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Accident Analysis and Prevention 40 (2008) 527–533

Escalator-related injuries among older adultsin the United States, 1991–2005

Joseph O’Neil a,∗, Gregory K. Steele b,Carrie Huisingh c, Gary A. Smith d

a Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine,702 Barnhill Drive, Room 1601, Indianapolis, IN 46202, USA

b Department of Public Health, Indiana University School of Medicine, 714 N. Senate Avenue,Room 250E, Indianapolis, IN 46202, USA

c Massachusetts Department of Public Health, 250 Washington Street, 4th Floor, Boston, MA 02108, USAd The Ohio State University College of Medicine and Public Health, and Center for Injury Research and Policy,

Columbus Children’s Research Institute, Children’s Hospital, Columbus, OH 43230, USA

Received 16 March 2007; received in revised form 10 August 2007; accepted 15 August 2007

bstract

This study describes the epidemiology of escalator-related injuries among adults age 65 and older in the U.S. between 1991 and 2005, throughretrospective analysis of data from the National Electronic Injury Surveillance System of the U.S. Consumer Product Safety Commission.There were an estimated 39,850 escalator-related injuries and no fatalities. The overall injury rate was 7.8/100,000 population. During the study

eriod 1991–2005, the rate of escalator-related injuries doubled. The mean age of the study population was 80.1 years (S.D. = 8.5 years) with3.3% female. The most frequent cause of injury was a slip, trip or fall (84.9%, 95% CI: 82.7–87.2%). The most frequently injured body partsere the lower extremities (25.9%, 95% CI: 21.5–30.2%) and the head (25.0%, 95% CI: 20.5–29.5%). The leading type of injury was soft tissue

njuries (54.2%, 95% CI: 49.7–58.7%) followed by lacerations (22.3%, 95% CI: 18.4–26.1%) and fractures (15.6%, 95% CI: 13.1–18.1%). Theate of head injuries and the rate of hospitalizations increased with age.

Escalator-related injuries occur infrequently but may result in significant trauma. These injuries are often associated with a slip, trip or fall.wareness of the risks and the circumstances leading to escalator injuries allows for better direction of intervention strategies on the part of injuryrevention specialists.

2007 Elsevier Ltd. All rights reserved.

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eywords: Older adults; Escalators; Surveillance; NEISS

. Introduction

Escalators have become an accepted part of urban life. Therere approximately 33,000 escalators operating in the Unitedtates (Vertical Analysis, 2007). The United States Consumerroduct Safety Commission (USCPSC) estimates that therere approximately 7300 escalator-related injuries in the Unitedtates each year (USCPSC, 2003). Most of the studies examining

scalator-related injuries have either been case reports or haveocused on children. McGeehan et al. (2006) recently evaluatedscalator-related injuries among US children between 1990 and

∗ Corresponding author. Tel.: +1 317 274 4846; fax: +1 317 278 0126.E-mail address: joeoneil@iupui.edu (J. O’Neil).

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001-4575/$ – see front matter © 2007 Elsevier Ltd. All rights reserved.oi:10.1016/j.aap.2007.08.008

002. Using the National Electronic Injury Surveillance SystemNEISS) database, McGeehan identified approximately 2000hildren who sought medical attention for an escalator-relatednjury each year. Among children, falls and entrapment (whileraveling on an escalator) were the leading causes of injury withsubstantial number of injuries occurring to the head and dis-

al extremities. Chi et al. (2005) studied escalator-related injuryatterns occurring at Taipei Metro Rapid Transit stations. Theirtudy reported that the majority of escalator injuries were causedy passengers trying to perform other tasks while riding, loss ofalance, not holding the handrail, or riders who were struck by

ther passengers. The study was to evaluate the effect of pro-osed safety rules and passenger education. The outcome ofhis study led to recommendations for the Taipei Rapid Transitorporation (TRTC) to provide improved signage and encour-

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ged patrons to wear better footwear to reduce the incidencef escalator-related injuries. The authors of the study also sug-ested that females older than 65 may be safer using elevators.his study contributed to the publication of the Metro Etiquettend Safety Guide that lists recommendations for escalator safetynd etiquette (Taipei Rapid Transit Corporation, 2007). A studyy Murphy and Moore (1992) at the University College Hos-ital of London evaluated 50 escalator-related injuries over a-month-period. Of the 50 individuals who were treated, onlywere aged 70 or older. Falls caused by riders walking on theoving escalator or losing their balance stepping on or off were

he leading causes of injury. Those individuals over the age of0 appeared to be at an increased risk.

