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Teens at work: A statewide study of jobs, hazards, and injuries
J O U R N A L OF A D O LES C EN T H E A L T H 1998;22:19-25
ORIGINAL ARTICLE
Teens at Work: A Statewide Study of Jobs, Hazards, and Injuries K A T H L E E N A. D U N N , M.D., M.S.P.H., CAROL W. R U N Y A N , M.P.H., Ph.D., LISA R. C O H E N , Dr. P.H., A N D M I C H A E L D. S C H U L M A N , Ph.D.
Purpose: Occupational injury is an o n g o i n g and serious threat to American youth. However, little is k n o w n about the environments in w h i c h youth work or the hazards to w h i c h they are exposed. The purpose of this study was to document the patterns of work, exposures to hazardous e q u i p m e n t and situations, and work-related injury experiences of adolescents. Methods: We identified a statewide targeted sample of North Carolina h o u s e h o l d s with teens age 14-17 years and interviewed those w h o had ever worked for pay or worked on a farm. Results: Five hundred sixty-two teens from 700 eligible h o u s e h o l d s reported that they had worked non-farm jobs for pay. One-third were paid for work before age 14 years; two-thirds had held more than one paid job. Place of e m p l o y m e n t was most often someone's home, a retail store, or a restaurant. C o m m o n jobs were l a w n care worker, cashier, and dishwasher. C o m m o n hazards to w h i c h teens were exposed included ladders or scaffolding; forklifts, tractors or riding mowers; and working around loud noises. Over half were injured at least once w h i l e working a paid job, most often from being cut or burned. Conclusions: Work among youth is common. Teens hold a variety of jobs, m o s t l y in the retail trade and the service sector, exposing them to hazardous e q u i p m e n t and situations. Injuries at work are frequent and some From the University of North Carolina Injury Prevention Research Center, Chapel Hill, North Carolina (K.A.D., C.W.R., L.R.C., M.D.S.); the Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina (K.A.D.); the Department of Health Behavior and Health Education, University of North Carolina School of Public Health, Chapel Hill, North Carolina (C.W.R., L.R.C.); and the Department of Sociology and Anthropology, North Carolina State University, Raleigh, North Carolina (M.D.S.). Address reprint requests to: Carol W. Runyan, PhD, Injury Prevention Research Center, Chase Hall, CB ~ 7505, Chapel Hill, NC 275997505. Manuscript accepted April 8, 1997.
are serious. This study supports the need to include an occupational history and work-related safety counseling in clinical encounters with adolescents. © Society for
Adolescent Medicine, 1998 KEY W O R D S :
Accidents, occupational Adolescence Occupations Employment Wounds and injuries
Occupational injury is an ongoing and serious threat to American youth. An estimated 28% of 15-yearolds (1) and 42% of 16- and 17-year-olds are employed (2), often in jobs prohibited by child labor laws (1). Although many argue for the potential benefits of early work (e.g., development of a sense of responsibility, acquisition of new skills, opportunity to explore career goals, and economic advancement), there is also evidence that early work experiences may have detrimental health effects (3,4). In 1992, over 64,000 14-17-year-olds required treatment in the emergency department for work-related injuries (5). In 1993, 21,620 work-related injuries and illnesses caused teen workers to miss at least i day of work (6). Lacerations, contusions, strains and sprains, burns, and fractures are the most frequently reported types of nonfatal occupational injury among youth (5-10). Motor vehicles, machines, electrocution, and homicide are the most common causes of fatal occupational injury (11-13). Rates of occupational injury are highest among adolescents working in the retail and manufacturing industries (5).
© Society for Adolescent Medicine, 1998 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
1054-139X/98/$19.00 PII $1054-139X(97)00071-2
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The federal Fair Labor Standards Act (FLSA) of 1938 was enacted in part to protect children from hazardous occupations. It prohibits persons younger than 18 years from working in 17 hazardous nonagricultural occupational and industrial settings: manufacturing and storing of explosives, mining, logging, excavation, demolition, manufacturing of brick and tile, slaughtering and meat packing, roofing operations, exposure to radioactive substances, driving motor vehicles, and operating selected powerdriven equipment (14). Each state also has child labor laws that can be even more restrictive of adolescent work hours, jobs, and equipment use. Recent studies, however, indicate that many teens injured on the job are working under conditions which violate the FLSA (1,12,15,16). Because little is known about the environments in which youth work or the hazards to which youth are exposed, the purpose of this study was to document the patterns of work, exposures to hazardous equipment and situations, and work-related injury experiences among North Carolina adolescents.
Methods North Carolina teens age 14-17 years who had ever had a job for pay or worked on a farm were selected through a statewide telephone survey. A list of phone numbers targeted toward households with children was purchased from Survey Sampling Incorporated (SSI). This age-targeted sample was drawn from SSI's database of households with telephone numbers listed in U.S. white-pages directories. Information used to identify households with children is obtained from multiple secondary sources including school registration lists, magazine subscriptions, and driver's license information. According to the U.S. Bureau of Census, there were 912,659 family households with children under age 18 years (47% of all family households) and 357,198 teens age 14-17 years in North Carolina in 1990 (17). Interviewers from the North Carolina State University Applied Research Group, using a computerassisted telephone interviewing (CATI) system, attempted to contact 3850 North Carolina households during spring 1995. Interviewers placed up to 12 calls to each number, staggering calls between 3:30 P.M. and 9:00 P.M. during each callback period. The initial contact established the presence of an eligible teen in the household and elicited consent from the parent or guardian. If the eligible teen was not present to give assent and be interviewed at the time,
JOURNAL OF ADOLESCENTHEALTHVol. 22, No. 1
an appointment was made for a return call. Most teens completed the interview on the second or third callback. If there was more than one eligible teen in the household, the oldest eligible teen age 14-17 years was selected. Only one teen from each household was selected, to maintain a representative sample. Of these 3850 households, contact resulted in completed interviews with 572 teens who met the eligibility criteria of having ever worked a paid job or on a farm, being age 14-17 years, receiving parental consent to participate, and having the ability to communicate in English over the telephone. One hundred and twenty eligible households refused to participate and eight households terminated the interview. The majority of contacted households were ineligible because there were no teens (n = 1953) or because the teen(s) had never worked for pay or on a farm (n = 968). Other reasons for ineligibility included number out of service (n = 116), business or government number (n = 38), wrong number (n = 2), teen incarcerated or institutionalized (n -- 3), unable to locate teen (n = 2), or deaf or language barrier (n = 1). For 67 households, there was no answer after the maximum (12) attempts at contact. The survey included questions about places of work, types of job, exposures to potential workrelated hazards, and injury experience. Because the time frame for each question was "ever," teens could report multiple places, jobs, exposures, and injuries. Earlier results from several pilot studies with a similar self-administered questionnaire demonstrated that teens had difficulty linking responses to different questions, so we did not attempt to link work experience, hazard exposure, and injury experience. In other words, we did not ask about exposure to hazards in relationship to work at a specific job, or injury experience in the context of work around a specific hazard. To identify places worked, respondents were asked, "Have you ever worked a paid job at a . . . " followed by a specific place, such as "fast-food restaurant." This question was asked for each of 14 places of work. To identify types of jobs held, we asked, "Have you ever been a(n) . . . " followed by, for example, "cashier." This question was asked for 16 types of jobs. To identify exposure to hazards, we asked "Have you ever worked in a paid job where you had to . . . " followed by, for example, "use a ladder or scaffolding." This question was asked for each of nine types of work-related hazards. To identify mechanism of injury, we asked, "Have you ever been hurt by [falling, tripping, or slipping] while
January 1998
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Table 1. Places worked for pay, by gender, North Carolina teens (n = 562) % Worked at Each Place (95% Confidence Interval) Female (n = 223)
Places Worked: Have You Ever Worked a Paid Job at a . . .
