Preventive Medicine 74 (2015) 9–13
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Prevention counseling among pediatric patients presenting with unintentional injuries to physicians' offices' in the United States Bart Hammig ⁎, Kristen Jozkowski Community Health Promotion, University of Arkansas, 306 HPER Building, Fayetteville, AR 72701, United States
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Available online 7 February 2015 Keywords: Injury Pediatric Primary care Prevention Health education
a b s t r a c t Objectives. There is increasing emphasis on preventive care delivery among primary care providers. In accordance with this, health education approaches have been shown to positively influence patients' behavior. As injuries are the leading public health problem among youth, primary care providers may play a critical role in the prevention of unintentional injuries among their pediatric populations. Method. Data from the 2007–2010 National Ambulatory Medical Care Survey (NAMCS) were used to examine patient visits presenting to physicians' offices with unintentional injuries. The prevalence of the delivery of injury prevention counseling was assessed, as were factors associated with the provision of injury prevention education. Results. Findings indicated that injury prevention counseling was low. Overall, 14.6% of patients presenting with an unintentional injury received injury prevention counseling. Gender differences were notable, with 8% of injured girls receiving injury education compared to 18% of boys. Results of multivariable logistic regression analyses revealed odds of injury counseling to be 2.4 times more likely among boys when compared to girls (OR = 2.4; 95% CI: 1.2–4.6). Conclusion. Findings indicate that physician counseling about injury prevention was low. Reasons for the findings are discussed, as are issues related to gender differences in injury risk and prevention. © 2015 Elsevier Inc. All rights reserved.
Introduction Unintentional injuries continue to be a salient public health issue, particularly for youth as children and adolescents are disproportionately affected (Hu and Baker, 2009). Unintentional injuries remain the leading cause of death in the United States for persons aged 1–44, with an estimated 2.8 million hospitalizations and 32 million emergency department (ED) visits annually (Centers for Disease Control and Prevention, 2012). Among pediatric populations, rates of fatal and non-fatal unintentional injuries tend to vary by gender and age. In general, boys have a higher rate of both fatal and non-fatal unintentional injuries compared to girls, and older youth (15–19 years old) experience higher rates of unintentional injury compared to younger youth (5–9 years old). Specifically, in regard to gender, in 2012, boys, aged 0–19, had a mortality rate of 12.9 per 100,000 due to injury, while girls of the same age had a rate of 7.1 per 100,000 (Centers for Disease Control and Prevention, 2012). Similar patterns for non-fatal unintentional injuries were reported among youth treated in EDs. Boys had an estimated rate of 12,411 per 100,000 whereas girls had a rate of 9387 per 100,000 (Centers for Disease Control and Prevention, 2012). When stratifying rates of unintentional injury by both age and gender, rates ⁎ Corresponding author. Fax: +1 479 575 5778. E-mail address: [email protected] (B. Hammig).
http://dx.doi.org/10.1016/j.ypmed.2015.02.001 0091-7435/© 2015 Elsevier Inc. All rights reserved.
of non-fatal injuries treated in EDs in 2012 ranged from a low of 12,339 per 100,000 among boys aged 5–9 to a high of 19,710 per 100,000 for boys aged 15–19. A similar pattern emerged for girls, though the rates were lower; rates ranged from a low of 8868 per 100,000 for girls aged 5–9 to a high of 12,788 for girls aged 15–19 (Centers for Disease Control and Prevention, 2012). Additionally, boys and men are more likely to die from injury compared to girls and women (Sorenson, 2011). The clear gender disparity and generally high rates of unintentional injury among youth undoubtedly warrant continued attention. There is extensive research identifying reasons why rates of unintentional injury remain high for children and adolescents in general and especially high for boys specifically. First, children and adolescents are at an increased risk of engaging in health-risk behaviors (e.g., riding a bicycle without a helmet; riding in the car without a seat belt) that contribute to unintentional injury resulting in morbidity and mortality (Eaton et al., 2012). The propensity toward risk-taking theory is often utilized to contextualize the link between youth and risk taking behavior. The theory suggests that youth engage in risky behaviors (e.g., driving faster than the speed limit, engaging in “dare devil” stunts, skipping school) because they do not understand the long term ramifications of their behavior (Pharo et al., 2011; Racz et al., 2011). More specifically in regard to gender, several theories exist which attempt to explain the disparity to exposure to and death
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from unintentional injury. Gender differences in cognitive development, impulsivity, and personality (Bijttebier et al., 2003; Schwebel and Gaines, 2007) have been found to play a role in injury occurrence and propensity toward risk-taking behaviors. For example, Granie (2010) found that conforming to masculine stereotypes, even among three to six year old children, predicted engagement in risk-taking behavior that could result in injury. Such findings highlight the importance of gender–role socialization as boys are more likely to adopt masculine stereotypes and personality characteristics and, thus, are at an increased risk for engaging in behaviors resulting in injury. Social and environmental factors have also been linked to behaviors resulting in unintentional injury. For example, expectations and assumptions that boys should or will engage in more risk-taking behavior than girls can result in boys actually engaging in more risk-taking behavior. Additionally, Collins et al. (2013) found that boys age 0–17 years were more likely to engage in high intensity risk-taking behaviors and less likely to use protective equipment during these behaviors compared to girls. Motivation for engaging in such behaviors without the use of protection equipment may stem from the perception that “boys are tough,” and should ignore the ramifications of injury. Parental factors may also play a role in contributing to the gender disparity in unintentional injuries. Research suggests that parents apply more direct supervision to girls compared to boys during play and associate risk as being inherently part of boy-play, but not girl-play (Hagan and Kuebli, 2007; Morrongiello et al., 2000; Morrongiello and Rennie, 1998; Morrongiello et al., 2009). These types of gender biases