics of Rollover Casualties [Kennerly Digges, PhD,
DeBlois & Associates; (804)924-6230]

Biomechanics of Side Impact [Albert King, PhD, Wayne State University; (313)577-1344]

Injury to Articular Cartilage Following Blunt Impact [Roger Haut, PhD, Michigan
State University; (517)355-0320]

Spectral Signature as a Predictor of Fall in the Elderly [Bruce McClenaghan, PED,
University of South Carolina; (803)777-5267]

Biomechanical Aspects of Spinal Trauma [Barry Myers, PhD, MD, Duke University;
(919)660-5150]

Biomechanics of Cervical Cord Injury [Frank Pintar, PhD, Medical College of
Wisconsin; (414)384-2000, x1534]

Biomechanics of Slips on Ramps and Level Surfaces [Mark Redfern, PhD, The Eye and
Ear Institute of Pittsburgh; (412)647-7923]

Dually Stiff Floors for Injury Prevention of the Elderly [Donald Streit, PhD,
Pennsylvania State University; ( 814)865-1972]

Spinal Canal Geometry Changes in Vertebral Fracture [Allan Tencer, PhD, Harborview
Medical Center, Seattle; (206)223-5414]

Take for example, hip fractures, which had fallen sideways. Contrary to popu-
are a major problem in the United lar belief, these people did not break
States, especially with its fast-aging pop- | their hips by twisting them as they fell.
ulation. About 280,000 people fracture They broke their hips only when there
their hips each year; about a quarter of was direct force on the greater

them die as a result, and another quarter trochanter, the bony knob of the hip.
never walk again. Medical costs associ-

ated with hip fractures are estimated at Two products that have evolved from
about $10 billion, these studies focus on reducing the force
| of a fall on the body, rather than on
CDC-supported studies of residents at preventing falls. One product is an energy-
three nursing homes found that most of absorbing pad containing silicon putty,

the older people who had hip fractures which could be sewn into clothing. The



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20

International health grou
recognizes violence problem

Violence has been publicly recognized
as a worldwide public health problem.
A resolution passed in May by the
World Health Assembly, governing
body of the World Health Organization
(WHO), noted “the dramatic increase in
the incidence of intentional injuries
affecting people of all ages and both
sexes, but especially women and chil-
dren” and acknowledged the serious
implications for health and psychologi-
cal and social development.

The resolution means that the member
nations of WHO have endorsed the con-
cept of violence prevention and support
epidemiology, research, and prevention
activities to advance that goal, according

to James Mercy, PhD, acting director of
NCIPC’s Division of Violence Preven-
tion, who attended the assembly meet-
ing in Geneva, Switzerland.

“WHO is in the process of developing a
plan that will integrate violence preven-
tion into current programs like women’s
health, substance abuse, and adolescent
health and will lead to concrete activi-
ties” said Dr. Mercy. “Just as CDC’s sup-
port of violence prevention in the Unit-
ed States has stimulated interest in other
sectors like foundations and state health
departments, | would expect that
WHO’s support would inspire wider
interest in violence prevention on a
global basis.”

el

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health Service

Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta, GA 30333

Official Business
Penalty for Private Use $300
Address Correction Requested


windowless room about 8 feet by 20 feet,
where up to four specialists answer a
daily average of 180 calls and give
advice about treating poisonings. The
specialists have computers linked to
Poisindex, the toxicology database. Toxi-
cology reference texts line the shelves
over the computer terminals.

Despite these modest facilities, the San
Francisco center faced a funding short-
fall in 1993, “Even though studies have
shown that poison center intervention
saves $5 for every $1 spent, or $3.3 mil-
lion in health care charges each year,”
said Kent R. Olson, MD, medical director
of the center, “poison centers have no
leverage with contributors. Staff are
expected to handle the emergency now
and worry about getting paid later.”

Indeed, without more funding for the
upcoming fiscal year, the center could
not have paid half the professional staff
at all. San Francisco County, the center’s
home county, responded to the crisis by
proposing a fair-share plan, according to
which each county was asked to contribute
local funding proportionate to the coun-
ty’s use of the poison center. One of the
counties, with budgetary problems of its
own, declined to contribute.

Working in a windowless 8 by 20 foot room, toxicologists at the San
Francisco Bay Area Regional Poison Control Center respond to an aver-
age of 180 callers each day. Funding shortages have forced the center

to look at alternative ways to meet this need.

Photo courtesy of San Francisco Bay Area Regional Poison Control Center

The center saw as its only option block-
ing direct public access of that county’s
residents to poison center services. For
emergency cases, the center agreed to
continue providing consultation through
911 operators on a fee-per-call basis.
County residents who dialed the poison
center heard a recorded message advis-
ing them to call 911 for assistance.

Evaluation finds call blocking
seriously flawed

Once this mechanism had been put into
place for fiscal reasons, the San Francisco
center decided to use it as an opportuni-
ty to study alternative ways of providing
poison control services. They received a
competitive award from NCIPC for a 3-
year study, with the first year focused on
the effects of blocking direct access to
centers, and the remaining two years on
the use of alternative providers.

To evaluate changes in the volume and
nature of calls coming into the center
from the blocked county, investigators
compared the calling history during an
8-month period under the new system
with calls that had come in during the
corresponding 8 months of the previous
year. Then they interviewed 300 people
who had called to report a poison expo-

my sure of a child 5 years old
or younger, to find out
what parents had done
after failing to reach the
poison center.