Male (n = 339) (%)
H o m e (yours or someone else's) Store other than grocery or convenience Fast-food restaurant Restaurant other t h a n fast food Building or construction site Supermarket or grocery store Camp, park, or s w i m m i n g pool Day care center Factory or mill Gas station or garage Nursing h o m e or hospital Convenience store Movie theater Some other business place
54 22 21 17 27 21 14 3 9 9 3 4 1 22
working a paid job?" This question was asked for each of 10 mechanisms of injury. If the r e s p o n d e n t answered yes to an injury question, it was followed by, "Were y o u hurt badly e n o u g h that y o u n e e d e d to miss w o r k or school for at least 1 day?" and "Was it bad e n o u g h that y o u had to go to a doctor, nurse, or hospital?" Copies of the s u r v e y instrument are available from the corresponding author. Categories of responses were based on data from earlier pilot studies of adolescent w o r k using a self-administered questionnaire and do not necessarily correspond to standardized U.S. Census Bureau Occupation and Industry codes. This article describes non-farm work, defined as e m p l o y m e n t for pay, excluding babysitting, chores, and any tasks or chores directly related to crop or livestock production. [The farm w o r k experience of this cohort is reported separately (18)]. Descriptive statistics and 95% confidence intervals b y Wilson's m e t h o d are reported (19). The s t u d y was a p p r o v e d by the University of N o r t h Carolina School of Public Health Institutional Review Board.
Results C o m p l e t e d interviews were obtained from 572 eligible teens from a m o n g 700 households (81% response rate). Of these 572 teens, 10 had w o r k e d only farmrelated jobs. This report describes the characteristics of the 562 teens w h o have ever held a non-farm job for pay.
(49, 60) (18, 27) (17, 26) (14, 22) (22, 32) (17, 26) (11, 18) (1, 5) (6, 12) (6, 12) (1, 5) (3, 7) (<1,3) (17, 26)
(%) 47 36 22 22 2 10 13 12 3 1 5 2 1 23
Total (n = 562) (%) (41, 54) (30, 42) (17, 28) (17, 27) (1, 5) (7, 15) (10, 19) (8, 17) (1, 6) (1, 4) (3, 9) (1, 5) (<1, 3) (18, 29)
51 28 21 19 17 17 14 6 6 6 4 3 1 22
(47, 56) (24, 32) (18, 25) (16, 22) (14, 20) (14, 20) (11, 17) (5, 9) (5, 9) (4, 8) (2, 6) (2, 5) (<1, 2) (19, 26)
Characteristics of Workers Sixty percent of the 562 respondents were male and 86% were white. Most (98%) were in Grades 8-12, with the largest n u m b e r in Grade 11. Ninety-six percent had ever w o r k e d a paid job for someone outside their family. Respondents reported that they started working a paid job for someone outside their household at ages ranging from 10 to 17 years.
Characteristics of Work for Pay Teens were asked to indicate all the places they had ever worked. Most (67%) reported having w o r k e d more than one place d u r i n g their occupational careers. As s h o w n in Table 1, more than half of the teens s u r v e y e d had w o r k e d at someone's home. The most c o m m o n n o n - h o m e places of e m p l o y m e n t were retail stores, restaurants, construction sites, and grocery stores. Both workplace and type of job differed b y gender. Males were m o r e likely than females to have ever w o r k e d at building or construction sites, supermarkets, factories or mills, and gas stations or garages. Males were proportionally at least twice as likely as females to have w o r k e d as cooks, dishwashers, lawn care workers, grocery baggers, n e w s p a p e r delivery persons, and gas station attendants. Females were at least twice as likely as males to have w o r k e d as cashiers, wait persons, office workers, sales clerks, child care workers, and nursing aides or orderlies (Table 2).
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Table 2. Types of jobs worked for pay, by gender, North Carolina teens (n = 562) Types of Jobs: Have You Ever Been a(n) ... Lawn care person Cashier Dishwasher Store clerk Cook Grocery bagger or stocker Office worker, receptionist, file clerk, or secretary Busboy or busgirl Waiter or waitress Child care worker (other than babysitter) Camp counselor Lifeguard Newspaper delivery person Gas station attendant Nursing aide or orderly Some other kind of job
Percent who worked each job (95% confidence interval) Male (n = 339) (%)
Female (n = 223) (%)
Total (n = 562) (%)
57 27 30 16 23 24 10
(51, 62) (23, 32) (25, 35) (12, 20) (19, 28) (19, 28) (8, 14)
11 55 15 28 12 9 26
(7, 16) (48, 61) (11, 21) (23, 34) (8, 17) (6, 14) (21, 32)
38 38 24 21 19 18 17
(35, 43) (34, 42) (21, 28) (17, 24) (16, 22) (15, 21) (14, 20)
17 7 5
(13, 21) (5, 11) (3, 8)
12 19 14
(8, 17) (14, 24) (10, 19)
15 12 8
(12, 18) (9, 15) (6, 11)
8 6 10 6 1 21
(5, 11) (4, 9) (7, 13) (4, 9) (<1, 2) (17, 26)
7 8 2 1 4 10
7 7 7 4 2 17
(5, 10) (5, 9) (5, 9) (2, 6) (1, 3) (14, 20)
Exposure to Hazards at Work Teens reported having worked with and around a number of potential hazards. In response to a list of specific hazards to which they might have been exposed, the largest numbers reported having used a ladder or scaffolding (36%) or a forklift, tractor, or riding mower (31%), or having worked around very loud noises (27%). Surprisingly, 13 respondents (2%) reported that they had to "be ready to use a gun to protect [them]selves" while working a paid job (Table 3). Males were more likely than females to have been exposed to all of the listed work hazards. Working at night is a potential risk factor for intentional injury on the job. Overall, 64% of all respondents reported that they had ever worked at a paid job between the hours of 7 P.M. and 11 P.M.; 14% had worked between the hours of 11 P.M. and 7 A.M.
