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* The University of North Carolina Injury Prevention Research Center
Department of Social Medicine
¶ Department of Pediatrics
# Department of Internal Medicine, University of North Carolina School of Medicine
|| Department of Health Behavior and Health Education, University of North Carolina School of Public Health, Chapel Hill, North Carolina
National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, Maryland
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIX: LIST OF PARENTING...REFERENCES |
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Methods. Top-selling parenting books for 2 major booksellers were reviewed to determine the presence and the accuracy of injury prevention messages as compared with those recommended by the American Academy of Pediatrics (AAP) through The Injury Prevention Program (TIPP) for younger children, aged 0 to 12 years, and the American Medical Association (AMA) through its Parent Package for the safety of adolescents.
Results. Forty-six parenting books were reviewed, including 41 with messages related to younger children and 19 with messages related to adolescents. These books varied widely with regard to the number of injury prevention messages included. Although some books covered the great majority of TIPP messages for parents of young children, others included very few. In the case of books that address safety for adolescents, no book had more than half of the messages recommended by the AMA. Prevention of burns and motor vehicle injury were the most commonly addressed injury prevention topics in the books focused on younger children, whereas gun safety was the most prevalent injury prevention topic in books that focused on adolescents. Books that were authored by physicians addressed more of the recommended topics and messages than books that were written by authors from other professional backgrounds. The quality of messages was good, ie, consistent with the advice given by the AAP and the AMA. In only a few cases, the parenting books gave injury prevention advice that was inconsistent with recommendations.
Conclusions. Overall, books on parenting adolescents are less likely to contain injury prevention messages than those that address younger children. However, the most frequent injury prevention messages for parents of adolescents describe strategies to prevent firearm injury, a leading cause of death for children in this age group. More emphasis should be placed on prevention of motor vehicle injuries, especially as relates to adolescents. Pediatricians and primary care physicians need to be aware of the strengths and weaknesses of parenting manuals in providing adequate guidance related to injury prevention.
Key Words: injury prevention • safety • parenting books • TIPP • anticipatory guidance
Abbreviations: AAP, American Academy of Pediatrics • TIPP, The Injury Prevention Program • AMA, American Medical Association • PP, Parent Package
Children who are aged 1 to 18 years continue to die more from injuries than from any other cause.1,2 Whereas motor vehicle injuries are the leading cause of death in this age group, other injury deaths vary by developmental stage. Children who are younger than 12 years are most likely to die from unintentional injuries, whereas for adolescents, intentional injuries that result from homicide and suicide (by firearms) are the second and third leading causes of death, respectively.3 Similarly, injury results in significant morbidity for children and adolescents. Estimates suggest that as many as 11.9 million children 12 years and younger and 8.2 million adolescents aged 13 to 19 years receive emergency department care for injuries each year.4
Over the past 25 years, advances in injury research have led to increased knowledge about effective strategies for injury prevention that include product or environmental modifications (eg, infant restraint systems, child-resistant packaging) and the introduction of policy or legislation designed to reduce injuries (eg, bicycle helmet, seat belt, and smoke detector laws).5 Even with the introduction of these changes, it remains important to educate the population, especially parents, about the importance of particular practices that can safeguard children from injury.6–10 To this end, in 1983, the American Academy of Pediatrics (AAP) developed The Injury Prevention Program (TIPP). The purpose of TIPP is to provide health care practitioners with age-specific sheets that contain targeted injury prevention messages to give to parents of very young children during well-child visits. Since then, the program has been expanded to include children from 5 to 12 years of age and updated to reflect the current patterns of childhood injuries.11 Similarly, the American Medical Association’s (AMA’s) Program on Child and Adolescent Health has designed a Parent Package (PP) series to help primary care providers educate parents about the health and safety of their adolescents through reproducible tip sheets.12
