Evaluating a novel sign's impact on whether park visitors enter a dangerous river.

BACKGROUND: Between 1972 and 2015, 56 visitors to the two national parks that border the Potomac River Gorge experienced fatal drowning. In 2016, the George Washington Memorial Parkway (GWMP), and the Chesapeake and Ohio National Historical Park (CHOH) partnered with a researcher to see if enhancement of their risk communication strategies could reduce behaviors that contribute to these deaths. METHODS: An experimental sign, which informed visitors that water entry was illegal and could result in a fine exceeding $200 was developed, and displayed on alternating weekend days from July 30 to September 11, 2016. Those signs were displayed at each park's entrance, on restroom doors, at trailheads, and at both shorelines of the Potomac. At other times the experimental signs were covered, but a standard safety sign was always present. Cameras were used to record water entries. RESULTS: Cameras captured 1441 images. Approximately 2% of the images in CHOH and 1% of the images in GWMP showed a visitor in the water. Our multivariate analysis revealed that air temperature, beach count, and sign condition were significantly associated with water entry. When our experimental sign was displayed, the odds of an image showing someone in the water was reduced by 63%. CONCLUSIONS: A sign alerting park visitors to the fact that water entry is illegal, and could potentially result in a considerable fine, was associated with significantly reduced risk-taking. While intuitive, this finding is a reminder to consider whether warnings that focus on non-health consequences might be more salient to at-risk populations.

Patterns of behaviour that pose potential drowning risk to hikers at Yosemite National Park.

PRIMARY OBJECTIVE: To analyse patterns of departure from a popular hiking trail in Yosemite National Park, at sites where fatal drownings have occurred in the past. METHODS: This study employed direct observation. For 32 days throughout the summer of 2013, study team members observed hikers who entered areas that brought them in close proximity to hazardous sections of the Merced River. Subject and environmental data were recorded for 1417 such approaches. RESULTS: In 81% of our observation hours, subjects entered 'risk zones.' The median number of hikers seen near/in the river was eight per hour at the Vernal Fall footbridge, and three at the top of the waterfall. A regression analysis found that air temperature and later hike starts were positively associated, and water level was negatively associated, with the rate of river approach. Means of river access were also identified. Males, teens and people who were alone were significantly more likely to be observed entering particularly dangerous areas. CONCLUSIONS: It is common for hikers to approach water sources during summer months, particularly as air temperatures rise. By analysing how behaviour and environmental factors co-vary, safety advocates can tailor risk reduction measures to specific settings and visitor populations.

Understanding hikers who approached a hazardous river in Yosemite National Park.

OBJECTIVES: To understand the perceptions and motivations of hikers who approached a swift river at locations that have been associated with drowning in the past. METHODS: A survey was completed by 399 adults who had been observed getting 'too close' to the Merced River. The questionnaire covered trail familiarity, information sources, timing and motivation of their decision, perceived safety, knowledge and opinion of park rules. RESULTS: Sixty-eight per cent of invited hikers agreed to participate. Almost all had received advance information about their hike, but most often that did not include a river warning. Most respondents were observed in the risk zone by the footbridge, and their most frequent motivation was to 'cool off'. Ninety-two per cent of hikers reported feeling very or somewhat safe by the river. Their risk perceptions did not correlate with expert ratings of danger. Males, younger subjects and those who had hiked the trail before were more likely to enter the most hazardous parts of the risk zone. Eleven per cent of people at the footbridge and 43% at the top of the waterfall thought that the park should not allow visitors to go where they had been. The most common reason they gave for this view was that the location was unsafe. CONCLUSIONS: While this needs assessment identified channels for informing hikers of drowning risk, there are indications that they might not personalise such warnings. Another option would be to explore cooling alternatives that could compete with the swift water that runs along many hiking trails.

Gauging popular support for traffic safety in the United States.