(4, (5, (1, (<1, (2, (7,
11) 12) 5) 3) 7) 14)
Males and females were equally likely to have worked at night. We asked respondents, "Has anyone ever attacked you or hurt you on purpose while you were working a paid job?" Fifteen youth said yes. Thirty answered yes to a subsequent question asking if they had ever felt in danger of being physically or sexually attacked while working a paid job. Twice the proportion of females (8%) as males (4%) reported fear of assault at work. Female cashiers were almost six times as likely as male cashiers to report fear of assault (11% vs. 2%).
Injury Experience Over half the teens (54%) reported having been injured at least once while working a paid job, with
Table 3. E x p o s u r e to selected h a z a r d s a s s o c i a t e d w i t h p a i d jobs, b y g e n d e r , N o r t h C a r o l i n a teens (n = 562) Hazard: Have You Ever Worked in a Paid Job Where You Had to ... Use a ladder or scaffolding Use a forklift, tractor, or riding mower Be around very loud noises Use restaurant fryers or slicers Drive a car or truck Work with gasoline Work with pesticides or other chemicals Use drills or chainsaws Be ready to use a gun to protect yourself
% Exposed to Each Hazard (95% Confidence Interval) Male (n = 339) (%)
Female (n = 223) (%)
Total (n = 562) (%)
45 45 36 27 32 36 27 30 3
22 9 14 19 12 4 9 1 1
36 31 27 24 24 23 19 19 2
(40, 50) (40, 50) (31, 42) (23, 32) (27, 37) (31,41) (22, 31) (25,35) (2, 6)
(17, 27) (6, 14) (10, 19) (14, 24) (8, 17) (2, 7) (6, 13) (<1, 3) (<1, 3)
(32, (27, (24, (21, (21, (20, (16, (16, (1,
40) 35) 31) 28) 28) 27) 23) 22) 4)
January 1998
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Table 4. Mechanism of injury while working a paid job, by proportion of respondents missing work or school for at least 1 day, and proportion seeking medical care for injury, North Carolina teens (n = 562) Mechanism of Injury: While Working a Paid Job, Have You Ever Been Injured by ... Being cut by something sharp Being burned by hot object or grease Falling, tripping, or slipping Lifting something heavy Having something fall on you Being hit, kicked, or bitten by a person Being hit, kicked, or bitten by an animal Being hit by car, truck, or equipment A car or truck crash Getting caught in machinery
n (% Total) 164(29) 134 (24) 69 (12) 57 (10) 24 (4) 23 (4) 20 (4) 10(2) 3 (0.5) 1 (0.2)
14% (n = 78) injured twice, 7% (n = 41) injured three times, and 6% (n = 32) injured four or m o r e times. A substantial p r o p o r t i o n of the 505 reported injuries were potentially serious; 12% resulted in at least 1 d a y of missed w o r k or school and 16% required a visit to a doctor, nurse, or hospital. A m o n g those reporting injuries, 29% indicated that their injuries resulted from being cut, while nearly a quarter were b u r n e d b y a hot object or grease (Table 4). Being cut was the only r e p o r t e d injury for which there was a statistically significant difference b y gender, with 34% of males reporting a laceration on the job, c o m p a r e d to 22% of females (p = 0.001).
Discussion This s t u d y confirms that work for p a y outside the h o m e is c o m m o n a m o n g teens. Over 95% of our sample had ever w o r k e d for p a y for someone outside their family, with 32% of the sample getting paid for work before age 14 years. This is a slightly higher percent than reported in 1994 in Minnesota (20). Consistent with other studies, the majority of y o u t h report having w o r k e d in the retail trade and the service sector, particularly the food industry (10,21). Although other studies (10,20) have characterized the types of jobs held b y teens, to our k n o w l e d g e this is the first systematic s t u d y of exposure to specific occupational hazards a m o n g a population-based sample of working youth. One-quarter or more of our respondents report having w o r k e d a r o u n d ladders and scaffolding; tractors, forklifts, and riding mowers; restaurant fryers and slicers; and m o t o r vehicles, hazards associated with occupational injury in case reports (11,12,16,22,23). Males were more likely than females to be exposed to every h a z a r d about which we asked. H o w e v e r , females were more
n (% Injured) Who Missed Work or School for at Least 1 Day 15/164 (9) 4/134 (3) 15/69 (22) 11/57 (19) 1/24 (4) 1/23 (4) 4/20 (20) 6/10 (6o) 2/3 (67) 0/1
(0)
n (% Injured) Who Visited a Doctor, Nurse, or Hospital 24/164 (15) 11/134 (8) 18/69 (26) 9/57 (16) 3/24 (13) 1/23 (4) 5/20 (25) 5/10 (50) 3/3 (100) 0/1
(0)
likely to be exposed to jobs which require handling of money, possibly placing t h e m at greater risk for assaults. Occupational sex segregation is a concept used by social scientists to describe gender differences in jobs (24). Although the degree of occupational sex segregation has declined since the 1970s, most workers remain in sex-segregated jobs. Female-typical jobs have lower pay, fewer benefits, less on-the-job training, and lower promotional opportunities than maletypical jobs, while exposure to job hazards is m o r e c o m m o n in disproportionately male occupations (24,25). Males of all ages are also overrepresented in occupational injury and fatality statistics. Differential exposure to hazards appears to be a result of occupational sex segregation. Our s t u d y provides evidence of occupational sex segregation a m o n g working youth, with g e n d e r differences in type of work, h a z a r d exposure, and, to a lesser extent, workrelated injury. While c o m m o n w i s d o m has it that teens, especially males, are injured because of carelessness and risk-taking, their injuries are more likely a reflection of their job experience, their exposure to work-related hazards, and e m p l o y e r expectations. Further research exploring the interaction a m o n g gender, risk of exposure to hazards, and response to situations of risk will help inform injury-prevention interventions. Injuries at w o r k are c o m m o n a m o n g teens. Over half of our respondents had been injured at w o r k at least once. Although few y o u t h missed w o r k or school or sought care for c o m m o n causes of injury, a substantially higher p r o p o r t i o n missed work or school or sought care for the few injuries related to m o t o r vehicles. Our s t u d y did not address w h e t h e r the decision to seek medical care for injuries stems from the y o u t h w o r k e r or the employer. H o w e v e r , the exploration of factors associated with seeking
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DUNN ET AL.
