Behaviors Related to Unintentional and Intentional Injuries United States, 1991 Among High School Students
-
D
uring 1988, injuries were the leading cause of death among persons ages 15-19 in the United States, according to unpublished data from the Centers for Disease Control (CDC). Of all deaths in this age group, 42% were motor vehicle related, 13% were due to homicide, 13% to suicides, and 1 1 (70 to other types of injuries and adverse effects. This report presents 1991 selfreported data on the prevalence of selected behaviors, such as attempted suicide, physical fighting, weapon carrying, safety belt use, motorcycle helmet use, and bicycle helmet use, associated with these causes of death among U.S. ninth to 12th grade students. Data were collected from two school-based components of CDC's Youth Risk Behavior Surveillance System:' 1) state and local Youth Risk Behavior Surveys (YRBSs) conducted by departments of education in 23 states and 10 cities during spring 1991 (the District of Columbia, Puerto Rico, and the Virgin Islands are categorized as states for funding purposes) and 2) the national YRBS conducted during the same period. The 33 state and local sites drew probability samples from defined sampling frames of schools and students in grades 9-12. Seventeen sites had adequate school- and student-response rates, which allowed computation of weighted results of known precision; 16 sites had overall responses below 60% or unavailable documentation, which precluded making estimates of known precision. The national survey used a three-stage sample design to Reported by: J. Moore, EdD, Alabama Dept. of Education; J. Campana, MA, San Diego Uniyied School District; M . Lam, MS W, Son Francisco Unified School District; D. Sandau-Christopher, Colorado Dept. of Education; J. Sadler, MPH, District of Columbia Public Schools; D. Scalise, MS,School Board of Broward County; N. Gay, MS W, School Board of Dade County, Florida; R. Stalvey. MS, Georgia Dept. of Education; J. Schroeder, Hawaii Dept. of Education; J. Pelton, PhD, Idaho Dept. of Education; B. Johnson Biehr, MS,Chicago Public Schools; J. Harris, MEd, Iowa Dept. of Education; N. Strunk. MS, Boston Public Schools; R. Chiotti, Montana Office of Public Instruction; J . Owens-Nausler, PhD, Nebraska Dept. of Education; B. Grenert, MEd, New Hampshire Dept. of Education; D. Chioda. MS,Jersey City Board of Education; D. Cole, MEd, New Jersey Dept. of Education; K. Meurer, MS,New Mexico Dept. of Education; G. Abelson, CS W, New York City Board of Education; A . Sheffield, MPH, New York State Education Dept.; P. Ruzicka, PhD, Oregon Dept. of Education; C. Balsley, EdD, School District of Philadelphia; M. Sutter, PhD, Pennsylvania Dept. of Education; M. del Pilar Cherneco, MPH, Puerto Rico Dept. of Education; J. Fraser, EdD, South Carolina Dept. of Education; M . Cam, MS, South Dakota Depl. of Education and Cultural Affairs; E. Word, MA. Tennessee Dept. of Education; P. Simpson, PhD, Dallas Independent School District; L. Lacy, MS,Utah Office of Education; S. Tye, PhD, Government of the Virgin Islands Dept. of Education; B. NehlsLowe. MPH. Wisconsin Dept. of Public Instruction; B. Anderson, Wyoming Dept. of Education; National Centerfor Injury Prevention and Control; and the Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control. MS K-33, 1600 Clifton Road, NE, Atlanta, GA 30333. This article is adapted from MMWR. 1992;41(41):760-765, 771-772.
obtain a sample of 12,272 students representative of students in grades 9-12 in the 50 states and the District of Columbia. For the state and local surveys, school-response rates ranged from 48% to 100V0, student-response rates ranged from 44% to 96%,* and state and local sample sizes ranged from 369 to 5,834 students. Students in most samples were distributed evenly across grades and between genders, and the racial/ethnic characteristics of the samples varied. The school-response rate for the national survey was 75%, and the student-response rate was 90%. Suicide Attempts
Of students participating in the state and local surveys, 14% to 35Vo (median: 27%; national prevalence: 29%), had thought seriously about attempting suicide, 9% to 22% (median: 17%; national prevalence: 19%) had made a specific plan to attempt suicide, 5% to 12% (median: 8%; nationd prevalence: 7%) actudy attempted suicide, and 1Yo to 5% (median: 2%; national prevalence: 2%) made a suicide attempt that resulted in an injury or poisoning that had to be treated by a doctor or nurse (Table 1). In all sites, female students were more likely than male students to report having thought seriously about attempting suicide, made a suicide plan, attempted suicide one or more times, and made a suicide attempt that required medical attention. Physical Fighting and Weapon Carrying
Of students participating in the state and local surveys, 34% to 56% (median: 42%; national prevalence: 42%) had been in at least one physical fight during the 12 months preceding the survey (Table 2). In every site, male students were more likely than female students to report having been in a physical fight. The 12-month incident rate for physical fighting ranged from 102 incidents per 100 students to 202 incidents per 100 students (median: 140; national incidence: 137 per 100 students). Of participating students, 16% to 39% (median: 26%; national prevalence: 26%) carried a weapon such as a gun, knife, or club at least one day during the 30 days preceding the survey; among students who carried a weapon, 5% to 41% (median: 11%; national prevalence: 11 Yo) most often carried a handgun (Table 2). In every site, male students were more likely than female students to have carried a weapon. The 30-day incidence rate for weapon carrying ranged from 62 to 164 incidents per 100 students (median: 110; national incidence: 107 per 100 students). The incidence rate was calculated by adding the number of times each student reported being in a physi-
Journal of School Health
November 1992, Vol. 62, No. 9
439
cal fight during the 12 months preceding the survey or carrying a weapon during the 30 days preceding the survey and dividing this sum by the total number of students. The number of physical fighting or weapon carrying episodes per student was then multiplied by 100 to determine the incidence rate per 100 students. Students who replied they had fought two or three times were assigned a physical fighting frequency of 2.5; four or five times, 4.5; six or seven times, 6.5; eight or nine times, 8.5; 10 or 11 times, 10.5; and 12 or more times, 12. Students who replied they carried a weapon two or three days were assigned a weapon carrying frequency of 2.5; four or five days, 4.5; and six or more days, 6.