In addition to anticipatory guidance received in primary care settings, parents have described family, friends, hospitals, school events, drug stores, Parent–Teacher Association meetings, mass media, and libraries as other places where they are likely to receive information about child safety.6,9 It is not known what percentage of parents consult books to help them raise healthier and safer children, but since Benjamin Spock published his first edition of The Commonsense Book of Infant and Child Care in 1946,13 hundreds of self-help parenting books have been written and millions have been sold.14 Spock’s manual alone has sold 50 million copies and has been translated into 39 languages.15,16 In 1978, Clarke-Stewart estimated that in the previous 5-year period, enough of the 3 most popular parenting books of the time (including Spock) were published to provide 1 book for every family with a young child.17 The Clarke-Stewart study also revealed that younger, more educated parents who lived far way from their families of origin were more likely to read parenting books and to be influenced by their content. Similarly Publishers Weekly cites the dwindling incidence of extended families living in close proximity as 1 reason for the continuing demand for parenting books that teach the basics in child rearing and offer advice on a variety of topics.14
Although the utility of health education to reduce injury has significant limitations and most injury professionals argue that education should not replace efforts to modify products and environments, there is general agreement about the desirability of increasing the awareness of parents about child safety.18 Consequently, ensuring that resources that are used by parents, sometimes at the suggestion of their health care providers, contain appropriate and accurate information is important. As with recommendations about the purchase of over-the-counter pharmaceuticals, recommendations made by health care practitioners about parenting books should be guided by evidence.
To our knowledge, no review of injury prevention messages in top-selling parenting books has been published. Furthermore, studies that have analyzed the contents of self-help parenting books have not identified safety or injury prevention as 1 of the major topics covered.19,20 Given the high rates of child and adolescent morbidity and mortality associated with injury, it is important to assess how often and how well prevention strategies are presented in parenting books, especially those that address the physical well-being of children. The purpose of this study was to analyze the contents of popular parenting books to document the presence and the accuracy of injury prevention messages as compared with those recommended by the AAP through TIPP for children aged 0 to 12 years and by the AMA through the PP program for adolescents. These programs have been designed to provide a systematic method for pediatricians to counsel parents and children about adopting behaviors to prevent injuries, behaviors that are effective and capable of being accomplished by most families. The programs and the messages of TIPP are supported by policy statements of panels of experts from the AAP. Because intentional injury by firearms is a particular problem for adolescents, we were especially interested in how parenting books addressed the issue of firearm safety. We were guided by 5 research questions:
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIX: LIST OF PARENTING...REFERENCES |
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Assessment Tools
Quantity and quality were measured by using the TIPP and PP messages as the gold standards for appropriate injury prevention messages. Books that contained more of these messages were judged to be of higher quality. We developed two assessment instruments: (1) the Child Form, to assess the presence of injury prevention messages for parents of children aged 0 to 12, and (2) the Adolescent Form, to assess messages for parents of adolescents. When a book addressed parents of both children and adolescents, the book was evaluated using both forms.
The Child Form contained 131 items, including all 113 TIPP messages for children (0–12 years) that address 10 topics: first aid or emergency care (11 recommendations), car safety (19 recommendations), bicycle safety (7 recommendations), pedestrian safety (6 recommendations), fire/burn prevention (16 recommendations), falls prevention (14 recommendations), suffocation/choking prevention (7 recommendations), poisoning prevention (10 recommendations), drowning prevention (16 recommendations), and firearm safety (7 recommendations). The Adolescent Form was composed of 50 items, including the 35 recommendations contained in the PP Teens and Injuries, designed by the AMA’s Program on Child and Adolescent Health. The PP recommendations address 6 topics: car safety (14 recommendations), bicycle safety (4 recommendations), sports safety (1 recommendation), water safety (5 recommendations), firearm safety (4 recommendations), and parents as role models for safety (7 recommendations). Both forms also included 15 items related to characteristics of the book or the book’s author.
