The Journal of TRAUMA威 Injury, Infection, and Critical Care

A Clustering of Injury Behaviors

Carol R. Schermer, MD, MPH, Ellen C. Omi, MD, Hieu Ton-That, MD, Karen Grimley, MSW,
Pamela Van Auken, RN, John Santaniello, MD, and Thomas J. Esposito, MD, MPH

Background: Alcohol is a well-known
risk factor for injury. A number of other
behaviors are also associated with injury
risk. We hypothesized that risky drinking
would be associated with other high risk
behaviors, thereby delineating a need for be-
havioral interventions in addition to alcohol.
Methods: A consecutive sample of
trauma patients was interviewed for
drinking and risky behaviors including
seat belt use, helmet use, and driving be-
haviors. The Alcohol Use Disorders Iden-
tification Test was used to screen for risky
drinking and risky behavior questions
were taken from validated questionnaires.
Behaviors were ranked on a Likert scale
ranging from a low to a high likelihood of
the behavior or assessed the frequency of
behavior in the past 30 days. An Alcohol
Use Disorders Identification Test score of
8 or more was considered risky drinking
for adults age 21 to 64, and 4 or more for
ages 16 to 20 and over 65. Risky and non-
risky drinkers were compared on behav-
ior risk items. A p value of less than 0.05
was considered significant.
Results: One hundred sixty patients
(mean age, 36.8 years, 72% men,) were
interviewed. Risky drinkers were more
likely to drive after consuming alcohol,
ride with drinking drivers, tailgate, weave
in and out of traffic, and make angry ges-
tures at other drivers (all p < 0.05). Risky
drinkers were less likely to wear motor-
cycle helmets. However, risky drinkers
were no more or less likely to talk on the
cell phone while driving, to use seatbelts,
or use turn signals. Although number of
lifetime vehicle crashes were similar, risky
drinkers were more likely to have been the
party at fault for the crash (mean 1.09 vs.
0.64, p ⴝ 0.03).
Conclusions: Factors other than al-
cohol increase injury risk in problem drink-
ers. Injury prevention programs performing
alcohol interventions should consider in-
cluding behavioral interventions along
with alcohol reduction strategies. New
screening and intervention programs
should be developed for injury behaviors
that increase risk but are not alcohol
related.
Key Words: Injury prevention, Alco-
hol misuse, Aggressive driving, Trauma.
J Trauma. 2008;65:1000 –1004.

A
lcohol is a well-known risk factor for injury. To de-
crease recurrent injury risk, trauma centers have begun
performing brief interventions (BI) as part of their in-
jury prevention programs. In addition to decreasing alcohol
use, behavior change counseling also can be used to improve
other behaviors such as such as seat belt use.1,2 To expand our
injury prevention counseling efforts, we sought to determine
whether problematic alcohol use was linked to other poten-
tially injurious behaviors related to vehicular injury.
A number of trauma centers have used trauma registry
data to show that acute alcohol intoxication, measured by
admission blood alcohol concentration (BAC), has an inverse
association with seat belt and helmet use.3–5 In addition,
population-based telephone surveys and national databases
have shown that alcohol use and in particular binge drinking
may be associated with aggressive driving behaviors and risk
taking.6 –12 Cell phone use,13–15 driving while sleepy,16,17 and
distracted driving18 –20 are known to increase motor vehicle
crash (MVC) risk but their association with alcohol misuse
Submitted for publication February 24, 2008.
Accepted for publication June 11, 2008.
Copyright © 2008 by Lippincott Williams & Wilkins
Department of Surgery, Loyola University Chicago, Maywood, Illinois.
Supported, in part, by NIH/NIAAA, R01 AA015067-01A2 (to C.R.S.).
Presented at the 38th Annual Meeting of the Western Trauma Association,
February 24 –March 1, 2008, Squaw Creek, Olympic Valley, California.
Address for reprints: Carol Schermer, MD, MPH, 2160 S First Avenue,
Maywood, IL 60153; email: cschermer@lumc.edu.
DOI: 10.1097/TA.0b013e318182f76b
has not been evaluated. The purpose of this study was to
determine whether trauma center patients would disclose
these risky behaviors so we could potentially target them for
intervention during a BI session for alcohol and to assess
whether the behaviors were linked to alcohol misuse.
We hypothesized that risky drinkers would be more
prone to exhibit other risk taking behaviors than nonrisky
drinkers and that we would be able to elucidate this via a
questionnaire. We also sought to determine whether these
high risk patients could be identified through formal alcohol
screening or whether the BAC was sufficient to capture these
behaviors.
METHODS
A prospective institutional review board approved study
was conducted of trauma and burn patients admitted to a
Level I trauma center between August 2007 and January
2008. A consecutive sample of admitted trauma patients was
surveyed for a number of different risk factors that are known
to increase injury risk. In addition we quantified the fre-
quency of particular injury events in the past year. Most items
were taken from previously validated surveys such as the
Behavioral Risk Factor Surveillance System and the Youth
Risk Behavior Survey and the National Epidemiologic Sur-
vey of Alcohol and Related Conditions. The questionnaire
was pilot tested on the first 50 patients in the sample and then
modified to improve reliability. The final questionnaire was
comprised of 48 items in addition to the Alcohol Use Disor-