perpetuate the belief that injuries are not preventable occurrences, especially among boys; however this is not the case. Although rates of unintentional injuries remain high, they can be prevented. Primary prevention through health education and promotion can increase engagement in preventative health behaviors and reduce risk-taking behaviors. Interestingly, the American Academy of Pediatrics outlines formal recommendations for health education and health promotion in their Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. According to this report, healthcare providers should be engaging in age-appropriate health education and health promotion with patients and/or parents during well-child physicians' visits. Unfortunately, many physicians do not meet these guidelines (Cabana et al., 1999) and when education is conducted, findings indicate that physicians do a poor job of counseling overall due to lack of confidence, knowledge and counseling skills (Leventer-Roberts et al., 2005; Schauer et al., 2014). In addition, research suggests that evidence-based practices were rarely utilized when conducting health education and other allied care professionals were also under-utilized or referred to for counseling (Schauer et al., 2014). However, when health education is conducted in the form of health counseling using evidence-based techniques, patient attitudes and behaviors showed a significant improvement in relation to weight control (Cox et al., 2011) and smoking (Ridner et al., 2014). In 2011, as part of the Affordable Care Act, the U.S. Surgeon General announced the National Prevention and Health Promotion Strategy (2011) to place an increased emphasis on prevention and health promotion efforts among a variety of constituents, including the healthcare community. One of the Surgeon General's priorities is for healthcare providers to offer education and skills-training to individuals and families specifically related to injury prevention with the goal of providing the necessary tools to make safer choices that prevent injuries (2011). However, little is known about the extent to which physicians currently engage in prevention tactics with patients or intervene when patients present with problems that suggest risky behavior resulting in injury. Additionally, little research has examined the extent to which gender stereotypes and biases presented by parents (i.e., boys will be boys and rough house; boys are at greater risk for actually getting hurt) extend into the healthcare community and influence the way in which health education counseling and care is provided.
Unlike many public health problems, the prevention of unintentional injuries presents unique challenges due to the variety of circumstances that can precipitate an injury, as well as the multitude of etiologic factors involved. For example, prevention of bicycle related injuries among children would require a somewhat different set of prevention tactics when compared to the prevention of poison-related injuries among children. Nonetheless, when treating pediatric patients who present with injuries, the primary care physician may serve an important role in the prevention of recurring injuries as the incident may serve as a teachable moment for both children and their caregivers. Given the importance of preventing unintentional injuries and the lack of information currently available, we sought to examine the prevalence and related factors associated with health education counseling by primary care physicians who treated pediatric patients presenting with unintentional injuries. Methods Sample Utilizing data from the National Ambulatory Medical Care Survey (NAMCS), we analyzed visits made to physicians' offices in the U.S. from 2007 through 2010. Participants were patients aged birth to 17 years who presented with an unintentional injury to a participating physician's office setting. The NAMCS is maintained by the Centers for Disease Control and Prevention's National Center for Health Statistics. A multistage, national probability sample design was employed for the NAMCS involving 112 geographic primary sampling units, physicians' practices within the primary sampling units, and patient visits within the practices. Data collection was completed using a patient record form completed by trained staff. A more detailed explanation of the NAMCS methodology has been published for further reference (McCaig and McLemore, 1994). Measures Patients presenting with unintentional injury visits were identified if the primary ICD-9-CM external cause of injury code (E code) was within the range of E800–E869, or E880–E929 (Centers for Disease Control and Prevention, 2013). Injury prevention counseling was measured by dichotomous response to a checkbox item provided on the patient record form (PRF). The item, under a section titled “Health Education,” stated “Mark all ordered or provided at this visit.” If the option “injury prevention” was checked, then the patient had received injury prevention counseling. Other variables utilized in the current analyses included age group, stratified into 4 categories: infant (aged b 1), toddler (aged 1–3), child (aged 4–11), and adolescent (aged 12–17), gender, race, primary source of payment, region, number of visits in the past 12 months, length of visit in minutes, whether the attending physician was the patient's primary care physician, and whether or not any imaging service was ordered (X-ray, CT scan, etc.) Data analysis Because of the complex multistage design, sample weights were employed for each sampled patient visit to produce unbiased national annualized estimates. The sampling weights have been adjusted by the National Center for Health Statistics (NCHS) for nonresponse, geographic region, physician specialty, metropolitan statistical area, and seasonality of the reporting period. Standard errors were determined using STATA MP 11 software. In addition, all records in the data files were included in the analysis to obtain the correct sample variance estimates. Because the NAMCS is a record based survey, population based incidence and prevalence estimates cannot be calculated. Rather, the figures reported are the average annual visits. All other reported estimates were also annualized. Bivariate and multivariate logistic regression models were implemented to examine the relationship between the provision of injury prevention counseling and selected covariates. Odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs) were calculated. Goodness of fit of the logistic models was assessed by methods proposed by Archer and Lemeshow (2006) that take into account the cluster sample design of the survey data. Collinearity diagnostics among the independent variables were assessed. Finally, interaction terms were created and examined for each pair of covariates. This study was approved by our Institutional Review Board.