medical care for work-related injury is a topic for future study. Another issue also deserves more detailed study. We identified a large proportion of youth who work at night. Without more information about the conditions of work, we were unable to determine whether this work violated the FLSA. Based on studies of adults, however, it appears that work at night poses a significant risk for injury. Alexander and colleagues reviewed workers' compensation records in Washington State to identify sexual assaults of women (26). Although fewer people work at night, over half of the reported rapes at work occurred between 7 P.M. and 6 A.M.. Fifty-five percent of Ohio workers' compensation cases resulting from violent crime at work occurred between 7 P.M. and 7 A.M. (27). Occupational homicides are also disproportionately frequent at night; from 1980 to 1989, 20% of all occupational homicides occurred in the 3 h between 10 P.M. and 1 A.M. (28). Sixty-one percent of all workplace homicides in North Carolina during 1977-1991 occurred between 6 P.M. and 5:59 A.M. (29). In our study, a small but concerning number of youth expressed fear of assault while at work. This concern and the relationship between working with money, working at night, and risk for assault deserve further investigation in this young and vulnerable group. One of the limitations of this study is that we were unable to ask questions about hazards and injuries in a specific job context. Because youth hold many different jobs in a short period of time, either in succession or simultaneously, it was impossible in a brief telephone interview to ask a series of questions about each specific job. Therefore, we opened the majority of our questions with the phrase, "Have you ever . . . " Thus, we are unable to determine the incidence of exposure to various hazards or incidence of injury. Ideally, one would like to be able to determine risk of injury per amount of time exposed to a particular hazard; future studies should attempt to collect this information. It is possible that the number of jobs reported and the numbers of types of exposures and injuries are underestimated because of recall bias associated with the recall period of "ever." Telephone surveys also have the potential for bias if teens without telephones have different work experiences and exposure to hazards than those with telephones. Future studies should sample those without telephones, verify respondent self-reports, and compare work patterns and hazard exposures in jurisdictions with different labor practices and enforcement.
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Occupational injuries are preventable. The National Institute for Occupational Safety and Health recently published recommendations for employers, parents, educators, and adolescents about workplace safety (30). Health care providers should take an occupational history on patients as young as 10 or 11 years of age, especially when a child presents with an injury. Documentation should include the activity at the time of injury, mechanical equipment contributing to the injury, use of personal protective equipment, and relationship of child to employer. Because teens may find themselves in situations where they do not have the developmental skills or experience to safely perform potentially hazardous job tasks, providers should also ask patients if they have concerns about their safety at work and with whom they would discuss these concerns. Providers should alert parents and adolescents to the potential risks of on-the-job injury and to the importance of safety equipment and practices. They should also familiarize themselves with the requirements of the FLSA to alert adolescents and their parents to work activities that may violate child labor laws. Programs on occupational safety and health should be offered through continuing medical education seminars and should be incorporated into training curricula for resident physicians, physician assistants, and nurses. Further studies quantifying exposure to specific hazards will help guide development of occupational safety interventions for teens. These include strengthening child labor laws and providing education about work safety for teens, their parents and employers, and other professionals who work with youth. This research was supported by Grant R01-CCR402444-10 from the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention, to the University of North Carolina Injury Prevention Research Center. Additional support was received from the North Carolina Cooperative Extension Service and the North Carolina Agricultural Research Service. The authors thank Connelly Simmons, Yvonne Brannon, and Diane Calleson for assistance with development of the interview protocol, and Stephen W. Marshall for help with data analysis.
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4. Kinney JA. Health hazards to children in the service industries. Am J Indust Med 1993;24:291-300. 5. Layne LA, CastiUo DN, Stout N, Cutlip P. Adolescent occupational injuries requiring hospital emergency department treatment: A nationally representative sample. Am J Public Health 1994;84:657-60. 6. Anonymous. Work-related injuries and illnesses associated with child labor--United States, 1993. MMWR 1996;45:464-8. 7. Parker DL, Carl W, French LR, Martin F. Characteristics of adolescent work injuries reported to the Minnesota Department of Labor and Industry. Am J Public Health 1994;84:60611. 8. Banco L, Lapidus G, Braddock M. Work-related injury among Connecticut minors. Pediatrics 1992;89:957-60. 9. Belville R, Pollack SH, Gobold JH, Landrigan PJ. Occupational injuries among working adolescents in New York State. JAMA 1993;269:2754-9. 10. Cohen LR, Runyan CW, Dunn KA, Schulman MD. Work patterns and occupational hazard exposures of North Carolina adolescents in 4-H clubs. Injury Prevent 1996;2:274-7. 11. Castillo DN, Landen DD, Layne LA. Occupational injury deaths of 16 and 17 year olds in the United States. A m J Public Health 1994;84:646-9. 12. Dunn KA, Runyan CW. Deaths at work among children and adolescents. A m J Dis Child 1993;147:1044-7. 13. Toscano G, Windau J. The changing character of fatal work injuries. In Bureau of Labor Statistics. Fatal workplace injuries in 1993: A collection of data and analysis (Report 891). Washington, D.C.: U.S. Department of Labor, 1995. 14. U.S. Department of Labor. Child labor requirements in nonagricultural occupations under the Fair Labor Standards Act: Child Labor Bulletin no. 101. Washington, D.C.: U.S. Government Printing Office, 1985. Employment Standards Administration, Wage and Hour Division, U.S. Department of Labor Wage and Hour publication 1330. 15. Suruda A, Halperin W. Work-related deaths in children. Am J Indust Med 1991;24:739-45. 16. Knight EB, Castillo DN, Layne LA. A detailed analysis of work-related injury among youth treated in emergency departments. Am J Indust Med 1995;27:793-805.
