A Survey of Aspirin Use and Reye's Syndrome Awareness among Parents LOUIS A. MORRIS, PHD, AND RONALD KLIMBERG, MS Abstract: A national telephone survey of 1,155 parents of children 19 years of age and younger solicited patterns of medication use during episodes of childhood flu and chicken pox. During the previous two years, 6 per cent of the parents whose children had chicken pox and 16 per cent of parents whose children had flu administered aspirin. Approximately 12 per cent of the total sample said they would give their child aspirin if their child were to get the flu or chicken pox today. About half (53 per cent) were aware of the Introduction Reye's Syndrome (RS) is a rare but severe disease associated with influenza and other viral diseases. It affects primarily children under the age of 18 years, especially in the 10-14 year age group. Although its pathogenesis is unknown, the mortality rate is estimated at 20 to 30 per cent and permanent brain damage may also occur.' During the 1970s and early 1980s, a number of case-control studies suggested an association between RS and use of salicylates (e.g., aspirin) during the antecedent illness. In November 1980, the US Surgeon General recommended to doctors that "parents should be advised to use caution when administering salicyl- ates to treat children with viral illness, particularly chicken pox and influenza-like illness."2 Several studies suggest that parents have become more aware of the possible association between aspirin and RS and are more likely to avoid aspirin use during flu or chicken pox episodes. Rowley, et al, investigated aspirin use during a February 1981 outbreak of influenza in a suburb of Houston, Texas.* Of the 108 parents who had a child with the flu, 44 per cent used aspirin, 27 per cent used acetaminophen, and 25 per cent used both medications. About 80 per cent of the parents were unaware of the association between aspirin and RS. In 1983, Taylor, et al, conducted a survey of antipyretic use in Houston, Texas during the flu season.3 Of 103 children who had the flu, 14 per cent received aspirin, 61 per cent received acetaminophen, and 20 per cent received both; 42 per cent knew about the association between RS and aspirin and 60 per cent said they had heard of RS. The present survey was undertaken to obtain current, national estimates of aspirin use from parents who treated a recent episode of the flu or chicken pox. Respondents were asked what medicine they had used and what medicine, if any, they would give their children if they got the flu or chicken pox today. Method Subjects for the study were parents with children age 19 years or younger living in the household telephoned during May to July 1985. Respondents were identified by using random digit telephone dialing techniques. There were 5,933 *Rowley D, Perrotta D, Finally A, et al: Aspirin use in an elementary population during an outbreak of influenza A (unpublished study). From the Food and Drug Administration. Address reprint requests to Louis A. Morris, PhD, Drug Labeling, Education and Research Branch, Food and Drug Administration, HFN-246, 5600 Fishers Lane, Rockville, MD 20857. This paper, submitted to the Journal September 19, 1985, was revised and accepted for publication May 9, 1986. 1422 contraindication against aspirin use and 40 per cent could sponta- neously recall the name Reye's Syndrome (RS). When measured by a recognition test, 84 per cent of the sample said they had heard of RS. People who continued to believe that aspirin was an appropriate medication were more likely to have treated older children. The RS contraindication for aspirin should be emphasized for teenagers in future public informational programs. (Am J Public Health 1986; 76:1422-1424.) telephone numbers dialed to identify 3,795 householders and 1,704 eligible respondents. Completed interviews were ob- tained from 1,155 of the 1,704 eligible respondents yielding an overall response rate of 68 per cent. This represents a minimal response rate as the nonresponse group includes refusers (27 per cent) and nonresponse for other reasons such as a continual busy signal or an unanswered telephone number. Results Approximately 40 per cent of the sample had one child in the household age 19 years or younger, 38 per cent had two children, 17 per cent had three, and the remainder had four or more. The median age of the parents in the sample was 36 years and most respondents (74 per cent) were female. The sample was primarily White (84 per cent), 10 per cent were Black, and the remaining subjects were of other racial/ethnic backgrounds. Of the sample, 4 per cent had less than a high school education, 8 per cent had some high school, 37 per cent had graduated from high school, 27 per cent had some college, and 24 per cent had graduated from