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 A Clustering of Injury Behaviors

ders Identification Test (AUDIT) and took approximately 10

Table 1 Demographic Characteristics
minutes to complete.
Enrolled Patients

Interviews Age (yrs) range 36.8 (16–86)

Bedside face-to-face interviews were conducted with Gender
trauma patients admitted for injury. Patients were initially M 115 (72%)
F 45 (28%)
screened with the AUDIT and then were asked questions Race/Ethnicity
regarding behaviors related to injury. Patients eligible for W 85 (53.1%)
study were English speakers age 16 and above who had been AA 39 (24.4%)
screened with the AUDIT. Risky behaviors studied included HL 28 (17.5%)
seat belt and helmet use, aggressive driving, driving after Other 8 (5%)
BAC mean (range) mg/dl, n ⫽ 118 38.4 (0–370)
drinking, riding with a drinking driver, cell phone use, dis- BAC ⬎ 0 32 (27.1%)
tracted and sleepy driving. AUDIT (range), n ⫽ 160 4.7 (0–28)
Tested items were ranked on a 5-point Likert scale rang- Risky drinkers 39 (24.4%)
ing from never doing the behavior to always doing the be- Mechanism of injury
havior. Other behaviors while driving such as cell phone use, MVC/MCC 47 (29.4%)
Burn 46 (28.8%)
eating, grooming, driving after drinking, and driving while Fall 25 (15.6%)
sleepy were quantified for the number of times they occurred Stab/GSW 19 (11.9%)
in the past 30 days. Pedestrian 9 (5.6%)
Risky drinking was defined based on AUDIT total score. Assault 6 (3.8%)
For patients ages 16 to 20 and 65 and older an AUDIT score Other 8 (5%)
of 4 or more was considered risky drinking, and for adults BAC ⫽ blood alcohol concentration; M ⫽ male; F ⫽ female; W ⫽
ages 21 to 64 an AUDIT score of 8 or higher was considered Non-Hispanic white; AA ⫽ black/African American; HL ⫽ Hispanic-
Latino. Risky drinker by AUDIT ⱖ 4 for ages 16 –20 and 65⫹, ⱖ8 for
risky drinking. Risky and nonrisky drinkers were compared
rages 21– 64. MVC/MCC ⫽ motor vehicle/motorcycle, GSW ⫽ gun-
on different injury prevention behaviors. Admission BAC shot wound.
was also used to determine whether it was able to identify
patients exhibiting risky injury prevention behaviors. For
analysis purposes, BAC was dichotomized into BAC mea- Table 2 Association of Risky Drinking by AUDIT and
sured as zero or BAC positive, with the lower limit for BAC With Risk Behaviors
detection in the laboratory being 10 mg/dL. Because nearly AUDIT Risky
BAC Measurement
50% of our patients are transferred in from other facilities, the Behavior Drinking