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17. U.S. Department of Commerce, Bureau of the Census. USA Counties, 1994. CD94-CTY-02. Washington DC, 1994. 18. Schulman MD, Evensen C, Runyan CW, et al. Farm work is dangerous for teens: Agricultural hazards and injuries among North Carolina teens. J Rural Health (in press). 19. Wilson EB. Probable inference: The law of succession and statistical inference. J Am Statist Assoc 1927;22:209-12. 20. Parker DL, Carl WR, French R, Martin FB. Nature and incidence of self-reported adolescent work injury in Minnesota. Am J Indust Med 1994;26:529-41. 21. Children's Safety Network at Education Development Center, Inc., and Massachusetts Occupational Health Surveillance Program. Protecting working teens: A public health resource guide. Newton, MA: Education Development Center, 1995. 22. Muir L, Kanwar S. Ladder injuries. Injury 1993;24:485-7. 23. Hayes-Lundy C, Ward KS, Saffle J, et al. Grease b u m s at fast-food restaurants: Adolescents at risk. J Burn Care Rehabil 1991;12:203-8. 24. Reskin B. Sex segregation in the workplace. Annu Rev Sociol 1993;19:241-70. 25. Jacobs JA, Steinbery RJ. Compensating differentials and the male-female wage gap: Evidence from the New York State comparable worth study. Social Forces 1990;69:439-68. 26. Alexander BH, Franklin GM, Wolf ME. The sexual assault of women at work in Washington State, 1980 to 1989. Am J Public Health 1994;84:640-2. 27. Hales T, Seligman PJ, N e w m a n SC, Timbrook CL. Occupational injuries due to violence. J Occup Med 1988;30:483-7. 28. Jenkins EL, Layne LA, Kisner SM. Homicide in the workplace. AAOHN J 1992;40:215-8. 29. Moracco KE, Runyan CW, Wolf S, et al. Occupational homicide: A 15 year statewide study. Paper presented at the annual meeting of the American Public Health Association, Washington, DC, 1994. 30. U.S. Department of Health and H u m a n Services. NIOSH Alert: Preventing deaths and injuries of adolescent workers. DHHS (NIOSH) Publication no. 95-125, 1995.
ORIGINAL ARTICLE
Teens at Work: A Statewide Study of Jobs, Hazards, and Injuries K A T H L E E N A. D U N N , M.D., M.S.P.H., CAROL W. R U N Y A N , M.P.H., Ph.D., LISA R. C O H E N , Dr. P.H., A N D M I C H A E L D. S C H U L M A N , Ph.D.
Purpose: Occupational injury is an o n g o i n g and serious threat to American youth. However, little is k n o w n about the environments in w h i c h youth work or the hazards to w h i c h they are exposed. The purpose of this study was to document the patterns of work, exposures to hazardous e q u i p m e n t and situations, and work-related injury experiences of adolescents. Methods: We identified a statewide targeted sample of North Carolina h o u s e h o l d s with teens age 14-17 years and interviewed those w h o had ever worked for pay or worked on a farm. Results: Five hundred sixty-two teens from 700 eligible h o u s e h o l d s reported that they had worked non-farm jobs for pay. One-third were paid for work before age 14 years; two-thirds had held more than one paid job. Place of e m p l o y m e n t was most often someone's home, a retail store, or a restaurant. C o m m o n jobs were l a w n care worker, cashier, and dishwasher. C o m m o n hazards to w h i c h teens were exposed included ladders or scaffolding; forklifts, tractors or riding mowers; and working around loud noises. Over half were injured at least once w h i l e working a paid job, most often from being cut or burned. Conclusions: Work among youth is common. Teens hold a variety of jobs, m o s t l y in the retail trade and the service sector, exposing them to hazardous e q u i p m e n t and situations. Injuries at work are frequent and some From the University of North Carolina Injury Prevention Research Center, Chapel Hill, North Carolina (K.A.D., C.W.R., L.R.C., M.D.S.); the Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina (K.A.D.); the Department of Health Behavior and Health Education, University of North Carolina School of Public Health, Chapel Hill, North Carolina (C.W.R., L.R.C.); and the Department of Sociology and Anthropology, North Carolina State University, Raleigh, North Carolina (M.D.S.). Address reprint requests to: Carol W. Runyan, PhD, Injury Prevention Research Center, Chase Hall, CB ~ 7505, Chapel Hill, NC 275997505. Manuscript accepted April 8, 1997.
are serious. This study supports the need to include an occupational history and work-related safety counseling in clinical encounters with adolescents. © Society for
Adolescent Medicine, 1998 KEY W O R D S :
Accidents, occupational Adolescence Occupations Employment Wounds and injuries
Occupational injury is an ongoing and serious threat to American youth. An estimated 28% of 15-yearolds (1) and 42% of 16- and 17-year-olds are employed (2), often in jobs prohibited by child labor laws (1). Although many argue for the potential benefits of early work (e.g., development of a sense of responsibility, acquisition of new skills, opportunity to explore career goals, and economic advancement), there is also evidence that early work experiences may have detrimental health effects (3,4). In 1992, over 64,000 14-17-year-olds required treatment in the emergency department for work-related injuries (5). In 1993, 21,620 work-related injuries and illnesses caused teen workers to miss at least i day of work (6). Lacerations, contusions, strains and sprains, burns, and fractures are the most frequently reported types of nonfatal occupational injury among youth (5-10). Motor vehicles, machines, electrocution, and homicide are the most common causes of fatal occupational injury (11-13). Rates of occupational injury are highest among adolescents working in the retail and manufacturing industries (5).
© Society for Adolescent Medicine, 1998 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
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The federal Fair Labor Standards Act (FLSA) of 1938 was enacted in part to protect children from hazardous occupations. It prohibits persons younger than 18 years from working in 17 hazardous nonagricultural occupational and industrial settings: manufacturing and storing of explosives, mining, logging, excavation, demolition, manufacturing of brick and tile, slaughtering and meat packing, roofing operations, exposure to radioactive substances, driving motor vehicles, and operating selected powerdriven equipment (14). Each state also has child labor laws that can be even more restrictive of adolescent work hours, jobs, and equipment use. Recent studies, however, indicate that many teens injured on the job are working under conditions which violate the FLSA (1,12,15,16). Because little is known about the environments in which youth work or the hazards to which youth are exposed, the purpose of this study was to document the patterns of work, exposures to hazardous equipment and situations, and work-related injury experiences among North Carolina adolescents.
