Using behavioral science theory to enhance public health nursing.

The application of behavioral science theory is instrumental in advancing nursing research and practice. Nurses can benefit from a thorough understanding of theoretical perspectives related to health behavior change. Behavioral science theory can provide a conceptual context for understanding patient behavior, it can guide research on the determinants of health behavior and health service delivery, and it can offer alternative approaches to nursing practice that may improve the effectiveness of patient care. The aim of this paper is to provide some examples of behavioral theories that can be used in nursing research and practice, and provide an example of how one theory, Stages of Change (Transtheoretical Model), can be applied to older adult fall prevention. Given the critical role behavior plays in premature morbidity and mortality, public health nurses and researchers can benefit by broadening the use of theory in the design and implementation of interventions, using behavioral theory as their guide.

Decreasing residential fire death rates and the association with the prevalence of adult cigarette smoking - United States, 1999-2015.

INTRODUCTION: Each year from 1999 through 2015, residential fires caused between 2,000 and 3,000 deaths in the U.S., totaling approximately 45,000 deaths during this period. A disproportionate number of such deaths are attributable to smoking in the home. This study examines national trends in residential fire death rates, overall and smoking-related, and their relationship to adult cigarette smoking prevalence, over this same period. METHODS: Summary data characterizing annual U.S. residential fire deaths and annual prevalence of adult cigarette smoking for the years 1999-2015, drawn from the National Vital Statistics System, the National Fire Protection Association, and the National Health Interview Survey were used to relate trends in overall and smoking-related rates of residential fire death to changes in adult cigarette smoking prevalence. RESULTS: Statistically significant downward trends were identified for both the rate of residential fire death (an average annual decrease of 2.2% - 2.6%) and the rate of residential fire death attributed to smoking (an average annual decrease of 3.5%). The decreasing rate of residential fire death was strongly correlated with a gradually declining year-to-year prevalence of adult cigarette smoking (r = 0.83), as was the decreasing rate of residential fire death attributed to smoking (r = 0.80). CONCLUSIONS AND PRACTICAL APPLICATIONS: Decreasing U.S. residential fire death rates, both overall and smoking-related, coincided with a declining prevalence of adult cigarette smoking during 1999-2015. These findings further support tobacco control efforts and fire prevention strategies that include promotion of smoke-free homes. While the general health benefits of refraining from smoking are widely accepted, injury prevention represents a potential benefit that is less recognized.

Vital Signs: Motor Vehicle Injury Prevention - United States and 19 Comparison Countries.

BACKGROUND: Each year >32,000 deaths and 2 million nonfatal injuries occur on U.S. roads. METHODS: CDC analyzed 2000 and 2013 data compiled by the World Health Organization and the Organisation for Economic Co-operation and Development (OECD) to determine the number and rate of motor vehicle crash deaths in the United States and 19 other high-income OECD countries and analyzed estimated seat belt use and the percentage of deaths that involved alcohol-impaired driving or speeding, by country. RESULTS: In 2013, the United States motor vehicle crash death rate of 10.3 per 100,000 population had decreased 31% from the rate in 2000; among the 19 comparison countries, the rate had declined an average of 56% during this time. Among all 20 countries, the United States had the highest rate of crash deaths per 100,000 population (10.3); the highest rate of crash deaths per 10,000 registered vehicles (1.24), and the fifth highest rate of motor vehicle crash deaths per 100 million vehicle miles traveled (1.10). Among countries for which information on national seat belt use was available, the United States ranked 18th out of 20 for front seat use, and 13th out of 18 for rear seat use. Among 19 countries, the United States reported the second highest percentage of motor vehicle crash deaths involving alcohol-impaired driving (31%), and among 15, had the eighth highest percentage of crash deaths that involved speeding (29%). CONCLUSIONS AND COMMENTS: Motor vehicle injuries are predictable and preventable. Lower death rates in other high-income countries, as well as a high prevalence of risk factors in the United States, suggest that the United States can make more progress in reducing crash deaths. With a projected increase in U.S. crash deaths in 2015, the time is right to reassess U.S. progress and set new goals. By implementing effective strategies, including those that increase seat belt use and reduce alcohol-impaired driving and speeding, the United States can prevent thousands of motor vehicle crash-related injuries and deaths and hundreds of millions of dollars in direct medical costs every year.

Health Care providers and Teen Driving Safety: Topics Discussed and Educational Resources Used in Practice.