college and/or had some post college education. About 22 per cent had an income of $15,000 or less, 46 per cent between $15,000 and $35,000, and 31 per cent an income above $35,000. Chicken Pox Approximately 13 per cent (n = 146) of the respondents said one of their children had the chicken pox during the previous two years. Slightly over half of these parents (58 per cent [n = 84]) said they gave their child a medication for the chicken pox and approximately one-third who gave medicine gave two different medications (n = 28). The most commonly provided medicine was a non-aspirin pain reliever such as acetaminophen administered by 54 per cent (n = 45) of the parents giving their children any medication. Aspirin prod- ucts were given to only 6 per cent of those children provided any medication (n = 5), 3 per cent of the total sample of parents whose children had the chicken pox during the past two years. Flu Approximately 42 per cent of the respondents (n = 479) said that one or more of their children had the flu during the past two years. Most (84 per cent [n = 403]) of the parents said they gave their child a medicine for the flu and about one-third of those giving medication administered two or more different drugs. Only eight subjects could not remember the drug that was given. The most frequently administered drug was a non-aspirin pain reliever/fever reducer given to 57 per cent of those children receiving any medication (n = 230). AJPH December 1986, Vol. 76, No. 12
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A Survey of Aspirin Use and Reye's Syndrome Awareness among Parents LOUIS A. MORRIS, PHD, AND RONALD KLIMBERG, MS
Abstract: A national telephone survey of 1,155 parents of children 19 years of age and younger solicited patterns of medication use during episodes of childhood flu and chicken pox. During the previous two years, 6 per cent of the parents whose children had chicken pox and 16 per cent of parents whose children had flu administered aspirin. Approximately 12 per cent of the total sample said they would give their child aspirin if their child were to get the flu or chicken pox today. About half (53 per cent) were aware of the
Introduction Reye's Syndrome (RS) is a rare but severe disease
associated with influenza and other viral diseases. It affects primarily children under the age of 18 years, especially in the 10-14 year age group. Although its pathogenesis is unknown, the mortality rate is estimated at 20 to 30 per cent and permanent brain damage may also occur.' During the 1970s and early 1980s, a number of case-control studies suggested an association between RS and use of salicylates (e.g., aspirin) during the antecedent illness. In November 1980, the US Surgeon General recommended to doctors that "parents should be advised to use caution when administering salicyl- ates to treat children with viral illness, particularly chicken pox and influenza-like illness."2
Several studies suggest that parents have become more aware of the possible association between aspirin and RS and are more likely to avoid aspirin use during flu or chicken pox episodes. Rowley, et al, investigated aspirin use during a February 1981 outbreak of influenza in a suburb of Houston, Texas.* Of the 108 parents who had a child with the flu, 44 per cent used aspirin, 27 per cent used acetaminophen, and 25 per cent used both medications. About 80 per cent of the parents were unaware of the association between aspirin and RS. In 1983, Taylor, et al, conducted a survey of antipyretic use in Houston, Texas during the flu season.3 Of 103 children who had the flu, 14 per cent received aspirin, 61 per cent received acetaminophen, and 20 per cent received both; 42 per cent knew about the association between RS and aspirin and 60 per cent said they had heard of RS.
The present survey was undertaken to obtain current, national estimates of aspirin use from parents who treated a recent episode of the flu or chicken pox. Respondents were asked what medicine they had used and what medicine, if any, they would give their children if they got the flu or chicken pox today.
Method
Subjects for the study were parents with children age 19 years or younger living in the household telephoned during May to July 1985. Respondents were identified by using random digit telephone dialing techniques. There were 5,933
*Rowley D, Perrotta D, Finally A, et al: Aspirin use in an elementary population during an outbreak of influenza A (unpublished study).
From the Food and Drug Administration. Address reprint requests to Louis A. Morris, PhD, Drug Labeling, Education and Research Branch, Food and Drug Administration, HFN-246, 5600 Fishers Lane, Rockville, MD 20857. This paper, submitted to the Journal September 19, 1985, was revised and accepted for publication May 9, 1986.