BAC was analyzed in a dichotomous fashion because of the NRD RD BAC ⫽ 0 BAC⫹
high variability and uncertainty in the timing of injury and Talk on cell phone 2.80 2.46 2.73 2.83
obtainment of the BAC. Fisher’s exact test and one-way Wear seat belt 3.29 3.65 3.04* 3.75*
analysis of variance were used were appropriate to compare Ensure child belted 3.68 4.56 3.42* 4.75*
Use turn signals 3.37 3.50 3.09 3.46
risky drinkers by AUDIT and BAC categories separately.
Speed 10 mph over 3.01 2.68 3.19* 2.62*
Normality for measures analyzed by analysis of variance was Wear MC Helmet 3.53* 1.40* 3.80 3.17
assessed using p-p plots. Reliability testing was performed Wear bicycle helmet 2.44 1.73 2.83 1.75
for select items using Cronbach’s alpha. All data analyses Ensure child helmet 3.42 4.00 3.85 2.57
were performed in SPSS version 15. Power analysis demon- Weave in traffic 1.05* 1.45* 1.73 1.83
Speed 20 mph over 1.51 1.45 1.49 1.33
strated that we needed to enroll a total of 150 patients in the
Tailgate 1.28* 1.75* 1.41 1.50
study to detect a difference of 30% (more than 1 category on Gesture 1.51* 2.35* 1.59 2.11
the Likert scale) between groups in bivariate analysis.
Values are mean score on scale from 1 to 5. 1 represents never
and 5 represents always.
RESULTS * Means p value ⬍0.05 between risky drinking groups compared
One hundred sixty-four patients were approached to by one-way ANOVA.
complete the AUDIT of which four patients refused making MC, motorcycle; mph, miles per hour.
them ineligible for the study. The demographic characteris-
tics of the enrolled patients are displayed in Table 1. The where the admission BAC was measured at 0 in 13 of 38
majority of patients were male and white, with the highest monthly binge drinkers. Reliability was excellent for seat belt
frequency mechanism of injury being motor vehicle colli- use (␣ ⫽ 0.88) and for driving after drinking (␣ ⫽ 0.95),
sions and burns. BAC measurements were not obtained in 42 moderate for aggressive driving (␣ ⫽ 0.68), but poor for cell
patients. BAC measured at 0 mg/dL did not pick up on 43.8% phone use (␣ ⫽ 0.54).
of drinkers categorized as risky by the AUDIT. In addition Table 2 demonstrates comparisons of risky and nonrisky
BAC failed to identify 46.4% of monthly binge drinkers drinkers on each of the injury prevention items. In addition to

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 The Journal of TRAUMA威 Injury, Infection, and Critical Care

Table 3 Average Number of Days of Each Behavior in Table 4 Percentage of Patients Admitting Behavior in
Last 30 Days Last 30 Days
AUDIT Risky AUDIT Risky
BAC Measurement BAC Measurement
Drinking Drinking
NRD RD BAC ⫽ 0 BAC⫹ NRD (%) RD (%) BAC ⫽ 0 (%) BAC⫹ (%)