Methods North Carolina teens age 14-17 years who had ever had a job for pay or worked on a farm were selected through a statewide telephone survey. A list of phone numbers targeted toward households with children was purchased from Survey Sampling Incorporated (SSI). This age-targeted sample was drawn from SSI's database of households with telephone numbers listed in U.S. white-pages directories. Information used to identify households with children is obtained from multiple secondary sources including school registration lists, magazine subscriptions, and driver's license information. According to the U.S. Bureau of Census, there were 912,659 family households with children under age 18 years (47% of all family households) and 357,198 teens age 14-17 years in North Carolina in 1990 (17). Interviewers from the North Carolina State University Applied Research Group, using a computerassisted telephone interviewing (CATI) system, attempted to contact 3850 North Carolina households during spring 1995. Interviewers placed up to 12 calls to each number, staggering calls between 3:30 P.M. and 9:00 P.M. during each callback period. The initial contact established the presence of an eligible teen in the household and elicited consent from the parent or guardian. If the eligible teen was not present to give assent and be interviewed at the time,
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an appointment was made for a return call. Most teens completed the interview on the second or third callback. If there was more than one eligible teen in the household, the oldest eligible teen age 14-17 years was selected. Only one teen from each household was selected, to maintain a representative sample. Of these 3850 households, contact resulted in completed interviews with 572 teens who met the eligibility criteria of having ever worked a paid job or on a farm, being age 14-17 years, receiving parental consent to participate, and having the ability to communicate in English over the telephone. One hundred and twenty eligible households refused to participate and eight households terminated the interview. The majority of contacted households were ineligible because there were no teens (n = 1953) or because the teen(s) had never worked for pay or on a farm (n = 968). Other reasons for ineligibility included number out of service (n = 116), business or government number (n = 38), wrong number (n = 2), teen incarcerated or institutionalized (n -- 3), unable to locate teen (n = 2), or deaf or language barrier (n = 1). For 67 households, there was no answer after the maximum (12) attempts at contact. The survey included questions about places of work, types of job, exposures to potential workrelated hazards, and injury experience. Because the time frame for each question was "ever," teens could report multiple places, jobs, exposures, and injuries. Earlier results from several pilot studies with a similar self-administered questionnaire demonstrated that teens had difficulty linking responses to different questions, so we did not attempt to link work experience, hazard exposure, and injury experience. In other words, we did not ask about exposure to hazards in relationship to work at a specific job, or injury experience in the context of work around a specific hazard. To identify places worked, respondents were asked, "Have you ever worked a paid job at a . . . " followed by a specific place, such as "fast-food restaurant." This question was asked for each of 14 places of work. To identify types of jobs held, we asked, "Have you ever been a(n) . . . " followed by, for example, "cashier." This question was asked for 16 types of jobs. To identify exposure to hazards, we asked "Have you ever worked in a paid job where you had to . . . " followed by, for example, "use a ladder or scaffolding." This question was asked for each of nine types of work-related hazards. To identify mechanism of injury, we asked, "Have you ever been hurt by [falling, tripping, or slipping] while
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Table 1. Places worked for pay, by gender, North Carolina teens (n = 562) % Worked at Each Place (95% Confidence Interval) Female (n = 223)
Places Worked: Have You Ever Worked a Paid Job at a . . .
Male (n = 339) (%)
H o m e (yours or someone else's) Store other than grocery or convenience Fast-food restaurant Restaurant other t h a n fast food Building or construction site Supermarket or grocery store Camp, park, or s w i m m i n g pool Day care center Factory or mill Gas station or garage Nursing h o m e or hospital Convenience store Movie theater Some other business place
54 22 21 17 27 21 14 3 9 9 3 4 1 22
working a paid job?" This question was asked for each of 10 mechanisms of injury. If the r e s p o n d e n t answered yes to an injury question, it was followed by, "Were y o u hurt badly e n o u g h that y o u n e e d e d to miss w o r k or school for at least 1 day?" and "Was it bad e n o u g h that y o u had to go to a doctor, nurse, or hospital?" Copies of the s u r v e y instrument are available from the corresponding author. Categories of responses were based on data from earlier pilot studies of adolescent w o r k using a self-administered questionnaire and do not necessarily correspond to standardized U.S. Census Bureau Occupation and Industry codes. This article describes non-farm work, defined as e m p l o y m e n t for pay, excluding babysitting, chores, and any tasks or chores directly related to crop or livestock production. [The farm w o r k experience of this cohort is reported separately (18)]. Descriptive statistics and 95% confidence intervals b y Wilson's m e t h o d are reported (19). The s t u d y was a p p r o v e d by the University of N o r t h Carolina School of Public Health Institutional Review Board.
Results C o m p l e t e d interviews were obtained from 572 eligible teens from a m o n g 700 households (81% response rate). Of these 572 teens, 10 had w o r k e d only farmrelated jobs. This report describes the characteristics of the 562 teens w h o have ever held a non-farm job for pay.
(49, 60) (18, 27) (17, 26) (14, 22) (22, 32) (17, 26) (11, 18) (1, 5) (6, 12) (6, 12) (1, 5) (3, 7) (<1,3) (17, 26)
(%) 47 36 22 22 2 10 13 12 3 1 5 2 1 23
Total (n = 562) (%) (41, 54) (30, 42) (17, 28) (17, 27) (1, 5) (7, 15) (10, 19) (8, 17) (1, 6) (1, 4) (3, 9) (1, 5) (<1, 3) (18, 29)
51 28 21 19 17 17 14 6 6 6 4 3 1 22
(47, 56) (24, 32) (18, 25) (16, 22) (14, 20) (14, 20) (11, 17) (5, 9) (5, 9) (4, 8) (2, 6) (2, 5) (<1, 2) (19, 26)
Characteristics of Workers Sixty percent of the 562 respondents were male and 86% were white. Most (98%) were in Grades 8-12, with the largest n u m b e r in Grade 11. Ninety-six percent had ever w o r k e d a paid job for someone outside their family. Respondents reported that they started working a paid job for someone outside their household at ages ranging from 10 to 17 years.