1422
contraindication against aspirin use and 40 per cent could sponta- neously recall the name Reye's Syndrome (RS). When measured by a recognition test, 84 per cent of the sample said they had heard of RS. People who continued to believe that aspirin was an appropriate medication were more likely to have treated older children. The RS contraindication for aspirin should be emphasized for teenagers in future public informational programs. (Am J Public Health 1986; 76:1422-1424.)
telephone numbers dialed to identify 3,795 householders and 1,704 eligible respondents. Completed interviews were ob- tained from 1,155 ofthe 1,704 eligible respondents yielding an overall response rate of 68 per cent. This represents a minimal response rate as the nonresponse group includes refusers (27 per cent) and nonresponse for other reasons such as a continual busy signal or an unanswered telephone number.
Results
Approximately 40 per cent of the sample had one child in the household age 19 years or younger, 38 per cent had two children, 17 per cent had three, and the remainder had four or more. The median age of the parents in the sample was 36 years and most respondents (74 per cent) were female. The sample was primarily White (84 per cent), 10 per cent were Black, and the remaining subjects were of other racial/ethnic backgrounds. Of the sample, 4 per cent had less than a high school education, 8 per cent had some high school, 37 per cent had graduated from high school, 27 per cent had some college, and 24 per cent had graduated from college and/or had some post college education. About 22 per cent had an income of $15,000 or less, 46 per cent between $15,000 and $35,000, and 31 per cent an income above $35,000. Chicken Pox
Approximately 13 per cent (n = 146) of the respondents said one of their children had the chicken pox during the previous two years. Slightly over half of these parents (58 per cent [n = 84]) said they gave their child a medication for the chicken pox and approximately one-third who gave medicine gave two different medications (n = 28). The most commonly provided medicine was a non-aspirin pain reliever such as acetaminophen administered by 54 per cent (n = 45) of the parents giving their children any medication. Aspirin prod- ucts were given to only 6 per cent of those children provided any medication (n = 5), 3 per cent of the total sample of parents whose children had the chicken pox during the past two years. Flu
Approximately 42 per cent of the respondents (n = 479) said that one or more of their children had the flu during the past two years. Most (84 per cent [n = 403]) of the parents said they gave their child a medicine for the flu and about one-third of those giving medication administered two or more different drugs. Only eight subjects could not remember the drug that was given. The most frequently administered drug was a non-aspirin pain reliever/fever reducer given to 57 per cent of those children receiving any medication (n = 230).
AJPH December 1986, Vol. 76, No. 12
PARENT AWARENESS OF REYE'S SYNDROME
TABLE 1-Reye's Syndrome Awareness Levels
Per Cent of Subjects
Awareness Level* (n = 1,155)
1. Respondents had not heard anything about giving aspirin to children with chicken pox or flu. 32
2. Respondents said they heard something about giving aspirin to children with flu or chicken pox, but could not recall it. 7
3. Respondents said they could recall information but did not recall any correct, salient information when asked to do so. 8
4. Respondents correctly recalled the contraindication of aspirin for children with chicken pox or flu. 13
5. Respondents named Reye's Syndrome. 14 6. Respondents described at least one symptom of
Reye's Syndrome. 26
*Subject's awareness level assumes correct answers to each previous level, e.g., only those who recalled the contraindication (level 4) were asked to name the conditon (level 5).
Aspirin-containing products were provided to 19 per cent of those children taking any medication (n = 75), 16 per cent of all children who had the flu during the two years.
The reason mentioned most often for choosing a partic- ular medicine was that it was recommended by the doctor, stated by 47 per cent of those giving medication and giving a reason for their choice (n = 190). Awareness of RS was cited by 17 per cent of those providing medication to their children with the flu (n = 70). Satisfaction with prior use of a medication ("it has worked well in the past") was mentioned by 16 per cent of those giving medication (n = 64), and 10 per cent (n = 40) said they gave a particular medication to reduce their child's fever. Intention to Give Aspirin
Subjects were asked what medicines or drugs, if any, they would give their child if their child were to get chicken pox or flu today. Multiple medication mentions were record- ed. Slightly over half of the subjects (53 per cent) said they would give their child only what the doctor recommended, about one-third (38 per cent) said they would give acetaminophen, 12 per cent said aspirin, and 9 per cent said they would not give their child any drug. A wide variety of cough/cold and stomach medications was also mentioned. Knowledge of Reye's Syndrome
After soliciting information about recent flu and chicken pox episodes and future treatment, respondents were asked a series ofquestions measuring their knowledge about RS and the use of aspirin in children with chicken pox or flu. As shown in Table 1, approximately two-thirds of subjects said they heard something about giving aspirin to children with flu or chicken pox (levels 2 through 6). Slightly over half the subjects (53 per cent) could correctly recall the contraindica- tion against giving aspirin (levels 4, 5, and 6) and 40 per cent spontaneously named RS (levels 5 and 6).
