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ARTICLE |
a Office of Statistics and Programming
Divisions of b Violence Prevention
c Unintentional Injury, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS. We conducted a cross-sectional, list-assisted random-digit-dial telephone survey of randomly selected children in English- or Spanish-speaking households in all 50 US states and the District of Columbia. The main outcome measures were respondents' reports that they or their children received injury-prevention counseling from their child's health care provider in the 12 months preceding the interview, children's practices of safety behaviors, and the association of injury-prevention counseling and such behaviors.
RESULTS. The overall proportion of US children receiving any injury-prevention counseling (42.4%) remained relatively unchanged, whereas counseling on selected injury-prevention topics increased significantly compared with reports based on the 1994 survey. Topic-specific injury-prevention counseling was positively associated with the posting of the poison control center telephone number in homes with children <6 years of age and with bicycle-helmet use among children 5 to 14 years of age.
CONCLUSIONS. Although the prevalence of pediatric injury-prevention counseling remains low, such counseling was associated with safer behaviors. This suggests the importance of pediatric injury-prevention counseling and indicates the need for health care providers to increase pediatric injury-prevention counseling in clinical practices.
Key Words: injury • counseling • safety behaviors
Abbreviations: CDC—Centers for Disease Control and Prevention • ICARIS-1994—1994 Injury Control and Risk Survey • ICARIS-2—Second Injury Control and Risk Survey • RDD—random-digit-dial
Injury, although highly preventable, continues to be an important cause of mortality and morbidity. In 2003, there were >164000 injury deaths and an estimated 29.2 million nonfatal injuries treated in US emergency departments.1
Various means have been used to reduce the burden of injury. An array of legislation (eg, child-proof safety caps on medicines, child safety seat and seatbelt use, and laws that hold gun owners responsible for safe storage practices) and regulations (eg, vehicle safety standards, sprinkler systems in new construction, and building codes to guard against fire) has been enacted to create a safer environment. Offering injury-prevention counseling by health care providers is another strategy to reduce the risk for injury by convincing people to modify their environment or behavior. The importance of injury-prevention counseling is recognized by the health care community and supported by the American Academy of Pediatrics,2 the American Academy of Family Physicians,3 the American Medical Association,4 and the US Preventive Services Task Force.5
In 1994, the Centers for Disease Control and Prevention (CDC) initiated a national Injury Control and Risk Survey (ICARIS-1994) in all 50 states and the District of Columbia to assess injury risk factors and the prevalence of injury-prevention counseling. Data collection covered a wide range of injury-related topics, including children's safety behaviors and pediatric counseling on injury prevention. Research based on the ICARIS-1994 data and other earlier studies has shown that injury-prevention counseling by health care providers promotes safer behaviors.6–8
The CDC recently conducted the Second Injury Control and Risk Survey (ICARIS-2), the only national survey of this scope since ICARIS-1994. The purpose of this article is to provide recent prevalence estimates of pediatric injury-prevention counseling on the basis of ICARIS-2 data, to compare these new findings with the prevalence estimates from ICARIS-1994, and to reassess the association between injury-prevention counseling and safety behaviors.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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The sampling frame for this survey was the Genesys (Ft Washington, PA) Sampling System "1+ banks" composed of blocks of 100 telephone numbers, with each block containing 
1 residential directory listing. This frame covered 
96% of all households with landline telephones in the 50 US states and the District of Columbia.9 To ensure adequate racial and ethnic minority representation in the sample, telephone exchanges were stratified into high- (10% black or Hispanic households) and low-minority (all others) strata. Seventy percent of the ICARIS-2 sample was drawn from the high-minority stratum. With the addition of questions assessing posttraumatic stress disorder prevalence after the events of September 11, 2001, the sampling procedure was altered to incorporate a 10% oversample in the areas of New York and Washington, DC.
An eligible household was defined as a private residence that did not meet the US Bureau of the Census definition of a group quarter.10 Residents of institutions, dormitories, and dwelling units without working telephone landlines were not included in the sample.
One adult (aged 18 years) was selected from each eligible household. In households with both male and female adults, a gender category was selected with a higher probability of choosing a man. The gender distribution of the sample was monitored throughout the survey fielding period, and the probability of selecting a man was adjusted as needed to obtain a final sample with equal numbers of male and female respondents. The adult with the most recent birthday was chosen in households with multiple eligible adults of the selected gender.
The selected English- or Spanish-speaking adults who gave verbal consent to participate in the survey were interviewed using a computer-assisted telephone interviewing system. The respondent was asked to provide information about a variety of individual (eg, age, education, and employment status) and household (eg, type of dwelling and household income) characteristics and the age and gender of each child <15 years of age in the household. In households with 1 child <15 years of age, a child was randomly selected, and the respondent was asked to provide additional information specific to that child. The entire interview took an average of 21.5 minutes to complete. In recognition of survey participants' contribution to our study, we offered all of the respondents the option of receiving a $5 telephone card or approving a donation of $5 to either the United Way or the Safe Kids Worldwide.