28%) “always” used safety belts when riding in a car or truck driven by someone else (Table 3). Among students who rode motorcycles, 10% to 59% (median: 36%; national prevalence: 39%) “always” wore motorcycle helmets. Among students who rode bicycles, 0.2% to 3% (median: 1Yo; national prevalence: 1Yo) “always”
wore bicycle helmets. Rates of safety belt, motorcycle helmet, and bicycle helmet use were similar for female and male students in most sites. Editorial Note: The findings in this report can be used to plan and evaluate broad national, state, and local interventions for injury prevention and to monitor progress toward achieving national health objectives for the year 2000 (objectives 6.2, 7.8, 7.9, 7.10, 9.12, and 9.13).3 However, because the quality of the samples varied among the state and local surveys, data across sites may not be comparable.
Safety Belt and Helmet Use
Of students participating in the state and local surveys, 7% to 54% (median: 22%; national prevalence:
Table 1 Percentage of High School Students Who Reported Having Thought Seriously about Suicide and Who Reported Suicidal Behavior,’ by Gender United States and Selected U.S. Sites, Youth Rlsk Behavior Surveys, 1991
-
Thought serlwsly about suklde Mak Female
Site WEIGHTED DATA National survey state surveys Alabama Georgia Idaho Nebraska New Mexico New York‘ Puerto Rico’ South Carolina South Dakota Utah
Local surveys Chicago Dallas Ft. Lauderdale. Fla. Jersey City, N.J. Miami Philadelphia San Diego
Mode suicide plans Male
Total
Female
Total
Ammpbd sulclde Female Mala
Total
Sulclde lttrmpt reaulred mad& ettentlonl Fenuk Male
Total
37
21
29
25
13
19
11
4
7
2
1
2
NA’
NA
NA
2
1
NA 21
NA
NA
NA
9 16 10 10 10 12 10
4 6 4 4 5 4 4
MA 6 NA 7 11 7 7 7 8 7
NA
11
NA 8 NA
NA
21
NA 16 NA 17 22 17 12 18 18 17
NA
17 21 21 22 20 15 20 23 19
MA 25 27 28 31 28 20 26 30 28
NA
33 34 36 40 36 24 31 37 32
2 4 3 2 3 4 3
2 2 1 1 2 1
NA 2 NA 2 3 2 1 2 2 2
30 32 30 39 32 32 35
20 17 22 30 19 18 22
25 25 27 35 26 26 28
22 19 18 24 19 21 22
13 9 12 13 11
18 14 15 19 15 16 17
11 9 8 15 9 11 10
8 4 4 6 4 4 3
10 7 6 11 7 8 6
4 4 2 7 2 3 3
3 2 0 4 1 1 2
4 3 1 5 2 2 2
37 27 41 35 39 38 31 36 35 34 18 37 37
20 19 25 22 22 23 20 19 20 23 10 24 22
28 24 33 29 31 31 28 28 28 29 14 31 30
25 19 28 24 26 24 22
13
12 10 15 9 12 12 11
5 6 8 5 5 6 6
NA
NA
NA
23 23 12 23 25
13 16 6 15 15
19 15 22 20 20 20 18 NA 18 19 9 19 20
NA 5
5 2 4 2 4 3 3 5 2 2
2 3 3 2 2 2 2 3 2 2
NA
NA
12 12
6 5 6 6
8 8 12 7 8 8 9 NA 7 8 5 8 8
3 4
2 2
3 3 3 2 3 3 2 4 2 2 MA 2 3
27 36 34
16 21 20
22 29 27
17 24 20
10 12 10
14 18 16
9 12 10
4 4 5
7 8 8
2 2 4
2 2 1
2 2 2
30 23 16 20 24 21
13 15 11 8 13 13 12
8
11
4 NA
1
UNWEIGHTED DATA SbtS SUNOYS
Colorado. District of Columbia’ Hawaii Iowa Montana New Hampshire New Jersey‘ Oregon Pennsylvania‘ Tennessee Virgin Islands’ Wisconsin Wyoming Local surveys Boston New York City San Francisco
11
16 15 14 16
14
’During the 12 months preceding the survey. ’Resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse. ’Not available; survey did not include these questions. ‘Survey did not include students from the largest city. ’Categorized as a state for funding purposes.
440
Journal of School Health
November 1992, Vol. 62, No. 9
9 11 5
Objectives 6.2 and 7.8 are to reduce by 15% the incidence of injurious suicide attempts that required medical attention among adolescents ages 14-17. Based on results from the 1991 national YRBS, the annual prevalence of injurious suicide attempts will need to be reduced from 2.0% to 1.4% by the year 2000 to meet the objectives. Only two sites have met these objectives. Objective 7.9 is to reduce by 20% the incidence of physical fighting among adolescents ages 14-17; based on the 1991 national YRBS, the 12-month incidence must decline from 137 to 110 or fewer episodes per 100 students by the year 2000. Only one site has met this criteria. Objective 7.10 is to reduce by 20% the incidence of
weapon carrying by adolescents ages 14-17. To meet this objective by the year 2O00, the 30-day incidence rate must be reduced from 107 to 86 or fewer episodes per 100 students. Six sites have met this objective. Objective 9.12 is to increase to at least 85% the proportion of motor vehicle occupants who use occupant-protection systems, and objective 9.13 is to increase use of helmets to at least 80% among motorcyclists and at least 50% among bicyclists. In all 33 sites, the prevalence of safety belt, motorcycle helmet, and bicycle helmet use is substantially below these objectives. Comprehensive health education programs in elementary, middle, and secondary schools may help meet the national health objectives. These programs should