BACKGROUND: Recent concerns have been raised about the United States' "Traffic Safety Culture." While the "safety culture" construct has been studied in occupational settings, it appears that no assessments of national traffic safety culture have been published in the scientific literature. PURPOSE: To assess whether current public attitudes and behaviors support traffic safety advancement in the United States. METHODS: A mail survey containing items that had been endorsed by traffic safety experts was fielded to a nationally representative sample of U.S. households in 2009. Completed surveys were returned by 46% of recipients. RESULTS: Mean ratings indicated that respondents support a majority of the items that were developed to reflect positive Traffic Safety Culture. They "neither agreed nor disagreed," however, with 43% of pro-safety statements. The item that was mostly highly rated by subjects suggested that "the whole key to road safety" lies in educating drivers. When items were grouped by topic, those which focused on the control of alcohol-impaired driving were most popular. Female respondents and older respondents demonstrated more support for traffic safety advancement. CONCLUSIONS: The U.S. public appears to be favorably disposed to traffic safety but their support is not uniform across topics or population subgroups. Their responses also suggest they may not know or like some of the evidence-based recommendations being promoted by traffic safety experts. Future research should explore the bases for public resistance to policies and practices that have been shown to save lives.

Towards operationalising and measuring the Traffic Safety Culture construct.

The purpose of this study was to increase our understanding of traffic safety culture (TSC) by identifying its constituent components. A review of existing safety culture literature was conducted. Next, 18 international experts participated in a Delphi Technique to rate candidate TSC components. Corresponding survey items were then developed and pretested. Our final survey instrument was mailed to a representative sample of 1700 US households. Their data were used to conduct a factor analysis that yielded a 15 factor structure. The factors that explained the most variance in TSC were support for increased government attention to traffic safety, strict monitoring and control of alcohol-impaired drivers, disapproval of speeding, and avoidance of aggressive driving. Other factors included local engagement, desire for government and private sector accountability, more information, school involvement, teen restrictions, willingness to invest and seatbelt use. This work represents a first attempt to operationalise TSC. Future research will be needed to refine and extend the tentative structure that has been identified. Valid and reliable measurement of this construct should facilitate traffic safety advocates' efforts to overcome the social challenges they face.

'It was a freak accident': an analysis of the labelling of injury events in the US press.

OBJECTIVES: Given that the news media shape our understanding of health issues, a study was undertaken to examine the use by the US media of the expression 'freak accident' in relation to injury events. This analysis is intended to contribute to the ongoing consideration of lay conceptualisation of injuries as 'accidents'. METHODS: LexisNexis Academic was used to search three purposively selected US news sources (Associated Press, New York Times and Philadelphia Inquirer) for the expression 'freak accident' over 5 years (2005-9). Textual analysis included both structured and open coding. Coding included measures for who used the expression within the story, the nature of the injury event and the injured person(s) being reported upon, incorporation of prevention information within the story and finally a phenomenological consideration of the uses and meanings of the expression within the story context. Results The search yielded a dataset of 250 human injury stories incorporating the term 'freak accident'. Injuries sustained by professional athletes dominated coverage (61%). Fewer than 10% of stories provided a clear and explicit injury prevention message. Stories in which journalists employed the expression 'freak accident' were less likely to include prevention information than stories in which the expression was used by people quoted in the story. CONCLUSIONS: Journalists who frame injury events as freak accidents may be an appropriate focus for advocacy efforts. Effective prevention messages should be developed and disseminated to accompany injury reporting in order to educate and protect the public.

Evaluation of a brief intervention designed to increase CPR training among pregnant pool owners.

This study evaluated whether a brief videotape could motivate pregnant pool owners to be trained in infant/child cardiopulmonary resuscitation (CPR). Women were recruited from prenatal classes in South Florida. Eligible volunteers were randomized to view a video or receive standard treatment, after completing a questionnaire. The video explained toddler drowning risk, as well as the value of isolation pool fencing and CPR training. Women were contacted by phone 6 months after giving birth to complete a follow-up survey. Sixty-one percent of eligible mothers agreed to study enrollment and 92% of those completed a follow-up interview (n = 101). At baseline, there was no significant difference between the proportion of mothers with current CPR training in the treatment and control groups. At follow-up, 48% of those in the intervention group reported CPR instruction versus 28% of the control group (x(2) = 3.93, P = 0.03). Video viewers were also more likely to report significant changes in perceptions that favored CPR training. Health care facilities located in communities with high rates of toddler drowning may want to screen prenatal students for pool ownership and encourage at-risk families to be trained in infant/child CPR. Such programs should, however, emphasize the primacy of isolation fencing as a preventive measure.