A total of 113476 telephone numbers were sampled. Of these, 59% were ineligible (business or nonworking telephone numbers), 28% were of unknown eligibility, and 13% were eligible. From the 14724 eligible households (including eligible noninterviews, such as refusals and breakoffs), data from 9684 completed interviews were collected. We obtained a response rate of 48% using the standard definitions published by the American Association for Public Opinion Research (formula RR3).11 Formula RR3 uses a conservative approach by defining the response rate as the percentage of all definite and possible eligible adults who completed the entire interview. Thus, respondents who completed or partially completed the interview and those who refused to participate in the interview plus an estimated number of potentially eligible adults from households of unknown eligibility were all included in the denominator of this computational formula.
Measures
Counseling
To assess the opportunity for pediatric injury-prevention counseling, each respondent selected from households with children <15 years of age was asked, "During the past 12 months, how many times have you taken (the randomly selected child) to see a doctor, nurse, or health care provider about a health-related issue?" Consistent with ICARIS-1994 analysis for comparative purposes, an answer of "don't know" to this question was treated as a "no."
Respondents in households where a randomly selected child was reported having had 1 medical visit in the past 12 months were then asked if they or their children had received any written or verbal information about a variety of injury-prevention topics during any of these health care visit(s). The specific topics queried depended on the randomly selected child's age. For children <2 years of age, the counseling topics included residential smoke detectors, child car seats, and the poison control center telephone number. For children ages 2 to 6 years, the counseling topics included all of the above, plus bicycle-helmet use and proper storage of firearms. For children ages 7 to 14 years, the topics were residential smoke detectors, seat belts, proper storage of firearms, and bicycle-helmet use. In our analysis of pediatric counseling, a response of "don't know" was treated as a "no." Counseling received on any of these topics was defined as "counseled." This coding scheme causes only negligible differences in analysis results compared with those produced when "don't know" was left unchanged. Children who had no reported health care visits, including well-child visits, in the past 12 months were not asked if they had received any injury-prevention counseling.
Behavior
To assess safety practices related to children, respondents were asked if any smoke detectors were installed in the home, whether firearms were stored unloaded and locked, and if the randomly selected child "always used a car seat/seat belt while riding in a motor vehicle in the past 30 days." Respondents with children <9 years of age were asked if the poison control center telephone number was posted on or near a telephone. For children 5 to 14 years of age, respondents were also asked if the randomly selected child "always wore a bicycle helmet when riding a bicycle in the past 30 days." Respondents' seat belt use as a driver or a passenger was also assessed. An answer of "don't know" in response to whether firearms were safely stored at home was treated as missing (0.21% response), because respondents may not be able to observe other household members' firearm ownership and storage practices. An answer of "don't know" for other behaviors was coded as a "no" (range: 0.07%–0.18%).
Analysis
Survey data were weighted to account for the complex sample design, noncoverage, and nonresponse. Data were then poststratified by household composition to the US population estimates as provided by the March 2002 Current Population Survey and the 2000 US Census. Each respondent and randomly selected child was further ratio adjusted to their age-gender-race group in the population using data from the July 2002 Bridged Population data file prepared by the US Bureau of the Census in collaboration with the National Center for Health Statistics.
We used SUDAAN12 survey data analysis software to address the complex sample design and to compute national pediatric injury-prevention counseling prevalence estimates along with 95% confidence limits. The denominators for computing counseling prevalence were composed of all of the children for whom the counseling topics were age appropriate and for whom 1 past 12-month medical visit was reported. The denominators for computing safety behavior prevalence contain all of the children for whom the specific behaviors were age and environmentally appropriate. We examined the difference between the prevalence of injury-prevention counseling reported in ICARIS-2 with that reported in ICARIS-1994 using a standard t test. To control for the potential confounding effect of demographic factors on the relationship between the receipt of injury-prevention counseling and the practice of corresponding safety behaviors, we conducted multivariable logistic regression modeling adjusting for selected demographic characteristics.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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1 child age 0 to 14 years in the household. Of these, 2541 (83.0%) reported that their children had visited a health care provider at least once "in the past 12 months." Of the children who had any reported visit with a health care provider in the 12 months preceding the interview, 1046 (42.4%) were counseled on 1 of the injury-prevention topics examined (Table 1).