B. Hammig, K. Jozkowski / Preventive Medicine 74 (2015) 9–13
Results Overall, 27.3 million unintentional injury visits were identified during the study period, which is equivalent to an average annual estimate of 6.8 million visits between 2007 and 2010 for children aged birth through 17 years. Findings indicated that health education pertaining to injury prevention was lacking. Overall, 14.6% (11.1–18.8) of patients presenting with an unintentional injury received injury prevention counseling. Descriptive analyses are presented in Table 1. Findings from bivariate and multivariate analyses indicated that gender was the only significant factor associated with injury prevention counseling. When controlling for all other variables in the model, the odds that injury prevention education occurred was 2.4 times more likely among injured boys when compared to injured girls (OR = 2.4; 95% CI: 1.2–4.6). See Table 2. Discussion The current study examined predictors of injury-related health education counseling by primary healthcare providers who saw patients presenting with an injury-related health issue. Although it has been well-documented that unintentional injury is the leading cause of morbidity and mortality in the US among children and adolescents (Centers Table 1 Injury prevention education among pediatric patients presenting with unintentional injuries to physician's office settings, United States, 2007–2010 (N = 27,311a). No
Yes
% (95% CI)
% (95% CI)
Gender Female Male
92.1 (86.8–95.3) 81.7 (75.7–86.5)
8.0 (4.7–13.2) 18.3 (13.5–24.3)
Age group b1 1–3 4–11 12–17
81.8 (44.7–96.2) 81.3 (66.1–90.6) 86.7 (81.9–90.8) 85.4 (79.3–90.0)
18.2 (3.8–55.3) 18.7 (9.4–33.9) 13.3 (9.2–19.0) 14.6 (10.2–20.7)
Race White Black Other
84.4 (78.1–89.2) 83.1 (65.7–92.6) 89.9 (83.9–94.2)
15.6 (10.8–21.9) 16.9 (7.4–34.3) 10.1 (5.8–17.0)
Payment method Private Medicaid Self-pay Other
87.6 (83.5–90.8) 85.0 (74.8–91.5) 65.0 (42.2–82.5) 68.0 (34.9–89.4)
12.4 (9.2–16.5) 15.0 (8.5–25.2) 35.0 (17.5–57.8) 32.0 (10.6–65.1)
Patients primary care physician was the attending No 87.0 (80.6–91.5) Yes 83.6 (77.0–88.6)
13.0 (8.5–19.4) 16.4 (11.4–23.0)
Imaging No Yes
85.0 (79.1–89.5) 85.9 (79.4–90.6)
15.0 (10.5–20.9) 14.1 (9.4–20.6)
Region Northeast Midwest South West
84.4 (68.7–93.0) 87.3 (81.0–91.7) 87.3 (80.5–91.9) 80.9 (70.5–88.3)
15.6 (7.0 (31.3) 12.7 (8.3–19.0) 12.7 (8.1–19.5) 19.1 (11.7–18.8)
Length of visit ≤7 min 8–15 min ≥16 min
85.5 (77.8–90.8) 88.2 (81.4–92.8) 81.0 (72.9–87.0)
14.5 (9.2–22.2) 11.8 (7.3–18.6) 19.0 (13.0–27.1)
# Visits past year 0 1 2–3 3 or more
85.0 (62.3–95.1) 79.5 (70.2–86.5) 86.5 (78.2–92.0) 82.0 (73.8–88.1)
15.0 (4.92–37.7) 20.5 (13.5–29.8) 13.5 (8.0–21.8) 18.0 (11.9–26.2)
a
Total number of visits in thousands.
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Table 2 Factors associated with injury prevention counseling provisions among pediatric patients presenting with unintentional injuries to physician's office settings, United States, 2007– 2010 (N = 6828a). Model 1a OR (95% CI)
Model 2 b,c
OR (95% CI)c
Gender Female Male
1.0 2.6 (1.3–4.9)
1.0 2.4 (1.2–4.6)
Age group b1 1–3 4–11 12–17
1.0 1.0 (0.2–6.0) 0.7 (0.1–4.1) 0.8 (0.1–4.6)
1.0 1.2 (0.6–2.3) .4 (.07–1.7) 0.5 (0.1–2.2)
Race White Black Other
1.0 1.1 (0.4–3.1) 4.8 (1.3–17.4)
1.0 1.2 (0.5–3.1) 4.4 (1.1–17.4)
Payment method Private Medicare/Medicaid Self-pay Other
1.0 1.3 (0.7–2.4) 3.8 (1.5–10.0) 3.3 (0.8–13.7)
1.0 1.2 (0.6–2.3) 3.7 (1.4–9.7) 2.7 (0.5–13.8)
Patients primary care physician was the attending No 1.0 Yes 1.0 (0.9–1.1)
1.0 1.0 (0.9–1.1)
Imaging No Yes
1.0 0.9 (0.5–1.7)
1.0 1.0 (0.6–1.9)
Region Northeast Midwest South West
1.0 0.8 (0.3–2.1) 0.8 (0.3–2.2) 1.3 (0.4–3.7)
1.0 0.7 (0.2–2.0) 0.6 (0.2–1.8) 1.0 (0.3–2.8)
Length of visit ≤7 min 8–15 min ≥16 min
1.0 0.8 (0.4–1.6) 1.4 (0.7–2.8)
1.0 0.8 (0.4–1.6) 1.5 (0.7–3.2)
# Visits past year 0 1 2–3 3 or more
1.0 1.4 (0.4–5.5) 0.9 (0.2–3.3) 1.2 (0.3–4.7)
– – – –
a Model 1 is bivariate analyses; model 2 is adjusted for all listed variables except # of past visits due to collinearity. b OR indicates odds ratio; value in parentheses indicates 95% confidence intervals. c Modeling injury prevention counseling = “yes”.