Table 2 Percentage of High School Students Who Were in a Physical FigM,' Carried a Weapon,' or Carried a Handgun Most Often,' and the Incidence of Physical Fighting4 and Weapon Carrying' per 100 Students, by Gender United States and Selected U.S. Sites, Youth Risk Behavior Surveys, 1991
-
~~
She
In a physlwl flgM Female Mab Total
12-month Incidence ol physlul HgMing Femab Mah Total
Carhd a wwpon Fernlo Male Tab1
Carrkd a handgun molt often Femab Mab Total
30-day Incldenc8 of wwpon urrylng Female Male Total
WEIDHTEO DATA N i t l o ~SUNO~ l
34
50
42
103
170
131
11
41
26
7
12
11
40
172
101
Sbto sumys Alabama Georgia Idaho Nebraska New Mexico New York' Puerto Rico' South Carolina South Dakota Utah
28 31 34 33 37 38 26 32 34 33
47 48 52 50 54 50 43 51 47 51
38 39 44 42 46 44 34 42 40 42
80 89 118 110 102 133 74 91 107 123
150 154 188 177 195 179 134 180 161 185
115 122 151 144 152 151 102 136 134 154
9 8 9 5 10 11 7 12 6
57 46
7
52 42 46 39 32 50 43 42
33 21 32 24 29 25 1n 31 25 24
8 7 7 3 9 3 13 8 10 5
10 15 9 11 11 6 18 17 9 11
10 14 1 11 11 5 11 15 9 10
36 36 32 19 35 44 23 48 21 23
266 210 232 179 20 1 164 128 221 190 175
151 122 140 99 124 104 12 134 108 98
LDul surveys Chicago Dallas Ft. Lauderdaie, Fla. Jersey City. N.J. Miami Philadelphia San Diego UNWEIQHTEO DATA
44 41 31 46 35 51 32
60 53 45 51 48 62 44
51 47 31
4a
141 133 93 128 104 144 98
167 196 154 215 150 218 152
202 164 120 169 128 111 126
23 16 6 26 14 26 12
44 45 29 52 35 49 34
33 30 16 39 24 38 23
7 28 8 4 20 6 5
31 46 18 26 25 28 13
23 41 15 18 23 19 11
99 63 23 103 48 112 44
177 185 109 228 134 213 124
131 122 62 164 91 158
Colorado' District of Columbia' Hawaii Iowa Montana New Hampshire New Jersey' Oregon Pennsylvania' Tennessee Virgin Islands' Wisconsin Wyoming
36 40 35 35 34 25 34 28 34 31 NA' 35 36
48 49 44 50 50 42 51 42 46 45 NA 51 52
42 44 40 42 42 34 42 35 40 38 NA 43 44
97 112 121 110 124 88 98 89 115 96
131 131 147 147 145 118 142 121 140 122 NA 144 155
10 28 7
48 39 36 42
29 34 22 23
11 7 10 7 8 10 NA 7 10
50
30
41 30 44 45 51 NA 37 50
25 19 26 21 30 NA 22 31
4 8 8 5 8 7 7 8 5 5 NA 7 5
11 46 12 6 10 8 13 9 7 11 NA 13 8
10 29 11 1 9 8 12 9 6 10 NA 12 1
38 122 26 14 41 30 35 28 30 44 NA 28 45
214 173 142 182 222 172 120 187 182 233 NA 147 234
129 148
110 118
174 162 172 182 167 146 189 149 162 150 NA 179 188
81 144
30 38 29
45 46 42
36 42 35
86 122 91
168 166 145
122 153 117
17 21 12
39 42 30
21 31 21
3 7 10
18 15 12
13 12 12
72 a4 47
174 186 119
117 134 02
41 56 39
a4
sm SUNWS
NA
5
a4 % 129 102 15 110 109 136
NA
LDul sumys
Boston New York City San Francisco
'At least one fight during the 12 months preceding the survey. 'At least one day during the 30 days preceding the survey. 'Rather than any other weapon such as a rifle, shotgun, knife, razor, or club, among those who carried a weapon. 'Students who reported fighting two or three times were assigned a fighting frequency of 2.5; four or five times, 4.5; six or seven times, 6.5; eight or nine times, 8.5; 10 or 11 times, 10.5; and 12 or more times, 12. 8Studentswho replied that they carried a weapon two or three days were assigned a weapon-carrying frequency of 2.5; four or five days, 4.5; and six or more days, 6. 'Survey did not include students from the largest city. 'Categorized as a state for funding purposes. 'Not available; survey did not include these questions.
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November 1992, Vol. 62, No. 9
441
include information about the warning signs of suicide and suicide prevention services, teach nonviolent conflict resolution skills, discourage physical fighting and weapons carrying, and promote the use of safety belts and helmets to prevent motor vehicle injurie~.~ Other strategies that have been employed in the school setting to reduce weapon carrying are random locker searches, walk-throughs with metal detectors, and policies requiring clear plastic or mesh book bags so weapons cannot be concealed easily.‘ Complementary educational and legal strategies are needed at the community level, including decreasing the cultural acceptance of ~iolence,~ decreasing aggressive behavior between parents and children,6 reducing the exposure of children and adolescents to violence in the media,’ and improving the recognition of children and adolescents at high risk for assaults.s Gatekeeper training and screening programs can help identify youth at
risk for suicide and refer them to mental health services.I Legislation that requires safety belt and helmet use among adolescents and adults is needed in every state.’ National health objective 9.14 calls for the enactment and enforcement of laws requiring safety belt and helmet use for persons of all ages. Increasing the use of safety belts, use of motorcycle and bicycle helmets, and the practice of other safety precautions among adolescents will require cooperative efforts by local and state health, traffic safety, and education officials, families, medical practitioners, retailers, community agencies rn serving youth, and legislators. References 1 . Kolbe LJ. An epidemiological surveillance system to monitor the prevalence of youth behaviors that most affect health. Heulth