Results showed that
despite the electronic
blocking, more than half
the callers eventually
received advice from the
center, mostly through
dialing 911 or a local hos-
pital. This advice was
obtained, however, only
after making additional
calls, and sometimes with
significant delays. Nearly
one-fifth of callers were

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involved in a crash: the incentive for
returning the damaged seat was replace-
ment with a new model. With the identi-
ties of the families established through
the records linked to the returned car
seats, Lawrence then went to the state
police for follow-up information about
the crash.

Typical loaner programs
provide a child safety seat to
families but leave out an

important component:

showing parents how to use

the seat correctly.

The findings were impressive. Out of 26
loaned car seats known to have been
involved in crashes between 1990 and
1993, 24 were returned, and police infor-
mation could be obtained about all but
one of those crashes. Of the 23 crashes
for which information was available, 17
resulted in the hospitalization or death
of at least one unbelted adult occu-
pant—in none of those cases was an
infant or young child seriously injured.
“This demonstrates that proper use of
child car safety seats can reduce
injuries,” Lawrence said. “Not only is
this good for Louisiana’s families—it
means that safety saves tax dollars.”

The Louisiana injury unit received tech-
nical assistance in evaluating the project
from NCIPC’s Division of Acute Care,
Rehabilitation Research, and Disability
Prevention. Lawrence expressed appre-
ciation for this support, saying that hav-
ing a national organization help with
the study design gave assurance that the

results were meaningful and would be
comparable to those in other parts of the
country.

Overall funding for the project came
from the Disability Prevention Program
(DPP) in the National Center for Envi-
ronmental Health at CDC. NCIPC
addresses injury-related disability in
partnership with DPP and serves as
project technical advisor to the DPP
program grants.

The multiplier effect

Although it no longer provides the car
seats or direct training, the unit remains
active in motor vehicle prevention
through train-the-trainer programs,
evaluation, and coordination efforts. A
number of other organizations and
community-based groups now carry out
essential parts of the car seat program,
Lawrence said.

From the beginning, the Louisiana
Highway Safety Commission was a
partner in the car safety seat project,
helping to provide the seats, staff the
evaluation project, and obtain crash
data. Lawrence applauded their role:
“Because of their ties to transportation
and public safety agencies, they were
able to cut through red tape in ways
that the health department can’t always
do. We are fortunate in Louisiana in
having a productive relationship with
the commission.”

As the Injury Research and Prevention
Section moved to a train-the-trainer
approach, they enlisted the help of local
police departments and Safe Kids chap-
ters to take on the role of educating fam-
ilies about the proper ways to use car
safety seats. Lawrence said that involv-
ing local police in this effort helped pro-
mote better enforcement of safety seat
laws, while giving the law officers a
direct way to foster good community
relations. ll

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- A

NCIPC has recently funded research projects that examine various facets of biomechan-
ics. The first two projects listed below address injuries related to motor vehicle crashes,
and the following seven emphasize other types of unintentional injury. The name and

affiliation of the principal investigator, plus a contact number, are included in brackets.

CDC-FUNDED BIOMECHANICS RESEARCH PROJECTS

The Mechanics and Biomechanics of Rollover Casualties [Kennerly Digges, PhD,
DeBlois & Associates; (804)924-6230]

Biomechanics of Side Impact [Albert King, PhD, Wayne State University; (313)577-1344]

Injury to Articular Cartilage Following Blunt Impact [Roger Haut, PhD, Michigan
State University; (517)355-0320]

Spectral Signature as a Predictor of Fall in the Elderly [Bruce McClenaghan, PED,
University of South Carolina; (803)777-5267]

Biomechanical Aspects of Spinal Trauma [Barry Myers, PhD, MD, Duke University;
(919)660-5150]

Biomechanics of Cervical Cord Injury {Frank Pintar, PhD, Medical College of
Wisconsin; (414)384-2000, x1534]

Biomechanics of Slips on Ramps and Level Surfaces [Mark Redfern, PhD, The Eye and
Ear Institute of Pittsburgh; (412)647-7923]

Dually Stiff Floors for Injury Prevention of the Elderly [Donald Streit, PhD,
Pennsylvania State University; ( 814)865-1972]

Spinal Canal Geometry Changes in Vertebral Fracture [Allan Tencer, PhD, Harborview
Medical Center, Seattle; (206)223-5414]

Take for example, hip fractures, which
are a major problem in the United
States, especially with its fast-aging pop-
ulation. About 280,000 people fracture
their hips cach year; about a quarter of
them die as a result, and another quarter
never walk again. Medical costs associ-
ated with hip fractures are estimated at
about $10 billion.

CDC-supported studies of residents at
three nursing homes found that most of
the older people who had hip fractures

had fallen sideways. Contrary to popu-
lar belief, these people did not break
their hips by twisting them as they fell.
They broke their hips only when there
was direct force on the greater
trochanter, the bony knob of the hip.

Two products that have evolved from
these studies focus on reducing the force
of a fall on the body, rather than on
preventing falls. One product is an energy-
absorbing pad containing silicon putty,
which could be sewn into clothing. The


other is flooring material that buckles
and yields under impact, thus absorbing
the force of a fall.