Characteristics of Work for Pay Teens were asked to indicate all the places they had ever worked. Most (67%) reported having w o r k e d more than one place d u r i n g their occupational careers. As s h o w n in Table 1, more than half of the teens s u r v e y e d had w o r k e d at someone's home. The most c o m m o n n o n - h o m e places of e m p l o y m e n t were retail stores, restaurants, construction sites, and grocery stores. Both workplace and type of job differed b y gender. Males were m o r e likely than females to have ever w o r k e d at building or construction sites, supermarkets, factories or mills, and gas stations or garages. Males were proportionally at least twice as likely as females to have w o r k e d as cooks, dishwashers, lawn care workers, grocery baggers, n e w s p a p e r delivery persons, and gas station attendants. Females were at least twice as likely as males to have w o r k e d as cashiers, wait persons, office workers, sales clerks, child care workers, and nursing aides or orderlies (Table 2).
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Table 2. Types of jobs worked for pay, by gender, North Carolina teens (n = 562) Types of Jobs: Have You Ever Been a(n) ... Lawn care person Cashier Dishwasher Store clerk Cook Grocery bagger or stocker Office worker, receptionist, file clerk, or secretary Busboy or busgirl Waiter or waitress Child care worker (other than babysitter) Camp counselor Lifeguard Newspaper delivery person Gas station attendant Nursing aide or orderly Some other kind of job
Percent who worked each job (95% confidence interval) Male (n = 339) (%)
Female (n = 223) (%)
Total (n = 562) (%)
57 27 30 16 23 24 10
(51, 62) (23, 32) (25, 35) (12, 20) (19, 28) (19, 28) (8, 14)
11 55 15 28 12 9 26
(7, 16) (48, 61) (11, 21) (23, 34) (8, 17) (6, 14) (21, 32)
38 38 24 21 19 18 17
(35, 43) (34, 42) (21, 28) (17, 24) (16, 22) (15, 21) (14, 20)
17 7 5
(13, 21) (5, 11) (3, 8)
12 19 14
(8, 17) (14, 24) (10, 19)
15 12 8
(12, 18) (9, 15) (6, 11)
8 6 10 6 1 21
(5, 11) (4, 9) (7, 13) (4, 9) (<1, 2) (17, 26)
7 8 2 1 4 10
7 7 7 4 2 17
(5, 10) (5, 9) (5, 9) (2, 6) (1, 3) (14, 20)
Exposure to Hazards at Work Teens reported having worked with and around a number of potential hazards. In response to a list of specific hazards to which they might have been exposed, the largest numbers reported having used a ladder or scaffolding (36%) or a forklift, tractor, or riding mower (31%), or having worked around very loud noises (27%). Surprisingly, 13 respondents (2%) reported that they had to "be ready to use a gun to protect [them]selves" while working a paid job (Table 3). Males were more likely than females to have been exposed to all of the listed work hazards. Working at night is a potential risk factor for intentional injury on the job. Overall, 64% of all respondents reported that they had ever worked at a paid job between the hours of 7 P.M. and 11 P.M.; 14% had worked between the hours of 11 P.M. and 7 A.M.
(4, (5, (1, (<1, (2, (7,
11) 12) 5) 3) 7) 14)
Males and females were equally likely to have worked at night. We asked respondents, "Has anyone ever attacked you or hurt you on purpose while you were working a paid job?" Fifteen youth said yes. Thirty answered yes to a subsequent question asking if they had ever felt in danger of being physically or sexually attacked while working a paid job. Twice the proportion of females (8%) as males (4%) reported fear of assault at work. Female cashiers were almost six times as likely as male cashiers to report fear of assault (11% vs. 2%).
Injury Experience Over half the teens (54%) reported having been injured at least once while working a paid job, with
Table 3. E x p o s u r e to selected h a z a r d s a s s o c i a t e d w i t h p a i d jobs, b y g e n d e r , N o r t h C a r o l i n a teens (n = 562) Hazard: Have You Ever Worked in a Paid Job Where You Had to ... Use a ladder or scaffolding Use a forklift, tractor, or riding mower Be around very loud noises Use restaurant fryers or slicers Drive a car or truck Work with gasoline Work with pesticides or other chemicals Use drills or chainsaws Be ready to use a gun to protect yourself
% Exposed to Each Hazard (95% Confidence Interval) Male (n = 339) (%)
Female (n = 223) (%)
Total (n = 562) (%)
45 45 36 27 32 36 27 30 3
22 9 14 19 12 4 9 1 1
36 31 27 24 24 23 19 19 2
(40, 50) (40, 50) (31, 42) (23, 32) (27, 37) (31,41) (22, 31) (25,35) (2, 6)
(17, 27) (6, 14) (10, 19) (14, 24) (8, 17) (2, 7) (6, 13) (<1, 3) (<1, 3)
(32, (27, (24, (21, (21, (20, (16, (16, (1,
40) 35) 31) 28) 28) 27) 23) 22) 4)
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Table 4. Mechanism of injury while working a paid job, by proportion of respondents missing work or school for at least 1 day, and proportion seeking medical care for injury, North Carolina teens (n = 562) Mechanism of Injury: While Working a Paid Job, Have You Ever Been Injured by ... Being cut by something sharp Being burned by hot object or grease Falling, tripping, or slipping Lifting something heavy Having something fall on you Being hit, kicked, or bitten by a person Being hit, kicked, or bitten by an animal Being hit by car, truck, or equipment A car or truck crash Getting caught in machinery
n (% Total) 164(29) 134 (24) 69 (12) 57 (10) 24 (4) 23 (4) 20 (4) 10(2) 3 (0.5) 1 (0.2)
14% (n = 78) injured twice, 7% (n = 41) injured three times, and 6% (n = 32) injured four or m o r e times. A substantial p r o p o r t i o n of the 505 reported injuries were potentially serious; 12% resulted in at least 1 d a y of missed w o r k or school and 16% required a visit to a doctor, nurse, or hospital. A m o n g those reporting injuries, 29% indicated that their injuries resulted from being cut, while nearly a quarter were b u r n e d b y a hot object or grease (Table 4). Being cut was the only r e p o r t e d injury for which there was a statistically significant difference b y gender, with 34% of males reporting a laceration on the job, c o m p a r e d to 22% of females (p = 0.001).