Traffic crashes are the leading cause of death among teens. Health care providers have an opportunity to address what works to keep teens safe on the road during the patient visit. An online survey was conducted of 1088 health care providers who saw patients at or near driving age. The survey assessed which road safety topics were discussed and which types of educational products were used most often. Family and general practice physicians represented 44.3% of the sample, followed by pediatricians (22.5%), nurse practitioners (17.6%), and internists (15.5%). Nearly all respondents (92.9%) reported addressing one or more driving safety factors (seat belt use, nighttime driving, fatigue, teen passengers, alcohol/drug use, speeding/reckless driving, and cell phone use/texting) with adolescent patients and/or their parents. Seat belt use was reported more often (83.7%) than other topics. The use of parent-teen driving agreements, a known effective intervention, was reported by less than 10% of respondents. Since health care providers expressed interest in receiving written resource materials, distribution of parent-teen driving agreements to health care providers might encourage greater uptake and use of this effective intervention.

The impact of alcohol and road traffic policies on crash rates in Botswana, 2004-2011: a time-series analysis.

In Botswana, increased development and motorization have brought increased road traffic-related death rates. Between 1981 and 2001, the road traffic-related death rate in Botswana more than tripled. The country has taken several steps over the last several years to address the growing burden of road traffic crashes and particularly to address the burden of alcohol-related crashes. This study examines the impact of the implementation of alcohol and road safety-related policies on crash rates, including overall crash rates, fatal crash rates, and single-vehicle nighttime fatal (SVNF) crash rates, in Botswana from 2004 to 2011. The overall crash rate declined significantly in June 2009 and June 2010, such that the overall crash rate from June 2010 to December 2011 was 22% lower than the overall crash rate from January 2004 to May 2009. Additionally, there were significant declines in average fatal crash and SVNF crash rates in early 2010. Botswana's recent crash rate reductions occurred during a time when aggressive policies and other activities (e.g., education, enforcement) were implemented to reduce alcohol consumption and improve road safety. While it is unclear which of the policies or activities contributed to these declines and to what extent, these reductions are likely the result of several, combined efforts.

Years of potential life lost from unintentional child and adolescent injuries--United States, 2000-2009.

INTRODUCTION: Quantifying years of potential life lost (YPLL) highlights childhood causes of mortality and provides a simple method to identify important causes of premature death. METHODS: CDC analyzed data from the National Vital Statistics System multiple cause of death files for 2000-2009. RESULTS: An average of 890YPLL were lost each year due to unintentional injuries for every 100,000 persons aged 0-19 years. YPLL rates differed by sex, age group, race/ethnicity, injury mechanism and state. CONCLUSIONS: This report provides new information which can be used to prioritize interventions and identify subgroups of the population most at risk.

Using baseline and formative evaluation data to inform the Uganda Helmet Vaccine Initiative.

Motorcycles are an important form of transportation in Uganda, and are involved in more road traffic injuries than any other vehicle. The majority of motorcycles in Uganda are used as motorcycle taxis, better known locally as boda bodas. Research shows that a motorcycle helmet is effective at reducing a rider's risk of death and head injury. As part of the Uganda Helmet Vaccine Initiative (UHVI), researchers collected baseline and formative evaluation data on boda boda operators' helmet attitudes, beliefs, and behaviors to inform UHVI activities. Researchers collected data on motorcycle helmet-related attitudes and beliefs through focus group discussions and structured roadside interviews, and researchers conducted roadside observations to collect data on helmet-wearing behaviors. Of the 12,189 motorcycle operators and passengers observed during roadside observations, 30.8% of drivers and <1% of passengers were wearing helmets. The most commonly reported helmet-wearing barriers from the focus group discussions and structured roadside interviews were: (1) 'Helmet is uncomfortable', (2) 'Helmet is too hot', (3) 'Helmet is too expensive', and (4) 'Helmet is of low quality'. Researchers incorporated findings from the formative research into the UHVI campaign to increase motorcycle helmet use. Radio messages addressing helmet comfort and cost were widely aired throughout Kampala, Uganda. In addition, campaign staff held nine boda boda operator workshops, covering approximately 900 operators, in which the facilitator addressed barriers and facilitators to helmet use. Each workshop participant received a high-quality tropical motorcycle helmet. UHVI will continue to use a data-driven approach to future campaign activities.

From modest beginnings to a winnable battle: road safety efforts at CDC's Injury Center.

There are now more than 200 million licensed drivers, who drive an average of 13,000 miles per year on 4 million miles of roads. In 2010 crashes resulted in nearly 33,000 deaths and millions of nonfatal injuries. This article describes the Injury Center's response to this public health threat from our beginnings as a small Center in 1992, current motor vehicle injury prevention priorities, and emerging road safety issues that will need attention in the future.

Healthcare utilization and costs among older adult female drivers and former drivers.