Biomechanics challenges
assumptions

Biomechanics research often challenges
conventional thinking, as it has in
describing what happens when older
people fall. Barry Myers, MD, PhD, of
Duke University’s Department of Bio-
medical Engineering, offered another
example, this one having to do with
neck injury.

In investigating the role of a range of
devices to protect against neck injury,
Dr. Myers and his research team posed
basic questions: Do they work? Do they
help people? Do they make people more
resistant to injuries? Common sense sug-
gests that surface padding would
enhance a helmet’s impact-absorbing
effect. But in some situations, Dr. Myers
and his team found, surface padding
may actually put the neck at risk.

Conventional wisdom held that impact
was the main factor in a neck injury.
However, the Duke experiments showed
that padded surfaces increase the risk of
neck injury because they hold the head
still, causing the falling body to put all
its pressure on the neck.

Padded surfaces have the potential to do
harm as well as good, Dr. Myers said.
“That idea had never been demonstrated
quantitatively.”

Just as understanding the mechanism of
hip fractures has led to hip pads and
soft flooring, our understanding of how
soft surfaces contribute to neck injuries
might help us develop ways to protect a
rider thrown from a horse or a passen-
ger in a rollover collision.

CDC leads the way in
biomechanics research

CDC is a major supporter of biomechan-
ics research at the federal level, with
NCIPC supporting many biomechanics
research projects around the country. To
date, CDC has committed about $13.8
million to the extramural biomechanics
projects (See list of projects on page 6).
NHTSA, the National Institutes of
Health, and various military agencies
also fund biomechanics research programs.

“Biomechanics tells researchers how to
modify the environment and provides
new tools to prevent or modify injuries.”
Dr. Myers said. “It gives the injury com-
munity one of its greatest returns on its
investments.” ll

Injury Control Update is a quarterly
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
Virginia Ross, PhD * Daphna Gregg, RN
Valerie R. Johnson

LAYOUT ARTISTS
Martha Boyd ¢ Leslie S. Parker

Direct editorial correspondence to:
Gwen Ingraham, Director, Office of Health
Communications, NCIPC, CDC,

MS K-65
4770 Buford Hwy. NE ¢ Atlanta, GA 30341-3724
Internet: GNIT@CIPCOD1.EM.CDC.GOV

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ANA

Pac

Although the number of children who die from poisoning has declined dramatically
since the Poison Prevention Packaging Act was passed in 1970, unintentional poisoning
is still an important problem among children.

A Of the 2.4 million poisonings reported to poison control centers each year, 60%
involve children under 6 years of age. Children under 2 have the highest number of
poisoning exposures.

A Minority children are especially at risk, with black children ages 9 and under being
three times more likely than white children of the same age to die from unintentional
poisoning.

A More than 90% of poisonings reported to poison control centers happen in the home.

A Easily accessible substances, like mouthwash, rubbing alcohol, iron supplements, pes-
ticides, kerosene, and windshield washer fluid, are a serious threat to young children.

A The most frequently implicated substances are cleaning products, analgesics, cosmet-

ics, personal care products, cough and cold preparations, and plants like aloe and

philodendron.

either unable to get advice or chose to
wait and watch their child to see if
symptoms developed.

There were other problems as well.
Many health care providers offered
advice without consulting the poison
center, and at times this advice was not
what a toxicologist would have recom-
mended. The poison control center was
not directly accessible to physicians in
private practice, and hospitals may have
hesitated to increase the number of calls
to the center for fear of incurring a high-
er membership fee. In some cases,
blocked calls led to unnecessary emer-
gency department visits, resulting in
much higher cos the average cost of
a case managed by a poison center is
about $25, while emergency department
costs range from $95 to $400 per case.

None of the children in the survey
group was seriously harmed because of
call blocking, but the study showed that
the potential for harm was there. In one
instance, a man who had called because
his 10-month-old baby was vomiting

from eating chewing tobacco panicked
and gave the baby mustard and then
ipecac. Over the next hour and a half, he
tried several more times to reach the
poison center and finally took the baby
to an emergency department. The child
recovered with no ill effects, but the
poison control center advised that the
inappropriate first aid and the delay in
getting medical help could have been
dangerous.

When these results came in, blocked
access was abandoned as a means of
controlling cost. First and foremost, it
held the potential of endangering lives,
but it also proved not to be particularly
cost effective. By essentially shifting the
burden of managing poisoning cases to
other parts of the emergency response
system, it caused calls to the poison
center from 911 operators to increase by
543%. Ironically, because the blocked
county had agreed to pay the center a
premium fee-per-call rate for 911 consul-
tations, they ended up paying almost as
much as they would have paid under
the fair-share plan.


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CHILD CAR SAFTY SEATS

Imaginative Louisiana program
links education and evaluation

Creative evaluation—is that an oxy-
moron? Not if you're in Louisiana, and
you want to document that correct use
of child car safety seats saves lives.

The creativity began when David
Lawrence, MPH, supervisor of injury
epidemiology for the Injury Research
and Prevention Section of the Louisiana
Office of Public Health, and his col-
leagues examined surveillance data on
spinal cord injuries (SCIs) in the state.
Their review showed that most children
with motor vehicle-related SCIs had
medical costs reimbursed by Medicaid.
And they knew from a statewide base-
line survey that only about 18% of chil-
dren were restrained in car seats or seat
belts. Those findings

in turn prompted the
health department, with
CDC support, to launch a
car safety seat loaner
program at the local health
departments in three
southeast Louisiana
parishes in 1990.

