Swimming Pool Owners' Opinions of Strategies for Prevention of Drowning

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Swimming

Pool Owners’

Opinions

of Strategies

for Prevention

of Drowning

Garen

J. Wintemute,

MD, MPH,

and

Mona

A. Wright,

BS

From the Department of Family Practice, University of California, Davis

ABSTRACT. Training in cardiopulmonary resuscitation

for pool owners and mandatory placement of a barrier around pools, two commonly suggested strategies for prevention of drowning, will depend, in part, on the support of pool owners to be successfully implemented.

To measure this support, an equal probability sample of 795 Sacramento County households with pools was

sur-veyed. An 80% response rate was achieved. A large ma-jority (86%) favored voluntary cardiopulmonary resusci-tation training, and a plurality (40%) favored required cardiopulmonary resuscitation certification for poo1 own-ers. However, 61% opposed a universal barrier require-ment, and 49% objected to a barrier requirement for new pools only. Respondents with small children at home were more likely (P .0001) to support a required barrier. The previous occurrence of a significant immersion event

had surprisingly little effect. The results suggest some specific directions for programs to prevent swimming pool drownings. Pediatrics 1990;85:63-69; drowning, im-mersion, resuscitation, swimming pool.

Immersion events (drowning and near-drowning)

remain an important cause of mortality and mor-bidity in the United States, particularly for young

children. In 1985, 690 children 0 to 5 years of age drowned in this country, whereas 483 were killed as motor vehicle occupants and 565 as pedestrians.’ Improvements in pediatric intensive care appear to have enhanced the likelihood of surviving a serious immersion event, but an increasing number of these

survivors have severe and permanent neurologic

impairment.2’3 In California, health care costs for

these children can reach $100 000 per child per

year4

The epidemiology of childhood immersion events

suggests that they are particularly amenable to

Received for publication Dec 20, 1988; accepted Feb 28, 1989. Reprint requests to (G.J.W.) Dept ofFamily Practice, University of California, Davis, Medical Center, 2221 Stockton Blvd, Rm

2111, Sacramento, CA 95817.

PEDIATRICS (ISSN 0031 4005). Copyright © 1990 by the American Academy of Pediatrics.

prevention. Children 1 to 3 years of age constitute a discrete and relatively homogenous risk group, with drowning rates far higher than those for older children.57 At this high-risk age, as many as 90% of drownings occur in a single high-risk environ-ment-the residential swimming pool.9

Two commonly suggested prevention strategies will depend, in part, on the support and cooperation of residential pool owners for successful implemen-tation. The first of these is to require that a barrier, particularly a fence, surround each residential pool and set it off from the house and yard. The second

is to encourage or require that persons with home

pools be certified in the use of cardiopulmonary resuscitation (CPR).

Pool owners’ support for these interventions has never been evaluated. We, therefore, surveyed an equal probability sample of Sacramento County households with pools to measure support for alter-native forms of these two strategies and to identify factors associated with a greater or lesser likelihood

of support.

We hypothesized that CPR training specifically to prevent swimming pool drownings would receive

substantial support, because community-wide CPR

training without this specific focus has been pro-moted periodically in Sacramento. A mandated bar-rier, we thought, would be widely opposed. We further hypothesized that support for one or both interventions would be positively associated with younger respondent age, presence of children 5 years of age or younger in the household, occurrence of a significant immersion event at home,

respond-ent’s personal knowledge of or involvement in an

immersion event elsewhere, recent pool installation (defined as within 3 years of the survey), and in-stallation of the pool during the respondent’s own-ership of the house.

Respondents were specifically asked whether

they thought pools would be safer with a pool fence

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invited to give reasons for their support or

opposi-tion to the proposed interventions and to suggest alternatives.

For comparative purposes, we obtained opinions regarding three frequently proposed options to

pre-vent drowning which do not focus on residential pools: increased education in water safety, stronger enforcement of current limitations on alcohol at aquatic recreation sites, and an outright ban on alcohol at such locations. We hypothesized that respondents would show greater support for these interventions, which would impact upon them less directly, than for either CPR training or mandated barriers.