Table 3 Percentage of High School Students who Reported “Always” Using Safety Belts,’ Motorcycle Helmets,* or Bicycle Helmets,’ by Gender United States and Selected U.S. Shes, Youth Risk Behavior Surveys, 1991
-
Slte
Safety Bell Use Female Male
Total
Motorcycle Helmet Use Female Mils
Total
Bicycle Helmet Use Female Male
Total
WEIGHTED OATA Natlonal r u ~ e y
29.5
25.9
27.7
41.1
38.2
39.3
0.9
1.2
1.1
state rurvsya Alabama Georgia Idaho Nebraska New Mexico New York‘ Puerio Rico5 South Carolina South Oakola Ulah
20.0 31.4 19.9 10.2 33.9 31.1 25.5 30.8 6.2 24.2
11.8 25.5 15.4 7.6 27.5 28.4 23.1 23.6 7.0 19.0
15.9 28.4 17.5 8.9 30.5 29.7 24.3 27.2
40.4 36.9 34.4 29.2 26.4 54.3 20.5 22.7 27.0 25.0
41.6 38.3 32.5 33.1 24.8 57.5 22.4 28.3 24.2 24.0
0.7 1.6
0.9 1.4 1.2
0.8
0.8
0.6
21.6
44.7 41.2 28.9 41.7 21.7 64.6 25.3 34.0 20.6 22.6
1.2 1 .o 1 .o 1 .o 0.5 1.9
0.9 0.8 0.7 0.8 0.3 1.4
LOMI SUNOyS Chicago Dallas Fl Lauderdale. Fla Jersey City N J Miami Philadelphia San Oiego
12.6 37.5 29.3 12.0 22.8 12.7 44.7
9.4 35.8 28.1 7.9 19.9
11.0 36.6
17.4 30.5
14.4 28.8 54.1 58.9
1.3 0.5 2.1
0.8 1.3 0.4 1.9
0.8
0.6
42.2
35.2
0.8 1.3 0.2 1.6 0.3 0.5 1.5
0.8
39.7
12.1 28.0 50.7 59.3 39.6 39.5 32.4
0.9 2.4
0.7 2.0
22.6 20.1 57.4 17.1 18.2 24.5 30.3 60.1 35.8 30.0
19.7 15.6 50.1 12.7 15.2 21.8 26.4 48.3 27.5 24.8
24.9 53.7 16.1 10.3 24.2 56.2 54.6 59.0 55.0 43.8
24.8 41.8 14.6 10.1 27.1 51.0
1.2
0.9 1.7
40.6 33.2
24.7 38.7 14.0 10.0 29.1 48.1 56.9 49.6 39.1 35.5 40.4 29.2 40.5
1 .o 1.3 0.7 0.4 0.9 1.2 1.5 2.7 1.3 0.9 NA 0.2 0.7
41.7 36.8 10.4
42.8 38.1 15.2
42.2 37.6 13.4
UNWEIGHTED DATA State surveys Colorado‘ District of Columbia’ Hawaii Iowa Montana New Hampshire New Jersey‘ Oregon Pennsylvania‘ Tennessee Virgin Islands’ Wisconsin Wyoming
Local surveys Boston New York City San Francisco
6.6
8.6
NA’
NA
21.7 17.3
19.7 13.7
21.1 18.0 53.7 15.0 16.7 23.2 28.4 54.0 31.4 27.5 NA 20.7 15.4
10.3 15.9 30.5
7.7 13.7 29.3
9.3 14.8 29.9
I When riding in a car or truck driven by someone else ‘Among students who rode motorcycles )Among students who rode bicycles ‘Survey did not include students from the largest city ’Categorized as a state for funding purposes Wot available, survey did not include these questions
442
Journal of School Health
November 1992, Vol. 62, No. 9
50.0
40.8 39.2 33.6
56.0 52.6 43.6 38.3 43.2 33.8 38.1
0.6
0.4 0.4 0.6
0.4 0.6
0.1 0.8
0.6
0.4 0.1 0.9 0.4 0.8
1.9 0.8 0.6 NA 0.0
0.3
0.8 0.7
0.9 1.8 2.2 3.4 1.6 1.3 NA
0.3 1.0
0.8
1.0
0.7 1.1
0.8
2.1
1.5 0.9
0.9 0.7 1.7
Educ. 1990,21:44-48. 2. Centers for Disease Control. Participation in school physical education and selected dietary patterns among high school students United States, 1991. MMWR. 1992;41(33):597-601, 607. 3. US Public Health Service. Healthy People 2000; National health promotion and disease prevention objectives - full report, with commentary. Washington, DC: US Dept of Health and Human Services publication (PHS) 91-50212; 1991. 4. Office of Juvenile Justice and Delinquency Prevention. Weapons in School. Washington, DC: US Dept of Justice; 1989.
5. National Committee for Injury Prevention and Control. Injury prevention: Meeting the challenge. Am J Prev Med. 1985;5(suppl): 192-203. 6.Widom CS. The cycle of violence. Science. 1989;244:160-166. 7. Television and Behavior: Ten years of scientific progress and implication for the eighties, summary report, Vol 1. Rockville, Md: National Institute of Mental Health; 1982. 8. Centers for Disease Control. Youth Suicide Prevention Program: A resource guide. Atlanta, Ga: US Dept of Health and Human Services; to be published. ~~
ASHA Regional Conference - The American School Health Association and the Arizona School Health Association will co-sponsor a conference April 30 - May 1, 1993. The Crescent Hotel in Phoenix is the conference site. For more information, contact: Robert J. Synovitz, HSD, American School Health Association, P.O. Box 708, Kent, OH 44240;216/678-1601.
A S H A
P A R T N E R S
These institutions and corporationshave expressed their commitment to and support of comprehensive school health programs by joining with the American School Health Association as an ASHA Partner. The contributionsof ASHA Partners enable ASHA to continue to shape standards of practice for school nurses, physicians, and health educators, to maintain highquality education programs, and to conduct and report research on the cuttingedge.