To measure recognition rates, respondents were also asked directly if they ever heard of RS.** Most respondents who were asked this question (1,035) recognized the term (83 per cent [n = 860]) and the majority (71 per cent) could
**Due to a mistake in the original questionnaire design, 390 respondents who said they had not heard anything about giving aspirin to children were not asked the RS recognition question and the ensuing questions soliciting a description of RS. In attempts to call back these respondents to complete the missing data, successful contact was made in 270 of the 390 cases.
spontaneously recall that aspirin was the drug associated with RS. However, as the question soliciting aspirin awareness in relationship to RS followed many other questions about aspirin use, the cuing effects of earlier questions may have influenced recall of this association.
Cross tabulations were run to examine characteristics of subjects who intended to use aspirin for future flu or chicken pox episodes. Parents who said they would use aspirin were older than the non-aspirin users and had older children. About three-fourths (73 per cent) of parents who said they would use aspirin treated children over age 10 during the last flu episode, whereas, less than half (46 per cent) of those who did not intend to use aspirin treated children over age 10. Intended aspirin users also were less likely to be aware of RS, knew less about it, thought it was less dangerous and, if aware, were less likely to have learned about it from their doctor.
Discussion
Compared to the surveys undertaken in Houston during 1981 and 1983, the present national survey shows a lower incidence of aspirin use for childhood flu. In the present study, only 16 per cent of the sample said they used aspirin for the flu compared to 69 per cent in the 1981 survey and 34 per cent in the 1983 survey. Furthermore, slightly over half of the parents in the present survey (53 per cent) knew that aspirin should not be used by children with flu or chicken pox and 40 per cent of the sample spontaneously recalled RS as the reason for the contraindication.
Nonetheless, 12 per cent of the surveyed parents said they would give their children aspirin if they were to have the flu or chicken pox today. It should be noted that the present survey used a spontaneous recall question so the 12 per cent figure may be a conservative estimate of intention to use aspirin. When their child is sick, parents may be likely to use whatever medicine is available in the medicine cabinet. They may not recognize the symptom being treated as the flu, or they may not recall the contraindication during the stress of making a treatment decision. In addition, three-fourths of those intending to use aspirin were unaware of the RS-aspirin contraindication. Nevertheless, children's age is an impor- tant correlate of the intention to provide aspirin to children with flu or chicken pox. Parents who use aspirin may not realize that the RS warning applies to teenagers (age 10-19 years) as well as to children under 10 years old. This result is consistent with epidemiological studies that find the inci- dence of RS to be stable for children 10-19 years old but reduced for younger children.4 Increased emphasis of the RS warning for teenagers seems warranted. Furthermore, the degree to which teenagers self-medicate is not known nor is their use (or intended use) of aspirin known. Informational programs directed to both teenagers and their parents would appear appropriate. In March of 1986, the Food and Drug Administration began requiring manufacturers of aspirin- containing drug products to revise their labeling to include the RS warning.5
ACKNOWLEDGMENTS The views expressed are those of the authors and do not reflect the policy
of the Food and Drug Administration. Data for this study were collected under FDA Contract #223-85-6010. We would like to express our thanks to Dr. Evelyn Gordon for her help in questionnaire design, to the Westat Corporation for their aid in data collection, and to Dr. Janet Arrowsmith for providing background information and editorial assistance.