for Disease Control and Prevention, 2012), our findings indicate that health education related to injury prevention is markedly low. Less than 15% of the patients who presented with a health problem stemming from an injury received any kind of health education or health counseling regarding the prevention of injuries from their healthcare provider. These findings, though discouraging, may not be surprising given that previous research indicates that healthcare providers' delivery of health education during well-child visits was also relatively low and does not meet recommended standards (Yarnall et al., 2003). The well-child visit is intended to be a time for healthcare providers to answer questions and offer general health education (Abdus and Selden, 2013). If providers are failing to offer adequate health education and meet the recommended standards during the well-child visit, a time which is explicitly designated for health education, it may be expected that they would also fall short in terms of offering health education or health counseling during visits when patients present with an ailment. Our findings do suggest, however, that healthcare providers offer more education/counseling to boys (and/or their parent/caregiver) who present with an injury in comparison to girls (and/or their parent/caregiver) who present with an injury. On the one hand, this
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can be viewed positively given that boys are more likely to experience an unintended injury and thus may be more likely to experience reinjury. On the other hand, these findings could suggest that healthcare providers hold similar biases related to gender socialization and risk for injury which may infringe on their likelihood to counsel their female patients (and/or parent/caregiver). Regardless of gender, healthcare providers should be offering more health education than is currently being offered with regard to patients presenting with unintentional injuries. Given that healthcare providers have been encouraged to participate in increased health education efforts (Weinehall et al., 2014) and unintentional injury remains a salient public health issue, why are injuryspecific health education provisions so low? When examining other health issues, research suggests that patients respond positively to physicians' counseling on health matters such as tobacco use, physical activity, dietary behaviors, and weight loss (Butler et al., 2013; Sim et al., 2009; Thijs, 2007). Furthermore, training primary care providers in health education delivery and behavior change approaches has been shown to positively influence patients' behavior change intentions, without requiring an excessive amount of the providers' time (Butler et al., 2013). However, injury-specific education is unique. Overall, injuries may be more difficult to counsel patients on compared to tobacco or weight loss due to the wider variety of injury circumstances. That is, the category of “unintentional injuries” is so vast; unintentional injuries could include, motor vehicle accidents (MVA), falls, injuries associated with the use of equipment (e.g., lawn mowers, snow blowers), injuries associated with recreation (e.g., water skiing, hang gliding, roller blading, bicycling), and more. Thus, different strategies and tactics should be implemented based on different behaviors. Evidence-based prevention practices specific to injuries exist and research indicates that parents respond positively to health education in general (Jhanjee et al., 2004). However, utilization among physicians is low and this should be further investigated in future studies. Time constraints experienced by physicians may be another reason more providers do not offer injury-related counseling/education. Previous research suggests that time availability is the main predictor of whether physicians engage in health education with patients, and consistently healthcare providers seem to lack adequate time to devote to health education (Yarnall et al., 2003). In fact, Yarnall et al. (2003) found that if physicians met recommendations for prevented health services, they need to devote over 7 h per working day to such services. Devoting this amount of time to preventative services, while important, is simply unrealistic. Riesch et al. (2013) suggests involving not only physicians in primary prevention education, but also nurses, nurse practitioners and public health professionals. Given that physicians may not have the available time or feel as comfortable providing health education to parents (Yarnall et al., 2003), it may actually be beneficial for public health professionals, and health educators in particular, to provide such counseling. In this vein, offering health coaching or direct health education in the physicians' clinic or office may provide an ideal solution. That is, after a medical consultation, the physician could refer patients to health educators to provide more in-depth follow up information and answers to any questions patients (or parents/caregivers) may have. Shifting this responsibility from the physician solely to other healthcare professionals including health educators has been recommended by others as well (Bodenheimer and Smith, 2013; Yarnall et al., 2003). Because health educators have specific training in offering health information and health counseling in this format, they may be better equipped and feel more comfortable accomplishing this task which would in turn reduce the amount of time physicians would need to spend on prevention and education with their patients. Study limitations It is important to note the limitations which apply to the study. As is always the case, nonsampling errors, such as reporting and processing
errors, as well as nonresponse, are inherent in all surveys. More specific to the current study, the quality or quantity of the education provided by physicians concerning the topics examined was not assessed; we could only report on whether it was or was not provided during the visit in question. Therefore, we also cannot establish what preventive practices, if any, occurred during prior office visits. We also could not decipher if the provider or the patient initiated discussion regarding a select health behavior. Some estimates may be tenuous based on wide confidence intervals, as evidenced in Table 1. Future studies would benefit from ascertaining the source of the initial discussion as well as assessing the quality of the education provided. Conclusion Injuries are preventable, with known risk and protective factors, and antecedents (Liller, 2012). However, our findings show that very few physicians are engaging their patients in preventive counseling around the issue of injuries. The prevention of injuries requires a multifactorial approach, adopting from public health, medicine, education and other disciplines. More specifically, health education, implementation of evidence-based intervention, improved surveillance efforts, adaptations in the physical environmental, changes in public policy, and improvements in product design and availability are a few of the factors that may serve an important role in the prevention of unintentional injuries. Although patient education alone may not prevent and control subsequent injuries in pediatric populations, it may be an important first step in the process of injury prevention. Future studies should investigate the effect of increasing physician injury prevention counseling on unintentional injury rates among pediatric patients. Conflict of interest statement The authors declare that there are no conflicts of interests.