PURPOSE: This study compared the healthcare utilization and costs for specific types of medical services among older adult women who currently drive and those who no longer drive. METHODS: This study included 347 women aged 65 or older who were either former (had stopped driving) or current drivers, randomly sampled from a large U.S. health plan to participate in a telephone survey, and who had automated health records with healthcare utilization and cost data. Bivariate analyses and generalized linear modeling were used to examine associations between driving status and healthcare utilization and costs. RESULTS: Adjusting for age, income, and marital status, former drivers were more likely than current drivers to use mental health care services (RR=3.37; 95% CI: 1.03, 10.98). Former drivers also tended to use more inpatient (RR=1.85; 95% CI: 0.88, 3.87) and emergency services (RR=1.89; 95% CI: 0.96, 3.70), but results did not reach statistical significance. Total annual healthcare costs in 2005 were almost twice as high for former drivers compared with current drivers ($13,046 vs. $7,054; mean difference=$5,992; 95% CI: -$360, $12,344), although this relationship was not statistically significant (CR=1.61; 95% CI: 0.88, 2.96). IMPACT ON INDUSTRY: Former drivers were more than three times as likely as current drivers to use mental health services, and tended to use more emergency and inpatient services. Further research on factors that potentially mediate the relationship between driving status and health service use is warranted.

Maternal injuries during the periconceptional period and the risk of birth defects, National Birth Defects Prevention Study, 1997-2005.

Maternal injuries during pregnancy are common (∼7% prevalence). However, few studies have examined the association between maternal injuries and birth defects. The National Birth Defects Prevention Study is a population-based case-control study of birth defects in 10 U.S. states. Cases were ascertained through surveillance; controls were randomly selected from infants delivered without major birth defects in the study regions. Mothers completed a telephone interview on exposures before and during pregnancy, including injuries. We assessed associations between periconceptional (month before until the end of the third month of pregnancy) maternal injuries and birth defects. We used logistic regression to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CI). Periconceptional injuries were associated with interrupted aortic arch type B [AOR = 5.2, 95% CI 1.2, 23.2]; atrioventricular septal defect [AOR = 2.2, 95% CI 1.1, 4.4]; pulmonary atresia [AOR = 3.2, 95% CI 1.6, 6.4]; tricuspid atresia [AOR = 2.8, 95% CI 1.2, 6.7]; hypoplastic left heart syndrome [AOR = 2.0, 95% CI 1.1, 3.4]; anorectal atresia/stenosis [AOR = 1.7, 95% CI 1.0, 2.7]; longitudinal limb deficiency [AOR = 2.1, 95% CI 1.1, 3.9]; and gastroschisis [AOR = 1.8, 95% CI 1.2, 2.8]. Associations with longitudinal limb deficiency, gastroschisis and hypoplastic left heart syndrome were stronger for intentional injuries. Our results suggest maternal injury during the periconceptional period, particularly those inflicted intentionally, may be associated with select birth defects. This analysis was hypothesis-generating, with many associations tested. Further research is warranted.

A road traffic injury surveillance system using combined data sources in Peru.

A national hospital-based nonfatal road traffic injury surveillance system was established at sentinel units across Peru in 2007 under the leadership of the Ministry of Health. Surveillance data are drawn from three different sources (hospital records, police reports, and vehicle insurance reports) and include nonfatal road traffic injuries initially attended at emergency rooms. A single data collection form is used to record information about the injured, event characteristics related to the driver of the vehicle(s), and the vehicle(s). Data are analyzed periodically and disseminated to all surveillance system participants. Results indicated young adult males (15-29 years old) were most affected by nonfatal road traffic injuries and were most often the drivers of the vehicles involved in the collision. Four-wheeled vehicle occupants comprised one-half of cases in most regions of the country, and pedestrians injured in the event accounted for almost another half. The system established in Peru could serve as a model for the use of multiple data sources in national nonfatal road traffic injury surveillance. Based on this study, the challenges of this type of system include sustaining and increasing participation among sentinel units nationwide and identifying appropriate prevention interventions at the local level based on the resulting data.

Driving self-restriction in high-risk conditions: how do older drivers compare to others?

