Consumer Product Safety Commission: Better Data Collection and Assessment of Consumer Information Efforts Could Help Protect Minority Children
Published: 2009-08-05T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In 2004, the U.S. Consumer Product Safety Commission (CPSC) estimated that 29,400 deaths in the United States were related to consumer products. As required under Section 107 of the Consumer Product Safety Improvement Act of 2008, this study reviews what is known about the relative incidence of preventable injuries and deaths among minority children associated with products intended for children's use and also examines what actions CPSC has taken through its public information and education initiatives to minimize these injuries and deaths. To address these issues, we assessed injury and death data sources used by CPSC, compared CPSC's consumer education efforts with key practices, and interviewed federal officials and groups representing the health and consumer interests of minority populations.
section_title: What GAO Found
paragraphs: Few studies have assessed racial and ethnic differences in child death rates from injuries related to consumer products, and CPSC has not analyzed whether specific racial or ethnic groups are disproportionately affected by product hazards because of data limitations. These limitations include incomplete and inconsistent race and ethnicity data on emergency room reports and the inconsistent presence of product-related information on death certificates. In 2007, race and ethnicity data were not coded in about 31 percent of cases in CPSC's National Electronic Injury Surveillance System (NEISS), which collects data from a nationally representative sample of hospital emergency rooms. In addition, the hospitals that do record race and ethnicity information in CPSC's NEISS system do so inconsistently, in part because of limited CPSC guidance. While death certificates may include more complete race and ethnicity information compared with nonfatal injury data from hospitals, related product information is not consistently documented on the certificates. Despite this lack of data, CPSC has developed or modified some consumer information efforts to reach specific minority populations, but it has not assessed the results of these efforts. CPSC provides information in Spanish for many of its outreach efforts, including its telephone hotline, Web site, television, radio, and print publications. CPSC has also identified and established relationships with other organizations to help disseminate consumer safety information to minority communities. And while CPSC has used some consumer input to develop safety information, it has not assessed outreach efforts for specific audiences. CPSC has also established goals for its overall consumer information efforts, but not for its messages targeted to specific populations. In addition, CPSC relies on its Neighborhood Safety Network, a group of organizations that have expressed interest in receiving product safety information, to share information with audiences that can be hard to reach, but the agency has not assessed whether these populations are receiving and using the information. Organizations we contacted for this report, including Neighborhood Safety Network members and children's safety groups, generally reported using safety information provided by CPSC, but some offered suggestions for improvement of efforts to reach minority communities, such as providing safety information in other languages and additional exposure through broadcast media.

section_title: Letter
paragraphs: The U.S. Consumer Product Safety Commission (CPSC), an independent  federal agency charged with protecting the public from consumer  products that pose an unreasonable risk of injury and death, estimated  that 29,400 deaths in the United States related to consumer products  occurred in 2004. CPSC works to fulfill its broad mission in part by  conducting research into the causes and prevention of product-related  deaths, illnesses, and injury and assisting consumers in evaluating the  comparative safety of consumer products. CPSC has identified certain  populations as vulnerable or hard to reach with safety information,  including older Americans, urban and rural low-income families, new  parents, and minority groups. Consumer groups and researchers have also  suggested that minority children, particularly those living in low-income  communities, may face an increased risk of death from injuries because of  factors associated with living in poverty, such as poor living conditions  and less access to health care, quality recreational activities, and safety  devices. Similarly, reports from the Centers for Disease Control and  Prevention (CDC) have documented racial disparities in injury-related  death rates among children.
The Consumer Product Safety Improvement Act of 2008 (CPSIA)  established consumer product safety standards and other safety  requirements for children’s products. It also contained a provision  requiring GAO to study disparities in the risks and incidence of  preventable injuries and deaths among children of minority populations  related to consumer products intended for children’s use. Specifically,  GAO is to look at preventable injuries and deaths related to suffocation,  poisoning, and drowning, including those associated with the use of  swimming pools and spas; toys; cribs, mattresses, and bedding materials;  and other products intended for children’s use. Minority populations  specified in the mandate include Black, Hispanic, American Indian, Alaska  Native, Native Hawaiian, and Asian/Pacific Islander. The mandate also  required GAO to provide information about ways to minimize risks of  preventable injuries and deaths among minority children, including  through consumer education initiatives. To address this mandate, we  examined (1) what is known about the relative incidence of preventable  injuries and deaths related to drowning, poisoning, and suffocation  associated with products intended for children’s use among minority  children compared with nonminority children, and (2) what actions CPSC  has taken through its public information and education initiatives to  minimize child injuries and deaths, including those in minority  populations, related to products intended for children’s use.
To answer these questions, we reviewed studies and reports by the  Institute of Medicine, federal agencies, researchers, and other  organizations that assessed racial or ethnic differences in injury and death  among children and related studies that discussed injury prevention  programs targeted to minority populations. We reviewed injury and death  data sources used by CPSC to estimate product-related injuries and  deaths. We interviewed federal officials at CPSC and five Department of  Health and Human Services (HHS) organizations to learn about their  related programs and initiatives. In addition, we obtained information  about injury data, racial and ethnic disparity issues, and injury prevention  campaigns from researchers, representatives of injury prevention  programs, consumer groups, and groups representing the health and  consumer interests of minority populations. Finally, we reviewed CPSC  documents and interviewed CPSC officials regarding the development,  operation, and evaluation of the agency’s consumer information efforts.  We compared the processes used by CPSC with key practices identified by  experts in GAO’s previous work on consumer information and education.