METHODS

The Sacramento County Building Department provided a list of all permits for pool construction

issued since 1959. This list was purified by

exciud-ing permits for spas and for pools at commercial or

multiple-unit residential locations. A systematic sample from a random starting point was drawn.

The current county assessor’s record for each

ad-dress in the sample was then reviewed, and the

name of the present owner was determined. Houses where no pool had, in fact, been built, houses not occupied by their owners, and a few remaining commercial and multiunit residential locations were excluded. Only households with permanent pools were eligible, because no means of identifying

houses with temporary pools existed.

There were 825 households in the final sample, approximately 4% of eligible households in the county. The survey was conducted by mail, during January to April 1987, and we adhered to the Total Design Method developed by Dillman.’#{176}’1’

Accord-ing to this method, three mailings of the

question-naire were precisely timed, and the last was sent by certified mail. When the respondent had moved,

the name of the new owner was determined

when-ever possible and the questionnaire remailed.

“Immersion event” was defined in the question-naire as “an event in which a person gets into trouble in the water and actually drowns, or might have drowned if they had not been rescued or managed to save themselves.” Pool fencing and

similar approaches were aggregated and described

as “a barrier (like a fence or alarm) that separates

the pool from the house and yard.”

Items were designed to measure respondent

opin-ions using a 5-point scale of the type designed by

Likert, with “strongly disagree” assigned a value of

1 and “strongly agree” a value of 5.” Group mean scores were calculated. Comparisons between

groups were based on the difference between group means; the null hypothesis was that no difference

existed. For comparisons involving two groups, this hypothesis was tested using the two-tailed test for

Student’s t with an assumption of unequal van-ances.’2”3 One-way analysis of variance was used

for comparisons involving more than two groups.’3

The conventional probability for a type I error, P < .05, was used as the threshold for statistical significance. Statistical procedures were performed

using the Statistical Analysis System for personal computers.

Strata for the continuous hypothesized contrib-uting factors, age and year of pool installation, were

defined after the results were obtained. Because

88% of respondents were either 35 to 44 or 45 to 54 years of age, a dichotomous distribution <45, 45 years of age was chosen. Three years was taken as the definition of “recent” pool acquisition to aug-ment the size of the “recent” group, after no

signif-icant differences were seen using a cutoff at 1 or 2 years.

Mean scores facilitate intergroup comparisons but omit essential detail. In most cases, we have,

therefore, presented both group mean responses to

an item of interest and the percentage of

respond-ents expressing each level of agreement with that item. Means are given with their standard errors.

RESULTS

An 80% response rate was achieved; 637 of the

825 questionnaires were completed and returned,

and 30 respondents were found to be ineligible. The

percentage nonresponse to individual questions was

usually <2% and was never >4%. The distribution

of the respondents with regard to the hypothesized

contributing factors is shown in Table 1.

Most respondents (86%) favored voluntary CPR

training for pool owners as a means to prevent swimming pool drownings (Table 2). No such

con-sensus emerged for required CPR training, but a slight plurality (40%) favored this approach.

Man-dated barriers received meager backing, with 61%

opposing a barrier requirement for all poois and

49% opposing required barriers for new pools only. Only 50% agreed that pools would be safer with a fence or other barrier in place.

The majority of respondents also favored in-creased education in water safety (83%) and further

restrictions (77%) or a ban (53%) on alcohol at

aquatic recreation sites. Support for voluntary CPR

training exceeded that for any of these interven-tions, the difference in mean scores reaching

statis-tical significance for both increased enforcement of alcohol restrictions (4.34 ± 0.04 and 4.22 ± 0.04, respectively, P = .0150) and the alcohol ban (4.34

± 0.04 and 3.48 ± 0.06, respectively, P = 0001).

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TABLE 1. Distribution of Pool Owners on Factors Hy-pothesized to Shape Their Opinions of Pool Drowning Prevention Strategies*

*percentages may not add to 100 because of rounding.