This study is the first, to our knowledge, to describe thepidemiology of escalator-related injuries among older adultssing a national sample. This study is a retrospective analysis ofscalator-related injuries among adults aged 65 years and oldereported through the NEISS from 1991 to 2005. Results basedn the analysis of aggregated morbidity data can be used toevelop injury prevention programs and document the need forontinued improvement in escalator safety.

. Methods

.1. Data source

The USCPSC monitors consumer product-related injurieshat are treated in US hospital emergency departments (ED)hrough NEISS. The NEISS obtains data from a probabilityample of 98 hospitals selected from the population of all hospi-als with ED in the United States and its territories (Kessler andchroeder, 1999; USCPSC, 2006; Schroeder and Ault, 2001a,b).ccording to the USCPSC (2006), since NEISS represents more

han 6100 hospitals, statistical weights are applied to the dataollected from the 98 sample hospitals to generate nationalstimates. At each NEISS-associated hospital ED; records areeviewed by a professional NEISS coder and injury data arentered into the NEISS database. For each injury event, infor-ation is collected on the patient’s age, gender, race, injury

iagnosis, body part injured, consumer product involved, dispo-ition (e.g., admitted to the hospital or released), location wherehe injury occurred and a brief narrative of the event. The NEISSas been shown to be highly sensitive and accurate in identifyingonsumer product-related injury cases (Hopkins, 1989; Davis etl., 1996).

Data regarding escalator-related injuries were identifiedsing the NEISS consumer product code for escalators (1890)uring the 15-year-period, 1991–2005 (USCPSC, 2006). Thearrative description for each event was reviewed to verify that itid involve an escalator-related injury. Those not directly relatedo escalators were removed from the database, for example thosenvolving either moving walkways or elevators. The narrativeescription of the event also was used to generate variables to

escribe the cause of the injury, further define the location wherehe injury occurred, determine if alcohol was involved, and iden-ify other hazards that contributed to the injury. National injurystimates were rounded to the nearest 10.

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Prevention 40 (2008) 527–533

.2. Variables

The types of injuries were grouped into five categories duringtudy analysis: (1) soft tissue injury (abrasion, contusions, crush,prain, and strain), (2) fracture/dislocation, (3) laceration (ampu-ation, avulsion, laceration, and hemorrhage), (4) closed headnjury, and (5) other (burns, cardiac, complete body trauma).he injured body regions were grouped into seven categories fornalysis: (1) head (head, face, eye, ear, and mouth), (2) shoul-er, (3) upper extremity (upper arm, elbow, forearm, wrist, hand,nd fingers), (4) torso (neck, trunk, and pelvis), (5) hip, (6) lowerxtremity (leg, knee, ankle, foot, and toes), and (7) other (car-iac, complete body trauma, and respiratory tract). Informationn the cause, type, body region injured, and location where thenjury occurred was gathered from the coded variables and thearrative section of the NEISS database. The causes of injury cat-gories included (1) slip/trip/fall, (2) escalator malfunction, (3)ontact or collision with another escalator passenger, (4) entrap-ent of a body part, clothing, or footgear in the escalator, (5)isstep, loss of balance, or syncope, (6) other. NEISS reports a

eparate field indicating the general location of each injury. Thearrative sections were used with this field to identify seven loca-ions where the incident occurred and were listed as (1) hospital,2) nursing home or retirement center, (3) apartment or primaryesidence, (4) public building, (5) hotel, casino, or racetrack,6) mall or store, and (7) other. For analysis, public buildings,otels, casinos, racetracks, malls and stores were considered toe a single category of public buildings. Patients were stratifiednto five age groups for data analysis (65–69, 70–74, 75–79,0–84, 85+). These age groups were chosen to match with otherational data sets reporting morbidity and mortality rates in thisopulation.