The key practices include defining goals and objectives; analyzing the  situation; identifying stakeholders; identifying resources; researching  target audiences; developing consistent, clear messages; identifying  credible messengers; designing media mix; and establishing metrics to  measure success. Appendix I explains our scope and methodology in more  detail.
We conducted this performance audit from December 2008 through  August 2009 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: CPSC was created in 1972 under the Consumer Product Safety Act to  regulate consumer products that pose an unreasonable risk of injury,  assist consumers in using products safely, develop uniform safety  standards for consumer products, minimize conflicting state and local  regulations, and promote research and investigation into product-related  deaths, injuries, and illnesses. CPSC oversees about 15,000 types of  consumer products used in the home, in schools, and in sports and  recreation. In fiscal year 2008, CPSC carried out its mission with a budget  of about $80 million and 396 full-time employees. Prior to 2008, CPSC  experienced significant budget cuts and a sharp decline in its staffing level  from a high of 978 employees in 1980. Congress appropriated increased  funding totaling about $105 million for fiscal year 2009. This appropriation  funds a staffing level of 483 full-time employees, according to CPSC’s 2010  budget request.
subsections: section_title: CPSC Efforts to Inform Consumers about Product Hazards
paragraphs: CPSC uses different methods to inform the public about product recalls  and safety practices that can help prevent product-related injuries (see fig.  1). CPSC maintains a National Injury Information Clearinghouse that  disseminates information to the public related to deaths and injuries  associated with consumer products under the agency’s jurisdiction. CPSC  also warns the public about product hazards by announcing product  recalls and providing other safety information through print and electronic  media, a telephone hotline, electronic mail, and the Internet. For example,  CPSC works with manufacturers to provide public notice of product  recalls, in which a defective item is to be removed from store shelves and  consumers are alerted to return the item for repair, replacement, or  refund, or otherwise dispose of them. To further its reach, CPSC also  provides safety information to broadcast outlets, such as radio and  television stations, and to print media outlets. According to CPSC officials,  CPSC has allocated approximately $1 million annually to support its  consumer information efforts and has nine employees in the Office of  Public Affairs, the office responsible for developing and implementing  CPSC’s consumer information efforts in consultation with CPSC’s  technical experts and other CPSC staff. Congress appropriated funding in  2009 to help CPSC administer the Virginia Graeme Baker Pool and Spa  Safety Act, including about $2.4 million for a state grant program and over  $4 million for a program to inform the public and pool owners of pool and  spa hazards to prevent children from drowning.
Recently passed legislation requires CPSC to improve its consumer  information activities. For example, the Consumer Product Safety  Improvement Act (CPSIA) requires CPSC to develop an online database  that is publicly available and searchable by date, product name, model,  and manufacturer. The database must contain reports of harm relating to  the use of consumer products. CPSIA also specifies the information that  must be included in a mandatory product recall notice, including details  about related injuries and deaths. The act also authorizes CPSC to require  manufacturers to give public notice in languages other than English,  although this provision applies only to mandatory recalls, according to  CPSC officials.
subsections: section_title: Related Department of Health and Human Services Efforts
paragraphs: While CPSC is charged with protecting the public from unreasonable risks  of injury and death from the thousands of types of consumer products  under the agency’s jurisdiction, HHS offices and agencies also play a role  in injury prevention by conducting injury prevention research and  information campaigns, collecting injury data, and promoting the health of  minority populations. For example, according to agency officials and  documents, CDC and the National Institutes of Health support research on  a variety of topics, including injury prevention, and have conducted public  information campaigns to reduce childhood injury. CDC’s National Center  for Health Statistics (NCHS) collects information about injuries, including  race and ethnicity characteristics, from death certificates in all 50 states  and the District of Columbia, as well as from household surveys and health  care provider surveys. The Maternal and Child Health Bureau (MCHB) and  the Indian Health Service (IHS) finance public health services, including  injury prevention programs. HHS offices and agencies also lead efforts  aimed at understanding and addressing racial and ethnic disparities in  health care, including rates of unintentional injury among minority groups.  For example, HHS’s Office of Minority Health serves as a focal point  within HHS to coordinate efforts to improve racial/ethnic minority health  and eliminate racial/ethnic health disparities. The Office of Minority Health  is charged with providing leadership and coordination for offices of  minority health operating in other HHS agencies and in states to reduce  racial and ethnic health disparities, according to agency officials. CDC is  the lead agency charged with measuring progress toward national HHS  goals to eliminate disparities in injuries, disabilities, and deaths due to  unintentional injuries and violence.
section_title: Injury and Death Data Sources Used by CPSC
paragraphs: CPSC collects and analyzes data on consumer product-related injuries and  deaths for products under its jurisdiction to determine where hazards  exist and how to address them. CPSC obtains most of its information on  injuries from its National Electronic Injury Surveillance System (NEISS),  which gathers information from a nationally representative sample of  about 100 hospital emergency rooms. NEISS provides national estimates  of the number and severity of emergency room-treated injuries associated  with, although not necessarily caused by, consumer products in the United  States. Characteristics coded in the NEISS system include the date of  treatment; the patient’s age, gender, race and ethnicity, injury diagnosis,  body part affected, case disposition; incident location; as well as the  product involved. In 2000, NEISS was expanded to provide data on all  trauma-related injuries. The expanded data provide other federal agencies,  researchers, and the public with more comprehensive information on  injuries from all sources, not just consumer products. CPSC receives  approximately $2 million each year from CDC to support this effort.
