Addressing health disparities using multiply imputed injury surveillance data.

BACKGROUND: Assessing disparities in injury is crucial for injury prevention and for evaluating injury prevention strategies, but efforts have been hampered by missing data. This study aimed to show the utility and reliability of the injury surveillance system as a trustworthy resource for examining disparities by generating multiple imputed companion datasets. METHODS: We employed data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) for the period 2014-2018. A comprehensive simulation study was conducted to identify the appropriate strategy for addressing missing data limitations in NEISS-AIP. To evaluate the imputation performance more quantitatively, a new method based on Brier Skill Score (BSS) was developed to assess the accuracy of predictions by different approaches. We selected the multiple imputations by fully conditional specification (FCS MI) to generate the imputed companion data to NEISS-AIP 2014-2018. We further assessed health disparities systematically in nonfatal assault injuries treated in U.S. hospital emergency departments (EDs) by race and ethnicity, location of injury and sex. RESULTS: We found for the first time that significantly higher age-adjusted nonfatal assault injury rates for ED visits per 100,000 population occurred among non-Hispanic Black persons (1306.8, 95% Confidence Interval [CI]: 660.1 - 1953.5), in public settings (286.3, 95% CI: 183.2 - 389.4) and for males (603.5, 95% CI: 409.4 - 797.5). We also observed similar trends in age-adjusted rates (AARs) by different subgroups for non-Hispanic Black persons, injuries occurring in public settings, and for males: AARs of nonfatal assault injury increased significantly from 2014 through 2017, then declined significantly in 2018. CONCLUSIONS: Nonfatal assault injury imposes significant health care costs and productivity losses for millions of people each year. This study is the first to specifically look at health disparities in nonfatal assault injuries using multiply imputed companion data. Understanding how disparities differ by various groups may lead to the development of more effective initiatives to prevent such injury.

Association between traumatic brain injury and suicidality using a mediation approach and MarketScan.

INTRODUCTION: Negative outcomes, including suicidal ideation/attempts, are a major public health concern, particularly among individuals who sustain a traumatic brain injury (TBI). TBI is associated with high rates of postinjury substance use, psychiatric disorders, post-traumatic stress disorder and sleep disturbances. This study examines the mediation effects of substance use, psychiatric disorder and sleep disorder on the associations between TBI and suicidal ideation/attempts. METHODS: A matched case-control study using data from MarketScan databases for private health insurance and Medicaid from October 2015 to December 2018 estimated the association between TBI and suicidal ideation/attempts using a mediation approach. Individuals less than 65 years of age were included. RESULTS: In the Medicaid sample, psychiatric disorders mediated 22.4% of the total effect between TBI and suicidal ideation/attempt, while substance use disorders other than opioid use disorder mediated 7.47%. In the private health insurance sample, psychiatric disorders mediated 3.97% of the total effect, opioid use disorders mediated 2.08% of the total effect and sleep disorder mediated 1.25% of the total effect. CONCLUSIONS: Mediators explained less than 30% of the relationship between TBI and suicidal ideation/attempt. Findings reinforce the importance of primary prevention of TBI and monitoring patients with a TBI for risk of suicide in the first 6-12 months following injury.

Parent-Child communication about concussion: what role can the Centers for Disease Control and Prevention's HEADS UP concussion in youth sports handouts play?

BACKGROUND: Concussion education for parents/guardians (hereafter referred to as parents) has the potential to play an important role in youth athlete concussion safety. The goal of this study was to evaluate the impact of the Centers for Disease Control and Prevention's (CDC) HEADS UP handout on parent-child communication about concussion. METHODS: YMCA branches from 15 associations from across the United States were randomized to CDC HEADS UP intervention condition or education as usual control condition using a cluster randomization strategy. In the intervention condition, coaches shared parent- and athlete-specific handouts with parents and asked parents to share and discuss the athlete-specific handouts with their child. Generalized estimating equations, with repeated measures to account for the correlation among matched participants and YMCA associations, were employed. RESULTS: Multivariable analyses exploring the relationship between time (pre- and post-intervention) and communication showed that the percent of parents who talked to their child about concussion increased in the intervention group (aRR=1.33, 95% CI=1.22, 1.44), but not in the control group. CONCLUSION: CDC HEADS UP handouts help families talk about concussion safety. Sports organizations seeking to educate parents of athletes about concussion should consider using CDC HEADS UP handouts and following a similar dissemination strategy.