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Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Prevention counseling among pediatric patients presenting with unintentional injuries to physicians' offices' in the United States Bart Hammig ⁎, Kristen Jozkowski Community Health Promotion, University of Arkansas, 306 HPER Building, Fayetteville, AR 72701, United States
a r t i c l e
i n f o
Available online 7 February 2015 Keywords: Injury Pediatric Primary care Prevention Health education
a b s t r a c t Objectives. There is increasing emphasis on preventive care delivery among primary care providers. In accordance with this, health education approaches have been shown to positively influence patients' behavior. As injuries are the leading public health problem among youth, primary care providers may play a critical role in the prevention of unintentional injuries among their pediatric populations. Method. Data from the 2007–2010 National Ambulatory Medical Care Survey (NAMCS) were used to examine patient visits presenting to physicians' offices with unintentional injuries. The prevalence of the delivery of injury prevention counseling was assessed, as were factors associated with the provision of injury prevention education. Results. Findings indicated that injury prevention counseling was low. Overall, 14.6% of patients presenting with an unintentional injury received injury prevention counseling. Gender differences were notable, with 8% of injured girls receiving injury education compared to 18% of boys. Results of multivariable logistic regression analyses revealed odds of injury counseling to be 2.4 times more likely among boys when compared to girls (OR = 2.4; 95% CI: 1.2–4.6). Conclusion. Findings indicate that physician counseling about injury prevention was low. Reasons for the findings are discussed, as are issues related to gender differences in injury risk and prevention. © 2015 Elsevier Inc. All rights reserved.
Introduction Unintentional injuries continue to be a salient public health issue, particularly for youth as children and adolescents are disproportionately affected (Hu and Baker, 2009). Unintentional injuries remain the leading cause of death in the United States for persons aged 1–44, with an estimated 2.8 million hospitalizations and 32 million emergency department (ED) visits annually (Centers for Disease Control and Prevention, 2012). Among pediatric populations, rates of fatal and non-fatal unintentional injuries tend to vary by gender and age. In general, boys have a higher rate of both fatal and non-fatal unintentional injuries compared to girls, and older youth (15–19 years old) experience higher rates of unintentional injury compared to younger youth (5–9 years old). Specifically, in regard to gender, in 2012, boys, aged 0–19, had a mortality rate of 12.9 per 100,000 due to injury, while girls of the same age had a rate of 7.1 per 100,000 (Centers for Disease Control and Prevention, 2012). Similar patterns for non-fatal unintentional injuries were reported among youth treated in EDs. Boys had an estimated rate of 12,411 per 100,000 whereas girls had a rate of 9387 per 100,000 (Centers for Disease Control and Prevention, 2012). When stratifying rates of unintentional injury by both age and gender, rates ⁎ Corresponding author. Fax: +1 479 575 5778. E-mail address: [email protected] (B. Hammig).
http://dx.doi.org/10.1016/j.ypmed.2015.02.001 0091-7435/© 2015 Elsevier Inc. All rights reserved.
of non-fatal injuries treated in EDs in 2012 ranged from a low of 12,339 per 100,000 among boys aged 5–9 to a high of 19,710 per 100,000 for boys aged 15–19. A similar pattern emerged for girls, though the rates were lower; rates ranged from a low of 8868 per 100,000 for girls aged 5–9 to a high of 12,788 for girls aged 15–19 (Centers for Disease Control and Prevention, 2012). Additionally, boys and men are more likely to die from injury compared to girls and women (Sorenson, 2011). The clear gender disparity and generally high rates of unintentional injury among youth undoubtedly warrant continued attention. There is extensive research identifying reasons why rates of unintentional injury remain high for children and adolescents in general and especially high for boys specifically. First, children and adolescents are at an increased risk of engaging in health-risk behaviors (e.g., riding a bicycle without a helmet; riding in the car without a seat belt) that contribute to unintentional injury resulting in morbidity and mortality (Eaton et al., 2012). The propensity toward risk-taking theory is often utilized to contextualize the link between youth and risk taking behavior. The theory suggests that youth engage in risky behaviors (e.g., driving faster than the speed limit, engaging in “dare devil” stunts, skipping school) because they do not understand the long term ramifications of their behavior (Pharo et al., 2011; Racz et al., 2011). More specifically in regard to gender, several theories exist which attempt to explain the disparity to exposure to and death
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from unintentional injury. Gender differences in cognitive development, impulsivity, and personality (Bijttebier et al., 2003; Schwebel and Gaines, 2007) have been found to play a role in injury occurrence and propensity toward risk-taking behaviors. For example, Granie (2010) found that conforming to masculine stereotypes, even among three to six year old children, predicted engagement in risk-taking behavior that could result in injury. Such findings highlight the importance of gender–role socialization as boys are more likely to adopt masculine stereotypes and personality characteristics and, thus, are at an increased risk for engaging in behaviors resulting in injury. Social and environmental factors have also been linked to behaviors resulting in unintentional injury. For example, expectations and assumptions that boys should or will engage in more risk-taking behavior than girls can result in boys actually engaging in more risk-taking behavior. Additionally, Collins et al. (2013) found that boys age 0–17 years were more likely to engage in high intensity risk-taking behaviors and less likely to use protective equipment during these behaviors compared to girls. Motivation for engaging in such behaviors without the use of protection equipment may stem from the perception that “boys are tough,” and should ignore the ramifications of injury. Parental factors may also play a role in contributing to the gender disparity in unintentional injuries. Research suggests that parents apply more direct supervision to girls compared to boys during play and associate risk as being inherently part of boy-play, but not girl-play (Hagan and Kuebli, 2007; Morrongiello et al., 2000; Morrongiello and Rennie, 1998; Morrongiello et al., 2009). These types of gender biases perpetuate