CPSC obtains most of its information on fatal injuries from death  certificates. Information recorded on death certificates includes the date  and place of death, cause of death, age, gender, race and ethnicity, and  residence of the deceased. CPSC estimates the number of consumer  product-related deaths from data collected by NCHS about all deaths  through the National Vital Statistics System. Because of the complexity  and volume of collecting information about all deaths, there is over a 2  year lag before NCHS mortality data become available. According to a  CPSC official, to obtain more timely information, CPSC annually  purchases about 8,000 death certificates directly from states for selected  causes of death that the agency has determined are likely to be product- related, such as bicycle accidents or falls involving playground equipment.
CPSC supplements information from the NEISS system and death  certificates with reports from individual consumers and with data from  private organizations such as fire prevention groups and poison control  centers. CPSC collects approximately 4,600 additional reports from  participating medical examiners and coroners throughout the country,  about 7,400 news clips, and 14,300 other reports of product-related injuries  and deaths from consumers, lawyers, physicians, fire departments, and  other sources, according to its 2010 performance budget request.
section_title: Few Studies Assess Racial and Ethnic Differences in Children’s Risk of Death from Injuries Related to Consumer Products, and Data Limitations Constrain CPSC Analysis
subsections: section_title: Few Studies Assess Racial and Ethnic Differences in Child Death Rates from Injuries Related to Consumer Products
paragraphs: Although some research suggests racial disparities in child death rates  resulting from general causes of injury—including drowning, poisoning,  and suffocation—we identified few studies that assessed racial and ethnic  differences in child death rates from injuries related to consumer  products. The studies we identified included two that identified racial and  ethnic disparities in drownings in swimming pools and a study that  identified a disparity between black and white infants in the risk of  suffocation or strangulation in bed. We did not identify any studies that  compared the incidence of poisoning related to consumer products by  children’s race and ethnicity. While these studies identified racial and  ethnic differences in death rates related to specific products, the  researchers were not consistently able to consider all factors that may  contribute to these differences, such as differences in exposure to the  consumer products.
subsections: section_title: Drowning
paragraphs: Mortality data reported by CDC suggest racial disparities in drowning  rates, although these data do not specify whether the deaths involved  consumer products. Drownings can occur in a variety of settings, such as  natural water settings, swimming pools, bathtubs, and buckets. According  to CDC, between 2000 and 2005, the fatal unintentional drowning rate of  black children ages 5 to 14 was 3.2 times that of white children in the same  age range. For American Indian and Alaska Native children, the fatal  drowning rate was 2.4 times higher than for white children.
One study, conducted by researchers from HHS’s National Institutes of  Health, CPSC, and a research institute, found racial and ethnic disparities  in swimming pool drowning rates. This study examined circumstances  surrounding 678 swimming pool drownings among U.S. residents aged 5 to  24 years that occurred between 1995 and 1998. The study used data  collected by CPSC about drowning deaths from death certificates, medical  examiner reports, and newspaper clippings. The study found that black  non-Hispanic males and females had higher swimming pool drowning  rates compared with white non-Hispanic males and females of comparable  age. Drowning rates were highest among black males, often occurring  during the day at public pools, and this increased risk persisted after  controlling for differences in neighborhood income. Hispanic males also  had higher rates of pool drowning compared with white non-Hispanic  males, but they had lower rates compared with black non-Hispanic males  of comparable age. The drowning rates among Hispanic females were  similar to those of white non-Hispanic females. The drowning rates among  foreign-born victims were higher than among American-born victims. The  study concluded that targeted interventions are needed to reduce the  incidence of swimming pool drownings across racial and ethnic groups; it  particularly recommended adult supervision at public pools and swimming  instruction to increase children’s swimming ability.
Another study examining racial disparities in drowning rates in specific  locations found that after the age of 5 years, the risk of drowning in a  swimming pool was greater among black males compared with white  males. Specifically, this study analyzed death certificate data collected by  CPSC and NCHS about U.S. drowning deaths of children aged up to 19 in  1995. This research found that among black males aged 5 to 19 years,  about 37 percent of drowning deaths with known location of drowning  were in swimming pools, while only 10 percent of similar drownings  among white males occurred in pools.