In scoring the forms, each TIPP and PP message was searched for within the books and was counted as "present" only when the message conformed with the specific recommendation of TIPP and PP. Recommendations on an injury prevention area that did not conform with TIPP or PP were scored as "in conflict." Otherwise, messages were scored as "absent."
Because of our special interest in firearm safety, we supplemented the firearm safety section of the 2 forms with additional messages that have been recommended by medical organizations and injury researchers.24–29 Two reviewers (S.H. and G.S.) searched the books for the presence and the accuracy of injury prevention content, including the specific messages recommended by TIPP and PP. Percent agreement between the 2 reviewers, on a random sample of 10 books reviewed by both, was 82.5%.
Statistical Analysis
We entered the raw data into an EpiInfo, Version 6 (Atlanta, GA)30 database and later converted the data set to SAS, Version 8 (Cary, NC).31 We generated frequency distributions for all variables. Cross-tabulations were used to compare coverage of recommended injury topics and messages by pediatrician and nonpediatrician authors.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIX: LIST OF PARENTING...REFERENCES |
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Of the 113 messages recommended by TIPP, the 2 most frequently appearing messages for parents of younger children related to fire and prevention of scald burns: maintaining a working smoke alarm and a safe hot water heater temperature. The 10th most frequent message also related to burn prevention; the other top 7 messages related to a number of different types of child injury, including choking, motor vehicle, poisoning, drowning, and falls. None of the top 10 messages related to firearm safety (Table 5).
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Firearm Safety
Despite the finding that firearm safety was the leading injury prevention topic in books for parents of adolescents and the least found topic in books for parents of younger children, the likelihood of firearm injury prevention’s being addressed in each type of book was similar, 
60% (Table 4). All firearm safety messages that were assessed on the 2 forms, including some supplementary messages that were contained in neither the TIPP nor the PP guidelines, are listed in Table 6 with the proportions of books that contained them. Four of these messages (keep guns unloaded, separate guns from ammunition, keep guns in a locked place, and do not keep a gun in the home) were found in >40% of books for both age groups. Some TIPP messages that are not contained in the PP guidelines but that do have relevance for adolescents (eg, ask whether guns are in homes where children visit or ask whether friends have guns) were found in books for parents of younger children but not in books on adolescents. Two messages that are in neither the TIPP nor the PP guidelines—"teach children to avoid guns and tell an adult if they find one" and "use trigger locks"—appeared with moderate frequency in books that address both age groups.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIX: LIST OF PARENTING...REFERENCES |
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The AAP’s TIPP guidelines do not have specific information sheets for the adolescent age range, and the teen PP guidelines from the AMA contain only approximately one third the number of injury prevention messages found in TIPP. Although the likelihood of adolescents’ sustaining some types of unintentional injuries diminishes with their increased developmental maturity, their vulnerability for other types of injury (specifically motor vehicle crashes and firearm injury) increases.
We addressed the quality of the messages by comparing the completeness and the accuracy of the messages with those recommended by TIPP and PP. When messages were present, they tended to be accurate. Another measure of the quality of injury prevention messages that were found in these books might be the extent to which they address the most important causes of injury to children at different developmental stages. Currently, the top 5 causes of fatal injuries for children who are younger than 14 years are (1) motor vehicle crashes, (2) suffocation, (3) drowning, (4) fires and burns, and (5) homicide by firearm.33 According to our results, the 5 leading messages that were found in books for parents of younger children relate to 3 of these 5 causes: drowning, fire and burns, and suffocation. Similarly, the 3 leading messages in the books that we reviewed conform to 3 of the top 4 strategies that have been identified by experts as critical for anticipatory guidance to prevent childhood injury, namely use of smoke alarms, pool fencing, and lowering hot water temperature.18 The experts’ highest priority strategy for injury prevention—the use of car seats, which has been shown to reduce child fatalities from motor vehicle crashes34—was the seventh leading message in the books that we reviewed, found in only two thirds of the books.