.3. Data analysis

The data were analyzed using EpiInfo®, SPSS® 14.0 for Win-ows, and SAS version 9.1 software (Epidemiology Programffice, 2005; SPSS, 2004; SAS/STAT, 2004). Proportions with5% confidence intervals (CI) were calculated by age groupor cause of injury, injured body region, injury type, and geo-raphic location. All statistical analyses took into considerationample weights and the complex survey design. The CPSC con-iders an estimate to be unstable and possibly unreliable whenhe estimated number of emergency department visits recordedn the database is <1200 or the number of sample observations is20.

.4. Injury rate calculation

Population data (1991–2005) obtained from the CDC Won-er Bridged-Race Population Estimates was used to estimatennual injury rates (CDC Wonder, 2006). National estimatesere calculated using sample weights provided by NEISS.

ate estimates and 95% confidence intervals (CI) were cal-ulated using SAS to take into account the sample weightsnd cluster sample design (USCPSC, 2006; Schroeder andult, 2001a,b). Injury rates per 100,000 population were cal-

is and Prevention 40 (2008) 527–533 529

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Fig. 1. Rate of escalator-related injuries among older adults per 100,000 popu-lation by year, United States, 1991–2005.

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ulated for individual age groups, total population, and forender.

. Results

There were an estimated 39,850 escalator-related injuriesmong adults age 65 and older reported between 1991 and005. On average, there were 2660 injuries annually. The meange of the population was 80.1 (S.D. = 8.5 years, range 65–102ears). Approximately, 73% (29,070/39,850) of all escalator-elated injuries were seen in females. Race was not included inhe analysis because field entries for race were missing in morehan half of the cases. Overall, the national escalator-relatednjury rate for adults aged 65 years and older was 7.8 (95%I: 4.0–11.6) per 100,000 population. The rate of overall injury

anged from a low of 4.4 (95% CI: 2.4–6.4) per 100,000 popula-ion in the 65–69 age group to a high of 13.3 (95% CI: 6.0–20.7)er 100,000 population in the 80–84 age group. The injury ratesere not significantly different when examined by age group orender. The age group, gender distributions, and overall injuryates are shown in Table 1.

Almost 92% of the patients were treated and released fromhe emergency department. Of those admitted for treatmentr observation (2570) the admitting injuries were: 60% frac-ures, 20% soft tissue injury and lacerations, 20% closed headnjuries, and less than 1% were other. The rate of admis-ions for the different age groups increased from 3.0 per 100D visits in the 65–69 age group to 8.9 per 100 ED vis-

ts in the 85+ group. There were no fatalities. The highestumber of reported injuries was seen in 2005; the rate ofscalator-related injury increased steadily between 1991 and005 (Fig. 1). There was no significant monthly variation innjury frequency (mean: 3322; S.D.: 549). The location wherehe injury occurred was noted in greater than 83% of the injuries

eported in NEISS. In those records where the location was iden-ified, approximately 1% of escalator-related injuries occurredt a residence and the remaining injuries occurred in publicuildings.

able 1ge group, gender and rate of injury among older adults receiving emergency

reatment for escalator-related injuries, United States, 1991–2005

haracteristics Na Nb N% Ratea 95% CI for rate

ge group (years)65–69 225 6,500 16.3 4.4 2.4–6.470–74 292 7,810 19.6 6.0 3.3–8.875–79 374 10,040 25.2 9.6 4.9–14.380–84 349 9,450 23.7 13.3 6.0–20.785+ 233 6,050 15.2 10.3 4.2–16.4

enderMale 424 10,780 27.1 5.1 2.1–8.2Female 1049 29,070 72.9 9.6 5.1–14.0

Total 1473 39,850 100.0 7.8 4.0–11.6

a = actual number of escalator-related injuries reported to NEISS;b = national estimate based on weighted NEISS data.a Injury rate per 100,000 population.

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ig. 2. Escalator-related injuries in the elderly, United States, 1991–2005, byype of injury.