Nonfatal Assaults Among Persons Aged 10-24 Years - United States, 2001-2015.

In 2015, persons aged 10-24 years who were treated for nonfatal assault injuries in emergency departments (EDs) in the United States accounted for 32% of the approximately 1.5 million patients of all ages that EDs treated for nonfatal assault injuries (1). CDC analyzed data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) to examine 2001-2015 trends in nonfatal assault injuries among youths treated in EDs, by sex and age group, and to assess current rates by sex, age group, mechanism of injury, and disposition (1). Rates for 2001-2015 were significantly higher among males than among females and among young adults aged 20-24 years than among youths aged 10-14 and 15-19 years. During 2011-2015, rates declined for all groups. The 2015 rate among persons aged 10-24 years was 753.2 per 100,000 population, the lowest in the 15-year study period. Despite encouraging trends, the assault rate among young persons remains high. Rates in 2015 were higher among males, persons aged 20-24 years, and those who incurred intentional strike or hit injuries. Nearly one in 10 patients were admitted to the hospital, transferred to another hospital, or held for observation. Youth violence prevention strategies, including primary prevention approaches that build individual skills, strengthen family relationships, or connect young persons treated in EDs to immediate and ongoing support, can be implemented to decrease injuries and fatalities (2).

Comparability of national estimates for traumatic brain injury-related medical encounters.

OBJECTIVE: To describe similarities and differences in the number of civilian traumatic brain injury (TBI)-related hospitalizations and emergency department visits between national databases that capture US hospital data. PARTICIPANTS: TBI-related hospitalizations included in the National Hospital Discharge Survey (NHDS) and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) and emergency department visits in the National Hospital Ambulatory Medical Care Survey (NHAMCS) and HCUP Nationwide Emergency Department Sample (HCUP-NEDS) for 2006-2010. DESIGN: Cross-sectional design. MAIN MEASURES: Nationwide counts of TBI-related medical encounters. RESULTS: Overall, the frequency of TBI is comparable when comparing NHDS with HCUP-NIS and NHAMCS with HCUP-NEDS. However, annual counts in both NHDS and NHAMCS are consistently unstable when examined in smaller subgroups, such as by age group and injury mechanism. Injury mechanism is consistently missing from many more records in NHDS compared with HCUP-NIS. CONCLUSION: Given the large sample size of HCUP-NIS and HCUP-NEDS, these data can offer a valuable resource for examining TBI-related hospitalization and emergency department visits, especially by subgroup. These data hold promise for future examinations of annual TBI counts, but ongoing comparisons with national probability samples will be necessary to ensure that HCUP continues to track with estimates from these data.

Vital signs: health burden and medical costs of nonfatal injuries to motor vehicle occupants - United States, 2012.

BACKGROUND: Motor vehicle crashes are a leading cause of death and injury in the United States. The purpose of this study was to describe the current health burden and medical and work loss costs of nonfatal crash injuries among vehicle occupants in the United States. METHODS: CDC analyzed data on emergency department (ED) visits resulting from nonfatal crash injuries among vehicle occupants in 2012 using the National Electronic Injury Surveillance System ­ All Injury Program (NEISS-AIP) and the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS). The number and rate of all ED visits for the treatment of crash injuries that resulted in the patient being released and the number and rate of hospitalizations for the treatment of crash injuries were estimated, as were the associated number of hospital days and lifetime medical and work loss costs. RESULTS: In 2012, an estimated 2,519,471 ED visits resulted from nonfatal crash injuries, with an estimated lifetime medical cost of $18.4 billion (2012 U.S. dollars). Approximately 7.5% of these visits resulted in hospitalizations that required an estimated 1,057,465 hospital days in 2012. CONCLUSIONS: Nonfatal crash injuries occur frequently and result in substantial costs to individuals, employers, and society. For each motor vehicle crash death in 2012, eight persons were hospitalized, and 100 were treated and released from the ED. IMPLICATIONS FOR PUBLIC HEALTH: Public health practices and laws, such as primary seat belt laws, child passenger restraint laws, ignition interlocks to prevent alcohol impaired driving, sobriety checkpoints, and graduated driver licensing systems have demonstrated effectiveness for reducing motor vehicle crashes and injuries. They might also substantially reduce associated ED visits, hospitalizations, and medical costs.