For adolescents, the leading causes of injury deaths are (1) motor vehicle crashes, (2) homicide by firearm, (3) suicide by firearm, (4) suicide by suffocation, and (5) drowning. We were pleased to find that, of the injury prevention messages that were found in books that are directed toward parents of adolescents, firearm safety messages were prominent. Far less attention was given to helping adolescents avoid the significant risks associated with motor vehicles. Of the 35 injury prevention messages recommended by the AMA in their PP program, 14 address car safety, yet fewer than one fourth of the books for parents of adolescents contained any of these messages.
In our review, 1 primary prevention message that conflicts with TIPP guidelines and that has the potential to increase, rather than reduce, injury was found. Two books recommended caution when using infant walkers to avoid injuries. Research has shown that despite the use of prevention strategies such as adult supervision, warning labels, caregiver education programs, and stairway gates, serious injuries with infant walkers continue to occur.35,36 Consequently, the AAP recommends against their use altogether, and Canada recently banned production and sale of infant walkers.35,37
Study Limitations
The gold standard criteria against which we assessed the quality of these parenting books (recommendations from the AAP and the AMA) were the best available; however, not all these strategies and recommendations have been studied for effectiveness. It is also possible that important injury prevention strategies that may or may not have been contained in the reviewed books have not yet been embraced by the AAP and the AMA. For example, TIPP includes a message about keeping balloons out of the reach of 6- to 12-month-old children only, yet balloons are a significant cause of suffocation death for children up to the age of 6 years.38,39
Another limitation of the study is that the percentage of parents who read parenting books is unknown. Furthermore, whether books are read comprehensively for anticipatory guidance or used as a reference guide is also unclear. If the latter is true, then they may never read the injury prevention messages contained therein.
Research suggests that parents who use parenting guides tend to be better educated parents than those who do not use parenting guides. Furthermore, they tend to live farther away from their families.17 Consequently, the implications of this study may apply only to a small proportion of American parents. These particular parents may already be more motivated to engage in safety behaviors than those who do not access and read parenting guides. Furthermore, even if all parents used parenting guides, the extent to which reading these guides results in modifying parent behavior is not known.
Finally, books that were intended for children or adolescents themselves or for substitute caregivers, such as child care providers, were not reviewed in this study. Although we found a smaller number of books directed toward parents of adolescents, examining health and safety books that are written expressly for the adolescent population might provide useful information.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIX: LIST OF PARENTING...REFERENCES |
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Of the 19 best-selling books for parents of adolescents, important injury prevention topics were missing in all of the books reviewed. The topic that appeared most frequently was firearm safety, a heartening finding given the large number of gun-related homicides and suicides experienced by adolescents each year. The relative lack of attention to motor vehicle safety for teen drivers and passengers was surprising. A number of these books recommended that parents encourage their teens to wear bicycle helmets while neglecting to give the same advice for seat belts.
In general, few parenting books are written by authors with health and safety credentials, such as pediatricians, yet parents cite physicians as their first choice for credible information on injury control and child safety.6 Consequently, there are important roles for injury prevention specialists and pediatricians to play in authoring parenting books that are based on sound evidence or in serving as resources to other authors who may lack substantive background in injury prevention. Recognizing that providing good advice in parenting books is only 1 strategy for keeping our children safe, it is important to continue our efforts on multiple fronts, providing anticipatory guidance in clinical settings and supplementing education strategies with environmental, engineering, and regulatory interventions.
This study has other important implications for pediatricians. Because many parenting handbooks do not contain comprehensive injury prevention counseling and injuries are the leading cause of death for youth, extra efforts should be made to provide parents with this information through anticipatory guidance with written materials such as TIPP handouts at all visits and other creative means such as media campaigns. Furthermore, this study highlights the injury prevention areas that frequently are omitted from parenting books that potential pediatrician authors should address.