the belief that injuries are not preventable occurrences, especially among boys; however this is not the case. Although rates of unintentional injuries remain high, they can be prevented. Primary prevention through health education and promotion can increase engagement in preventative health behaviors and reduce risk-taking behaviors. Interestingly, the American Academy of Pediatrics outlines formal recommendations for health education and health promotion in their Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. According to this report, healthcare providers should be engaging in age-appropriate health education and health promotion with patients and/or parents during well-child physicians' visits. Unfortunately, many physicians do not meet these guidelines (Cabana et al., 1999) and when education is conducted, findings indicate that physicians do a poor job of counseling overall due to lack of confidence, knowledge and counseling skills (Leventer-Roberts et al., 2005; Schauer et al., 2014). In addition, research suggests that evidence-based practices were rarely utilized when conducting health education and other allied care professionals were also under-utilized or referred to for counseling (Schauer et al., 2014). However, when health education is conducted in the form of health counseling using evidence-based techniques, patient attitudes and behaviors showed a significant improvement in relation to weight control (Cox et al., 2011) and smoking (Ridner et al., 2014). In 2011, as part of the Affordable Care Act, the U.S. Surgeon General announced the National Prevention and Health Promotion Strategy (2011) to place an increased emphasis on prevention and health promotion efforts among a variety of constituents, including the healthcare community. One of the Surgeon General's priorities is for healthcare providers to offer education and skills-training to individuals and families specifically related to injury prevention with the goal of providing the necessary tools to make safer choices that prevent injuries (2011). However, little is known about the extent to which physicians currently engage in prevention tactics with patients or intervene when patients present with problems that suggest risky behavior resulting in injury. Additionally, little research has examined the extent to which gender stereotypes and biases presented by parents (i.e., boys will be boys and rough house; boys are at greater risk for actually getting hurt) extend into the healthcare community and influence the way in which health education counseling and care is provided.
Unlike many public health problems, the prevention of unintentional injuries presents unique challenges due to the variety of circumstances that can precipitate an injury, as well as the multitude of etiologic factors involved. For example, prevention of bicycle related injuries among children would require a somewhat different set of prevention tactics when compared to the prevention of poison-related injuries among children. Nonetheless, when treating pediatric patients who present with injuries, the primary care physician may serve an important role in the prevention of recurring injuries as the incident may serve as a teachable moment for both children and their caregivers. Given the importance of preventing unintentional injuries and the lack of information currently available, we sought to examine the prevalence and related factors associated with health education counseling by primary care physicians who treated pediatric patients presenting with unintentional injuries. Methods Sample Utilizing data from the National Ambulatory Medical Care Survey (NAMCS), we analyzed visits made to physicians' offices in the U.S. from 2007 through 2010. Participants were patients aged birth to 17 years who presented with an unintentional injury to a participating physician's office setting. The NAMCS is maintained by the Centers for Disease Control and Prevention's National Center for Health Statistics. A multistage, national probability sample design was employed for the NAMCS involving 112 geographic primary sampling units, physicians' practices within the primary sampling units, and patient visits within the practices. Data collection was completed using a patient record form completed by trained staff. A more detailed explanation of the NAMCS methodology has been published for further reference (McCaig and McLemore, 1994). Measures Patients presenting with unintentional injury visits were identified if the primary ICD-9-CM external cause of injury code (E code) was within the range of E800–E869, or E880–E929 (Centers for Disease Control and Prevention, 2013). Injury prevention counseling was measured by dichotomous response to a checkbox item provided on the patient record form (PRF). The item, under a section titled “Health Education,” stated “Mark all ordered or provided at this visit.” If the option “injury prevention” was checked, then the patient had received injury prevention counseling. Other variables utilized in the current analyses included age group, stratified into 4 categories: infant (aged b 1), toddler (aged 1–3), child (aged 4–11), and adolescent (aged 12–17), gender, race, primary source of payment, region, number of visits in the past 12 months, length of visit in minutes, whether the attending physician was the patient's primary care physician, and whether or not any imaging service was ordered (X-ray, CT scan, etc.) Data analysis Because of the complex multistage design, sample weights were employed for each sampled patient visit to produce unbiased national annualized estimates. The sampling weights have been adjusted by the National Center for Health Statistics (NCHS) for nonresponse, geographic region, physician specialty, metropolitan statistical area, and seasonality of the reporting period. Standard errors were determined using STATA MP 11 software. In addition, all records in the data files were included in the analysis to obtain the correct sample variance estimates. Because the NAMCS is a record based survey, population based incidence and prevalence estimates cannot be calculated. Rather, the figures reported are the average annual visits. All other reported estimates were also annualized. Bivariate and multivariate logistic regression models were implemented to examine the relationship between the provision of injury prevention counseling and selected covariates. Odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs) were calculated. Goodness of fit of the logistic models was assessed by methods proposed by Archer and Lemeshow (2006) that take into account the cluster sample design of the survey data. Collinearity diagnostics among the independent variables were assessed. Finally, interaction terms were created and examined for each pair of covariates. This study was approved by our Institutional Review Board.