AJPH December 1986, Vol. 76, No. 12 1 423
MORRIS AND KLIMBERG
products. Federal Register, December 28, 1982; 47:57886-57901. 2. Centers for Disease Control: Reye syndrome-Ohio, Michigan. MMWR
1980; 29:532-539. 3. Taylor J, Gustafson TL, Johnson CC, et al: Antipyretic use among children
during the 1983 influenza season. Am J Dis Child 1985; 139:486-488. 4. Barrett MJ, Huritz ES, Schonberger LB, et al: Changing epidemiology of
Reye Syndrome in the United States. Pediatr 1986; 77:598-602. 5. Food and Drug Administration: Labeling for oral and rectal over-the-
counter aspirin and aspirin-containing drug products; final rule. Federal Register, March 7, 1986; 51:8180-8182.
Eight Health Agencies Win 'Model Standards' Community I Recognition Awards
Eight health agencies received community recognition awards, during the American Public Health Association's 114th annual meeting in Las Vegas, for their efforts in implementing preventive health programs in their communitites. These programs, based on the Model Standards: A Guide for Community Preventive Health Services, are designed to reduce preventable illness, disability, and death. The health agencies so recognized are:
* Colorado Department of Health * Delaware Division of Public Health * Hartford Health Department (Connecticut) * Health Officers Association of California/Alameda County Department of Public Health * Gateway District Health Department (Kentucky) * Jefferson County Department of Health (Alabama) * Onondaga County Health Department (New York) * Tulsa City-County Health Department (Oklahoma) These agencies, selected from proposals submitted by health departments nationwide, have begun
three-year projects in which they use the Model Standards as a tool for identifying and addressing health problems in their communities. In each program area, community-specific objectives, action plans, and data tracking systems to monitor the impact of these efforts on the public's health are being developed. The projects also place special emphasis on involving the public, private, and voluntary sectors in solving local public health problems.
The Model Standards Project is a collaborative effort of the American Public Health Association, the Centers for Disease Control, Association of Schools of Public Health, Association of State and Territorial Health Officials, National Association of County Health Officials, and US Conference of Local Health Officers. Funding is provided by CDC through a cooperative agreement with APHA.
Model Standards: A Guide for Community Preventive Services, 2nd edition, 1985, may be ordered from the American Public Health Association, 1015 15th Street, NW, Washington, DC 20005. Cost is $8 (APHA members) and $10 (nonmembers) in the US and Canada; $15 elsewhere.
1424 AJPH December 1986, Vol. 76, No. 12
Abstract: A national telephone survey of 1,155 parents of children 19 years of age and younger solicited patterns of medication use during episodes of childhood flu and chicken pox. During the previous two years, 6 per cent of the parents whose children had chicken pox and 16 per cent of parents whose children had flu administered aspirin. Approximately 12 per cent of the total sample said they would give their child aspirin if their child were to get the flu or chicken pox today. About half (53 per cent) were aware of the
Introduction Reye's Syndrome (RS) is a rare but severe disease
associated with influenza and other viral diseases. It affects primarily children under the age of 18 years, especially in the 10-14 year age group. Although its pathogenesis is unknown, the mortality rate is estimated at 20 to 30 per cent and permanent brain damage may also occur.' During the 1970s and early 1980s, a number of case-control studies suggested an association between RS and use of salicylates (e.g., aspirin) during the antecedent illness. In November 1980, the US Surgeon General recommended to doctors that "parents should be advised to use caution when administering salicyl- ates to treat children with viral illness, particularly chicken pox and influenza-like illness."2
Several studies suggest that parents have become more aware of the possible association between aspirin and RS and are more likely to avoid aspirin use during flu or chicken pox episodes. Rowley, et al, investigated aspirin use during a February 1981 outbreak of influenza in a suburb of Houston, Texas.* Of the 108 parents who had a child with the flu, 44 per cent used aspirin, 27 per cent used acetaminophen, and 25 per cent used both medications. About 80 per cent of the parents were unaware of the association between aspirin and RS. In 1983, Taylor, et al, conducted a survey of antipyretic use in Houston, Texas during the flu season.3 Of 103 children who had the flu, 14 per cent received aspirin, 61 per cent received acetaminophen, and 20 per cent received both; 42 per cent knew about the association between RS and aspirin and 60 per cent said they had heard of RS.