President's Diamond Endowment Partner
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Burroughs Wellcome, 3030 CornwallisRoad, Research Triangle Park, NC 27709
Platinum Endowment Partner
+
McCovern Fund for the Behavioral Sciences, 6969 Brompton, Houston, TX 77025
Gold Endowment Partner
+ + +
Consumer Health Care Division of Pfizer, Inc., New York, NY 10017 Mead JohnsonLaboratories, 2400 West Lloyd Expressway, Evansville, IN 47221 Tambrands, Inc., One Marcus Ave., Lake Success, NY 11042
Silver Endowment Partner
+ + +
Dept. of Applied Health Science, Indiana University, Bloomington, IN 47405 Dept. of Health Education, The Pennsylvania State University, University Park, PA 16802 Dept. of Health Science Education, University of Florida, Cainesville, FL 32611
Century Partner
+ + + + +
Commercial Press, Inc., 115 S.Depeyster St., Kent, OH 44240 Harcourt Brace Jovanovich,School Dept., 3rd Floor, Orlando, FL 32887 Home Savings Bank, P.O. Box 310, Kent, OH 44240 Kleidon & Associates, 525 Cleveland-MassilonRoad, Akron, OH 44333 Mosby-Year Book, Inc., 11830 Westline Industrial Drive, St. Louis, MO 63146
Journal of School Health
November 1992, Vol. 62, No. 9
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-
D
uring 1988, injuries were the leading cause of death among persons ages 15-19 in the United States, according to unpublished data from the Centers for Disease Control (CDC). Of all deaths in this age group, 42% were motor vehicle related, 13% were due to homicide, 13% to suicides, and 1 1 (70 to other types of injuries and adverse effects. This report presents 1991 selfreported data on the prevalence of selected behaviors, such as attempted suicide, physical fighting, weapon carrying, safety belt use, motorcycle helmet use, and bicycle helmet use, associated with these causes of death among U.S. ninth to 12th grade students. Data were collected from two school-based components of CDC's Youth Risk Behavior Surveillance System:' 1) state and local Youth Risk Behavior Surveys (YRBSs) conducted by departments of education in 23 states and 10 cities during spring 1991 (the District of Columbia, Puerto Rico, and the Virgin Islands are categorized as states for funding purposes) and 2) the national YRBS conducted during the same period. The 33 state and local sites drew probability samples from defined sampling frames of schools and students in grades 9-12. Seventeen sites had adequate school- and student-response rates, which allowed computation of weighted results of known precision; 16 sites had overall responses below 60% or unavailable documentation, which precluded making estimates of known precision. The national survey used a three-stage sample design to Reported by: J. Moore, EdD, Alabama Dept. of Education; J. Campana, MA, San Diego Uniyied School District; M . Lam, MS W, Son Francisco Unified School District; D. Sandau-Christopher, Colorado Dept. of Education; J. Sadler, MPH, District of Columbia Public Schools; D. Scalise, MS,School Board of Broward County; N. Gay, MS W, School Board of Dade County, Florida; R. Stalvey. MS, Georgia Dept. of Education; J. Schroeder, Hawaii Dept. of Education; J. Pelton, PhD, Idaho Dept. of Education; B. Johnson Biehr, MS,Chicago Public Schools; J. Harris, MEd, Iowa Dept. of Education; N. Strunk. MS, Boston Public Schools; R. Chiotti, Montana Office of Public Instruction; J . Owens-Nausler, PhD, Nebraska Dept. of Education; B. Grenert, MEd, New Hampshire Dept. of Education; D. Chioda. MS,Jersey City Board of Education; D. Cole, MEd, New Jersey Dept. of Education; K. Meurer, MS,New Mexico Dept. of Education; G. Abelson, CS W, New York City Board of Education; A . Sheffield, MPH, New York State Education Dept.; P. Ruzicka, PhD, Oregon Dept. of Education; C. Balsley, EdD, School District of Philadelphia; M. Sutter, PhD, Pennsylvania Dept. of Education; M. del Pilar Cherneco, MPH, Puerto Rico Dept. of Education; J. Fraser, EdD, South Carolina Dept. of Education; M . Cam, MS, South Dakota Depl. of Education and Cultural Affairs; E. Word, MA. Tennessee Dept. of Education; P. Simpson, PhD, Dallas Independent School District; L. Lacy, MS,Utah Office of Education; S. Tye, PhD, Government of the Virgin Islands Dept. of Education; B. NehlsLowe. MPH. Wisconsin Dept. of Public Instruction; B. Anderson, Wyoming Dept. of Education; National Centerfor Injury Prevention and Control; and the Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control. MS K-33, 1600 Clifton Road, NE, Atlanta, GA 30333. This article is adapted from MMWR. 1992;41(41):760-765, 771-772.
obtain a sample of 12,272 students representative of students in grades 9-12 in the 50 states and the District of Columbia. For the state and local surveys, school-response rates ranged from 48% to 100V0, student-response rates ranged from 44% to 96%,* and state and local sample sizes ranged from 369 to 5,834 students. Students in most samples were distributed evenly across grades and between genders, and the racial/ethnic characteristics of the samples varied. The school-response rate for the national survey was 75%, and the student-response rate was 90%. Suicide Attempts
Of students participating in the state and local surveys, 14% to 35Vo (median: 27%; national prevalence: 29%), had thought seriously about attempting suicide, 9% to 22% (median: 17%; national prevalence: 19%) had made a specific plan to attempt suicide, 5% to 12% (median: 8%; nationd prevalence: 7%) actudy attempted suicide, and 1Yo to 5% (median: 2%; national prevalence: 2%) made a suicide attempt that resulted in an injury or poisoning that had to be treated by a doctor or nurse (Table 1). In all sites, female students were more likely than male students to report having thought seriously about attempting suicide, made a suicide plan, attempted suicide one or more times, and made a suicide attempt that required medical attention. Physical Fighting and Weapon Carrying
Of students participating in the state and local surveys, 34% to 56% (median: 42%; national prevalence: 42%) had been in at least one physical fight during the 12 months preceding the survey (Table 2). In every site, male students were more likely than female students to report having been in a physical fight. The 12-month incident rate for physical fighting ranged from 102 incidents per 100 students to 202 incidents per 100 students (median: 140; national incidence: 137 per 100 students). Of participating students, 16% to 39% (median: 26%; national prevalence: 26%) carried a weapon such as a gun, knife, or club at least one day during the 30 days preceding the survey; among students who carried a weapon, 5% to 41% (median: 11%; national prevalence: 11 Yo) most often carried a handgun (Table 2). In every site, male students were more likely than female students to have carried a weapon. The 30-day incidence rate for weapon carrying ranged from 62 to 164 incidents per 100 students (median: 110; national incidence: 107 per 100 students). The incidence rate was calculated by adding the number of times each student reported being in a physi-
Journal of School Health
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439
cal fight during the 12 months preceding the survey or carrying a weapon during the 30 days preceding the survey and dividing this sum by the total number of students. The number of physical fighting or weapon carrying episodes per student was then multiplied by 100 to determine the incidence rate per 100 students. Students who replied they had fought two or three times were assigned a physical fighting frequency of 2.5; four or five times, 4.5; six or seven times, 6.5; eight or nine times, 8.5; 10 or 11 times, 10.5; and 12 or more times, 12. Students who replied they carried a weapon two or three days were assigned a weapon carrying frequency of 2.5; four or five days, 4.5; and six or more days, 6.