Typical loaner programs
provide a child safety seat
to families but leave out
an important component:
showing parents how to
use the seat correctly. And
studies show that an incor-
rectly restrained child is

at increased risk of injury
in a crash.

When Loui:

Health educators at the local health clin-
ics went the extra mile by educating
families who borrowed a car seat,
Lawrence said. “They would go out to
the family’s car, show them how to put
the seat into the car properly, how to
restrain the child—and then observe the
family do it.”

Would adding this extra education and
practice make a difference in reducing
serious injuries among children
involved in motor vehicle crashes?

Again, Louisiana took a creative
approach. The project asked families to
return car seats that had been in a car

COC stoff photo
na’s car seat loaner program added education and

practice in using car seats, it paid off in lives saved.


A QUARTERLY PUBLICATION OF THE NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL

Vol. 1, No. 2

A Spring/Summer 1996

Biomechanics delivers powerful
measures for preventing injury

The year is 1954. The place is a wind-
ing, two-lane road in a rural area. As
a car approaches a curve, the driver
swerves to miss a deer. He over-
corrects, crosses the solid yellow line,
and collides head-on with an oncom-
ing car. Both drivers die at the scene
from head and chest injuries.

Flash forward forty years or so. The
same scenario, the cars crash. This
time, both drivers walk away with
only minor injuries. The difference?
Safety belts, air bags, and front-end
protection.

Examples like this of the life-saving
value of improved motor vehicle
design abound,
and so do exam-
ples of protection
from other safety
measures, like soc-
cer helmets,
ergonomically
designed floor
thresholds, and
high-speed rotary
machines with pro-
tective guards. But
how many people
know about the sci-
ence of biome-
chanics, which is
responsible for
developing them?
The field has been

hailed as one of the most powerful
countermeasures for preventing
injury, and yet the science and its
potential remain a mystery to most
people and even to many injury con-
trol practitioners.

Using engineering, mathematics, and
physics to determine how the human
body responds to “insult,” biome-
chanics researchers provide the fun-
damental understanding needed to
develop interventions that will
reduce trauma, save lives, and lower
the cost of treating injuries. Perhaps

CONTINUED ON PaGE 4

Photo couresy ofthe Insurance Insitute for Highway Safety

Crash-test dummies are the most familiar of the biomechanics
researchers’ tools. Studies

ing them have led to many life-saving

improvements in motor vehicles.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

IN THIS
ISSUE
v

A NEw Way TO.

FUND VIOLENCE
PREVENTION ..... 2

v

IMAGINATIVE CaR
SEAT LOANER
PROGRAM....... 8

v
City CAMPAIGN

AGainsT Domestic
VIOLENCE ...... 10

v

ACCESSING NEWS OF
NCIPC Grants . 15
v

New INyuRY

CONTROL
RESOURCES .

v

E-CODE GROUPINGS
Unoer Review. . 16

v

CUTTING THE
Cost OF Poison

CONTROL ...... 16
Vv
WHO RESOLUTION

ON VIOLENCE .. . 20

CDC



groups—residents of battered women’s
shelters and participants in batterers’
groups.

“When you have something to
offer and you reach out and ask

for help, people in the community

really respond.”
—  TeRRY STRODTHOFF
Project MANAGER
SAFE AT HOME

The catalyst for the community’s
involvement in the campaign was Carey
Tradewell, executive director of the
MWC and a well-respected community
activist. When she gave a talk about the
Safe at Home project to the Milwaukee
Advertising Club, she sparked the inter-
est of Bill Eisner, club president and
owner of William Eisner & Associates, a
major advertising firm in the city. He
approached Ms. Tradewell about
“adopting” the project for the life of the
campaign. He collaborated with another
ad agency, Kohnke & Koeneke, for the
creative work. Bob Guiffra at P & C
Media made available public service
advertising space on the buses for the
life of the campaign, a contribution of
well over $100,000.

“The excitement about the campaign just
kept snowballing,” said Terri Strodthoff,
project manager for Safe at Home. She
said that the Milwaukee groups
involved in domestic violence preven-
tion have a history of working together
and providing a coordinated community
response. With the public awareness
campaign, the collaboration has spread
to the private sector and groups not tra-
ditionally involved in such activism.
“When you have something to offer and
you reach out and ask for help, people
in the community really respond,” said
Ms. Strodthoff.

The campaign, which began in February,
has sparked interest in family and inti-
mate violence issues throughout the city.
Media coverage has been sustained and
positive, and hotline calls to the MWC
and Sojourner Truth House indicate that
people are responding to the “moving
billboard” campaign. One man told the
hotline operator that, after seeing the
posters for weeks, he finally acknowl-
edged to himself that he was an abuser
and needed to do something about it.

Campaign reflects real concerns

The campaign messages were developed
by listening to audiotape discussions
that captured the real concerns of
women and men affected by domestic
violence. Clients at batterers’ treatment

DEFINING THE ISSUE y

The term “domestic violence” has been used for many years, but people are often con-
fused by what it encompasses. The Milwaukee Women’s Center defines the term as
meaning primarily physical abuse by intimate partners. Other terms, aimed at broaden-
ing the definition, are coming into use. For example, “partner violence” is sometimes
used to encompass all aspects of violence—physical, sexual, and emotional—involving
intimate partners. “Family and intimate violence” has been used to encompass partner
violence, child abuse, elder abuse, dating violence, children affected by witnessing
family violence, and other violence and abuse involving family and intimates.