Behavior Behavior while driving

Drive within hour of 0.22* 1.67* 0.33* 1.21* Drive within hour of 14.0* 42.4* 16.7* 39.3*
1–2 drinks 1–2 drinks
Drive within hour of 3 0.09* 0.85* 0.18 0.25 Drive within hour of 3 4.7* 27.3* 9.0 14.3
or more drinks or more drinks
Drive while high from 0.13* 0.95* 0.20 0.28 Drive while high from 8.1* 27.3* 12.5 22.2
drinking drinking
Ride with drinking 0.95* 4.11* 0.99* 5.56* Ride with drinking 12.0* 27* 16.5 22.6
driver driver
Following behaviors Following behaviors
asked while driving asked while driving
Talk on cell phone 9.62 11.59 9.71 10.76 Talk on cell phone 76.8 69.2 75.8 79.2
Eat in car 5.00 8.12 4.46* 10.07* Eat in car 52.1 61.5 51.2 68.8
Grooming 0.40 0.44 0.13 0.59 Grooming 14.9 15.4 9.3 15.6
Become distracted 4.58 6.00 3.34 6.79 Become distracted 41.3 43.6 34.9 40.6
Feeling as if could 1.88 6.91 4.49 1.38 Feeling as if could 41.3 41.0 39.5 40.6
easily fall asleep easily fall asleep
Doze off while driving 0.20 0.30 0.13 0.66 Doze off while driving 16.5 25.6 14.0 18.8
Drive after usual 1.00 2.24 1.33 1.79
Percentage of respondent stating that the behavior occurred at
sleep time
least once in the last 30 days.
Average number of days of behavior by group behavior in past * Denotes p ⬍ 0.05 by Fisher’s exact test comparing AUDIT risky
30 days. drinkers to nonrisky drinkers or BAC ⫽ 0 to BAC positive.
* Represents p value ⬍.05 between risky drinking groups com- NRD, nonrisky drinker by AUDIT; RD, risky drinker by AUDIT.
pared by one-way ANOVA.
NRD, nonrisky drinker by AUDIT; RD, risky drinker by AUDIT.
high from drinking. However, similar to the AUDIT, BAC
detecting risky drinkers, the AUDIT cutoff score was able to was able to differentiate a high rate of driving after one or two
detect less frequent use of motorcycle helmets, and higher drinks and riding with a drinking driver. Although cell phone
frequency of aggressive driving measure by weaving in and use while driving was frequent, averaging 10 of the past 30
out of traffic, tailgating and gesturing. BAC measurements days for the group, it was unrelated to risky alcohol use.
were not able to detect any of the aggressive driving behav- Risky drinking as measured by BAC appeared to be associ-
iors. They unexpectedly uncovered higher rates of seat belt ated with eating in the car, but risky drinking wither by the
use and ensuring child belt use than BAC zero patients and AUDIT or BAC cutoffs was associated with distracted or
were also associated with a lower likelihood of speeding. sleepy driving. Because means of less than one can be diffi-
Classification of risky drinkers by either measure did not cult to interpret we also chose to evaluate the number of times
appear to be related to cell phone use. Most cell phone use each behavior occurred more than once in the last 30 days to
occurred in the “often” category. Categorization as a risky get a sense of the frequency of occurrence of each behavior.
drinker by either method was also not associated with use of Table 4 shows the frequency of each behavior occurring at
turn signals which were “almost always” used by both risky least one time in the past 30 days by drinking group. Al-
and nonrisky drinkers. though few items differed by drinking group, it was clear that
Only 65% of patients wore their seatbelts every time they certain behaviors associated with vehicular injury risk are
rode in a car in the past 30 days. There were 141 people who quite frequent.
had driven in the last 30 days. On average, cell phone use Table 5 shows the frequency of lifetime motor vehicle
while driving occurred on 10 days of 30 days. One third (n ⫽ collisions, collisions for which the patient was at fault, and
47) of drivers reported at least 1 day where they drove while number of tickets given for red-light running. Risky drinking
feeling they could easily fall asleep and 11 (7.8%) reported was only associated with being at fault in a collision. This
that they actually dozed off while driving. Table 3 demon- association was not detected by using BAC measurement.
strates the average number if times behaviors were reported Questions regarding the frequency of receiving a ticket for
by each group in the past 30 days by risky drinking category. red-light running were only on the second version of the
Problem drinking as measured by the AUDIT was associated questionnaire. Eighty-eight drivers were asked how many
with driving after drinking and riding with a drinking driver. tickets they had received for running a red light and 15 (17%)
The BAC cutoff did not demonstrate an association with had received at least one ticket for running a red light. To
driving after having three or more drinks or driving while estimate red-light running and not just tickets received, the