section_title: Suffocation
paragraphs: One study conducted by CDC researchers found that black infants were  disproportionately affected by accidental suffocation and strangulation in  bed (27.3 versus 8.5 deaths per 100,000 live births for blacks and whites,  respectively). This study analyzed infant deaths occurring between 1984  and 2004 using CDC’s National Center for Health Statistics mortality files  containing information from all death certificates. Researchers only  analyzed differences between black and white infants in this study  because of concerns about misreporting of racial and ethnic identity on  death certificates for other racial and ethnic groups. Although not  reported by racial group, beds, cribs, and couches were reported overall as  the most common sleep surfaces where accidental suffocation and  strangulation deaths occurred. In addition, co-sleeping or bed sharing  was reported in over half of the cases. The study concluded that efforts  should target those at highest risk and focus on helping parents and  caregivers provide safer sleep environments.
section_title: Poisoning
paragraphs: We did not identify any studies that compared the incidence of poisoning  related to consumer products by children’s race and ethnicity. CPSC has  assessed differences in the incidence of product-related poisonings among  children by age group and gender. A recent study conducted by CPSC staff  found that 70 percent of an estimated 86,194 child poisoning incidents  involving children less than 5 years of age treated in hospital emergency  rooms that occurred in 2004 involved children 1 to 2 years of age; slightly  more than one-half involved boys; and about 60 percent involved oral  prescription drugs, nonprescription drugs, and supplements. The study  concluded that while fatal child poisonings involving drugs and other  hazardous household substances have decreased in recent years, nonfatal  child poisonings treated in hospital emergency rooms have remained at  high levels.
Poisoning can also occur when children swallow or put in their mouths  products that contain excessive levels of lead paint or lead content, such  as toys or children’s costume jewelry; however, CPSC receives little  information about such incidents through its data systems. According to  CPSC officials, the agency rarely receives reports of child lead poisoning  through its data systems because lead poisoning usually appears as a  chronic illness rather than an acute injury, and as we have previously  reported, CPSC’s data systems are not set up to capture information about  chronic illnesses.
section_title: CPSC Has Not Analyzed Racial and Ethnic Differences in Product- Related Injury and Death because of Data Limitations
paragraphs: CPSC estimates product-related injury and death rates by age group, but  because neither emergency room nor death certificate data provide  complete information about both race and ethnicity and related products,  CPSC has not analyzed product-related injury and death rates by race and  ethnicity or other characteristics that could identify particularly  vulnerable populations. While other federally supported data collection  efforts provide more, or more reliable, information on the range of factors,  including race and ethnicity, that may contribute to injury risk, these  efforts have not collected data on consumer product involvement or CPSC  has not been involved with them.
subsections: section_title: NEISS System
paragraphs: While products related to patients’ injuries are coded in the NEISS system,  limited patient race and ethnicity information has hindered analysis of  racial and ethnic differences in product-related injuries. CPSC’s NEISS  system specifies the products involved in injuries treated in hospital  emergency rooms. NEISS coders can choose from approximately 900  product codes when identifying any products mentioned in hospital  emergency room records, such as toys, cribs, and swimming pools.  Consumer products are coded to allow for specificity. For example, a baby  bathtub seat would be specified differently from a baby bath. In its 2008  performance report, CPSC reported conducting annual monitoring visits to  all of the NEISS hospitals in its sample, concluding that data were  collected on over 90 percent of product-related cases in emergency room  records through the NEISS system.
As shown in figure 2, our analysis of CPSC’s NEISS data found that race  and ethnicity data were not coded in about 31 percent of cases in 2007.  The percentage of NEISS cases missing race and ethnicity information has  prevented CPSC and CDC from assessing racial and ethnic differences in  nonfatal injury rates, according to agency officials. According to a CPSC  official, the agency has been aware of the missing race and ethnicity data  and considered ways of statistically estimating race and ethnicity  information using existing data, but has not pursued such analysis because  of competing agency priorities.
Our analysis of CPSC’s NEISS data found that some hospitals have a high  percentage of cases missing race and ethnicity information. As shown in  figure 3, about one-quarter of NEISS hospitals had more than 75 percent of  cases missing race and ethnicity information in 2007.
In addition, NEISS hospitals that have recorded race and ethnicity  information do so inconsistently, in part because of limited CPSC  guidance. For example, a NEISS coder in one NEISS hospital we visited  reported that the hospital registrar would generally record the patient’s  race and ethnicity using visual observation and rarely verify this  information with the patient. Staff at other NEISS hospitals reported that  the admitting staff may ask for race or ethnicity data along with other  information when the patient is checking into the emergency room. In its  manual, CPSC does not specify how hospital staff should obtain the  information about patient race and ethnicity, although some researchers  suggest that information reported by patients or patient representatives is  more accurate than visual observation by hospital staff. In addition,  CPSC’s coding system for race and ethnicity is limited to white, black, and  a narrative field for “other” categories, resulting in inconsistent coding and  making data on other categories challenging to analyze. Our review of  NEISS data found that NEISS hospitals use different terminology to code  the same racial or ethnic categories in the “other” category.
According to a few organizations we interviewed, hospital-based  collection of data on the race and ethnicity of patients is a challenge for  several reasons. A hospital staff member from one NEISS hospital we  visited said that these data are missing because hospital staff are  uncomfortable asking patients about race and ethnicity. CDC officials and  a researcher we interviewed said that hospital staff may not be trained to  collect race and ethnicity information or may not understand that it is  being used for purposes other than providing medical care.