TABLE 2. Pool Owners’ Opinions of Drowning Prevention Strategies

% Expressing Each Level of Agreement Mean Score

(SEM)

Strongly Disagree Neither Agree Strongly

Disagree Disagree Agree

nor Agree

Pool drownings

Encourage people with pools to learn 2 1 11 31 55 4.34 (0.04)

CPR

Require people with pools to learn CPR 20 17 23 20 20 3.02 (0.06)

Require new pools to be fenced 32 17 23 16 13 2.61 (0.06)

Require all pools to be fenced 43 18 21 10 8 2.21 (0.05)

Non-pool drownings

Strengthen enforcement of drinking 4 4 15 21 57 4.22 (0.04)

laws at beaches

Ban alcohol from beaches 12 16 19 19 34 3.48 (0.06)

General effect: increase public education 3 1 13 27 56 4.31 (0.04)

on water safety

affected pool owners’ opinion of and support for barrier interventions (Table 3). Respondents with children in the high-risk age group strongly sup-ported the statement that pools were safer when a

barrier was present and were more likely to support either of the proposed barrier requirements. Even

so, only the requirement for new pools received majority support (51%) from this group; 41% sup-ported a universal barrier requirement.

Respondents who had personal knowledge of an

immersion event, whether at home or elsewhere,

were also more likely to believe that adding a barrier made pools less hazardous (Table 3). This belief was not reflected in support for barrier

interven-Hypothesized Contributing Factor and Stratum or Response

No. (%)

Demographic factors Age of respondent

44 y 278 (44)

45+ y 352 (56)

Children 5 y of age at home

Yes 84 (14)

No 540 (87)

Historical factors

Immersion event occurred at home

Yes 48 (8)

No 586 (92)

Other immersion event experience

Yes 194 (32)

No 418 (68)

Year in which pool acquired

1959-1977 235 (38)

1978-1984 234 (38)

1985-1987 144 (23)

Pool installed by respondent

Yes 364 (57)

No 273 (43)

tions, however. Those having had an immersion

event at home were only slightly more likely to favor required pool barriers and those with other immersion event experience were slightly less so; none of these differences reached statistical signif-icance.

Conversely, respondents whose pool had been installed by a previous owner, although not

signif-icantly more likely to believe in the preventive

efficacy of pool barriers, were more supportive of

both the limited and universal pooi barrier

require-ments (the latter difference just failing to reach

statistical significance).

Fifty-four self-selected respondents offered one or more comments concerning their opposition to barrier interventions. Twenty-one would have sup-ported a barrier requirement for poois at homes

with small children. Six respondents who opposed

fencing per se would support a requirement for pooi

alarms or covers. The belief that required barrier interventions would not prevent childhood pool drownings, either because fencing would not be a

sufficient barrier or because enforcement would be difficult, was the most common reason given for opposition (19 cases), followed by an objection to government intervention (10 cases), environmental concerns (5 cases), and cost (5 cases).

Support for voluntary CPR training was associ-ated with two of the hypothesized contributing factors. Respondents whose pool had been installed

by a previous owner were slightly more favorable

than those who had had the pooi installed

them-selves (4.44 ± 0.05 and 4.27 ± 0.05, respectively; P = .0131). Those with knowledge or experience of an immersion event away from home were more

supportive than those without (4.46 ± 0.06 and 4.29

± 0.04, respectively; P = .0267). Support for

man-datory CPR training was not affected by any of the

possible contributing factors.

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Contributing Factor and Response %

Strongly

Expressing Each Level of Agreement Mean SEM P Value

core

Disagree Neither Agree Strongly

Disagree Disagree

Nor Agree

Agree

8 8 7 27 48 4.00 0.14

15 12 28 27 19 3.23 0.06

15 2 15 32 36 3.72 0.20

14 12 26 27 21 3.29 0.05

12 9 23 28 28 3.50 0.09

14 13 25 27 20 3.26 0.06

14 15 25 24 22 3.26 0.07

14 7 24 31 23 3.41 0.08

18 16 16 22 29 3.28 0.16

34 17 24 15 11 2.51 0.05

32 11 15 23 19 2.87 0.23

32 17 23 16 12 2.60 0.06

33 18 22 13 13 2.57 0.10

31 17 23 17 12 2.62 0.07

36 17 22 13 12 2.46 0.07

25 17 23 21 14 2.82 0.08

27 21 12 22 18 2.84 0.17

46 18 22 8 6 2.10 0.05

36 19 15 21 9 2.47 0.20

44 18 21 9 8 2.20 0.05

48 17 18 9 8 2.14 0.10

42 19 22 10 8 2.23 0.06

47 17 20 9 8 2.12 0.07

38 20 22 12 8 2.32 0.08

.0001

.0438

.0382

.1437

.0001

.2416

.6248

.0014

.0001

.2049

.4027

.0551 TABLE 3. Selected Contributing Factors Hypothesized as Affecting Pool Owners’ Opinions of Pool Fencing