Discussion This s t u d y confirms that work for p a y outside the h o m e is c o m m o n a m o n g teens. Over 95% of our sample had ever w o r k e d for p a y for someone outside their family, with 32% of the sample getting paid for work before age 14 years. This is a slightly higher percent than reported in 1994 in Minnesota (20). Consistent with other studies, the majority of y o u t h report having w o r k e d in the retail trade and the service sector, particularly the food industry (10,21). Although other studies (10,20) have characterized the types of jobs held b y teens, to our k n o w l e d g e this is the first systematic s t u d y of exposure to specific occupational hazards a m o n g a population-based sample of working youth. One-quarter or more of our respondents report having w o r k e d a r o u n d ladders and scaffolding; tractors, forklifts, and riding mowers; restaurant fryers and slicers; and m o t o r vehicles, hazards associated with occupational injury in case reports (11,12,16,22,23). Males were more likely than females to be exposed to every h a z a r d about which we asked. H o w e v e r , females were more
n (% Injured) Who Missed Work or School for at Least 1 Day 15/164 (9) 4/134 (3) 15/69 (22) 11/57 (19) 1/24 (4) 1/23 (4) 4/20 (20) 6/10 (6o) 2/3 (67) 0/1
(0)
n (% Injured) Who Visited a Doctor, Nurse, or Hospital 24/164 (15) 11/134 (8) 18/69 (26) 9/57 (16) 3/24 (13) 1/23 (4) 5/20 (25) 5/10 (50) 3/3 (100) 0/1
(0)
likely to be exposed to jobs which require handling of money, possibly placing t h e m at greater risk for assaults. Occupational sex segregation is a concept used by social scientists to describe gender differences in jobs (24). Although the degree of occupational sex segregation has declined since the 1970s, most workers remain in sex-segregated jobs. Female-typical jobs have lower pay, fewer benefits, less on-the-job training, and lower promotional opportunities than maletypical jobs, while exposure to job hazards is m o r e c o m m o n in disproportionately male occupations (24,25). Males of all ages are also overrepresented in occupational injury and fatality statistics. Differential exposure to hazards appears to be a result of occupational sex segregation. Our s t u d y provides evidence of occupational sex segregation a m o n g working youth, with g e n d e r differences in type of work, h a z a r d exposure, and, to a lesser extent, workrelated injury. While c o m m o n w i s d o m has it that teens, especially males, are injured because of carelessness and risk-taking, their injuries are more likely a reflection of their job experience, their exposure to work-related hazards, and e m p l o y e r expectations. Further research exploring the interaction a m o n g gender, risk of exposure to hazards, and response to situations of risk will help inform injury-prevention interventions. Injuries at w o r k are c o m m o n a m o n g teens. Over half of our respondents had been injured at w o r k at least once. Although few y o u t h missed w o r k or school or sought care for c o m m o n causes of injury, a substantially higher p r o p o r t i o n missed work or school or sought care for the few injuries related to m o t o r vehicles. Our s t u d y did not address w h e t h e r the decision to seek medical care for injuries stems from the y o u t h w o r k e r or the employer. H o w e v e r , the exploration of factors associated with seeking
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DUNN ET AL.
medical care for work-related injury is a topic for future study. Another issue also deserves more detailed study. We identified a large proportion of youth who work at night. Without more information about the conditions of work, we were unable to determine whether this work violated the FLSA. Based on studies of adults, however, it appears that work at night poses a significant risk for injury. Alexander and colleagues reviewed workers' compensation records in Washington State to identify sexual assaults of women (26). Although fewer people work at night, over half of the reported rapes at work occurred between 7 P.M. and 6 A.M.. Fifty-five percent of Ohio workers' compensation cases resulting from violent crime at work occurred between 7 P.M. and 7 A.M. (27). Occupational homicides are also disproportionately frequent at night; from 1980 to 1989, 20% of all occupational homicides occurred in the 3 h between 10 P.M. and 1 A.M. (28). Sixty-one percent of all workplace homicides in North Carolina during 1977-1991 occurred between 6 P.M. and 5:59 A.M. (29). In our study, a small but concerning number of youth expressed fear of assault while at work. This concern and the relationship between working with money, working at night, and risk for assault deserve further investigation in this young and vulnerable group. One of the limitations of this study is that we were unable to ask questions about hazards and injuries in a specific job context. Because youth hold many different jobs in a short period of time, either in succession or simultaneously, it was impossible in a brief telephone interview to ask a series of questions about each specific job. Therefore, we opened the majority of our questions with the phrase, "Have you ever . . . " Thus, we are unable to determine the incidence of exposure to various hazards or incidence of injury. Ideally, one would like to be able to determine risk of injury per amount of time exposed to a particular hazard; future studies should attempt to collect this information. It is possible that the number of jobs reported and the numbers of types of exposures and injuries are underestimated because of recall bias associated with the recall period of "ever." Telephone surveys also have the potential for bias if teens without telephones have different work experiences and exposure to hazards than those with telephones. Future studies should sample those without telephones, verify respondent self-reports, and compare work patterns and hazard exposures in jurisdictions with different labor practices and enforcement.
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Occupational injuries are preventable. The National Institute for Occupational Safety and Health recently published recommendations for employers, parents, educators, and adolescents about workplace safety (30). Health care providers should take an occupational history on patients as young as 10 or 11 years of age, especially when a child presents with an injury. Documentation should include the activity at the time of injury, mechanical equipment contributing to the injury, use of personal protective equipment, and relationship of child to employer. Because teens may find themselves in situations where they do not have the developmental skills or experience to safely perform potentially hazardous job tasks, providers should also ask patients if they have concerns about their safety at work and with whom they would discuss these concerns. Providers should alert parents and adolescents to the potential risks of on-the-job injury and to the importance of safety equipment and practices. They should also familiarize themselves with the requirements of the FLSA to alert adolescents and their parents to work activities that may violate child labor laws. Programs on occupational safety and health should be offered through continuing medical education seminars and should be incorporated into training curricula for resident physicians, physician assistants, and nurses. Further studies quantifying exposure to specific hazards will help guide development of occupational safety interventions for teens. These include strengthening child labor laws and providing education about work safety for teens, their parents and employers, and other professionals who work with youth. This research was supported by Grant R01-CCR402444-10 from the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention, to the University of North Carolina Injury Prevention Research Center. Additional support was received from the North Carolina Cooperative Extension Service and the North Carolina Agricultural Research Service. The authors thank Connelly Simmons, Yvonne Brannon, and Diane Calleson for assistance with development of the interview protocol, and Stephen W. Marshall for help with data analysis.
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