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Results Overall, 27.3 million unintentional injury visits were identified during the study period, which is equivalent to an average annual estimate of 6.8 million visits between 2007 and 2010 for children aged birth through 17 years. Findings indicated that health education pertaining to injury prevention was lacking. Overall, 14.6% (11.1–18.8) of patients presenting with an unintentional injury received injury prevention counseling. Descriptive analyses are presented in Table 1. Findings from bivariate and multivariate analyses indicated that gender was the only significant factor associated with injury prevention counseling. When controlling for all other variables in the model, the odds that injury prevention education occurred was 2.4 times more likely among injured boys when compared to injured girls (OR = 2.4; 95% CI: 1.2–4.6). See Table 2. Discussion The current study examined predictors of injury-related health education counseling by primary healthcare providers who saw patients presenting with an injury-related health issue. Although it has been well-documented that unintentional injury is the leading cause of morbidity and mortality in the US among children and adolescents (Centers Table 1 Injury prevention education among pediatric patients presenting with unintentional injuries to physician's office settings, United States, 2007–2010 (N = 27,311a). No
Yes
% (95% CI)
% (95% CI)
Gender Female Male
92.1 (86.8–95.3) 81.7 (75.7–86.5)
8.0 (4.7–13.2) 18.3 (13.5–24.3)
Age group b1 1–3 4–11 12–17
81.8 (44.7–96.2) 81.3 (66.1–90.6) 86.7 (81.9–90.8) 85.4 (79.3–90.0)
18.2 (3.8–55.3) 18.7 (9.4–33.9) 13.3 (9.2–19.0) 14.6 (10.2–20.7)
Race White Black Other
84.4 (78.1–89.2) 83.1 (65.7–92.6) 89.9 (83.9–94.2)
15.6 (10.8–21.9) 16.9 (7.4–34.3) 10.1 (5.8–17.0)
Payment method Private Medicaid Self-pay Other
87.6 (83.5–90.8) 85.0 (74.8–91.5) 65.0 (42.2–82.5) 68.0 (34.9–89.4)
12.4 (9.2–16.5) 15.0 (8.5–25.2) 35.0 (17.5–57.8) 32.0 (10.6–65.1)
Patients primary care physician was the attending No 87.0 (80.6–91.5) Yes 83.6 (77.0–88.6)
13.0 (8.5–19.4) 16.4 (11.4–23.0)
Imaging No Yes
85.0 (79.1–89.5) 85.9 (79.4–90.6)
15.0 (10.5–20.9) 14.1 (9.4–20.6)
Region Northeast Midwest South West
84.4 (68.7–93.0) 87.3 (81.0–91.7) 87.3 (80.5–91.9) 80.9 (70.5–88.3)
15.6 (7.0 (31.3) 12.7 (8.3–19.0) 12.7 (8.1–19.5) 19.1 (11.7–18.8)
Length of visit ≤7 min 8–15 min ≥16 min
85.5 (77.8–90.8) 88.2 (81.4–92.8) 81.0 (72.9–87.0)
14.5 (9.2–22.2) 11.8 (7.3–18.6) 19.0 (13.0–27.1)
# Visits past year 0 1 2–3 3 or more
85.0 (62.3–95.1) 79.5 (70.2–86.5) 86.5 (78.2–92.0) 82.0 (73.8–88.1)
15.0 (4.92–37.7) 20.5 (13.5–29.8) 13.5 (8.0–21.8) 18.0 (11.9–26.2)
a
Total number of visits in thousands.
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Table 2 Factors associated with injury prevention counseling provisions among pediatric patients presenting with unintentional injuries to physician's office settings, United States, 2007– 2010 (N = 6828a). Model 1a OR (95% CI)
Model 2 b,c
OR (95% CI)c
Gender Female Male
1.0 2.6 (1.3–4.9)
1.0 2.4 (1.2–4.6)
Age group b1 1–3 4–11 12–17
1.0 1.0 (0.2–6.0) 0.7 (0.1–4.1) 0.8 (0.1–4.6)
1.0 1.2 (0.6–2.3) .4 (.07–1.7) 0.5 (0.1–2.2)
Race White Black Other
1.0 1.1 (0.4–3.1) 4.8 (1.3–17.4)
1.0 1.2 (0.5–3.1) 4.4 (1.1–17.4)
Payment method Private Medicare/Medicaid Self-pay Other
1.0 1.3 (0.7–2.4) 3.8 (1.5–10.0) 3.3 (0.8–13.7)
1.0 1.2 (0.6–2.3) 3.7 (1.4–9.7) 2.7 (0.5–13.8)
Patients primary care physician was the attending No 1.0 Yes 1.0 (0.9–1.1)
1.0 1.0 (0.9–1.1)
Imaging No Yes
1.0 0.9 (0.5–1.7)
1.0 1.0 (0.6–1.9)
Region Northeast Midwest South West
1.0 0.8 (0.3–2.1) 0.8 (0.3–2.2) 1.3 (0.4–3.7)
1.0 0.7 (0.2–2.0) 0.6 (0.2–1.8) 1.0 (0.3–2.8)
Length of visit ≤7 min 8–15 min ≥16 min
1.0 0.8 (0.4–1.6) 1.4 (0.7–2.8)
1.0 0.8 (0.4–1.6) 1.5 (0.7–3.2)
# Visits past year 0 1 2–3 3 or more
1.0 1.4 (0.4–5.5) 0.9 (0.2–3.3) 1.2 (0.3–4.7)
– – – –
a Model 1 is bivariate analyses; model 2 is adjusted for all listed variables except # of past visits due to collinearity. b OR indicates odds ratio; value in parentheses indicates 95% confidence intervals. c Modeling injury prevention counseling = “yes”.