1002 November 2008


Table 5 Lifetime Motor Vehicle Crashes and Tickets
for Red Lights
AUDIT Risky
BAC Measurement
Behavior Drinking
NRD RD BAC ⫽ 0 BAC⫹
Lifetime MVC 2.25 2.84 2.72 2.05
At fault MVC 0.64* 0.1.09* 0.67 0.90
Red light tickets 0.24 0.19 0.28 0.32
* Denotes p ⬍ 0.05 between groups by one way ANOVA.
NRD, nonrisky drinker by AUDIT; RD, risky drinker by AUDIT.
second version of the questionnaire also asked the question
“recalling the last 10 intersections you drove through, how
many were the lights red when you entered the intersection?”
Eighty drivers responded to the question and 21 (25.9%) had
run at least one red light of the last 10. Neither positive BAC
nor risky drinking by the AUDIT was associated with red-
light running.
Because responses to questions about vehicular injury
risk may be confounded by the mechanism of injury for
which the patient was admitted or by age, we determined
whether risky drinking or the injury behaviors were associ-
ated with either of these two variables. The average age of
nonrisky drinkers by the AUDIT was 36.4 and for risky
drinkers was 36.9 ( p ⫽ 0.93). The average age for BAC
positive patients was 33.7 years and it was 36.7 years in those
with BAC measured at zero ( p ⫽ 0.39). Because there were
so many mechanisms of injury, we compared motorvehicle or
motorcycle patients to all other mechanisms. Comparing ve-
hicular mechanism of injury to all others, 34% were of
patients admitted for a motorvehicle or motorcycle mecha-
nism were BAC positive as opposed to 24% of patients with
all other mechanisms of injury ( p ⫽ 0.26). By the AUDIT,
23.4% of motorvehicle or motorcycle patients met criteria for
risky drinking compared with 24.8% of patients with a non-
vehicular mechanism of injury ( p ⫽ 1.0).
There were no statistically significant associations be-
tween mechanism of injury and any of the injury prevention
behaviors listed in Tables 2– 4 (all p ⬎ 0.05). To evaluate
whether age was associated with the injury behaviors, Pear-
son’s correlations were performed using age and the Likert
scale responses as a continuous variables. There were two
statistically significant correlations of age with any behavior
and both were weak, inverse correlations. Age was inversely
correlated with the likelihood of tailgating (r ⫽ -0.30, p ⫽
0.01) and with gesturing (r ⫽ -0.25, p ⫽ 0.01).
DISCUSSION
In this sample of admitted trauma patients, we were able
to detect some risky behaviors related to injury in MVCs but
not others. Some of the behaviors related to alcohol misuse
were not surprising such as driving after drinking and riding
with a drinking driver. In addition the lower frequency of
helmet use among risky drinkers has also been described
Volume 65 • Number 5
A Clustering of Injury Behaviors
previously in similar populations.4,5 New to this study and
different from trauma registry studies is that the AUDIT also
helped identify people who drive aggressively via weaving,
gesturing and tailgating. The association of risky drinking
and aggressive driving is corroborated in population-based
samples that show that aggressive drivers often report high
levels of drinking.10 Eating while driving is thought to in-
crease crash risk because of general distraction and physical
demands.20 However, one could surmise that an intoxicated
driver who is also eating while driving would likely have a
higher crash risk than a nonrisky drinker who eats while
driving. The AUDIT outperformed the BAC in detecting
most of these behaviors that place people at increased risk in
traffic crashes.
It is not clear why we were unable to detect an inverse
association with seat belt use and risky drinking that has been
seen in other studies. These data are self-reported and may
differ from trauma registry data because this study included
many different mechanisms of injury and not just vehicular
injury. We performed a post-hoc analysis to determine
whether seat belt usage differed between MVC mechanism
patients and those with other mechanisms but it did not. Both
cell phone use13,14 and driving while sleepy16 are known to
increase injury risk. These occurred at a frequency that seems
to warrant intervention given that one third of the group
reported driving while sleepy at least once in the last 30 days
and cell phone use while driving occurred 3 of 10 days.
Although we expected to see driving while sleepy and
distracted driving to be associated with risky alcohol use,
existing literature is also not clear on this topic. Chronic