Intimate Partner Violence and Health Conditions Among U.S. Adults-National Intimate Partner Violence Survey, 2010-2012.

INTRODUCTION: Few studies of intimate partner violence and health outcomes include multiple forms of intimate partner victimization, so this paper sought to examine health associations with intimate partner violence (IPV), including sexual, physical, stalking, and psychological forms, as well as polyvictimization. METHODS: Data are from the 2010-2012 National Intimate Partner and Sexual Violence Survey, an on-going national random-digit-dial telephone survey of U.S. adults. There were 41,174 respondents. Logistic regression was used to compute prevalence ratios for any IPV, adjusted for demographics and non-IPV victimization. For individual forms of IPV, prevalence ratios were further adjusted for other forms of IPV. Tests for linear trend in poly-victimization were performed. RESULTS: Any IPV was associated with all health conditions for both sexes with a few exceptions for males. Female penetrative sexual victimization and male stalking victimization were associated with the most health conditions. For each health condition, a significant linear trend indicated that as the number of forms of IPV experienced increased, prevalence of each health condition increased, with a few exceptions for males. CONCLUSIONS: It is important for service providers to screen for multiple forms of IPV, including psychological aggression, because individual forms or polyvictimization may have unique and cumulative health effects.

Prevalence of Intimate Partner Reproductive Coercion in the United States: Racial and Ethnic Differences.

Reproductive coercion (RC) is a specific type of intimate partner violence (IPV). Although clinical studies have highlighted women's experiences of RC, we know little about its national prevalence and differences in prevalence by sex category and race/ethnicity. Data are from the National Intimate Partner and Sexual Violence Survey (NISVS), years 2010 to 2012. NISVS is an ongoing, nationally representative random-digit-dial telephone survey of the noninstitutionalized English- or Spanish-speaking U.S. adult population. This article reports the national lifetime and 12-month prevalence of two RC victimization measures, and proportions among IPV victims. T tests were used to examine differences in estimates across racial/ethnic groups. In the United States, 9.7% of men and 8.4% of women experienced any RC by an intimate partner during their lifetime. Men reported more commonly than women that a partner tried to get pregnant when the man did not want her to; women reported higher prevalence of partner condom refusal. Examination by race/ethnicity revealed that non-Hispanic (NH) Black women and men had significantly higher lifetime prevalence of both RC types than all other groups; in the last 12 months, NH Blacks had significantly higher prevalence across the board than NH Whites. Hispanics had significantly higher lifetime and 12-month prevalence of any RC and partner condom refusal than NH Whites. RC is at the intersection of two public health concerns-IPV and reproductive health. Documenting its prevalence and differences by sex and race/ethnicity may inform prevention efforts to reduce occurrence and negative health outcomes among specific populations.

Victim and perpetrator characteristics in alcohol/drug-involved sexual violence victimization in the U.S.