INTRODUCTION: Many older drivers self-restrict or avoid driving under high-risk conditions. Little is known about the onset of driving self-restrictions or how widespread self-restrictions are among drivers of all ages. METHODS: The Second Injury Control and Risk Survey (ICARIS-2) was a nationwide cross-sectional, list-assisted random-digit-dial telephone survey from 2001 to 2003. National prevalence estimates and weighted percentages of those reporting driving self-restrictions were calculated. Multivariable logistic regression was used to explore associations between specific self-restrictions and age group, adjusting for other personal characteristics. RESULTS: More than half of all drivers reported at least one driving self-restriction. The most commonly reported restriction was avoidance of driving in bad weather (47.5%), followed by at night (27.9%) and on highways or high-speed roads (19%). A greater percentage of young adult women (18-24 years) reported self-restricting in bad weather compared to women in other age groups, and the percentage of drivers self-restricting at night, in bad weather, and on highways or high-speed roads increased steeply after age 64. We found that women, those in low income groups, and those who had driven low annual mileage were more likely to self-restrict. CONCLUSIONS: In addition to assessing self-restrictions among older drivers, a new finding from our study is that self-restrictions are also quite prevalent among younger age groups. Driving self-restrictions may be better understood as a spectrum across ages in which drivers' reasons for restriction change. IMPACT ON INDUSTRY: Future research on the ability of driving self-restrictions to reduce actual crash risk and prevent injuries is needed.

A road traffic injury surveillance system using combined data sources in Peru / Sistema de vigilancia de traumatismos por accidentes de tránsito con fuentes de datos combinadas en el Perú

A national hospital-based nonfatal road traffic injury surveillance system was established at sentinel units across Peru in 2007 under the leadership of the Ministry of Health. Surveillance data are drawn from three different sources (hospital records, police reports, and vehicle insurance reports) and include nonfatal road traffic injuries initially attended at emergency rooms. A single data collection form is used to record information about the injured, event characteristics related to the driver of the vehicle(s), and the vehicle(s). Data are analyzed periodically and disseminated to all surveillance system participants. Results indicated young adult males (15-29 years old) were most affected by nonfatal road traffic injuries and were most often the drivers of the vehicles involved in the collision. Four-wheeled vehicle occupants comprised one-half of cases in most regions of the country, and pedestrians injured in the event accounted for almost another half. The system established in Peru could serve as a model for the use of multiple data sources in national nonfatal road traffic injury surveillance. Based on this study, the challenges of this type of system include sustaining and increasing participation among sentinel units nationwide and identifying appropriate prevention interventions at the local level based on the resulting data.

Con el liderazgo del Ministerio de Salud, en el 2007 se estableció un sistema hospitalario nacional de vigilancia de traumatismos no mortales por accidentes de tránsito en unidades centinela de todo el Perú. Los datos de vigilancia se extraen de tres fuentes diferentes (registros hospitalarios, informes policiales e informes del seguro del vehículo) e incluyen los traumatismos no mortales por accidentes de tránsito atendidos inicialmente en las salas de urgencia. Se usa un único formulario de recopilación de datos para registrar la información sobre los heridos, las características del hecho relacionadas con el conductor o los conductores de los vehículos y del vehículo o los vehículos involucrados. Los datos se analizan periódicamente y se comunican a todos los participantes del sistema de vigilancia. Los resultados indicaron que los hombres adultos jóvenes (de 15 a 29 años) fueron los más afectados por traumatismos no mortales por accidentes de tránsito y con mayor frecuencia eran los conductores de los vehículos que participaron en la colisión. Los ocupantes de vehículos de cuatro ruedas representaron la mitad de los casos en la mayoría de las zonas del país y los peatones lesionados en el hecho representaron prácticamente la otra mitad. El sistema establecido en el Perú podría servir de modelo del uso de múltiples fuentes de datos para la vigilancia a nivel nacional de traumatismos no mortales por accidentes de tránsito. Según los resultados de este estudio, los retos de un sistema de este tipo consisten en mantener y aumentar la participación de las unidades de vigilancia de todo el país y determinar las intervenciones de prevención adecuadas en el nivel local según los datos obtenidos.

The burden of childhood injuries and evidence based strategies developed using the injury surveillance system in Pasto, Colombia.

OBJECTIVE: This article characterises the burden of childhood injuries and provides examples of evidence-based injury prevention strategies developed using a citywide injury surveillance system in Pasto, Colombia. METHODS: Fatal (2003-2007) and non-fatal (2006-2007) childhood injury data were analysed by age, sex, cause, intent, place of occurrence, and disposition. RESULTS: Boys accounted for 71.5% of fatal and 64.9% of non-fatal injuries. The overall fatality rate for all injuries was 170.8 per 100,000 and the non-fatal injury rate was 4,053 per 100,000. Unintentional injuries were the leading causes of fatal injuries for all age groups, except for those 15-19 years whose top four leading causes were violence-related. Among non-fatal injuries, falls was the leading mechanism in the group 0-14 years. Interpersonal violence with a sharp object was the most important cause for boys aged 15-19 years. Home was the most frequent place of occurrence for both fatal and non-fatal injuries for young children 0-4 years old. Home, school and public places became an important place for injuries for boys in the age group 5-15 years. The highest case-fatality rate was for self-inflicted injuries (8.9%). CONCLUSIONS: Although some interventions have been implemented in Pasto to reduce injuries, it is necessary to further explore risk factors to better focus prevention strategies and their evaluation. We discuss three evidence-based strategies developed to prevent firework-related injuries during festival, self-inflicted injuries, and road traffic-related injuries, designed and implemented based on the injury surveillance data.