An exploratory study of the relationship between socioeconomic status and motor vehicle safety features.

OBJECTIVE: The purpose of this study was to assess the association between motor vehicle owners' socioeconomic status (SES) and the safety of their motor vehicles. METHODS: Truncated vehicle identification numbers (VINs) were obtained from the Maryland Motor Vehicle Administration office. ZIP code-level income and educational data were assigned to each VIN. Software was used to identify safety-related vehicle characteristics including crash test rating, availability of electronic stability control and side impact air bags, age, and weight. Correlations and analyses of variance were performed to assess whether a ZIP code's median household income and educational level were associated with its proportion of registered vehicles with safety features. RESULTS: For 13 of the 16 correlations performed, SES was significantly associated with the availability of vehicle safety features in a direction that favored upper-income individuals. Vehicle weight was not associated with income or education. When ZIP codes were divided into median household income quintiles, their mean proportions of safety features also differed significantly, in the same direction, for availability of electronic stability control, side impact air bags, vehicle age, and crash test ratings. CONCLUSIONS: Safer motor vehicles appear to be distributed along socioeconomic lines, with lower income groups experiencing more risk. This previously unidentified mechanism of disparity merits further study and the attention of policy makers.

A systematic process to prioritize prevention activities sustaining progress toward the reduction of military injuries.

BACKGROUND: To sustain progress toward injury reduction and other health promotion goals, public health organizations need a systematic approach based on data and an evaluation of existing scientific evidence on prevention. This paper describes a process and criteria developed to systematically and objectively define prevention program and policy priorities. METHODS: Military medical surveillance data were obtained and summarized, and a working group of epidemiology and injury experts was formed. After reviewing the available data, the working group used predefined criteria to score leading military unintentional injury causes on five main criteria that assessed factors contributing to program and policy success: (1) importance of the problem, (2) effectiveness of existing prevention strategies, (3) feasibility of establishing programs and policies, (4) timeliness of implementation and results, and (5) potential for evaluation. Injury problems were ranked by total median score. RESULTS: Causes with the highest total median scores were physical training (34 points), military parachuting (32 points), privately-owned vehicle crashes (31 points), sports (29 points), falls (27 points), and military vehicle crashes (27 points). CONCLUSIONS: Using a data-driven, criteria-based process, three injury causes (physical training, military parachuting, and privately owned-vehicle crashes) with the greatest potential for successful program and policy implementation were identified. Such information is useful for public health practitioners and policymakers who must prioritize among health problems that are competing for limited resources. The process and criteria could be adapted to systematically assess and prioritize health issues affecting other communities.

Epidemiology of burn injuries II: psychiatric and behavioural perspectives.

Modern technological advances have decreased the incidence and severity of burn injuries, and medical care improvements of burn injuries have significantly increased survival rates, particularly in developed countries. Still, fire-related burn injuries are responsible for 300,000 deaths and 10 million disability-adjusted life years lost annually worldwide. The extent to which psychiatric and behavioural factors contribute to the incidence and outcomes of these tragedies has not been systematically documented, and the available data is often insufficient to reach definitive conclusions. Accordingly, this article reviews the evidence of psychiatric and behavioural risk factors and prevention opportunities for burn injuries worldwide. Psychiatric prevalence rates and risk factors for burn injuries, prevalence and risks associated with 'intentional' burn injuries (self-immolation, assault, and child maltreatment), and prevention activities targeting the general population and those with known psychiatric and behavioural risk factors are discussed. These issues are substantially interwoven with many co-occurring risk factors. While success in teasing apart the roles and contributions of these factors rests upon improving the methodology employed in future research, the nature of this entanglement increases the likelihood that successful interventions in one problem area will reap benefits in others.

Airline passengers' alcohol use and its safety implications.