The authors examine the prevalence and characteristics of sexual violence victimization - rape and being made to penetrate [MTP] (men only) - involving substances (alcohol or other drugs). Although it has been well-documented that perpetrators commit sexual violence against individuals who are using alcohol or drugs, more research is needed to describe the problem at a national level. Data are from the 2010-2012 National Intimate Partner and Sexual Violence Survey, a nationally representative random-digit-dial telephone survey of English- and Spanish-speaking adults in the United States (n = 41,174). Findings reveal that among victims of physically forced rape, 26.2 % of female and 30.0 % of male victims reported substance use; 44.5 % of male MTP victims reported substance use. The majority of forced rape and MTP victims reported the perpetrator was using alcohol or drugs. Among victims of alcohol/drug-facilitated rape, 29.7 % of female and 32.4 % of male victims reported involuntary use of substances, mostly drugs; 84.0 % of female and 82.6 % of male victims reported voluntary use. Among male victims of alcohol/drug-facilitated MTP, 14.6 % reported involuntary and 85.4 % reported voluntary use of substances. Female and male victims reported that the majority of intimate partner, acquaintance, and stranger perpetrators were using substances during the victimization. These findings suggest the importance of prevention efforts at the individual and community levels to reduce substance-involved sexual violence perpetration and risk reduction programs to reduce the likelihood of voluntary substance-facilitated sexual violence victimization.

Differences in Head Impact Exposures Between Youth Tackle and Flag Football Games and Practices: Potential Implications for Prevention Strategies.

BACKGROUND: Interventions designed to reduce the risk for head impacts and concussion in youth football have increased over the past decade; however, understanding of the role of regular game play on head impact exposure among youth tackle and flag football athletes is currently limited. PURPOSE: To explore head impact exposure among youth tackle and flag football athletes (age range, 6-14 years) during both practices and games. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Using the Vector MouthGuard sensor, the authors collected head impact data from 524 tackle and flag youth football athletes over the course of a football season. Quantities of interest were estimated from regression models using Bayesian methods. RESULTS: For impacts ≥10g, a tackle football athlete had an estimated 17.55 (95% CI, 10.78-28.96) times more head impacts per practice compared with a flag football athlete (6.85 [95% CI, 6.05-7.76] and 0.39 [95% CI, 0.24-0.62] head impacts, respectively). Additionally, a tackle football athlete had an estimated 19.48 (95% CI, 12.74-29.98) times more head impacts per game compared with a flag football athlete (13.59 [95% CI, 11.97-15.41] and 0.70 [95% CI, 0.46-1.05] head impacts, respectively). Among tackle football athletes, the estimated average impact rate was 6.51 (95% CI, 5.75-7.37) head impacts during a practice and 12.97 (95% CI, 11.36-14.73) impacts during a game, resulting in 2.00 (95% CI, 1.74-2.29) times more ≥10g head impacts in games versus practices. Tackle football athletes had 2.06 (95% CI, 1.80-2.34) times more high-magnitude head impacts (≥40g) during a game than during a practice. On average, flag football athletes experienced an estimated 0.37 (95% CI, 0.20-0.60) head impacts during a practice and 0.77 (95% CI, 0.53-1.06) impacts during a game, resulting in 2.06 (95% CI, 1.29-3.58) times more ≥10g head impacts in games versus practices. Because of model instability caused by a large number of zero impacts for flag football athletes, a comparison of high-magnitude head impacts is not reported for practices or games. CONCLUSION: This study provides a characterization of the head impact exposure of practices and games among a large population of youth tackle and flag football athletes aged 6 to 14 years. These findings suggest that a greater focus on game-based interventions, such as fair play interventions and strict officiating, may be beneficial to reduce head impact exposures for youth football athletes.

Head Impact Exposures Among Youth Tackle and Flag American Football Athletes.