28%) “always” used safety belts when riding in a car or truck driven by someone else (Table 3). Among students who rode motorcycles, 10% to 59% (median: 36%; national prevalence: 39%) “always” wore motorcycle helmets. Among students who rode bicycles, 0.2% to 3% (median: 1Yo; national prevalence: 1Yo) “always”
wore bicycle helmets. Rates of safety belt, motorcycle helmet, and bicycle helmet use were similar for female and male students in most sites. Editorial Note: The findings in this report can be used to plan and evaluate broad national, state, and local interventions for injury prevention and to monitor progress toward achieving national health objectives for the year 2000 (objectives 6.2, 7.8, 7.9, 7.10, 9.12, and 9.13).3 However, because the quality of the samples varied among the state and local surveys, data across sites may not be comparable.
Safety Belt and Helmet Use
Of students participating in the state and local surveys, 7% to 54% (median: 22%; national prevalence:
Table 1 Percentage of High School Students Who Reported Having Thought Seriously about Suicide and Who Reported Suicidal Behavior,’ by Gender United States and Selected U.S. Sites, Youth Rlsk Behavior Surveys, 1991
-
Thought serlwsly about suklde Mak Female
Site WEIGHTED DATA National survey state surveys Alabama Georgia Idaho Nebraska New Mexico New York‘ Puerto Rico’ South Carolina South Dakota Utah
Local surveys Chicago Dallas Ft. Lauderdale. Fla. Jersey City, N.J. Miami Philadelphia San Diego
Mode suicide plans Male
Total
Female
Total
Ammpbd sulclde Female Mala
Total
Sulclde lttrmpt reaulred mad& ettentlonl Fenuk Male
Total
37
21
29
25
13
19
11
4
7
2
1
2
NA’
NA
NA
2
1
NA 21
NA
NA
NA
9 16 10 10 10 12 10
4 6 4 4 5 4 4
MA 6 NA 7 11 7 7 7 8 7
NA
11
NA 8 NA
NA
21
NA 16 NA 17 22 17 12 18 18 17
NA
17 21 21 22 20 15 20 23 19
MA 25 27 28 31 28 20 26 30 28
NA
33 34 36 40 36 24 31 37 32
2 4 3 2 3 4 3
2 2 1 1 2 1
NA 2 NA 2 3 2 1 2 2 2
30 32 30 39 32 32 35
20 17 22 30 19 18 22
25 25 27 35 26 26 28
22 19 18 24 19 21 22
13 9 12 13 11
18 14 15 19 15 16 17
11 9 8 15 9 11 10
8 4 4 6 4 4 3
10 7 6 11 7 8 6
4 4 2 7 2 3 3
3 2 0 4 1 1 2
4 3 1 5 2 2 2
37 27 41 35 39 38 31 36 35 34 18 37 37
20 19 25 22 22 23 20 19 20 23 10 24 22
28 24 33 29 31 31 28 28 28 29 14 31 30
25 19 28 24 26 24 22
13
12 10 15 9 12 12 11
5 6 8 5 5 6 6
NA
NA
NA
23 23 12 23 25
13 16 6 15 15
19 15 22 20 20 20 18 NA 18 19 9 19 20
NA 5
5 2 4 2 4 3 3 5 2 2
2 3 3 2 2 2 2 3 2 2
NA
NA
12 12
6 5 6 6
8 8 12 7 8 8 9 NA 7 8 5 8 8
3 4
2 2
3 3 3 2 3 3 2 4 2 2 MA 2 3
27 36 34
16 21 20
22 29 27
17 24 20
10 12 10
14 18 16
9 12 10
4 4 5
7 8 8
2 2 4
2 2 1
2 2 2
30 23 16 20 24 21
13 15 11 8 13 13 12
8
11
4 NA
1
UNWEIGHTED DATA SbtS SUNOYS
Colorado. District of Columbia’ Hawaii Iowa Montana New Hampshire New Jersey‘ Oregon Pennsylvania‘ Tennessee Virgin Islands’ Wisconsin Wyoming Local surveys Boston New York City San Francisco
11
16 15 14 16
14
’During the 12 months preceding the survey. ’Resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse. ’Not available; survey did not include these questions. ‘Survey did not include students from the largest city. ’Categorized as a state for funding purposes.
440
Journal of School Health
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9 11 5
Objectives 6.2 and 7.8 are to reduce by 15% the incidence of injurious suicide attempts that required medical attention among adolescents ages 14-17. Based on results from the 1991 national YRBS, the annual prevalence of injurious suicide attempts will need to be reduced from 2.0% to 1.4% by the year 2000 to meet the objectives. Only two sites have met these objectives. Objective 7.9 is to reduce by 20% the incidence of physical fighting among adolescents ages 14-17; based on the 1991 national YRBS, the 12-month incidence must decline from 137 to 110 or fewer episodes per 100 students by the year 2000. Only one site has met this criteria. Objective 7.10 is to reduce by 20% the incidence of
weapon carrying by adolescents ages 14-17. To meet this objective by the year 2O00, the 30-day incidence rate must be reduced from 107 to 86 or fewer episodes per 100 students. Six sites have met this objective. Objective 9.12 is to increase to at least 85% the proportion of motor vehicle occupants who use occupant-protection systems, and objective 9.13 is to increase use of helmets to at least 80% among motorcyclists and at least 50% among bicyclists. In all 33 sites, the prevalence of safety belt, motorcycle helmet, and bicycle helmet use is substantially below these objectives. Comprehensive health education programs in elementary, middle, and secondary schools may help meet the national health objectives. These programs should
Table 2 Percentage of High School Students Who Were in a Physical FigM,' Carried a Weapon,' or Carried a Handgun Most Often,' and the Incidence of Physical Fighting4 and Weapon Carrying' per 100 Students, by Gender United States and Selected U.S. Sites, Youth Risk Behavior Surveys, 1991
-
~~
She
In a physlwl flgM Female Mab Total
12-month Incidence ol physlul HgMing Femab Mah Total
Carhd a wwpon Fernlo Male Tab1