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1 medical visit "in the past 12 months" decreased with increasing age (0–1 year: 62.8%; 2–6 years: 44.6%; 7–12 years: 39.0%; 13–14 years: 27.3%; P < .01, test for linear trend; Table 1). Counseling was also significantly associated with the adult's race/ethnicity. Among children who had 1 medical visit "in the past 12 months," those who were living with an adult of Hispanic origin were more likely than those living with an adult of white non-Hispanic origin to be counseled on any of the injury-prevention topics covered in the survey (P = .03). However, reported receipt of counseling was not associated with the gender of the child, number of children 0 to 14 years of age in the household, health insurance status of the adult, or other household-level demographic characteristics, such as the highest level of educational attainment, census region, urbanicity, or poverty status.
Comparison With ICARIS-1994
Current prevalence estimates indicate that reported pediatric counseling ranges from a low of 10% for children ages 2 to 14 years for proper firearm storage to a high of 39% for car seat/seat belt use for children ages 0 to 6 years (Table 2). Among children who had 1 reported medical visit in the past 12 months, the overall estimated 42% who reported receiving counseling was no higher than that in the 1994 survey (39.3%6; P = .12). The number of injury-prevention topics discussed, however, increased among those who reported receiving counseling. Data from ICARIS-2 show that whereas 34.3% of the children counseled received counseling on 3 topics, only 18.3% did so in 1994. As a result, we saw a statistically significant gain in reported counseling on several injury-specific topics. We observed the largest absolute increase (11.8%) in counseling on bicycle-helmet use for children ages 5 to 14 years (from 18.6% in 1994 to 30.4% in the current survey; P < .01), followed by counseling on car seat/seat belt use for children ages 0 to 6 years (7.8%; P < .01), smoke detectors for 0- to 14-year-olds (6.1%; P < .01), and proper firearm storage practices for 2- to 14-year-olds (3.7%; P < .01). We saw no significant change from the 1994 prevalence estimates in counseling on the poison control center telephone number for 0- to 6-year-olds and seat belt use for 7- to 14-year-olds.
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1 working smoke detector in the home or always using a seat belt when riding in a vehicle among children ages 7 to 14, there is some indication of a positive association between receiving counseling and practicing safe firearm storage and between receiving counseling and always using a car seat/seat belt when riding among children ages 0 to 6 years (bivariable analysis: .05 < P < .07). However, in both instances, these associations failed to hold after adjusting for person- and household-level demographic characteristics. For car seat/seat belt use among children, the multivariable analysis also controlled for seat belt use of the adult, either as a driver or a passenger. Children living with adults who always used a seat belt were more likely to always use car seats/seat belts compared with children living with adults who did not always do so (P < .01). This association held, regardless of the child's age.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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40%. With few exceptions, receipt of counseling was not dependent on demographic characteristics of the adult, the child, or the household. This suggests that characteristics of the health care visit explain some of the variation in counseling and calls our attention to the barriers for health care providers to more actively engage in injury-prevention counseling. A body of literature has cited mixed findings in the determinants of counseling in primary care pediatric practices. Factors such as physician attitudes toward the importance of a health issue; their confidence in their ability to counsel; their perceptions about the effectiveness of counseling; demographics of the physician, specialty, training, office time constraints, and professional and personal experience; and practice settings have been found to be associated with a physician's decision to incorporate injury-prevention counseling into routine patient care.13–16
The finding of an association between pediatric injury-prevention counseling and safety behaviors is supported by previous research. The ICARIS-1994 survey found an association between counseling and behavior for posting the poison control center telephone number (for children 
6 years of age), proper firearm storage (2–14 years of age), always using a helmet when biking (5–14 years of age), and always using car seats/seat belts when riding in a motor vehicle (6 years of age).6 The consistent association between counseling and some safety behaviors revealed by both the ICARIS-1994 and the recent ICARIS-2 surveys underscores the need for the pediatric health care community to overcome the barriers to routine injury-prevention counseling. While health care providers who already practice injury-prevention counseling should be encouraged to continue,17,18 others who support counseling more in theory than in practice should be urged to include age-appropriate injury-prevention counseling in their clinical practices.19–21 A clinical norm of active injury-prevention counseling among pediatric health care providers is a crucial step toward increased practice of children's safety behaviors. In turn, increasing the public's awareness of injury prevention through counseling will help to shape the developing norm for health care providers. Patients' interest in injury-prevention and health promotion could further encourage health care providers to increase their knowledge in injury prevention and to include such counseling as a regular component in clinical practices.