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FAMILY AND INTIMATE VIOLENCE

Milwaukee mobilizes resources to
keep women “Safe at Home”

As the big white city buses roll through
the streets of Milwaukee, they spread
powerful messages about preventing
domestic violence.

All 550 buses of the Milwaukee Transit
Company feature inside placards with
the image of a man’s face overprinted
with this stark tag line: “He threatened
her. He beat her. He raped her. But first
he married her.”

Posters with other messages are dis-
played on the sides and backs of 100
buses that cover different routes
throughout the city. The images depict a
woman (“You promised not to break her
heart. How about her nose?”) and a
child (“In a violent relationship, your
partner isn’t the only one who's scarred
for life”).

These “moving billboards” are the first
phase of a public awareness campaign
spearheaded by
the Milwaukee
Women’s Center,
Inc. (MWC) as
part of a compre-
hensive effort to
decrease violence
against women.
The “Safe at
Home” project
will also evalu-
ate three different
approaches to
working with
batterers, as well

as train health A

professionals and provide violence pre-
vention education in the schools and
community. Partners in the project
include Sojourner Truth House, Inc.;
Asha Family Services, Inc.; and the Uni-
versity of Wisconsin-Milwaukee School
of Social Welfare.

The Milwaukee project is one of five
NCIPC-funded community-based evalu-
ations of interventions to reduce family
and intimate violence nationwide. The
other projects are in Atlanta, Houston,
Duluth, Minnesota, and Johnson County,
North Carolina.

Private sector response

The underpinnings of the powerful
posters include a survey of public
perceptions about violence, pro bono
contributions by a top-notch advertising
firm and other media companies, and
review of the materials by affected

Photo courtesy of Safe a! Home

Milwaukee’s “moving billboards” are part of the city’s “Safe at Home” pro-

ject, which along with four other projects around the country, will evaluate
interventions to reduce family and intimate violence.


other is flooring material that buckles
and yields under impact, thus absorbing
the force of a fall.

Biomechanics challenges
assumptions

Biomechanics research often challenges
conventional thinking, as it has in
describing what happens when older
people fall. Barry Myers, MD, PhD, of
Duke University’s Department of Bio-
medical Engineering, offered another
example, this one having to do with
neck injury.

In investigating the role of a range of
devices to protect against neck injury,
Dr. Myers and his research team posed
basic questions: Do they work? Do they
help people? Do they make people more
resistant to injuries? Common sense sug-
gests that surface padding would
enhance a helmet’s impact-absorbing
effect. But in some situations, Dr. Myers
and his team found, surface padding
may actually put the neck at risk.

Conventional wisdom held that impact
was the main factor in a neck injury.
However, the Duke experiments showed
that padded surfaces increase the risk of
neck injury because they hold the head
still, causing the falling body to put all
its pressure on the neck.

Padded surfaces have the potential to do
harm as well as good, Dr. Myers said.
“That idea had never been demonstrated
quantitatively.”

Just as understanding the mechanism of
hip fractures has led to hip pads and
soft flooring, our understanding of how
soft surfaces contribute to neck injuries
might help us develop ways to protect a
rider thrown from a horse or a passen-
ger in a rollover collision.

CDC leads the way in
biomechanics research

CDC is a major supporter of biomechan-
ics research at the federal level, with
NCIPC supporting many biomechanics
research projects around the country. To
date, CDC has committed about $13.8
million to the extramural biomechanics
projects (See list of projects on page 6).
NHTSA, the National Institutes of
Health, and various military agencies
also fund biomechanics research programs.

“Biomechanics tells researchers how to
modify the environment and provides
new tools to prevent or modify injuries.”
Dr. Myers said. “It gives the injury com-
munity one of its greatest returns on its
investments.” i

Injury Control Update is a quarterly
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
Virginia Ross, PhD * Daphna Gregg, RN
Valerie R. Johnson

LAYOUT ARTISTS
Martha Boyd * Leslie S. Parker

Direct editorial correspondence to:
Gwen Ingraham, Director, Office of Health
Communications, NCIPC, CDC,

MS K-65
4770 Buford Hwy. NE ¢ Atlanta, GA 30341-3724
Internet: GNI1@CIPCOD1.EM.CDC.GOV

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BIOCAD: dynamic, interactive,
powerful

As biomechanics is changing our envi-
ronment to improve safety, the field
itself is evolving and progressing rapid-
ly. Traditionally, researchers have used
crash-test dummies, cadavers, and ani-
mals to study the mechanics of impacts
on the human body. But a new technolo-
gy on the horizon holds promise as an
alternative to these methods. BIOCAD—
which merges the science of bioengi-
neering (BIO) with computer-aided
design (CAD)—will be a computer-
based compilation of all existing infor-
mation about the interaction of the
human body and energy. The system
will use high-speed digital computers
and three-dimensional simulations of
the human body to show what happens
during injury. “It will be a dynamic,
interactive, and powerful tool,” predict-
ed Dr. Thibault, who originated the con-
cept of BIOCAD.