The present survey was undertaken to obtain current, national estimates of aspirin use from parents who treated a recent episode of the flu or chicken pox. Respondents were asked what medicine they had used and what medicine, if any, they would give their children if they got the flu or chicken pox today.
Method
Subjects for the study were parents with children age 19 years or younger living in the household telephoned during May to July 1985. Respondents were identified by using random digit telephone dialing techniques. There were 5,933
*Rowley D, Perrotta D, Finally A, et al: Aspirin use in an elementary population during an outbreak of influenza A (unpublished study).
From the Food and Drug Administration. Address reprint requests to Louis A. Morris, PhD, Drug Labeling, Education and Research Branch, Food and Drug Administration, HFN-246, 5600 Fishers Lane, Rockville, MD 20857. This paper, submitted to the Journal September 19, 1985, was revised and accepted for publication May 9, 1986.
1422
contraindication against aspirin use and 40 per cent could sponta- neously recall the name Reye's Syndrome (RS). When measured by a recognition test, 84 per cent of the sample said they had heard of RS. People who continued to believe that aspirin was an appropriate medication were more likely to have treated older children. The RS contraindication for aspirin should be emphasized for teenagers in future public informational programs. (Am J Public Health 1986; 76:1422-1424.)
telephone numbers dialed to identify 3,795 householders and 1,704 eligible respondents. Completed interviews were ob- tained from 1,155 ofthe 1,704 eligible respondents yielding an overall response rate of 68 per cent. This represents a minimal response rate as the nonresponse group includes refusers (27 per cent) and nonresponse for other reasons such as a continual busy signal or an unanswered telephone number.
Results
Approximately 40 per cent of the sample had one child in the household age 19 years or younger, 38 per cent had two children, 17 per cent had three, and the remainder had four or more. The median age of the parents in the sample was 36 years and most respondents (74 per cent) were female. The sample was primarily White (84 per cent), 10 per cent were Black, and the remaining subjects were of other racial/ethnic backgrounds. Of the sample, 4 per cent had less than a high school education, 8 per cent had some high school, 37 per cent had graduated from high school, 27 per cent had some college, and 24 per cent had graduated from college and/or had some post college education. About 22 per cent had an income of $15,000 or less, 46 per cent between $15,000 and $35,000, and 31 per cent an income above $35,000. Chicken Pox
Approximately 13 per cent (n = 146) of the respondents said one of their children had the chicken pox during the previous two years. Slightly over half of these parents (58 per cent [n = 84]) said they gave their child a medication for the chicken pox and approximately one-third who gave medicine gave two different medications (n = 28). The most commonly provided medicine was a non-aspirin pain reliever such as acetaminophen administered by 54 per cent (n = 45) of the parents giving their children any medication. Aspirin prod- ucts were given to only 6 per cent of those children provided any medication (n = 5), 3 per cent of the total sample of parents whose children had the chicken pox during the past two years. Flu
Approximately 42 per cent of the respondents (n = 479) said that one or more of their children had the flu during the past two years. Most (84 per cent [n = 403]) of the parents said they gave their child a medicine for the flu and about one-third of those giving medication administered two or more different drugs. Only eight subjects could not remember the drug that was given. The most frequently administered drug was a non-aspirin pain reliever/fever reducer given to 57 per cent of those children receiving any medication (n = 230).
AJPH December 1986, Vol. 76, No. 12
PARENT AWARENESS OF REYE'S SYNDROME
TABLE 1-Reye's Syndrome Awareness Levels
Per Cent of Subjects
Awareness Level* (n = 1,155)
1. Respondents had not heard anything about giving aspirin to children with chicken pox or flu. 32
2. Respondents said they heard something about giving aspirin to children with flu or chicken pox, but could not recall it. 7
3. Respondents said they could recall information but did not recall any correct, salient information when asked to do so. 8
4. Respondents correctly recalled the contraindication of aspirin for children with chicken pox or flu. 13
5. Respondents named Reye's Syndrome. 14 6. Respondents described at least one symptom of
Reye's Syndrome. 26
*Subject's awareness level assumes correct answers to each previous level, e.g., only those who recalled the contraindication (level 4) were asked to name the conditon (level 5).