Carrkd a handgun molt often Femab Mab Total
30-day Incldenc8 of wwpon urrylng Female Male Total
WEIDHTEO DATA N i t l o ~SUNO~ l
34
50
42
103
170
131
11
41
26
7
12
11
40
172
101
Sbto sumys Alabama Georgia Idaho Nebraska New Mexico New York' Puerto Rico' South Carolina South Dakota Utah
28 31 34 33 37 38 26 32 34 33
47 48 52 50 54 50 43 51 47 51
38 39 44 42 46 44 34 42 40 42
80 89 118 110 102 133 74 91 107 123
150 154 188 177 195 179 134 180 161 185
115 122 151 144 152 151 102 136 134 154
9 8 9 5 10 11 7 12 6
57 46
7
52 42 46 39 32 50 43 42
33 21 32 24 29 25 1n 31 25 24
8 7 7 3 9 3 13 8 10 5
10 15 9 11 11 6 18 17 9 11
10 14 1 11 11 5 11 15 9 10
36 36 32 19 35 44 23 48 21 23
266 210 232 179 20 1 164 128 221 190 175
151 122 140 99 124 104 12 134 108 98
LDul surveys Chicago Dallas Ft. Lauderdaie, Fla. Jersey City. N.J. Miami Philadelphia San Diego UNWEIQHTEO DATA
44 41 31 46 35 51 32
60 53 45 51 48 62 44
51 47 31
4a
141 133 93 128 104 144 98
167 196 154 215 150 218 152
202 164 120 169 128 111 126
23 16 6 26 14 26 12
44 45 29 52 35 49 34
33 30 16 39 24 38 23
7 28 8 4 20 6 5
31 46 18 26 25 28 13
23 41 15 18 23 19 11
99 63 23 103 48 112 44
177 185 109 228 134 213 124
131 122 62 164 91 158
Colorado' District of Columbia' Hawaii Iowa Montana New Hampshire New Jersey' Oregon Pennsylvania' Tennessee Virgin Islands' Wisconsin Wyoming
36 40 35 35 34 25 34 28 34 31 NA' 35 36
48 49 44 50 50 42 51 42 46 45 NA 51 52
42 44 40 42 42 34 42 35 40 38 NA 43 44
97 112 121 110 124 88 98 89 115 96
131 131 147 147 145 118 142 121 140 122 NA 144 155
10 28 7
48 39 36 42
29 34 22 23
11 7 10 7 8 10 NA 7 10
50
30
41 30 44 45 51 NA 37 50
25 19 26 21 30 NA 22 31
4 8 8 5 8 7 7 8 5 5 NA 7 5
11 46 12 6 10 8 13 9 7 11 NA 13 8
10 29 11 1 9 8 12 9 6 10 NA 12 1
38 122 26 14 41 30 35 28 30 44 NA 28 45
214 173 142 182 222 172 120 187 182 233 NA 147 234
129 148
110 118
174 162 172 182 167 146 189 149 162 150 NA 179 188
81 144
30 38 29
45 46 42
36 42 35
86 122 91
168 166 145
122 153 117
17 21 12
39 42 30
21 31 21
3 7 10
18 15 12
13 12 12
72 a4 47
174 186 119
117 134 02
41 56 39
a4
sm SUNWS
NA
5
a4 % 129 102 15 110 109 136
NA
LDul sumys
Boston New York City San Francisco
'At least one fight during the 12 months preceding the survey. 'At least one day during the 30 days preceding the survey. 'Rather than any other weapon such as a rifle, shotgun, knife, razor, or club, among those who carried a weapon. 'Students who reported fighting two or three times were assigned a fighting frequency of 2.5; four or five times, 4.5; six or seven times, 6.5; eight or nine times, 8.5; 10 or 11 times, 10.5; and 12 or more times, 12. 8Studentswho replied that they carried a weapon two or three days were assigned a weapon-carrying frequency of 2.5; four or five days, 4.5; and six or more days, 6. 'Survey did not include students from the largest city. 'Categorized as a state for funding purposes. 'Not available; survey did not include these questions.
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441
include information about the warning signs of suicide and suicide prevention services, teach nonviolent conflict resolution skills, discourage physical fighting and weapons carrying, and promote the use of safety belts and helmets to prevent motor vehicle injurie~.~ Other strategies that have been employed in the school setting to reduce weapon carrying are random locker searches, walk-throughs with metal detectors, and policies requiring clear plastic or mesh book bags so weapons cannot be concealed easily.‘ Complementary educational and legal strategies are needed at the community level, including decreasing the cultural acceptance of ~iolence,~ decreasing aggressive behavior between parents and children,6 reducing the exposure of children and adolescents to violence in the media,’ and improving the recognition of children and adolescents at high risk for assaults.s Gatekeeper training and screening programs can help identify youth at
risk for suicide and refer them to mental health services.I Legislation that requires safety belt and helmet use among adolescents and adults is needed in every state.’ National health objective 9.14 calls for the enactment and enforcement of laws requiring safety belt and helmet use for persons of all ages. Increasing the use of safety belts, use of motorcycle and bicycle helmets, and the practice of other safety precautions among adolescents will require cooperative efforts by local and state health, traffic safety, and education officials, families, medical practitioners, retailers, community agencies rn serving youth, and legislators. References 1 . Kolbe LJ. An epidemiological surveillance system to monitor the prevalence of youth behaviors that most affect health. Heulth
Table 3 Percentage of High School Students who Reported “Always” Using Safety Belts,’ Motorcycle Helmets,* or Bicycle Helmets,’ by Gender United States and Selected U.S. Shes, Youth Risk Behavior Surveys, 1991
-
Slte
Safety Bell Use Female Male
Total
Motorcycle Helmet Use Female Mils
Total
Bicycle Helmet Use Female Male
Total
WEIGHTED OATA Natlonal r u ~ e y
29.5
25.9
27.7
41.1
38.2
39.3