BIOCAD will allow researchers to tap
into decades of research data, create a
multitude of injury scenarios on screen,
watch computer-animated recreations of
these events in delayed or real times,
and analyze the injuries on screen down
to the level of tissue and cell with a high
degree of anatomical accuracy.

Dr. Thibault gave an example. “You
could simulate a child falling from a 4-
foot drop onto a particular type of play-
ground surface, and you could observe
the injuries. You could then design a dif-
ferent surface and rerun the program to
see the results with the new surface. You
create the environment, you then look
inside the body to see the stresses,
strains, and vascular damage, and you
predict with some level of confidence
what would happen.”

Biomechanics experts are excited about
BIOCAD’s potential and predict that it
will advance the field at a rapid pace,
opening research opportunities to peo-
ple who have practical problems to

solve, but lack resources. “Engineers and
scientists will be able to conduct once
highly expensive research experiments
at a fraction of the cost of traditional
methods, therefore advancing the sci-
ence in a quantum leap,” said J. Howard
Hill, director of NCIPC’s Office of
Research Grants, which established
CDC’s sponsorship of the initial devel-
opment of BIOCAD. “BIOCAD’s poten-
tial is unlimited, not only in research to
prevent injuries, but also in training for
trauma surgeons and rehabilitation
scientists.”

Developing interventions based
on biomechanics

How does research in biomechanics get
translated into specific interventions that
can prevent or ameliorate the impact of
injuries? Dr. States described five steps
in the process:

A Identify injuries that are the most costly
to society. These are the injuries that
either are life-threatening or cause
permanent impairment and disability.
Epidemiology is essential in identify-
ing the most significant injuries.

A Determine the injury mechanism. A cru-
cial question is, How does a particu-
lar type of injury actually happen? Is
the damage caused by the sheer force
of impact, or by the body twisting on
impact, or remaining rigid, or by
some other mechanism?

A Determine the tolerance to impact of the
injured tissue. This step examines how
much energy and what kind of energy
cause injury.

A Develop and evaluate a specific interven-
tion. The key is to find an intervention
that can keep the forces and accelera-
tions below the point at which they
cause injury.

A Manufacture the device and market it to
the public.

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14

differ and offer different things to the
community.”

A Nevermore, the Milwaukee Women’s
Center program, is based on a clinical
model. Eight 2-hour educational group
sessions are supported by at least
three individual counseling sessions.
The program concludes with a clini-
cal discharge interview, which may
direct the men to additional individ-
ual or group psychotherapy. The pro-
gram emphasizes the link between
domestic violence and substance
abuse and mental health issues.

A Batterers Anonymous/Beyond Abuse
(BA) is the program offered at
Sojourner Truth House. The largest
abuse prevention program in the
county, BA is a 23-week educational
program led by a facilitator who
helps participants focus on personal
responsibility in relationships and
learn skills to deal with conflict in
healthy ways.

A Ujima Violence Prevention Group is a
nontraditional abusers’ treatment
program that is designed specifically
for African-American men. Sponsored
by Asha Family Services, the 23-
session program involves weekly
meetings that address violence
against women and children within
the context of the African-American
cultural experience.

Follow-up assessment of all the men
will track their progress with a number
of measures, including shifts in attitude.
“Most of the men who come to these
sessions don’t want to be there—they
feel pushed into it,” explained Ms.
Strodthoff. “We hope to help them real-
ize that preventing domestic violence is
their responsibility and to give them
tools to make a change. So, we'll track
changes in attitude, as well as changes in
behavior.”

Educational efforts target
professionals, youth

Many young people know about family
and intimate violence in a general sense,
but are less clear about relating the
information to their own relationships.
The Milwaukee Women’s Center offers
two school-based programs for adoles-
cents, one for young men and a new one
for young women, which emphasize a
preventive approach to violence against
women. The 6-week programs, which
have been given at seven area schools,
use classroom-style presentations to
help teens recognize the early warning
signs of abuse in a dating relationship.
Soujourner Truth House also has imple-
mented an 8-week relationship abuse
prevention program, which is offered as
part of the curriculum in area high
school classes.

Involving a wide range of professionals
in preventing violence against women is
another goal of the Milwaukee project.
Curricula are being developed to pro-
vide training for different groups,
including staff in the probation and
parole office, various social service
agencies, and emergency department
staff in hospitals affiliated with the
Aurora Health Care system.

Virtually all aspects of the Milwaukee
project involve partners in the public,
private, and nonprofit sectors, as well as
medical professionals. The city has a
strong tradition of groups working
together in a coordinated way to identi-
fy a need and address it, said Ms.
Strodthoff. “Dollars are short, but peo-
ple focus on different aspects of the
problem and, at the same time, come
together as a united front. That
approach has helped win support from
the community.” Mi


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16

POISON CONTROL

San Francisco poison control center
examines impact of reduced service

Poison centers face funding
crisis

Most of us take poison control centers
for granted. Parents who panic at the
sight of their toddler playing beside an
open, empty bottle of pills count on
being able to pick up the phone, dial a
regional center, and get immediate and
expert advice on what to do.

People also tend to take the cost savings
of these centers for granted. By provid-
ing expert telephone advice to dis-
traught parents, poison control centers
avert an estimated 50,000 hospitaliza-
tions and 400,000 visits to a doctor or
emergency room each year.