BACKGROUND: This investigation was designed to identify individual and contextual factors associated with airline passengers' alcohol use, and to explore potentially dangerous in-flight alcohol consumption. METHODS: Passengers waiting to board 24 domestic flights at an international airport in the South Atlantic United States were asked to complete an anonymous questionnaire. Eighty percent of those approached agreed to participate. Our findings are based upon the responses of 1,548 adults. RESULTS: A majority (84%) of passengers indicated that they did not intend to consume alcoholic beverages on the plane they were waiting to board. Passengers who were more likely to report that they would drink were on longer flights, traveling with friends, and anticipating First or Business Class seating. Passengers who had already consumed alcohol that day and those who drank more often generally were also more likely to say that they intended to consume alcohol, as were people who thought that in-flight alcohol use was enjoyable, acceptable, and unlikely to make jet lag worse. Eighty-nine percent of the passengers who said they intended to drink reported that they would purchase one to two drinks. CONCLUSIONS: Very few respondents reported intentions that would pose a risk to others. Future studies should validate alcohol consumption and sample passengers at multiple airports throughout the year.

Usual seat belt practices reported by airline passengers surveyed in gate areas of a U.S. airport.

INTRODUCTION: Most people who are seriously injured or die as a result of air turbulence were not wearing seat belts, yet we find no published studies of airline passengers' seat belt use. Drawing from the traffic safety literature, we explored characteristics that might be associated with passenger restraint use on planes. METHODS: The study was conducted at a major U.S. airport. All passengers waiting to board 24 domestic flights were asked to complete a brief, anonymous survey. We solicited data on various passenger characteristics, including their alcohol consumption patterns. We then used bivariate and regression analyses to explore whether those factors covaried with passengers' usual seat belt use when the "Fasten Seat Belt" sign was turned on, and when it was off. RESULTS: We invited 2013 adults to participate; 1548 usable questionnaires were returned. Of those who responded, 7% (n=112) stated that they "rarely" or "never" fasten their belt in the "Sign Off" condition; that number fell to 2% (n=26) for the "Sign On" condition. Under "Sign Off" conditions, logistic regression revealed significant differences between the group that "always" or "usually" wore seat belts and the noncompliant group: the latter flew less frequently and were more likely to say they would consume alcohol on their upcoming flight. DISCUSSION: In general the rate of seat belt use by airline passengers appears to be higher than it is in motor vehicles. Nevertheless, airline passengers who resist using seat belts share some of the characteristics of motor vehicle occupants who underutilize passenger restraints.

Advice from bereaved parents: on forming partnerships for injury prevention.

We set out to learn whether, and how, parents of children who were fatally injured want to collaborate with injury prevention professionals. In this exploratory study, interviews were conducted with parents who had been identified through medical examiner files. Only a small minority of those we contacted chose to participate. The six mothers and five fathers who did felt that survivors should be offered such opportunities. They suggested waiting, however, at least a year before approaching parents. Our interviewees endorsed medical examiner's offices, health care providers, and police as legitimate avenues for identifying potential partners. They suggested that contact should first be made by mail. Professionals were encouraged to be sensitive, responsive, and realistic regarding the limits of our science. From a practical perspective, safety experts' contacts and political savvy appealed to respondents. Parents also expressed the need for coaching, and gentle understanding of the pain they live with every day.

A qualitative study of post-settlement influences on State tobacco control funding.

State settlements with the tobacco industry increased the availability of funds that might be used for improving health outcomes and increased scrutiny of tobacco control funding overall. This research identified potential explanatory factors for state tobacco control funding and developed a conceptual framework to guide further exploration. Key informant interviews with 14 tobacco policy professionals were conducted to augment the information available in the scientific literature on funding influences. Interviews yielded a comprehensive list of 26 factors that were returned to key informants for ratings of importance using a modified Delphi process. Results indicate that the top funding influences are budgetary constraints, lobbying, advocacy, tobacco economy, legislative priorities, public opinion, and leadership by the governor or state legislators. A conceptual diagram is presented of all factors clustered into three categories. Further research is planned to quantify these factors and assess their explanatory value

Parents of fatally injured children discuss taking part in prevention campaigns: an exploratory study.