BACKGROUND: Promoted as a safer alternative to tackle football, there has been an increase in flag football participation in recent years. However, examinations of head impact exposure in flag football as compared with tackle football are currently limited. HYPOTHESIS: Tackle football athletes will have a greater number and magnitude of head impacts compared with flag football athletes. STUDY DESIGN: Cohort study. LEVEL OF EVIDENCE: Level 4. METHODS: Using mouthguard sensors, this observational, prospective cohort study captured data on the number and magnitude of head impacts among 524 male tackle and flag football athletes (6-14 years old) over the course of a single football season. Estimates of interest based on regression models used Bayesian methods to estimate differences between tackle and flag athletes. RESULTS: There were 186,239 head impacts recorded during the study. Tackle football athletes sustained 14.67 (95% CI 9.75-21.95) times more head impacts during an athletic exposure (game or practice) compared with flag football athletes. Magnitude of impact for the 50th and 95th percentile was 18.15g (17.95-18.34) and 52.55g (51.06-54.09) for a tackle football athlete and 16.84g (15.57-18.21) and 33.51g (28.23-39.08) for a flag football athlete, respectively. A tackle football athlete sustained 23.00 (13.59-39.55) times more high-magnitude impacts (≥40g) per athletic exposure compared with a flag football athlete. CONCLUSION: This study demonstrates that youth athletes who play tackle football are more likely to experience a greater number of head impacts and are at a markedly increased risk for high-magnitude impacts compared with flag football athletes. CLINICAL RELEVANCE: These results suggest that flag football has fewer head impact exposures, which potentially minimizes concussion risk, making it a safer alternative for 6- to 14-year-old youth football athletes.

Alcohol-impaired driving and children in the household.

More children in the United States are killed in motor vehicle crashes annually than by any other cause; nearly a quarter of these deaths involve alcohol. This study examines the national prevalence of alcohol-impaired driving and riding with an alcohol-impaired driver and the association of these behaviors to having at least 1 child in the household. An estimated 2.5 million adult drivers with children living in their households reported that they had been a recent alcohol-impaired driver. Evidence-based approaches, including mass media campaigns and sobriety checkpoints, continue to be critically important public health activities.

Belief about seat belt use and seat belt wearing behavior among front and rear seat passengers in the United States.

INTRODUCTION: Unrestrained drivers and passengers represent almost half of all passenger vehicle occupant deaths in the United States. The current study assessed the relationship between the belief about importance of seat belt use and the behavior of always wearing a seat belt. METHOD: Data from 2012 ConsumerStyles were analyzed separately for front and rear passenger seating positions. Multivariable regression models were constructed to identify the association between seat belt belief and behavior (i.e., always wears seat belt) among adults. Models controlled for type of state seat belt law (primary, secondary, or none). RESULTS: Seat belt use was higher in front passenger seats (86.1%) than in rear passenger seats (61.6%). Similarly, belief that seat belt use was very important was higher in reference to the front passenger seat (84.2%) versus the rear passenger seat (70.5%). For the front passenger seat, belief was significantly associated with seat belt use in states with both primary enforcement laws (adjPR 1.64) and secondary enforcement laws (adjPR 2.77). For the rear passenger seat, belief was also significantly associated with seat belt use, and two 2-way interactions were observed (belief by sex, belief by region). CONCLUSIONS: Despite overall high rates of seat belt use in the United States, certain groups are less likely to buckle up than others. The study findings suggest that efforts to increase seat belt use among high-risk populations, such as those who live in states with secondary or no seat belt laws and those who ride in rear seats (which include people who utilize taxis or ride-hailing vehicles) could benefit from interventions designed to strengthen beliefs related to the benefits of seat belt use. Practical applications: Future research that uses a theoretical framework to better understand the relationship between beliefs and behavior may inform interventions to improve seat belt use.

Self-reports of violent victimization among U.S. adults.

This article describes the prevalence of violent victimization and injuries among U.S. adults and examines how these estimates differ by individual- and household-level characteristics using the second nationally representative Injury Control and Risk Survey (ICARIS-2). The ICARIS-2 was administered to 9,684 adults using a computer assisted random-digit-dial telephone survey. These data suggest that 5.4% of the U.S. adult population, approximately 11.66 million people, experienced at least one violent victimization in the past 12 months. Most victims (57%) believed that the person who struck them intended to injure them, and one in three victims reported that they were physically injured on at least one occasion. Effective violence prevention strategies require the collection of valid data to understand the scope of the problem, the consequences, and the groups most impacted. The results from ICARIS-2 indicate that the prevalence of violent victimization in the United States far exceeds the estimates derived from crime surveys.