In fact, many poison control centers rely
on an unstable patchwork of funding
sources. They stay in business through

partial funding from hospitals or univer-
sities, private donations, and some fed-
eral, state, and local support. The recent
experience of the San Francisco Bay Area
Regional Poison Control Center shows
how tenuous financing can affect the
quality of care of people in a poison cen-
ter’s service area. The withdrawal of one
county’s fiscal support provided an
opportunity to observe what happens
when a service that is taken for granted
is suddenly withdrawn.

San Francisco center looks for
ways to cut costs

The Bay Area poison control center
serves ten counties around San Francisco.
About four and a half million people
live in this region, encompassing the Bay
Area and California’s northern coastal
counties. The “center” is actually a

CONTINUED ON NEXT PAGE

Proposed E-code groupings

ready for comment

NCIPC and the National Center for
Health Statistics and other members of
the Injury Control and Emergency
Health Services section of the American
Public Health Association are develop-
ing E-code groupings for reporting
injury data. The intent is to work
toward establishing voluntary national
standards for a minimum framework for
reporting morbidity and mortality data
useful for injury prevention and control
activities.

The proposed E-code groupings can be
viewed at either of two addresses on the
Internet:

http://www.cde.gov/ncipc/
whatsnew/whatnew.htm

http:/ /www.cde.gov/ncipc/osp/
constr.htm

For more information or to comment,
contact J. Lee Annest, PhD, by E-mail at
jlal@cipcod1.em.cde.gov. Ml


financing mechanism.” The license plate
concept was ideal for their purposes,
Ms. Shaw said. “It’s voluntary, it edu-
cates people, and it symbolizes the issue
with beautiful art.”

The idea was modeled after a license
plate that raised money for environmen-
tal causes in the state.

Influential supporters helped
promote cause

Support at two levels helped assure
unanimous passage of the legislation.
First, the council won the backing of key
state leaders. Tom Ryder, the majority
leader in the House and chair of the
appropriations committee, helped gar-
ner bipartisan House and Senate sup-
port. The state attorney general, Jim
Ryan, was involved early on; his past
record of commitment to prevention of
domestic and child abuse made him an
ideal champion for the initiative.

Chicago Tribune photo by Karen Engstrom
Barbara Shaw, executive director of the Illinois Council for the Prevention
of Violence, displays Illinois’ special violence prevention license plate,
proceeds from which support violence prevention in the state.

In addition to leader-
ship at the state level,
a broad grassroots net-
work of groups and
individuals kept the
issue prominent by
promoting the cause
of violence prevention
with their legislators
and the public. The
bill passed without a
single “no” vote. “The
time was right,” said
Ms. Shaw. “There’s a
great deal of concern
about violence, and
we had across-the-
board support.”

The Violence Preven-
tion Authority is co-
chaired by Attorney
General Ryan and the
state director of pub-
lic health, Dr. John Lumpkin, signifying
a commitment to a combined public
health-public safety approach to
addressing the problem. Other groups
represented on the authority include
state agencies and nongovernmental
members representing health, justice,
and civic and business organizations.

Community violence prevention efforts
to be funded by the authority include
youth violence prevention programs,
school-based prevention efforts, early
childhood intervention programs, family
violence and sexual assault prevention
programs, and approaches to creative
law enforcement and community policing.

The new state program will vigorously
pursue funding from private sources, as
well as state or federal funds. “The
license plate is just a beginning,” said
Ms. Shaw. “But it’s a great beginning.”

INJURY CONTROL UPDATE A Spring/Summer 1996



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INNOVATIONS

Illinois license plates promote,
help finance violence prevention

The “Innovations” column appears for the first
time in this issue of Injury Control Update.
The column will feature new ideas that are show-
ing promise in preventing injury. We invite you
to let us know about fresh approaches to injury
control in your state or community. Please send
submissions to Editor Gwen Ingraham at
NCIPC, CDC, MS K-65, 4770 Buford Highway,
NE, Atlanta, GA 30341-3724, or send an E-mail
to gnil@cipcod] .em.cdc.gov

In a first for the nation, IJlinois has creat-
ed a separate state authority to plan,
coordinate, fund, and evaluate violence
prevention efforts. Even more impres-
sive is the state’s way of financing the
authority and its programs: a separate
fund that will seek private and public
dollars to be used exclusively for vio-
lence prevention.

“We knew we couldn’t compete
for dollars out of the state’s
general revenues. We had to come
up with an alternate financing

mechanism.”

— BARBARA SHAW
EXECUTIVE DIRECTOR
ILLINIOS COUNCIL FOR THE
PREVENTION OF ‘VIOLENCE

Special license plates will generate the
initial revenues for the Violence Preven-
tion Fund. Two peace symbols—a dove
and an olive branch—adorn the license
plates, and the initials “PV” identify the
plates as supporting prevention of
violence.

This innovative approach was spear-
headed by the IJlinois Council for the
Prevention of Violence (ICPV), a
statewide coalition of diverse groups
representing public health, law enforce-
ment, the state medical society, and a
wide range of civic and community
organizations. With a track record of ini-
tiating regional networks on prevention
of youth violence and other prevention
activities, the council set two major poli-
cy goals: to increase resources for state
and local violence prevention programs
and to create an infrastructure to coordi-
nate the effort. With backing from key
legislators, state officials, and a broad
base of community groups, the legisla-
tion sailed through the Illinois General
Assembly with no opposition and was
signed by Governor Jim Edgar in the
summer of 1995.