0.9
1.2
1.1
state rurvsya Alabama Georgia Idaho Nebraska New Mexico New York‘ Puerio Rico5 South Carolina South Oakola Ulah
20.0 31.4 19.9 10.2 33.9 31.1 25.5 30.8 6.2 24.2
11.8 25.5 15.4 7.6 27.5 28.4 23.1 23.6 7.0 19.0
15.9 28.4 17.5 8.9 30.5 29.7 24.3 27.2
40.4 36.9 34.4 29.2 26.4 54.3 20.5 22.7 27.0 25.0
41.6 38.3 32.5 33.1 24.8 57.5 22.4 28.3 24.2 24.0
0.7 1.6
0.9 1.4 1.2
0.8
0.8
0.6
21.6
44.7 41.2 28.9 41.7 21.7 64.6 25.3 34.0 20.6 22.6
1.2 1 .o 1 .o 1 .o 0.5 1.9
0.9 0.8 0.7 0.8 0.3 1.4
LOMI SUNOyS Chicago Dallas Fl Lauderdale. Fla Jersey City N J Miami Philadelphia San Oiego
12.6 37.5 29.3 12.0 22.8 12.7 44.7
9.4 35.8 28.1 7.9 19.9
11.0 36.6
17.4 30.5
14.4 28.8 54.1 58.9
1.3 0.5 2.1
0.8 1.3 0.4 1.9
0.8
0.6
42.2
35.2
0.8 1.3 0.2 1.6 0.3 0.5 1.5
0.8
39.7
12.1 28.0 50.7 59.3 39.6 39.5 32.4
0.9 2.4
0.7 2.0
22.6 20.1 57.4 17.1 18.2 24.5 30.3 60.1 35.8 30.0
19.7 15.6 50.1 12.7 15.2 21.8 26.4 48.3 27.5 24.8
24.9 53.7 16.1 10.3 24.2 56.2 54.6 59.0 55.0 43.8
24.8 41.8 14.6 10.1 27.1 51.0
1.2
0.9 1.7
40.6 33.2
24.7 38.7 14.0 10.0 29.1 48.1 56.9 49.6 39.1 35.5 40.4 29.2 40.5
1 .o 1.3 0.7 0.4 0.9 1.2 1.5 2.7 1.3 0.9 NA 0.2 0.7
41.7 36.8 10.4
42.8 38.1 15.2
42.2 37.6 13.4
UNWEIGHTED DATA State surveys Colorado‘ District of Columbia’ Hawaii Iowa Montana New Hampshire New Jersey‘ Oregon Pennsylvania‘ Tennessee Virgin Islands’ Wisconsin Wyoming
Local surveys Boston New York City San Francisco
6.6
8.6
NA’
NA
21.7 17.3
19.7 13.7
21.1 18.0 53.7 15.0 16.7 23.2 28.4 54.0 31.4 27.5 NA 20.7 15.4
10.3 15.9 30.5
7.7 13.7 29.3
9.3 14.8 29.9
I When riding in a car or truck driven by someone else ‘Among students who rode motorcycles )Among students who rode bicycles ‘Survey did not include students from the largest city ’Categorized as a state for funding purposes Wot available, survey did not include these questions
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50.0
40.8 39.2 33.6
56.0 52.6 43.6 38.3 43.2 33.8 38.1
0.6
0.4 0.4 0.6
0.4 0.6
0.1 0.8
0.6
0.4 0.1 0.9 0.4 0.8
1.9 0.8 0.6 NA 0.0
0.3
0.8 0.7
0.9 1.8 2.2 3.4 1.6 1.3 NA
0.3 1.0
0.8
1.0
0.7 1.1
0.8
2.1
1.5 0.9
0.9 0.7 1.7
Educ. 1990,21:44-48. 2. Centers for Disease Control. Participation in school physical education and selected dietary patterns among high school students United States, 1991. MMWR. 1992;41(33):597-601, 607. 3. US Public Health Service. Healthy People 2000; National health promotion and disease prevention objectives - full report, with commentary. Washington, DC: US Dept of Health and Human Services publication (PHS) 91-50212; 1991. 4. Office of Juvenile Justice and Delinquency Prevention. Weapons in School. Washington, DC: US Dept of Justice; 1989.
5. National Committee for Injury Prevention and Control. Injury prevention: Meeting the challenge. Am J Prev Med. 1985;5(suppl): 192-203. 6.Widom CS. The cycle of violence. Science. 1989;244:160-166. 7. Television and Behavior: Ten years of scientific progress and implication for the eighties, summary report, Vol 1. Rockville, Md: National Institute of Mental Health; 1982. 8. Centers for Disease Control. Youth Suicide Prevention Program: A resource guide. Atlanta, Ga: US Dept of Health and Human Services; to be published. ~~
ASHA Regional Conference - The American School Health Association and the Arizona School Health Association will co-sponsor a conference April 30 - May 1, 1993. The Crescent Hotel in Phoenix is the conference site. For more information, contact: Robert J. Synovitz, HSD, American School Health Association, P.O. Box 708, Kent, OH 44240;216/678-1601.
A S H A
P A R T N E R S
These institutions and corporationshave expressed their commitment to and support of comprehensive school health programs by joining with the American School Health Association as an ASHA Partner. The contributionsof ASHA Partners enable ASHA to continue to shape standards of practice for school nurses, physicians, and health educators, to maintain highquality education programs, and to conduct and report research on the cuttingedge.
President's Diamond Endowment Partner
+
Burroughs Wellcome, 3030 CornwallisRoad, Research Triangle Park, NC 27709
Platinum Endowment Partner
+
McCovern Fund for the Behavioral Sciences, 6969 Brompton, Houston, TX 77025
Gold Endowment Partner
+ + +
Consumer Health Care Division of Pfizer, Inc., New York, NY 10017 Mead JohnsonLaboratories, 2400 West Lloyd Expressway, Evansville, IN 47221 Tambrands, Inc., One Marcus Ave., Lake Success, NY 11042
Silver Endowment Partner
+ + +
Dept. of Applied Health Science, Indiana University, Bloomington, IN 47405 Dept. of Health Education, The Pennsylvania State University, University Park, PA 16802 Dept. of Health Science Education, University of Florida, Cainesville, FL 32611
Century Partner
+ + + + +
Commercial Press, Inc., 115 S.Depeyster St., Kent, OH 44240 Harcourt Brace Jovanovich,School Dept., 3rd Floor, Orlando, FL 32887 Home Savings Bank, P.O. Box 310, Kent, OH 44240 Kleidon & Associates, 525 Cleveland-MassilonRoad, Akron, OH 44333 Mosby-Year Book, Inc., 11830 Westline Industrial Drive, St. Louis, MO 63146
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