Rape-Related Pregnancy and Association With Reproductive Coercion in the U.S.

INTRODUCTION: Rape-related pregnancy is a public health problem where sexual violence and reproductive health intersect; yet, there is a dearth of research to inform public health practice. The authors examined the prevalence and characteristics of rape-related pregnancy in U.S. women and its association with intimate partner reproductive coercion. METHODS: Data years 2010-2012 are pooled from the National Intimate Partner and Sexual Violence Survey, a telephone survey of U.S. adults. Accounting for complex survey design, in 2017, authors estimated the prevalence of vaginal rape-related pregnancy for U.S. women overall and by race/ethnicity. The authors also examined the proportion of rape-related pregnancy among victims of vaginal rape overall, by perpetrator type and by presence of reproductive coercion in the context of intimate partner rape. RESULTS: Almost 2.9 million U.S. women (2.4%) experienced rape-related pregnancy during their lifetime. Among rape victims, 77.3% reported a current/former intimate partner perpetrator, and 26.2% of intimate partner rape victims reported rape-related pregnancy compared with those raped by an acquaintance (5.2%) or stranger (6.9%). Women raped by an intimate partner and reporting rape-related pregnancy were significantly more likely to have experienced reproductive coercion compared with women who were raped by an intimate partner but did not become pregnant. CONCLUSIONS: This paper reports the first national prevalence of rape-related pregnancy by any perpetrator in two decades. The high proportion of rape-related pregnancy committed by intimate partner perpetrators and its association with reproductive coercion suggest the need for primary prevention of intimate partner violence and access to trauma-informed reproductive health services for rape/intimate partner violence victims.

Characterizing Sexual Violence Victimization in Youth: 2012 National Intimate Partner and Sexual Violence Survey.

INTRODUCTION: Youth sexual violence victimization is an urgent public health concern that can lead to a variety of health problems and increased risk for victimization during adulthood. Examining the characteristics of early victimization and their association with subsequent victimization during adulthood may help strengthen primary prevention efforts. METHODS: Data are from the 2012 National Intimate Partner and Sexual Violence Survey. Prevalence estimates were computed in 2017 for rape and made to sexually penetrate, their subtypes, as well as proportions among victims by type of perpetrator. Chi-square tests of association were conducted between youth sexual violence victimization and the same experiences in adulthood. RESULTS: Approximately 10 million U.S. females (8.4%) experienced completed or attempted rape and 1.9 million U.S. males (1.6%) were made to penetrate someone during youth. Most victims knew their perpetrators. Being raped or made to penetrate during youth was associated with increased likelihood of such victimization in adulthood. CONCLUSIONS: Females and males experience youth sexual violence victimization at alarming rates. Primary prevention efforts with youth are critical to prevent early victimization, subsequent victimization in adulthood, and the mental and physical health consequences associated with sexual violence victimization.

Short-term Lost Productivity per Victim: Intimate Partner Violence, Sexual Violence, or Stalking.

INTRODUCTION: The purpose of this study is to estimate victims' lifetime short-term lost productivity because of intimate partner violence, sexual violence, or stalking. METHODS: U.S. nationally representative data from the 2012 National Intimate Partner and Sexual Violence Survey were used to estimate a regression-adjusted average per victim (female and male) and total population number of cumulative short-term lost work and school days (or lost productivity) because of victimizations over victims' lifetimes. Victims' lost productivity was valued using a U.S. daily production estimate. Analysis was conducted in 2017. RESULTS: Non-institutionalized adults with some lifetime exposure to intimate partner violence, sexual violence, or stalking (n=6,718 respondents; survey-weighted n=130,795,789) reported nearly 741 million lost productive days because of victimizations by an average of 2.5 perpetrators per victim. The adjusted per victim average was 4.9 (95% CI=3.9, 5.9) days, controlling for victim, perpetrator, and violence type factors. The estimated societal cost of this short-term lost productivity was $730 per victim, or $110 billion across the lifetimes of all victims (2016 USD). Factors associated with victims having a higher number of lost days included a higher number of perpetrators and being female, as well as sexual violence, physical violence, or stalking victimization by an intimate partner perpetrator, stalking victimization by an acquaintance perpetrator, and sexual violence or stalking victimization by a family member perpetrator. CONCLUSIONS: Short-term lost productivity represents a minimum economic valuation of the immediate negative effects of intimate partner violence, sexual violence, and stalking. Victims' lost productivity affects family members, colleagues, and employers.