Pools are safer with barrier in place

Children 5 y of age at home Yes

No

Immersion event occurred at home Yes

No

Other immersion event experience Yes

No

Pool installed by respondent

Yes No

Require new pools to have barrier

Children 5 y of age at home Yes

No

Immersion event occurred at home Yes

No

Other immersion event experience Yes

No

Pool installed by respondent Yes

No

Require all pools to have barrier Children 5 y of age at home

Yes

No

Immersion event occurred at home Yes

No

Other immersion event experience Yes

No

Pool installed by respondent

Yes No

Two factors, respondent age and year of pool

installation, did not influence support for any of

the pool drowning prevention measures.

DISCUSSION

As hypothesized, this population of residential

pool owners strongly supports CPR training, at

least on a voluntary basis, as a means to prevent

drownings and generally opposes mandatory pool

barriers.

Four of the six factors hypothesized to shape pool owners’ opinions of drowning prevention strategies appear to do so. The most influential such factor is

the presence of small children in the home, which

predicts a more favorable view of barrier interven-tions and a requirement for their use. The failure

of respondents with a history of an immersion event

to couple their belief in the efficacy of barriers with

support for a barrier requirement was unexpected. One possible explanation is that these previous immersion events occurred to young children-par-ticularly likely for those occurring at home6’7-who have since outgrown the high-risk age group. These respondents might, therefore, see barriers as effec-tive but no longer necessary for their own homes.

Contrary to our expectations, respondents who

had had their pool installed were generally less

supportive of the barrier approach, with the

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particu-lanly if installed by a previous owner, as less

oner-ous. Alternatively, these persons may have acquired

their pool more or less passively and may be

ambi-valent about its presence. (A swimming pool does

not add to the resale value of a residence, suggesting that this ambivalence may be widespread.) Such pool owners may, therefore, be particularly recep-tive to risk reduction measures.

Pool owners are not the only persons with a personal interest in pool drowning prevention, and

a survey like the one reported here could profitably be conducted in two other populations. The first is

potential pool owners, particularly those contem-plating having a pool installed. Adding a fence to the installation project may be more palatable than having an existing pool retrofitted. The second is nonpool-owning parents of small children whose friends, neighbors, or relatives have pools; of chil-dnen who drown in a pool not at their own home,

71% drown at the home of a family member, friend, or neighbor.6

Two limitations of this study should be

men-tioned. First, as a single-county study, its general-izability is limited to an unmeasured degree.

Rep-lication in other settings would be helpful. Second,

all but three of the respondents had in-ground pools (no permit is required for temporary, above-ground

pool installation). These results should not be ap-plied to all pool owners. However, the vast majority of significant immersion events appear to involve

in-ground pools,’4” perhaps because the design of above-ground pools makes them less accessible to young children. The focus on in-ground pools seems appropriate.

Our results suggest several directions for pool

drowning prevention programs. First, a community trial of CPR training for residential pool owners could be undertaken now and should be given high priority. This intervention, in its voluntary form, received the strongest support of any of the pool or non-pool drowning prevention strategies we stud-ied.

Data available to date suggest that a high

prey-alence of CPR competency could have a beneficial effect; in one study,6 42% of children who drowned in their own home pools were retrieved from the water by a layperson, usually a family member, but

CPR was not instituted until emergency services

personnel arrived.

Between 49% and 69% of all residential pool drownings in the United States involve children

younger than 10 years of age.6’7”6’9 The standard

CPR course, which emphasizes adult resuscitation, might reasonably be modified for this purpose to

focus on resuscitation of children. Because children are more likely than adults to maintain cardiac

activity in the event of respiratory arrest, consid-eration could be given to teaching only respiratory resuscitation and obstructed airway maneuvers to minimize the expense of a large-scale program.