This qualitative study explores how a small group of parents who have lost children to accidental injuries feel about taking part in prevention campaigns. Prospective participants were identified through a state medical examiner's office. Six mothers and 5 fathers of children who had died 3-5 years earlier agreed to be interviewed. All participants thought that it was appropriate to approach bereaved parents about such opportunities, after the most disabling phase of grief had subsided. Yet they raised cognitive, emotional, and practical barriers to engaging in prevention work. The appealing aspects of becoming a safety advocate included preventing emotional and physical injuries to others, as well as advancing their own recovery. It is very possible that the volunteers we spoke with held more positive views on participation than the many mothers and fathers who chose not to participate in our study. Nonetheless, their comments give us our first insights into how collaborating on prevention may feel to those for whom prevention has failed.

How readable are child safety seat installation instructions?

OBJECTIVES: To measure the required reading level of a sample of child safety seat (CSS) installation instructions and to compare readability levels among different prices of CSSs to determine whether the lower cost seats to which low-income parents have greater access are written to a lower level of education. METHODS: A CD-ROM containing CSS installation instructions was obtained from the National Highway Traffic Safety Administration. Pricing information was obtained for available models from an Internet-based company that provides comparative shopping information. Paper copies of the instruction sets were generated, and their readability levels were determined using the SMOG test. A second rater was used in addition to the primary investigator to assess interrater reliability of the SMOG as applied to the instruction sets. RESULTS: The readability of instruction sets ranged from the 7th- to 12th-grade levels, with an overall mean SMOG score of 10.34. No significant associations were found to exist between readability and seat prices; this was observed whether the data were treated as continuous or categorical. CONCLUSIONS: CSS instruction manuals are written at a reading level that exceeds the reading skills of most American consumers. These instruction sets should be rewritten at a lower reading level to encourage the proper installation of CSSs.

The effectiveness of injury prevention strategies: what does the public believe?

This article is based on a random digit dialed telephone survey in which adults were asked to name effective strategies for preventing deaths due to motor vehicle crashes, falls, drowning, fires/burns, and poisoning. A majority of the 943 respondents could name prevention techniques, although they were least likely to do so for fatal falls. Participants at highest risk for not naming a countermeasure were those with fewer years of education. The strategy cited most often for preventing deaths due to falls, poisoning, and drowning was safety education. These findings suggest that more advantaged members of the public feel they know how to prevent America's leading causes of injury death. They may not fully appreciate, however, the options of creating health-promoting environments and safer products. This work makes it very clear that people with less education also need to be exposed to the breadth of effective injury countermeasures.

Alcohol's contribution to fatal injuries: a report on public perceptions.

STUDY OBJECTIVE: We determine whether members of the public understand that alcohol contributes to each of the leading causes of unintentional-injury death in the United States and not just to motor vehicle-related fatalities. Public opinions of selected alcohol control policies were also assessed. METHODS: We used a national telephone survey of 943 adults, who were selected by random-digit dialing techniques. Respondents' mean estimates of alcohol's involvement in fatal injuries were compared with published data from a meta-analysis of medical examiner data. RESULTS: The study population accurately estimated the proportion of fatal fall, drowning, and poisoning victims who were legally drunk when they died. Respondents overestimated the proportion of drivers killed in motor vehicle crashes who were intoxicated and underestimated the proportion of fire/burn victims. Fifty-seven percent of participants endorsed the myth that alcohol intoxication is protective against injury in the event of a motor vehicle crash. Participants were divided over whether increasing the legal drinking age to 21 had resulted in fewer injury deaths. Seventy-eight percent of participants did not believe that raising alcohol taxes would reduce fatal injuries. A majority (58%) of respondents supported taking blood alcohol levels on all "seriously injured" patients brought to the hospital. CONCLUSION: This report suggests that public awareness of alcohol's contribution to the breadth of the injury problem in the United States is high. Conversely, public understanding of whether prevention strategies have proven to be effective is poor. Emergency medicine practitioners can serve as credible sources of more accurate information for patients and the community at large.