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APPENDIX: LIST OF PARENTING BOOKS REVIEWED |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIX: LIST OF PARENTING...REFERENCES |
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Dana TK. Safe and Sound: A Parent’s Guide to the Care of Children Home Alone. New York, NY: McGraw-Hill Book Company; 1988
De Becker G. Protecting the Gift: Keeping Children and Teenagers Safe (and Parents Sane). New York, NY: Dell Publishing; 1999
Fancher VK. Safe Kids: A Complete Child-Safety Handbook and Resource Guide for Parents. New York, NY: John Wiley & Sons, Inc; 1991
Hechinger G. How to Raise a Street Smart Child: The Complete Parent’s Guide to Safety on the Street and at Home. New York, NY: Facts on File Publications; 1984
Holtzman DS. The Panic-Proof Parent: Creating a Safe Lifestyle for Your Family. Chicago, IL: Contemporary Books; 2000
Malmstrom PM, Poland J. The Art of Parenting Twins: The Unique Joys and Challenges of Raising Twins and Other Multiples. New York, NY: Ballantine Books; 1999
Pearlman EM, Ganon JA. Raising Twins: What Parents Want to Know (and What Twins Want to Tell Them). New York, NY: HarperCollins Publishers, Inc; 2000
Schiff D, Shelov SP, eds. The American Academy of Pediatrics Guide to Your Child’s Symptoms: The Official, Complete Home Reference, Birth Through Adolescence. New York, NY: Villard Books; 1997
Settle MB, Price SC. The Complete Idiot’s Guide to Child Safety. Indianapolis, IN: Alpha Books; 2000
Shore K. Keeping Kids Safe. Paramus, NJ: Prentice Hall Press; 2001
Signal Hill Publications/American Institute for Preventive Medicine. The Safe, Self-Confident Child. Syracuse, NY: New Readers Press; 1994
Spock B, Parker S. Dr. Spock’s Infant and Child Care. 7th ed. New York, NY: Pocket Books; 1998
Widome MD. Ask Dr. Mark: Answers for Parents. Itasca, IL: NSC Press; 2003
Books That Address Younger Children Only
AID Association For Lutherans. Keep Kids Safe: A Parent’s Guide to Child Safety. Appleton, WI: AID Association For Lutherans; 2001
Brazelton TB. Touchpoints: Your Child’s Emotional and Behavioral Development: Birth–3: The Essential Reference for the Early Years. Boulder, CO: Perseus Books; 1992
Brott AA, Ash J. The Expectant Father: Facts, Tips, And Advice For Dads-To-Be. 2nd ed. New York, NY: Abbeville Press; 2001
Carter L, Marques L. Child Safety Made Easy. 2nd ed. Concord, CA: Screamin’ Mimi Publications; 1998
Chubet CT. Your Infant’s Health and Safety: From Infant to Toddler. Stamford, CT: Longmeadow; 1988
Dowshen SA, Izenberg N, Bass E. The KidsHealth Guide for Parents. New York, NY: Contemporary Books; 2001
Eisenberg A, Murkoff HE, Hathaway SE. What to Expect: The Toddler Years. New York, NY: Workman Publishing Company; 1996
Eisenberg A, Murkoff HE, Hathaway SE. What to Expect: The First Year. 2nd ed. New York, NY: Workman Publishing Company; 2003
Elston C. Safe and Secure: A Loving Parent’s Guide to Child Safety. New York, NY: Berkley Publishing Group; 1998
Green MI. A Sigh of Relief: The First-Aid Handbook of Childhood Emergencies. 4th ed. New York, NY: Bantam Books; 1994
Kelly K, Duncan RC. Living Safe in an Unsafe World: The Complete Guide to Family Preparedness. New York, NY: New America Library; 2000
Krueger A, Parenting Magazine. Parenting Guide to Your Infant’s First Year. New York, NY: Ballantine Books; 1999
Leach P. Your Infant and Child From Birth to Age Five. Rev ed. New York, NY: Alfred A. Knopf; 1997