.1. Injury type

Fig. 2 presents the distribution of escalator-related injuries byype of injury. Of all injuries among older adults, greater thanalf (54%) were soft tissue injuries. The next most frequently

ecorded type of injuries was lacerations (22%) followed byractures (16%).

ig. 3. Escalator-related injuries in the elderly, United States, 1991–2005, byody region injured.

530 J. O’Neil et al. / Accident Analysis and Prevention 40 (2008) 527–533

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.2. Injured body region

The distribution of injured body regions is shown in Fig. 3.verall, the lower extremities (26%) and the head (25%) were

he most frequently injured body regions. The remaining injuredody regions were divided between the torso (18%) and upperxtremities (16%). Among lower extremity injuries, soft tissuenjuries (58%) and lacerations (30%) were the most frequent.he head was the second most frequently injured region. Among

njuries to the head, lacerations (40%), and soft tissue injuries31%) were the most frequent. Closed head injury, blunt headrauma, concussion, or subdural hemorrhage comprised 28% ofhe head injuries. The torso injuries predominately were soft tis-ue injuries (72%) and fractures (25%). Almost half of the upperxtremity injuries were soft tissue injuries (47%), followed byractures (29%), and lacerations (25%). Fig. 4 compares theistribution of injuries between upper and lower extremities.

The distribution of injured body regions was shown to varyith age. For all age groups, the lower extremity and head had

imilar frequency of injuries. However, with increasing age, theroportion of head injuries increased from 22% in the 65–69roup to 38% for those 85 and older. The proportion of lowerxtremity injuries was greatest in the 65–69 group and lowestn the 85+ group.

.3. Cause of injury

Of all the injuries in this study, the majority (85%) were theesult of a slip, trip, or fall. Almost 14% occurred while step-ing on or off the escalator. The next most frequent cause wasn admitted misstep, loss of balance, or syncope (2340/39,850,%). Three percent of injuries were associated with a garment,ootwear, bag or purse, or body part becoming entrapped oraught in the escalator. Another 3% were due to contact or col-ision with another passenger. Escalator malfunction or using aalking assistance device was associated with a small numberf falls when compared to other causes.

. Discussion

This is the first study to estimate escalator-related injuriesn older adults based on a national sample of ED visits. Our

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ted States, 1991–2005, upper and lower extremity.

tudy describes age-specific injury rates, injury type, injuredody region, and cause of injury for escalator-related injuriesmong people 65 years of age and older. Prior to this study,ost of the information were occupational or industry injury

eports, newspaper accounts or case reports of escalator-relatednjuries (Campbell-Reid, 1968, 1973; Bleyer, 1987; McCann,004; Vertical Analysis, 2007).

The results of our study do reflect the general pattern of unin-entional injury in older adults in that slip trip or fall was theeading cause of escalator-related injury and females were moreften injured than males. These findings are consistent with othereviews of unintentional injury where falls, in general, are theeading cause of nonfatal injury, and women are more likely toxperience a nonfatal fall injury (CDC, 2007). Stepping on orff the escalator was cited as a contributing factor in approx-mately 15% of the injuries. Alcohol use was recorded in lesshan 1% of all cases. Individuals being injured while walking upr down the moving escalator were rarely reported. Contact orollision, resulting in a fall while riding the escalator was citeds a cause in less than 3% of all cases. Based on a much smalleropulation and for a shorter study period, the study by Murphynd Moore (1992) found differing results compared to our study.n their study, almost 60% of the escalator-related injuries wereaused by the person walking on a moving escalator, another5% occurred when the individual was either stepping on or offhe escalator, approximately 5% were due to being knocked overy passengers, or alcohol was a factor in 28% of the injuries.here were only 8 adults older than 70 years in their study. Of

hese, two fell while stepping on or off the escalator, two whilealking on a moving escalator, and four while standing on theoving escalator. However, of these four, two women fell after

eing struck and knocked down by another passenger walkingn the escalator. The data in Murphy and Moore’s paper wereased on a prospective study collecting survey data on indi-iduals who sustained escalator injuries compared to our study,hich was based on a retrospective electronic injury surveillanceatabase.