Prevalence of residential smoke alarms and fire escape plans in the U.S.: results from the Second Injury Control and Risk Survey (ICARIS-2).

OBJECTIVES: This study was conducted to estimate (1) the proportion of U.S. homes with installed smoke alarms and fire escape plans, and (2) the frequency of testing home smoke alarms and of practicing the fire escape plans. METHODS: The authors analyzed data on smoke alarms and fire escape plans from a national cross-sectional random-digit dialed telephone survey of 9,684 households. RESULTS: Ninety-five percent of surveyed households reported at least one installed smoke alarm and 52% had a fire escape plan. The prevalence of alarms varied by educational level, income, and the presence of a child in the home. Only 15% tested their alarms once a month and only 16% of homes with an escape plan reported practicing it every six months. CONCLUSION: While smoke alarm prevalence in U.S. homes is high, only half of homes have a fire escape plan. Additional emphasis is needed on testing of installed smoke alarms and on preparedness for fire escape plans.

The future of random-digit-dial surveys for injury prevention and violence research.

A central issue facing injury prevention research today is how to collect self-reported data on injury and violence from a geographically dispersed public, quickly, cost effectively, and with a reasonable degree of confidence in the quality of the results. Questions about eroding frame coverage, declining participation rates, and increasing potential for bias have raised doubts about the long-term viability of random-digit-dial (RDD) telephone surveys for injury prevention research. So where does the future lie? The four articles in this volume, as well as other research, point down two paths: (1) continued reliance on RDD, or (2) adoption of alternative survey designs. Continued use of RDD methodology will require additional research in the areas of response rate improvement, techniques for enhancing post-survey adjustments, and cost-effective approaches to nonresponse bias analysis. Moving away from a strict reliance on RDD methodology, injury prevention research could adopt mixed-mode approaches (such as combining telephone, mail, and web-based surveys) or make use of address-based sampling frames as a method for reaching sample members currently missed by most RDD approaches. Either way, the future of collecting self-reports of injury and injury prevention data will be more complex and require considerable resources.

Psychological responses to the sniper attacks: Washington DC area, October 2002.

BACKGROUND: This study assessed the psychological and behavioral responses of residents of the Washington DC metropolitan area to the October 2002 sniper shootings, as well as the association between measures of exposure to the shootings and elevated traumatic stress symptoms. METHODS: Random-digit-dial telephone survey of 1205 adults living in Washington DC and two surrounding counties during the shootings, conducted May 2003. Main outcome measures included self-reports regarding traumatic stress symptoms, perceptions of safety, behavioral responses, and exposures to incidents. RESULTS: Forty-five percent of residents reported going to public spaces such as parks and shopping centers less than usual, and 5.5% reported missing at least 1 day of work because of the sniper attacks. Women who reported living within 5 miles of any shooting incident were significantly more likely to report elevated traumatic stress symptoms-consistent with a probable diagnosis of post-traumatic stress disorder-than women who reported living farther from incidents (odds ratio = 4.2, 95% confidence interval = 1.9-9.3). Among men, there was no significant association between reported residential proximity and elevated traumatic stress symptoms. CONCLUSIONS: These results suggest the substantial behavioral and psychological impact that traumatic events such as these sniper shootings can have on communities. They support the importance of clinicians and community leaders addressing psychological functioning in the setting of such events that threaten a population. The results further suggest that women who report residing closest to such incidents are at greatest risk for experiencing elevated symptoms of traumatic stress, and perhaps warrant special attention.