Other studies have found incomplete and inconsistent collection of  information about patient race and ethnicity from hospitals. A panel  convened by the National Academy of Sciences conducted a survey of  hospitals and found that many hospitals report collecting race and  ethnicity information, but these data are not reported to state and federal  programs in a standardized format, and the information reported for racial  and ethnic groups other than white and black may be unreliable. The  panel recommended that HHS require health insurers, hospitals, and  private medical groups to collect data on race, ethnicity, socioeconomic  position, and acculturation and language and provide leadership in  developing standards for collecting these data. Another qualitative study,  funded by the California Endowment, reviewed hospital efforts to provide  culturally and linguistically appropriate health care in 60 hospitals  nationwide. The majority of hospitals reviewed in this study had  inconsistent methods for collecting data on patient race, ethnicity, and  primary language. In some hospitals, systems were in place but not used;  in others, staff appeared not to have been trained on methods to  accurately collect data from patients.
section_title: Death Certificates
paragraphs: Death certificates may include more complete and accurate race and  ethnicity information compared with nonfatal injury data from hospitals,  according to CDC officials, but concerns remain about the accuracy of this  information for some groups. The accuracy of race and ethnicity  information recorded on death certificates has been studied over time. A  recent evaluation conducted by CDC found that race and ethnicity  reporting on death certificates has been excellent for white and black  populations, poor for the American Indian or Alaska Native populations,  and reasonably good for the Hispanic and Asian or Pacific Islander  populations. According to CDC, studies have shown that individuals who  self-reported as American Indian, Asian, or Hispanic on census and survey  records were sometimes reported as white or non-Hispanic on the death  certificate, resulting in an underestimation of deaths and death rates for  the American Indian, Asian, and Hispanic groups.
While death certificates may contain more complete and accurate race and  ethnicity data than the NEISS system, according to CPSC and CDC  officials, related product information is not consistently documented on  the certificates. Unlike coders who enter data into CPSC’s NEISS system,  individuals who complete death certificates are not prompted or required  to record information identifying specific consumer products related to  the death. Information about product involvement may be found in the  narrative recorded on the certificate; however, this information is not  consistently recorded, according to both CPSC and CDC officials. CPSC  has developed national estimates of consumer product-related death rates  by age group using HHS data containing information about all deaths; but  CPSC has not analyzed these deaths by race and ethnicity, according to  CPSC officials. A CPSC official told us that CPSC staff could analyze  consumer product-related deaths by race and ethnicity, although the  agency has not done so to date. CDC officials said that given the limited  information about product involvement found on death certificates,  estimating product-related death rates by race and ethnicity could produce  underestimates.
Some states are collecting information about product-related deaths as  part of investigations to understand the causes of child deaths; however,  CPSC has not been involved in this effort. HHS’s Maternal and Child  Health Bureau funds a Web-based system and technical assistance center  to support state collection of data from child death reviews, including race  and ethnicity, type of injury, and details on product involvement. Child  death reviews involve state and local officials from multiple disciplines  sharing information to better understand child deaths and prevent future  deaths. Since 2002, HHS’s Maternal and Child Health Bureau has funded  the National Maternal Child Health Center for Child Death Review, a  technical assistance center that developed the Child Death Review Case  Reporting System. As of February 2009, 28 states have used the system,  and states vary in the types of deaths reviewed, the timing of entry into the  system, and the amount of detail entered into the system, according to  officials. The system prompts the user to record whether the death was a  consequence of a problem with a consumer product and, if so, collects  information about the product and whether the incident was reported to  CPSC. However, according to officials, CPSC has not been involved in the  development and implementation of this system. CPSC does not currently  receive updates from HHS or the states directly through the Child Death  Review Case Reporting System.
According to CDC, injury data collected from household interviews  through its National Health Interview Survey may include more accurate  data on race and ethnicity compared with medical records-based data  collection efforts because the information is self-reported or reported by a  knowledgeable representative. The National Health Interview Survey also  contains information about other factors that could account for health  conditions, such as socioeconomic status, but lacks consistently reported  information about product involvement, according to CDC officials. A  CPSC official said the agency has not pursued working with CDC to  augment its data collection efforts by modifying this survey, citing doubts  that the data collected could include sufficient detail about product  involvement even if the survey were modified.
section_title: CPSC Has Developed or Modified Some Consumer Information Efforts to Reach Specific Minority Populations, but Has Not Assessed the Results of These Efforts
paragraphs: CPSC has incorporated some elements of key consumer education  practices to provide consumer product safety information to minority  populations, such as periodically using consumer and other stakeholder  input to inform its outreach efforts, but it has not specifically defined goals  or developed measures to assess whether these efforts are effectively  reaching minority populations (see app. II for further detail on the key  practices).
subsections: section_title: CPSC Has Tailored Some Outreach for Hispanic Communities and Established Relationships to Assist in Reaching Other Minority Populations
paragraphs: CPSC’s consumer information efforts are intended to provide notice of  product recalls and guidance on safely using products to the general  public, although some of its safety information regarding children’s  products has also been targeted to minority populations, particularly the  Hispanic community. CPSC provides information in Spanish for many of  its outreach efforts, and according to CPSC officials, has hired a Hispanic  media consumer outreach specialist to assist with translations and to work  with the Hispanic media, and has established practices to develop and  disseminate safety information to this community. CPSC officials also told  us that they provide information to Spanish-language television and radio  stations, use Spanish-speaking telephone operators for CPSC’s toll-free  hotline, and maintain a language bank to provide assistance for calls in  other languages. During fiscal year 2008, CPSC records indicate that  CPSC hotline staff answered 1,570 calls in Spanish. The main CPSC Web  site also includes a section called El Mundo Hispano de la CPSC with  recall notices and other product safety information in Spanish. See figure 4  for examples of CPSC consumer information in Spanish and English.