Both process and outcome evaluations of a

CPR-training program should be feasible. An outcome evaluation would be essential. CPR is a postevent intervention; children who now drown might

in-stead survive with severe neurologic impairment. It is not clear that this would, or should, be considered an improvement.20 The overall benefits of commu-nity-wide CPR training are nonetheless well estab-lished, and pediatricians should encourage this

ef-fort.

Second, further preparation is needed to support

effective barrier interventions on a community-wide basis. Such interventions are widely opposed

at present. Among our respondents, only those with children in the high-risk age group gave significant

support to any barrier requirement.

The respondents’ comments suggest that an im-portant component of their opposition to the bar-nier approach is the erroneous belief that it will not be effective. There is, in fact, substantial evidence

from Australia,21’22 New Zealand,23 and the United States as well24’25 that pool fencing is an effective

drowning prevention measure. In New Zealand,

80% of the general population and 71% of pool owners support a pool fencing requirement.9

Information concerning barrier approaches, em-phasizing fencing, could be made a major

educa-tional component of the CPR program. Pool

own-ers, both in Sacramento County and nationally, are highly educated and relatively affluent.26’27 These characteristics enhance their responsiveness to the

educational component of a multifaceted

preven-tion program and would minimize the cost impact of acquiring fencing or other barrier devices.

At the same time, the development of fencing and alternative barrier devices must be completed. Australia, where childhood drowning has been a major focus for many years, has a set of detailed

standards for pool fences, gates, covers, and other

barrier hardware. No such standards exist in the

United States.

There is disagreement, for example, regarding

the proper height of pool fences. Behavioral evi-dence now suggests that the commonly used 120-cm (4-ft) height requirement is insufficient. Nixon and coworkers28empirically tested the ability of 515 children 3 to 4 years of age to climb seven different

designs of pool fences. Twenty percent of the 3-year-old children and 62% of the 4-year-old

chil-dren climbed a 120-cm fence. No 3-year-old and

52% of 4-year-old children climbed a 135-cm fence.

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human factors involved in childhood pool drown-ings by the US Consumer Product Safety

Commis-sion concluded that pool fencing “should be at least

5 feet high with vertical spacing of no more than 4 inches.”29 This recommendation was echoed by the project director for the major review of childhood

drowning conducted by the US Consumer Product

Safety Commission in 1987.#{176}However, when the agency subsequently issued a model residential

swimming pool barrier code, a fencing height of 120

cm or greater was specified.3’ The preamble to this code notes that the 120 cm “height currently spec-ified in the proposal should be regarded as an interim, minimum height . . .if it becomes evident

that this minimum height should be raised, a pro-posal to amend the applicable code will be made.”

If local jurisdictions adopt the model code as drafted, the fencing height requirement will allow fences that have been empirically demonstrated to permit access to a substantial percentage of chil-dren in the high-risk age group. If additional evi-dence supporting a taller fence subsequently

be-came available, fences installed in compliance with

this code might need to be replaced or altered at

substantial additional cost. An alternative, which

seems preferable to us, is to require fencing at least

135 cm in height pending new information.

A full set of design and materials specifications

is urgently needed. The Consumer Product Safety Commission is unaware of any research in progress in this area (J. Elder, personal communication,

1989).

In the interim, we recommend that parents be

educated about the benefits of pool fences. Those with pools, especially those with children younger than 5 years of age, should be strongly encouraged to have fencing installed.

Voluntary standards for pool covers are now un-der development and are expected in 1990. Pool covers are inherently limited, however, in that they require more of their user (through frequent re-moval and replacement) and, therefore, are likely to become less effective during the summer months when pool drownings are most frequent.6’7 They should not, in our view, be taken as a viable alter-native to fencing.