Older adult pedestrian injuries in the United States: causes and contributing circumstances.

As the US population ages, more older adults will face transportation and mobility challenges. This study examines the characteristics and contributing circumstances of nonfatal older adult pedestrian injuries. Data were obtained from the National Electronic Injury Surveillance System-All Injury Programme (NEISS-AIP) for the years 2001 through 2006. Cases included persons aged 65 years and older who were nonfatally injured on a public roadway. The results indicated that on average, an estimated 52,482 older adults were treated in emergency departments each year for nonfatal pedestrian injuries. Falling and being hit by a motor vehicle were the leading mechanisms of injury, resulting in 77.5% and 15.0% of older adult pedestrian injuries, respectively. More than 9000 older pedestrian fall-related injuries each year involved a kerb. It is concluded that the growth in the older adult population could add to the overall burden of these nonfatal pedestrian injuries. Making transportation and mobility improvements, including environmental modifications, is important for preventing these injuries.

Epidemiology of maternal injuries during pregnancy in a population-based study, 1997-2005.

BACKGROUND: Maternal injuries during pregnancy are common and can cause adverse pregnancy outcomes. We sought to describe factors related to injury during pregnancy. METHODS: We analyzed data from the National Birth Defects Prevention Study (NBDPS), a population-based, case-control study of birth defects in 10 U.S. states. We estimated the proportion of control mothers, a random sample of mothers delivering infants without major birth defects in the study regions, who reported an injury during pregnancy. We assessed associations with maternal and paternal characteristics using logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI). RESULTS: Between October 1997 and December 2005, 490 (7.4%) of 6609 mothers reported 527 injuries during pregnancy. Falls caused over half of reported injuries during pregnancy (51.6%), and 9.5% of reported injuries were intentionally inflicted. Mothers who reported an injury during pregnancy were more likely to be aged <18 years vs. 18-29 years (aOR 2.84, 95% CI 1.54-5.23) and less likely to be aged ≥30 years (aOR 0.67, 95% CI 0.51-0.89). They were more likely to use alcohol during pregnancy (aOR for nonbinge drinking 1.38, 95% CI 1.05-1.81), to smoke during pregnancy (aOR 1.37, 95% CI 1.02-1.85), to have epilepsy (aOR 3.31, 95% CI 1.48-7.38), and to be employed (aOR 1.44, 95% CI 1.08-1.93) than mothers who did not report an injury. CONCLUSIONS: We identified several factors associated with maternal injury during pregnancy, an important step in identifying women who may be at higher risk and in designing interventions to prevent injuries during pregnancy.

Bicycle helmet use among children in the United States: the effects of legislation, personal and household factors.

INTRODUCTION: Children ages 5-14 years have the highest rate of bicycle-related injuries in the country. Bicycle helmets can prevent head and brain injuries, which represent the most serious type of bicycle-related injury. OBJECTIVES: This paper compares children's bicycle helmet use to that estimated from an earlier study, and explores regional differences in helmet use by existing helmet legislation. METHODS: This study was a cross-sectional, list-assisted random-digit-dial telephone survey. Interviews were completed by 9,684 respondents during 2001-2003. The subset with at least one child in the household age 5-14 years (2,409 respondents) answered questions about bicycle helmet use for a randomly selected child in their household. RESULTS: Almost half (48%) of the children always wore their helmet, 23% sometimes wore their helmet, and 29% never wore their helmet. Helmet wearing was significantly associated with race, ethnicity, and child age but was not associated with the sex of the child. Other significant predictors of use included household income, household education, census region, and bicycle helmet law status. Statewide laws were more effective than laws covering smaller areas. The proportion of children who always wore a helmet increased from 25% in 1994 to 48% in 2001-2002. Significant increases in helmet use from 20% to 26% were seen among both sexes, younger (5-9 years) and older (10-14 years) children, and in all four regions of the country. CONCLUSIONS: While there has been substantial progress in the number of children who always wear their helmets, more than half do not. Further progress will require using a combination of methods that have been shown to successfully promote consistent helmet use. IMPACT ON INDUSTRY: minimal.