The causes of escalator-related injuries among older adultsre very similar to causes of injuries in other situations. Fac-ors that could contribute to a fall, such as poor equilibrium,ecreased visual acuity, coordination problems, changes in mus-

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le strength and balance, peripheral neuropathies, and the lack ofgility, may be experienced by older adults (Chen et al., 2005;ussell et al., 2006). In addition, medications (both prescrip-

ion and over-the-counter) and alcohol may cause drowsiness,r affect the balance and safe mobility of an older adult (Russellt al., 2006). The NEISS database has limited information abouthe individual’s medical history or the circumstances surround-ng the incident. Another phenomenon possibly associated withhese falls is the “wallpaper illusion.” This can occur when

person with normal binocular vision views a pattern that iseriodic in the horizontal meridian of the visual field that canroduce disorientation and loss of balance (Cohn and Lasley,985). Escalators may present such a pattern.

Falls for any reason are of importance to older adults.nintentional injuries, specifically falls, are the leading causef injury-related mortality and morbidity among older adultsCDC, 2006). In 2003, more than 1.8 million seniors were treatedn emergency departments for fall-related injuries and 387,000ere hospitalized (CDC, 2007). Falls account for 10–15% of

ll emergency department visits and 6% of all hospitalizationsmong those 65 and older (CDC, 2006). Among older adults whoall, 10–20% experience hip fractures or head traumas that couldead to reduced mobility and independence and increased riskf premature death (CDC, 2006). In this study, the proportion ofead injuries increased in the 85+ age group. Head injuries mayontribute to the burden of injury an older adult experiences inerms of severity, need for intensive care, potential for cogni-ive decline, and excess mortality (Peel et al., 2002; Mortimert al., 1985; van Duijn et al., 1992). The fear of injury may limithe activities of the older population and reduce their quality ofife (Tinetti et al., 1997). While all age groups could be at riskor an escalator-related injury, older adults may experience aore serious outcome. Identification of factors associated with

scalator-related injuries may assist engineers, advocates for thelderly, medical professionals, and older adults to reduce the riskf injury.

The overall rate of escalator-related injuries is similar to thateen by people over the age of 65 who suffer elevator-relatednjuries (Steele, personal communication). Given that there are60,000 elevators in the United States versus 33,000 escalators,he number of injuries per escalator (1.21 per escalator) is morehan 20 times greater than that seen in elevators (0.06 per ele-ator). This increased per-unit rate of escalator-related injuriesompared to elevator-related injuries has also been reportedithin the escalator manufacturing industry (Vertical Analysis,007).

The rate of hospital admissions or observations was directlyroportional to age. The rate was highest in the 80–84 and5+ age groups. As age increased, injuries to the extremi-ies decreased and head injuries increased. This is probablyxplained by a reduction in strength, balance and agility thatould prevent more severe injuries. The admissions recorded inEISS could reflect either a more severe injury or a more con-

ervative approach in management by the ED. Older adults mayresent as being more fragile with respect to their overall healthnd have more co-morbid conditions that may warrant a periodf hospital observation.

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Prevention 40 (2008) 527–533 531

The majority of the individuals reported to have escalator-elated injuries in this study could be evaluated, treated andeleased from the emergency department. Even though thenjured patients were treated in the emergency department andischarged, the risk factors that may have precipitated the fallay not have been addressed. Russell et al. (2006) studied

00 older adults who experienced falls within the communityetting. Their study highlighted a high prevalence of risk fac-ors for future falls as well as a risk for functional declineollowing discharge. Hospitals and other healthcare facilitieshat provide emergency department care for older adults mayonsider developing community programs to provide follow-upupport to older adults discharged from an emergency depart-ent following a fall-related injury. For example, the UCLAmergency Medicine Center in conjunction with the Kaiserermanente Medical Group of Southern California developedvidence-based multi-disciplinary guidelines to assist olderdults who experienced a fall-related injury that were treatednd discharged from an emergency department (Baraff et al.,997).