A variety of pool alarm systems are currently

marketed. Several have recently been evaluated under the aegis of the Consumer Product Safety Commission, and none of the systems tested per-formed adequately.32

Our results suggest that consideration might be

given to required but temporary fencing, to permit the intervention to be focused on high-risk

house-holds. Respondents with small children are

partic-ularly likely to favor barrier use, and others

mdi-cated support for a barrier requirement in such households. The epidemiology of childhood

drown-ing is supportive; half or more of childhood pool

drownings occur at the child’s own home,6”4”5 and the period of highest risk is less than 5 years long. Although a requirement for fencing in homes with children at risk would provide incomplete coverage, the offsetting benefits from minimizing

intrusive-ness, environmental impact, and cost might provide

a favorable balance.

Alternatively, fencing might be mandated for new pools and for established pools when the residence

is sold. Our respondents were more supportive of a new pool requirement than a general approach. Those who acquired their pool along with a resi-dence viewed fencing requirements more favorably than did those who had their poois installed.

ACKNOWLEDGMENT

The authors thank Glen Koven of the Sacramento

County Building Department for his cooperation and

Barbara Claire for assistance in executing the survey and

assembling the data.

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improve neurologic outcome in nearly drowned, flaccid-comatose children. Pediatrics. 1988;81:630-634

4. Brill D. The cost of drowning. In: Brill D, Micik 5, Yuwiler J, eds. Childhood Drownings: Current Issues and Strategies for Prevention. Proceedings of a conference sponsored by the US Consumer Product Safety Commission. Newport Beach, CA; 1987:45

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Lexington, MA: DC Heath; 1984

6. Wintemute GJ, Kraus JF, Teret SP, Wright M. Drowning in childhood and adolescence: a population-based study. Am J Public Health. 1987;77:830-832

7. O’Carroll PW, Alkon E, Weiss B. Drowning mortality in Los Angeles County, 1976 to 1984. J Am Med Assoc.

1988;260:380-383

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9. Geddis DC. The exposure of pre-school children to water hazards and the incidence of potential drowning accidents. NZ Med J. 1984;97:223-226

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Hand-book of Survey Research. New York, NY: Academic Press; 1983:359-377

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14. Present P. Child Drowning Study, A Report on the

Epide-miology of Drownings in Residential Pools to Children Under Age Five. Washington, DC: US Consumer Product Safety Commission; 1987

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1977;1:432-437

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20. Feinberg WM, Ferry PC. A fate worse than death: the persistent vegetative state in childhood. Am J Dis Child.

1984;138:128-130

21. Pearn JH, Thompson J. Drowning and near-drowning in the Australian Capital Territory: a five-year total population study of immersion accidents. Med J Aust. 1977;1:130-133 22. Milliner N, Pearn J, Guard R. Will fenced pools save lives?:

a 10-year study from Mulgrave Shire, Queensland. Med J Aust. 1980;2:510-511

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25. Spyker DA. Submersion injury: epidemiology, prevention and management. Pediatr Clin North Am. 1985;32:113-125 26. A Study to Evaluate SMUD’S Swimming Pool Pump Load

Management Program Prepared for Sacramento Municipal Utility District. San Rafael, CA: ADR Research; 1980 27. 1987 Swimming Pool & Spa Industry Market Report.

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TELEVISION CRITIC TAKES ANOTHER LOOK AT CHILDREN’S

TELEVISION

About 20 years ago, the new Action for Children’s Television, started by

mothers in the Boston area, prompted a national crusade when it attacked commercials in children’s programming as being exploitative and a disservice

to society. For the past couple of weeks, I have been dipping into the children’s schedule and watching endlessly repeated sales pitches for sugary cereals, sweet drinks, fruit-flavored candies and blond blue-eyed dolls with “fabulous hair” and “the hot-test clothes.”

Things haven’t changed much in the television business of children’s mer-chandising, and some aspects of the scene are even more appalling. ...

It is distressing enough that Madison Avenue’s constant message of “buy, buy, buy” is being delivered to homes that in many instances may not be able to afford the products in question. But it is downright infuriating when large sections of the audience being tantalized are left with the message that they are not important enough to merit equal visibility. The disservice to society noted

back in 1968 is still very much with us.

From Connor JJ. What are commercials selling to our children? The New York Times. June 6, 1989.

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1990;85;63

Pediatrics

Garen J. Wintemute and Mona A. Wright

Swimming Pool Owners' Opinions of Strategies for Prevention of Drowning

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Garen J. Wintemute and Mona A. Wright

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