Marin Child Care Council. Childhood Emergencies: What to Do, a Quick Reference Guide. Palo Alto, CA: Bull Publishing Company; 2000
Markel H, Oski FA. The Practical Pediatrician: The A to Z Guide to Your Child’s Health, Behavior and Safety. New York, NY: WH Freeman and Company; 1996
Metzger M, Whittaker CP. The Childproofing Checklist: A Parent’s Guide to Accident Prevention From Birth to Age Five. New York, NY: Doubleday; 1988
Nathanson LW. The Portable Pediatrician: A Practicing Pediatrician’s Guide to Your Child’s Growth, Development, Health and Behavior, From Birth to Age Five. 2nd ed. New York, NY: HarperCollins Publisher, Inc; 2002
National Safety Council. Pediatrics First Aid and CPR. 4th ed. Sudbury, MA: Jones and Bartlett Publishers; 2001
Parents Magazine. The Parents Answer Book: Everything You Need to Know About Your Child’s Physical, Emotional, and Cognitive Development, Health, and Safety From Birth Through Age Five. New York, NY: St Martin’s Press; 1998
Schmitt B. Your Child’s Health: The Parents’ Guide to Symptoms, Emergencies, Common Illnesses, Behavior and School Problems. 2nd ed. New York, NY: Bantam Books; 1991
Schor EL, ed. The American Academy of Pediatrics, Caring for Your School-Age Child: Ages 5 to 12. 3rd ed. New York, NY: Bantam Books; 1999
Sears W, Sears M. The Infant Book: Everything You Need to Know About Your Infant From Birth to Age Two. 2nd ed. New York, NY: Little Brown and Company; 2003
Shelov SP, Hannemann RE. The American Academy of Pediatrics Caring for Your Infant and Young Child: Birth to Age 5. 3rd ed. New York, NY: Bantam Books; 1998
Spencer P, Parenting Magazine. Parenting Guide to Your Toddler. New York, NY: The Ballantine Publishing Group; 2000
Vinci RJ. Keys to Child Safety and Care of Minor Injuries. Hauppauge, NY: Barron’s Educational Series, Inc; 1992
Wolf C. On the Safe Side: Your Complete Reference to Childproofing for Infants & Toddlers. Kansas City, MO: Whirlwind Publishing Company; 1998
Zand J, Walton R, Rountree B. A Parent’s Guide to Medical Emergencies: First Aid for Your Child. Garden City Park, NY: Avery Publishing Group; 1997
Books That Address Adolescents Only
Bradley M. Yes, Your Teen Is Crazy! Loving Your Teen Without Losing Your Mind. Boyne City, MI: Harbor House; 2003
Dinkmeyer D, McKay GD, McKay JL, Dinkmeyer D Jr. Parenting Teenagers: Systematic Training for Effective Parenting of Teens. Circle Pines, MN: American Guidance Service; 1998
Greydanus D, Bashe P. American Academy of Pediatrics Caring for Your Teenager: The Complete and Authoritative Guide. New York, NY: Bantam Dell; 2003
Harris-Johnson D. The African-American Teenagers Guide to Personal Growth, Health, Safety, Sex and Survival. Phoenix, AZ: Amber Books; 2001
Kelly K. The Complete Idiot’s Guide to Parenting a Teenager. New York, NY: Alpha Books; 1996
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ACKNOWLEDGMENTS |
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We thank J. Michael Bowling, PhD, and Jose Sandoval, MS, for assistance in analyzing the data.
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FOOTNOTES |
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Address correspondence to Carol W. Runyan, MPH, PhD, The University of North Carolina Injury Prevention Research Center, Bank of America Building, Ste 500, 137 East Franklin St, Chapel Hill, NC 27599–7505. E-mail: carol_runyan{at}unc.edu
No conflict of interest declared.
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REFERENCES |
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