License plates carry the message

As of August 1, more than 15,000 of the
special plates had been sold, and the
campaign expects to sell as many as
80,000 over the next several years. Each
plate costs $88, as opposed to $48 for a
standard plate in the state. Of the $40
difference, $25 goes to the Violence Pre-
vention Fund and $15 for production
costs. Annual renewals will cost an addi-
tional $27 over regular renewals, with
$25 going to the fund.

The idea for this funding emerged from
ICPV meetings about ways to raise
funds that would be dedicated solely for
violence prevention. “We knew we
couldn’t compete for dollars out of the
state’s general revenues,” said Barbara
Shaw, executive director of the ICPV.
“We had to come up with an alternate


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programs at MWC and Sojourner Truth
House talked about what might have
helped deter them from committing
domestic violence. Women at the two
agencies’ shelters also talked about the
experience of partner abuse in their
lives. With those perspectives, William
Eisner & Associates developed key mes-
sages and visuals and then went back to
the groups to get their reactions.

A survey of Milwaukee County resi-
dents also generated ideas for the cam-
paign. The study, administered by the
Social Science Research Center at the
University of Wisconsin at Milwaukee,

Pgs

surveyed 400 men and women random-
ly selected throughout the county and a
subset of 100 men and 100 African-
Americans. The findings helped under-
line the key themes of the campaign and
also will serve as baseline information
against which to measure changes in
attitude for follow-up evaluation. (See
sidebar below for highlights of the
survey findings.)

The advertising firm developed creative
strategies to target both men and
women. For both, a main message
underscored that domestic violence is a
crime and that resources are available to

SURVEY CAPTURES COMMUNITY’S VIEWS ON DOMESTIC VIOLENCE

The survey conducted by the University of Wisconsin-Milwaukee and the Social Science
Research Center showed that Milwaukee County residents held the following views:

A Domestic violence is an important and widespread problem. Almost 70% of people sur-
veyed said they personally knew a woman who had been abused by a partner, and
more than 70% said they considered domestic violence an important social problem.

A Violence has no place in an intimate relationship. Almost three-quarters of the public
said that even occasional physical violence in a relationship is a real problem, and an
overwhelming majority is no longer willing to blame the woman for abuse or accept
excuses and rationalizations for the violence.

A Domestic violence is a crime. Milwaukee County residents know that physical abuse in
a relationship is a crime.

A Abusive men need to be held legally and socially accountable. Slightly more than half the
people surveyed said that abusive men should be arrested for domestic violence.
People also expressed a hesitation to intervene personally, if they knew about abuse.

A Too few people know about resources for help. Almost a third of the people surveyed did
not know about places that women could turn to for help, and more than 70% were
unaware of hotline or counseling services for men.

A Men and women hold different attitudes about domestic violence. The problem has tradi-
tionally been considered “a women’s issue,” with educational resources targeted
primarily to women.



nga

Two options for information
about NCIPC grants

Injury control professionals who want
the latest news about extramural grant
funding from NCIPC have two choices
for obtaining information. They can
access announcements through the
Internet, via CDC’s and NCIPC’s home
pages, or through an interactive, auto-
mated telephone system.

The Internet address for CDC’s home
page is

http://www.cde.gov /(select “Funding”)
The address for NCIPC’s home page is

http://www.cde.gov/neipe/ncipchm.htm
(select “Research Grants and Funding
Opportunities”)

To reach the information you want,
select the specific program announce-
ment of interest. The telephone number
for the automated line is (404)332-4561.
You can hear descriptions of current
announcements and request full

application kits for specific program
announcements.

NCIPC grants to fund research centers
are announced in August. Applications
are due in October, and funding is
awarded in late summer of the follow-
ing year. For individual research pro-
jects, announcements appear during the
fall, applications are due the following
January or February, and awards are
made by September. Grants are for peri-
ods of up to three years.

A handbook, Guide to Applying for Injury
Research Grants, is available for those
who would like guidance in completing
research grant applications. For a copy,
write to Office of Research Grants,
National Center for Injury Prevention
and Control, Centers for Disease Control
and Prevention, 4770 Buford Highway,
NE, MS K-58, Atlanta, GA 30341-3724,
or call (770)488-4265.

Inventory of Federal Data Systems in the
United States for Injury Surveillance,
Research and Prevention Activities

J.L. Annest, J.M. Conn, and S.P. James.

This new report describes 31 federally funded
national data systems that provide information
on injury mortality, morbidity, and risk factors.
The inventory includes a brief overview of each
data system, its data collection methods, inclu-
sion and exclusion criteria, useful features for
injury research, and summary tables of the sys-
tems’ characteristics and data content.

P Rereurees You Can Ure

Eight of the systems provide data on work-relat-

ed injuries and deaths; the remaining systems

focus more broadly on injuries and deaths related

to violence and unintentional causes. Three sys-
tems provide injury cost data.

The inventory is available on NCIPC’s home page
(see page 19), and by writing J. Lee Annest, PhD,

Director, Office of Statistics and Programming,
NCIPC, CDC, MS K-59, 4770 Buford Highway,
NE, Atlanta, GA 30341-3724.

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