CPSC has also identified and established relationships with other  organizations to help disseminate consumer safety information to  additional minority communities through electronic, broadcast, and print  media. For example, CPSC officials noted that in 2000, CPSC worked with  the Bureau of Primary Health Care, Gerber, and Black Entertainment  Television (BET) to launch a safe sleep campaign to help lower sudden  infant death syndrome (SIDS) rates, especially among African-Americans.  The campaign included a nationwide television public service  announcement about placing babies to sleep on their backs to prevent  SIDS, and special programming to be televised on BET. CPSC has also  worked on media outreach campaigns with other organizations such as  public health agencies, industry groups, and child safety organizations. In  2004, CPSC launched the Neighborhood Safety Network (NSN), to enlist  support from community-based organizations in extending its messages to  communities it designated as hard to reach, including older Americans,  urban and rural low-income families, new parents, and minority groups.  According to CPSC officials, CPSC uses NSN, now numbering about 5,600  member organizations, to deliver information to minority populations.  Membership in NSN is free and enrollment is voluntary. Some of the  member organizations include HHS, hospitals and health clinics, day care  centers, fire stations, parent organizations, and American Indian  reservations. CPSC has developed a Web page offering online safety  materials that NSN members can modify for use with specific groups. NSN  member organizations receive CPSC’s e-mail updates with product safety  information on topics such as drowning prevention, crib and toy safety,  and poison prevention and may elect to employ these in their own  outreach efforts.
Organizations we contacted for this report, including NSN members,  consumer groups, and organizations that conduct injury prevention  research or implement injury prevention programs in diverse communities  generally reported using safety information provided by CPSC, and some  offered suggestions for improving efforts to reach minority communities.  Some of the organizations said that they receive information from CPSC  via e-mail notifications, and some mentioned distributing flyers or posters  provided by CPSC and incorporating information from CPSC into their  own pamphlets and brochures. Some suggestions to improve consumer  information efforts for minority populations included additional exposure  through broadcast media because access to electronic information via  computers may be limited. Some NSN members also said it would be  useful if safety information were provided in additional languages.  According to CPSC officials, the agency does not have the resources to  translate information into additional languages, but one NSN member we  interviewed mentioned that their organization had translated some CPSC  materials for its audiences. Some organizations also expressed interest in  collaborating more closely with CPSC on its consumer information efforts.
section_title: CPSC Has Used Some Consumer Input to Develop Safety Information, but Has Not Assessed Outreach Efforts to Specific Audiences
paragraphs: CPSC has periodically conducted audience research to strengthen its  consumer information efforts. In 2003, the agency funded a literature  review to examine the factors influencing consumers’ understanding of  and responses to recall notices and other safety information. The study  findings suggested ways product recall communications could be  improved to help consumers eliminate or reduce product hazards, such as  using pictures and signal language like “warning” or “danger” to help  consumers attend to and understand safety messages. CPSC also created  an online Consumer Opinion Forum that consumers can join to provide  feedback on product safety issues, such as how a recall notice could be  written more clearly; however, consumers must have Internet access to  participate in this forum. In addition, CPSC recognizes that to understand  the culture and diversity within the Hispanic community, it must take  certain steps such as interviewing members of the community, reviewing  related research, and consulting with colleagues from other federal  agencies. For example, to translate and adapt materials for one of its  outreach campaigns for different segments of the Spanish-speaking  audience, CPSC conducted interviews with members of the Hispanic  community from varying educational backgrounds. Although CPSC has  periodically conducted audience research, agency officials told us they do  not have the resources to regularly pretest safety messages. However,  officials from a few organizations we interviewed noted that CPSC could  conduct focus groups with members of the target audience or include  representatives of organizations that work with the target audience on an  advisory committee to help design and implement safety campaigns.
CPSC has also established goals for its overall consumer information  efforts, but not for its messages targeted to specific populations. In its  2008 performance and accountability report, CPSC stated that its goal for  using consumer information was to alert the public to children’s and other  hazards through consumer outreach, press releases, and conducting nine  public information efforts that included topics such as drowning and  poisoning prevention. CPSC sets annual performance goals that measure  the success for each of these consumer information methods according to  the total number of items issued, viewed, or conducted during that fiscal  year. For example, CPSC set a fiscal year 2008 goal to receive 450 million  views of its safety messages through television appearances, video news  releases, and downloads of e-publications.