alcohol use is often associated with poor sleep but we did not
find an impact on frequency of sleepy driving. Sleepy driving
is known to be associated with sleep apnea and poor sleep
habits but its association with alcohol use has not been de-
scribed. However, it is known that even low doses of alcohol
worsen the impact of sleepy driving21 but we were unable to
find studies describing them as a combined risk factor. Most
studies on distracted driving are performed via the use of
simulators18 or are based on data in administrative crash
databases19,22 and not via self-report. They test in-vehicle,
out of vehicle and passenger-related distractions. We did not
specifically test the psychometric properties of the distracted
driving questions and it may be that they did not have face
validity. To see if distracted driving is amenable to behavioral
counseling, better measures would need to be developed.
Questionnaires like the one administered in this study are
subject to different types of bias. One could postulate that
patients who were admitted for a vehicular injury would
potentially answer items regarding vehicular injury risk dif-
ferently than those admitted for other mechanisms. We were
unable to detect any differences in behaviors by mechanism
and hence do not think that this sort of bias had an impact on
the results. It also appears that mechanism of injury does not
confound the association of risky drinking and injury behav-
iors. In addition, because these interviews were face to face in
1003
 The Journal of TRAUMA威 Injury, Infection, and Critical Care
which the AUDIT screening was followed by the injury
behaviors questionnaire it is possible that drinkers were ques-
tioned and “probed” differently than nondrinkers. Although
there is no way to test whether this occurred, because all of
these patients were potential candidates for a randomized BI
trial that is currently ongoing, our research group is very
careful to not lead patients while questioning so as not to
unintentionally deliver an intervention. Other limitations in-
clude that our analysis methods were limited to bivariate
techniques. Although most of the bivariate analyses did not
show associations of these risky behaviors with age or mech-
anism of injury, a larger sample would have been amenable to
multivariate analysis. Age was weakly correlated with a few
behaviors but not with risky drinking. Multivariate tech-
niques could help elucidate if age either confounds or mod-
ifies the risky behaviors. That said our intent is to have BIs
delivered in as meaningful of a way as possible to all risky
drinkers. The bivariate analyses presented here allow the
clinicians to recognize that there are other issues that should
be addressed during the intervention process.
Much of these data corroborate other studies from
trauma centers based on toxicology findings and also corrob-
orate epidemiologic surveys. Riding with a drinking driver
occurred at a high frequency (4 of the last 30 days) among
risky drinkers and this topic should be addressed while per-
forming BIs to further reduce subsequent harm. Although
four patients declined AUDIT screening, nobody turned
down study participation for the questionnaire. From this
study, we learned that patients are willing to discuss these
behaviors regarding vehicular injury risk although more than
half were admitted for nontraffic-related injuries. Risky be-
havior patterns may very well make people more susceptible
to both intentional and unintentional injuries. BIs during
hospitalization can address all areas where patients are at risk
and not just those for which they were admitted.
Screening for alcohol use will help trauma programs
identify people who are at risk for alcohol-related vehicular
injuries and for injuries related to aggressive driving and
helmet use. Although alcohol misuse is associated with a
number of behaviors that also increase injury risk, other risky
behaviors are highly prevalent in the admitted trauma popu-
lation and they would not be addressed if injury prevention
programs select patients for counseling only via alcohol
screening. Further development of short questionnaires that
can be used by trauma programs to accurately assess injury
risk is needed. Injury prevention programs performing alco-
hol interventions should consider including behavioral inter-
ventions along with alcohol reduction strategies and should
also evaluate screening and intervention programs for other
risky behaviors.
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