for Disease Control and Prevention, 2012), our findings indicate that health education related to injury prevention is markedly low. Less than 15% of the patients who presented with a health problem stemming from an injury received any kind of health education or health counseling regarding the prevention of injuries from their healthcare provider. These findings, though discouraging, may not be surprising given that previous research indicates that healthcare providers' delivery of health education during well-child visits was also relatively low and does not meet recommended standards (Yarnall et al., 2003). The well-child visit is intended to be a time for healthcare providers to answer questions and offer general health education (Abdus and Selden, 2013). If providers are failing to offer adequate health education and meet the recommended standards during the well-child visit, a time which is explicitly designated for health education, it may be expected that they would also fall short in terms of offering health education or health counseling during visits when patients present with an ailment. Our findings do suggest, however, that healthcare providers offer more education/counseling to boys (and/or their parent/caregiver) who present with an injury in comparison to girls (and/or their parent/caregiver) who present with an injury. On the one hand, this
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can be viewed positively given that boys are more likely to experience an unintended injury and thus may be more likely to experience reinjury. On the other hand, these findings could suggest that healthcare providers hold similar biases related to gender socialization and risk for injury which may infringe on their likelihood to counsel their female patients (and/or parent/caregiver). Regardless of gender, healthcare providers should be offering more health education than is currently being offered with regard to patients presenting with unintentional injuries. Given that healthcare providers have been encouraged to participate in increased health education efforts (Weinehall et al., 2014) and unintentional injury remains a salient public health issue, why are injuryspecific health education provisions so low? When examining other health issues, research suggests that patients respond positively to physicians' counseling on health matters such as tobacco use, physical activity, dietary behaviors, and weight loss (Butler et al., 2013; Sim et al., 2009; Thijs, 2007). Furthermore, training primary care providers in health education delivery and behavior change approaches has been shown to positively influence patients' behavior change intentions, without requiring an excessive amount of the providers' time (Butler et al., 2013). However, injury-specific education is unique. Overall, injuries may be more difficult to counsel patients on compared to tobacco or weight loss due to the wider variety of injury circumstances. That is, the category of “unintentional injuries” is so vast; unintentional injuries could include, motor vehicle accidents (MVA), falls, injuries associated with the use of equipment (e.g., lawn mowers, snow blowers), injuries associated with recreation (e.g., water skiing, hang gliding, roller blading, bicycling), and more. Thus, different strategies and tactics should be implemented based on different behaviors. Evidence-based prevention practices specific to injuries exist and research indicates that parents respond positively to health education in general (Jhanjee et al., 2004). However, utilization among physicians is low and this should be further investigated in future studies. Time constraints experienced by physicians may be another reason more providers do not offer injury-related counseling/education. Previous research suggests that time availability is the main predictor of whether physicians engage in health education with patients, and consistently healthcare providers seem to lack adequate time to devote to health education (Yarnall et al., 2003). In fact, Yarnall et al. (2003) found that if physicians met recommendations for prevented health services, they need to devote over 7 h per working day to such services. Devoting this amount of time to preventative services, while important, is simply unrealistic. Riesch et al. (2013) suggests involving not only physicians in primary prevention education, but also nurses, nurse practitioners and public health professionals. Given that physicians may not have the available time or feel as comfortable providing health education to parents (Yarnall et al., 2003), it may actually be beneficial for public health professionals, and health educators in particular, to provide such counseling. In this vein, offering health coaching or direct health education in the physicians' clinic or office may provide an ideal solution. That is, after a medical consultation, the physician could refer patients to health educators to provide more in-depth follow up information and answers to any questions patients (or parents/caregivers) may have. Shifting this responsibility from the physician solely to other healthcare professionals including health educators has been recommended by others as well (Bodenheimer and Smith, 2013; Yarnall et al., 2003). Because health educators have specific training in offering health information and health counseling in this format, they may be better equipped and feel more comfortable accomplishing this task which would in turn reduce the amount of time physicians would need to spend on prevention and education with their patients. Study limitations It is important to note the limitations which apply to the study. As is always the case, nonsampling errors, such as reporting and processing
errors, as well as nonresponse, are inherent in all surveys. More specific to the current study, the quality or quantity of the education provided by physicians concerning the topics examined was not assessed; we could only report on whether it was or was not provided during the visit in question. Therefore, we also cannot establish what preventive practices, if any, occurred during prior office visits. We also could not decipher if the provider or the patient initiated discussion regarding a select health behavior. Some estimates may be tenuous based on wide confidence intervals, as evidenced in Table 1. Future studies would benefit from ascertaining the source of the initial discussion as well as assessing the quality of the education provided. Conclusion Injuries are preventable, with known risk and protective factors, and antecedents (Liller, 2012). However, our findings show that very few physicians are engaging their patients in preventive counseling around the issue of injuries. The prevention of injuries requires a multifactorial approach, adopting from public health, medicine, education and other disciplines. More specifically, health education, implementation of evidence-based intervention, improved surveillance efforts, adaptations in the physical environmental, changes in public policy, and improvements in product design and availability are a few of the factors that may serve an important role in the prevention of unintentional injuries. Although patient education alone may not prevent and control subsequent injuries in pediatric populations, it may be an important first step in the process of injury prevention. Future studies should investigate the effect of increasing physician injury prevention counseling on unintentional injury rates among pediatric patients. Conflict of interest statement The authors declare that there are no conflicts of interests.
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