CPSC relies on the Neighborhood Safety Network to share product safety  information with audiences that can be hard to reach, but the agency has  not formally assessed whether these populations are receiving and using  the information. And while CPSC tracks the number of views its safety  messages receive, CPSC officials stated that they do not collect  information on audience demographics, which could indicate the target  audiences being reached. Likewise, CPSC has conducted surveys to assess  customer satisfaction with its toll-free hotline, Web site, and partnerships  with state government agencies, and these surveys indicate a high level of  satisfaction with CPSC services; however, these surveys do not collect  information about the demographic characteristics of the consumers using  CPSC’s services to determine the extent to which they are representative  of the general population. According to CPSC officials, CPSC has also not  identified outcome measures to evaluate how well its campaigns affected  the attitudes and behaviors of the target audiences it set out to influence.  We previously identified strategies used by other federal agencies to  evaluate the effectiveness of information campaigns, including analyzing  findings from previous research, collaborating with program partners to  help meet the information needs of diverse audiences and expand the  usefulness of evaluations, and surveying the intended audience to ask  about program exposure, knowledge, and attitude change. CPSC officials  have also cited a lack of resources as a challenge to establishing  evaluation programs to measure results; however, CPSC has recently  received more resources from the fiscal year 2009 appropriation for the  Virginia Graeme Baker Pool and Spa Safety Act. In the course of our  review, CPSC officials stated that with this new funding for the act, they  planned to include an evaluation component, but as of the writing of this  report, it was not yet known how CPSC planned to implement this  component.
section_title: Conclusions
paragraphs: Protecting children from dangerous consumer products is a critical part of  CPSC’s mission. Some research suggests that there are racial and ethnic  disparities in child death rates due to injuries related to particular  consumer products; however, CPSC does not routinely assess whether  such disparities exist, primarily because data limitations make it  challenging to conduct such analyses. In addition, the lack of information  about other characteristics of individuals who are injured or die from  involvement with a consumer product, such as socioeconomic status,  prevents CPSC from identifying potential underlying causes of racial and  ethnic differences in injury and death rates. Without efforts to augment or  improve existing data, CPSC may not know which groups are most  vulnerable to product-related injury or death. If available data are  improved, CPSC may be better able to identify hazards that  disproportionately affect certain communities and develop ways to reduce  those hazards.
Despite limited information on racial and ethnic differences in product- related injury and death, CPSC has made some special efforts to deliver  some of its consumer information to audiences the agency identified as  hard to reach, including minority groups. However, CPSC has not  collected information on whether these targeted groups are receiving and  acting on the safety information. Without fully assessing its consumer  education and public outreach campaigns, CPSC cannot know how  effective these initiatives are at reaching intended audiences, some of  which may be at an elevated risk of injury or death.
section_title: Recommendations for Executive Action
paragraphs: To better understand the relative risk of product-related injury among  minority and nonminority children, we recommend that the Commission,  in consultation with HHS,    Develop and implement cost-effective means of improving CPSC’s data  collection on factors that may contribute to differences in the incidence of  injury and death related to specific types of consumer products, including  race, ethnicity, and other patient characteristics. For example, steps CPSC  could consider include improving the NEISS racial and ethnic  classification system; working with NEISS hospitals to improve collection  of data on patient race and ethnicity; and leveraging related data collection  efforts, such as those sponsored by the Maternal and Child Health Bureau,  the National Center for Health Statistics, or the National Institutes of  Health.
To improve the effectiveness of consumer information efforts, we  recommend that the Commission,    Develop and implement cost-effective ways to enhance and assess the  likelihood that CPSC’s safety messages are received and implemented by  all the intended audiences. For example, CPSC could consider convening  groups of consumers or Neighborhood Safety Network members to advise  on the design and implementation of campaigns targeted to specific  communities, surveying NSN members, establishing metrics to measure  NSN’s success, and evaluating the effectiveness of information campaigns  targeted to the racial and ethnic groups at highest risk of drowning as part  of its implementation of the Virginia Graeme Baker Pool and Spa Safety  Act.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to CPSC and HHS for review and  comment. CPSC and HHS concurred with our recommendations and  provided technical comments, which we incorporated as appropriate. A  letter conveying HHS’s comments is reproduced in appendix III.
We are sending copies of this report to the appropriate congressional  committees, the Chairman of the U.S. Consumer Product Safety  Commission, the Secretary of Health and Human Services, and other  interested parties.  In addition, the report will be available at no charge on  GAO’s Web site at http://www.gao.gov.
If you or your staff have any questions regarding this report, please  contact me at (202) 512-7215 or ashbyc@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this report. GAO staff who made major contributors to this  report are listed in appendix IV.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: The objectives of this report were to examine (1) what is known about the  relative incidence of preventable injuries and deaths related to drowning,  poisoning, and suffocation associated with products intended for  children’s use among minority children compared with nonminority  children, and (2) what actions the Consumer Product Safety Commission  (CPSC) has taken through its public information and education initiatives  to minimize child injuries and deaths, including those in minority  populations, related to products intended for children’s use.