In prior case studies, the primary location of the injuryas a public building (Campbell-Reid, 1968, 1973; Bleyer,987). Our study also observed that public buildings are theost frequent location for escalator-related injuries. Owners

f public buildings with escalators need to ensure that thesenits are kept in proper working condition and provide mes-ages that remind the rider of safe behavior while riding thescalator. Safe riding behavior includes not using walkers,anes, wheelchairs, or carts on the escalator, facing forwardnd holding the handrail, avoiding contact with the sides ofhe escalator, exercising caution when stepping on or off anscalator, and moving away from the exit area after steppingff (The Elevator Escalator Safety Foundation, 2007). Themerican Society of Mechanical Engineers/American Nationaltandards Institute set voluntary standards for escalators. These

nclude emergency shutoff buttons, low-friction sidewalls, skirtbstruction devices, side clearances less than 3/16 in., warningigns, and bright colored boarders on each step (ASME 17.1,004).

Fall-related injuries in older adults are a major public healthoncern because of their frequency, associated morbidity andortality, and the health care costs associated with treatment

Roudsari et al., 2005). In 2000, the direct medical costs relatedo falls for individuals 65 years of age and older exceeded20 billion in the United States alone (Roudsari et al., 2005).ncreased awareness of the risk of falls and improved meth-ds for predicting individuals at risk may provide directionor the development of intervention strategies. These strategiesould include physician assessment of the patient’s fall his-ory, reviewing medications for possible sedative side effects,eferrals for strength and balance training, checking vision,nd identifying hazards within the home or in the commu-ity (American Geriatrics Society, British Geriatrics Society,

merican Academy of Orthopaedic Surgeons Panel on Fallsrevention, 2001). As our data demonstrated, falls were asso-iated with stepping on or exiting the escalator, misstep or lossf balance, or having a garment, footwear, or bag/purse become

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ntrapped in the escalator. Educating older adults to always faceorward and hold the handrail, stand on the center of the step,imit the number of packages carried, and exercise caution whentepping on and off an escalator may help reduce the frequencyf injury.

.1. Limitations

This study has several limitations. The NEISS database con-ains only records of injuries that are treated in emergencyepartments. Therefore this study may not be representativef injuries treated in other types of health care facilities ornjuries that do not receive medical attention. Some injuries

ay be under-reported, because the NEISS database includesocumentation for only one body region and one type of injurythe most serious injury) per case. Also, in the classification ofariables, the narrative section was used to help establish cat-gories which may result in underreporting. Error may resultrom incomplete or incorrect documentation in the emergencyepartment or data entry into the NEISS database. Data valid-ty checks are routinely performed by CPSC staff to preventhe latter source of error. After stratification, the number ofertain recorded events was small and may not be statisti-ally stable. The NEISS database provides limited informationbout the circumstances surrounding the injury, and informa-ion contained in the narrative section may be inconsistent,ncomplete, or poorly defined. Data gaps were identified for pas-enger behavior and information regarding the circumstancesurrounding the incident, geographic location, alcohol use, andace. Efforts should be undertaken to improve the reporting ofhese variables in the medical record so they may be abstractednto the NEISS database. In addition, data regarding the fre-uency of use of escalators by older adults are unavailablend for this reason, calculations of true injury rates were notossible.

. Conclusion

This is the first study of escalator-related injuries to olderdults based on a national sample. Although escalators are aafe form of transportation, fall-related injuries still occur. Olderdults should be informed of possible dangers associated with anscalator and should use caution while riding an escalator andspecially when stepping on or off. Also, older adults shouldot try to walk up a moving escalator, carry large objects, orear loose garments while riding an escalator since these behav-

ors appear to be associated with an increased risk of falling.lder adults who have difficulty walking or maintaining bal-

nce may want to consider using elevators when traversingultiple level buildings. Escalators should be frequently mon-

tored to ensure that they are in good working condition to

inimize hazards that could lead to escalator-related injuries.his study provides information about the risk of escalator-

elated injuries, and is useful for engineers, advocates, andedical professionals to improve safe escalator use by older

dults.

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Prevention 40 (2008) 527–533

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