Several limitations of the ICARIS-2 survey warrant discussion. First, this study was subject to the potential of recall bias. While recognizing the varying ability and effort on the part of respondents to recall information, we lack the data to conclusively ascertain how well our survey respondents remembered and reported receipt of counseling or practice of safety behaviors. The counseling data were collected from respondents' reports, rather than independent observation, that they or their randomly selected children received counseling on age-appropriate injury-prevention topics at the time of the child's medical visit(s). The respondent may not be the child's primary caregiver or may not be the adult who took the child to the doctor. In the case of an older child, the child may not have told the adult about information that he or she received while alone with the health care provider. Either of these instances could lead to an underreporting of receipt of counseling and, hence, an underestimation of pediatric counseling prevalence. This might help explain why only 2 of the 5 injury topics were statistically linked to safety behaviors. On the other hand, because respondents were also asked about injury-prevention counseling (on the use of seat belt, smoke detector, and proper firearm storage) received in conjunction with their own medical visit(s) "in the past 12 months," they may recall counseling at their own visit and attribute the experience to that of their child's visit(s) resulting in an overreporting of pediatric injury-prevention counseling. In addition to the potential recall bias, reporting of behaviors may also be influenced by social desirability such that reports of safety behaviors were inflated. This potential for overreporting, however, is expected to be similar among counseling recipients and nonrecipients, and, hence, it is unlikely that the significant associations observed between counseling and behaviors are explained by differences in overreporting across counseling status. We were able to verify neither the reported practice of safety behaviors nor the proper use of safety equipment. Readers should use caution when interpreting findings shown in Table 3, because these associations do not mean that the safety behaviors were performed properly.
Second, given the cross-sectional nature of this study, we cannot establish a causal relationship between injury-prevention counseling and injury-prevention practice. We cannot ascertain whether injury-prevention counseling led to injury-prevention practice, nor can we detect whether injury-prevention counseling, when it occurred, was prompted by the medical issues that brought the child to the attention of the health care provider.
A third limitation to consider in the interpretation of our findings is the unknown extent to which the likelihood of counseling varied by type of health care visit. Although a well-child visit may provide the time for a comprehensive injury-prevention counseling, an acute care visit might prompt an opportunity for counseling on a specific injury-prevention topic. Because information on the type of health care visit was not collected, we cannot know definitively whether pediatric counseling was a part of well-child visit or related to certain kinds of visits for treating acute illness or injury.
Finally, ICARIS-2 was conducted amid rapid changes in the telecommunication environment. The impact of changes, such as increased use of Privacy Manager, caller ID, answering machines, and cell phones, and the introduction of "do-not-call" lists contributed to the difficulties in telephone data collection. As noted, our response rate was calculated by using American Association for Public Opinion Research formula RR3 and assumed that households of unknown eligibility contained the same percentage of eligible adults as households with confirmed eligibility. Such a conservative assumption tends to overestimate the eligibility rate among those of unknown eligibility, thereby lowering the response rate. Our response rate is comparable to those calculated for other RDD studies conducted during the same time period using the same definitions and formula.22,23 Researchers have shown that low response rates in RDD studies do not necessarily equate to high nonresponse bias and that telephone survey results may still be generalizable.24,25 To assess the representativeness of our data, we compared the demographics of our sample at various stages of the weighting process with those from the 2000 US Census, the July 2002 US Bureau of the Census/National Center for Health Statistics Bridged Population data file, and the March 2002 Current Population Survey. Data comparisons indicate that the ICARIS-2 sample was representative with respect to age, gender, race/ethnicity, household income, and employment status. Respondents in our sample were slightly more likely to be married, to be more highly educated, and to own their own homes compared with the general US population; however, even here, differences were <10%.26 We controlled for educational attainment in multivariable analyses. Because marital status and home ownership are not strongly associated with our outcomes of interest, we do not expect this slight overrepresentation to have impacted our findings.
Although much remains to be studied about the degree of modification in behavior attributable to pediatric counseling, the positive associations between injury-prevention counseling and safety behaviors observed in this study and others are encouraging and support the recommendation to continue to increase injury-prevention counseling by pediatric health care providers. Injuries are the leading cause of preventable death in children, and progress can be made in reducing this burden by implementing effective strategies while continuing to search for other practical solutions. We lack the evidence to identify effective prevention strategies in many areas of public health. This study and the previous ICARIS-1994 study indicate that, for 2 safety behaviors (posting the poison control center telephone number and bicycle-helmet use), counseling is significantly associated with protective behaviors. In 2003, poisoning was the cause of 130 deaths and >89335 visits to the emergency departments among children ages 0 to 14 years, and bicycle-related injury caused 127 deaths and >286020 visits in this population.1 These grim statistics impart a responsibility to adopt now what we know works while we learn more about how to encourage injury-prevention counseling by health care providers and to maximize the behavioral impact of such counseling.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Address correspondence to Jieru Chen, MS, Office of Statistics and Programming, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Mailstop K59, 4770 Buford Hwy, Atlanta, GA 30341-3724. E-mail: chen{at}cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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This article has been cited by other articles:
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  Splinters & Fragments Inj. Prev., August 1, 2007; 13(4): 288 - 288. [Full Text] [PDF]
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