To address the first objective, we reviewed injury and death data sources  used by CPSC to estimate product-related injuries and deaths. We  reviewed data and documentation obtained from CPSC concerning its  databases that contain injury and death data, including the Death  Certificates database, National Electronic Injury Surveillance System  (NEISS), Injury or Potential Injury Incidents file, and In-Depth  Investigations file. We reviewed information describing Department of  Health and Human Services (HHS) mortality data, which includes  information from death certificates filed in the United States collected  through the National Vital Statistics System. We also reviewed HHS  household and health care provider surveys that include injury data, such  as the National Health Interview Survey and the National Hospital  Discharge Survey. We also interviewed CPSC officials, HHS officials, and  researchers to gather information about the strengths and weaknesses of  available data sources.
We assessed the completeness and reliability of the NEISS data set by (1)  reviewing NEISS’s technical documentation and methodological reports,  (2) interviewing CPSC officials, (3) examining these data for obvious  inconsistencies, and (4) visiting three NEISS hospitals to better  understand how the data are coded. We determined that these data were  sufficiently reliable to use as sources of summary statistics about the  extent of missing race and ethnicity information in the NEISS system. To  determine the extent of missing race and ethnicity information in CPSC’s  NEISS system, we analyzed NEISS data obtained from CPSC for the years  1999-2007.
To explore available data published in related studies, we searched  relevant databases, including PubMed, ProQuest, PsycFirst, and  ScienceDirect. We also consulted with CPSC and HHS staff to identify  related studies. We limited the scope of our work by looking at studies  published since 1999. Through this process, our literature search identified  about 70 studies, but only 3 studies published data on racial and/or ethnic  differences in child injury or death rates related to specific consumer  products, and we conducted detailed reviews of these studies. Our reviews  entailed an assessment of each study’s research methodology, including its  data quality, research design, and analytic techniques, as well as a  summary of each study’s major findings and conclusions. We also assessed  the extent to which each study’s data and methods supported its findings  and conclusions.
To address the second objective, we reviewed CPSC documents and  interviewed CPSC officials regarding the development, operation, and  evaluation of the agency’s consumer information efforts. Specifically, we  reviewed CPSC’s Web site, and documents such as CPSC customer  satisfaction surveys, press releases, strategic plans, and performance and  accountability reports. We compared the processes used by CPSC with  key practices identified by experts in GAO’s previous work as important to  planning a consumer education campaign, motivating a target audience,  and alleviating challenges in a campaign (see app. II for a description of  these practices). We interviewed federal officials at CPSC and five HHS  organizations—Centers for Disease Control and Prevention, Indian Health  Service, Maternal and Child Health Bureau, National Institutes of Health,  and the Office of Minority Health—to learn about their related programs  and initiatives. In addition, we interviewed representatives of injury  prevention programs, consumer groups, and members of CPSC’s  Neighborhood Safety Network to obtain their views on CPSC’s efforts to  provide product safety information to minority communities.
We conducted this performance audit from December 2008 through  August 2009 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
section_title: Appendix II: Key Practices for Consumer Education Planning
paragraphs: In a 2007 GAO report on consumer issues pertaining to the digital  television transition, a panel of 14 senior management-level experts in  strategic communications identified and came to consensus on key  planning components for consumer education and outreach (see table 1).
section_title: Appendix III: Comments from the Department of Health and Human Services
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, individuals making key  contributions to this report include Betty Ward-Zukerman (Assistant  Director), Carl Barden, Mitch Karpman, Kristy Kennedy, Jim Rebbe, Cathy  Roark, Jay Smale, Gabriele Tonsil, and Kate van Gelder.
section_title: Related GAO Products
paragraphs: Feasibility of Requiring Financial Assurances for the Recall or  Destruction of Unsafe Consumer Products. GAO-09-512R. Washington,  D.C.: April 22, 2009.
Traffic Safety: Improved Reporting and Performance Measures Would  Enhance Evaluation of High-Visibility Campaigns. GAO-08-477.  Washington, D.C.: April 25, 2008.
Digital Television Transition: Increased Federal Planning and Risk  Management Could Further Facilitate the DTV Transition. GAO-08-43.  Washington, D.C.: November 19, 2007.
Health Care: Approaches to Address Racial and Ethnic Disparities.  GAO-03-862R. Washington, D.C.: July 8, 2003.
Program Evaluation: Strategies for Assessing How Information  Dissemination Contributes to Agency Goals. GAO-02-923. Washington,  D.C.: September 30, 2002.
Internet: Federal Web-based Complaint Handling. GAO/AIMD-00-238R.  Washington, D.C.: July 7, 2000.
Consumer Product Safety Commission: Injury Data Insufficient to  Assess the Effect of the Changes to the Children’s Sleepwear Safety  Standard. GAO/HEHS-99-64. Washington, D.C.: April 1, 1999.
Lead Poisoning: Federal Health Care Programs Are Not Effectively  Reaching At-Risk Children. GAO/HEHS-99-18. Washington, D.C.: January  15, 1999.
Children’s Health: Elevated Blood Lead Levels in Medicaid and Hispanic  Children. GAO/HEHS-98-169R. Washington, D.C.: May 18, 1998.
Consumer Product Safety Commission: Better Data Needed to Help  Identify and Analyze Potential Hazards. GAO/HEHS-97-147. Washington,  D.C.: September 29, 1997.