Aspirin-containing products were provided to 19 per cent of those children taking any medication (n = 75), 16 per cent of all children who had the flu during the two years.
The reason mentioned most often for choosing a partic- ular medicine was that it was recommended by the doctor, stated by 47 per cent of those giving medication and giving a reason for their choice (n = 190). Awareness of RS was cited by 17 per cent of those providing medication to their children with the flu (n = 70). Satisfaction with prior use of a medication ("it has worked well in the past") was mentioned by 16 per cent of those giving medication (n = 64), and 10 per cent (n = 40) said they gave a particular medication to reduce their child's fever. Intention to Give Aspirin
Subjects were asked what medicines or drugs, if any, they would give their child if their child were to get chicken pox or flu today. Multiple medication mentions were record- ed. Slightly over half of the subjects (53 per cent) said they would give their child only what the doctor recommended, about one-third (38 per cent) said they would give acetaminophen, 12 per cent said aspirin, and 9 per cent said they would not give their child any drug. A wide variety of cough/cold and stomach medications was also mentioned. Knowledge of Reye's Syndrome
After soliciting information about recent flu and chicken pox episodes and future treatment, respondents were asked a series ofquestions measuring their knowledge about RS and the use of aspirin in children with chicken pox or flu. As shown in Table 1, approximately two-thirds of subjects said they heard something about giving aspirin to children with flu or chicken pox (levels 2 through 6). Slightly over half the subjects (53 per cent) could correctly recall the contraindica- tion against giving aspirin (levels 4, 5, and 6) and 40 per cent spontaneously named RS (levels 5 and 6).
To measure recognition rates, respondents were also asked directly if they ever heard of RS.** Most respondents who were asked this question (1,035) recognized the term (83 per cent [n = 860]) and the majority (71 per cent) could
**Due to a mistake in the original questionnaire design, 390 respondents who said they had not heard anything about giving aspirin to children were not asked the RS recognition question and the ensuing questions soliciting a description of RS. In attempts to call back these respondents to complete the missing data, successful contact was made in 270 of the 390 cases.
spontaneously recall that aspirin was the drug associated with RS. However, as the question soliciting aspirin awareness in relationship to RS followed many other questions about aspirin use, the cuing effects of earlier questions may have influenced recall of this association.
Cross tabulations were run to examine characteristics of subjects who intended to use aspirin for future flu or chicken pox episodes. Parents who said they would use aspirin were older than the non-aspirin users and had older children. About three-fourths (73 per cent) of parents who said they would use aspirin treated children over age 10 during the last flu episode, whereas, less than half (46 per cent) of those who did not intend to use aspirin treated children over age 10. Intended aspirin users also were less likely to be aware of RS, knew less about it, thought it was less dangerous and, if aware, were less likely to have learned about it from their doctor.
Discussion
Compared to the surveys undertaken in Houston during 1981 and 1983, the present national survey shows a lower incidence of aspirin use for childhood flu. In the present study, only 16 per cent of the sample said they used aspirin for the flu compared to 69 per cent in the 1981 survey and 34 per cent in the 1983 survey. Furthermore, slightly over half of the parents in the present survey (53 per cent) knew that aspirin should not be used by children with flu or chicken pox and 40 per cent of the sample spontaneously recalled RS as the reason for the contraindication.
Nonetheless, 12 per cent of the surveyed parents said they would give their children aspirin if they were to have the flu or chicken pox today. It should be noted that the present survey used a spontaneous recall question so the 12 per cent figure may be a conservative estimate of intention to use aspirin. When their child is sick, parents may be likely to use whatever medicine is available in the medicine cabinet. They may not recognize the symptom being treated as the flu, or they may not recall the contraindication during the stress of making a treatment decision. In addition, three-fourths of those intending to use aspirin were unaware of the RS-aspirin contraindication. Nevertheless, children's age is an impor- tant correlate of the intention to provide aspirin to children with flu or chicken pox. Parents who use aspirin may not realize that the RS warning applies to teenagers (age 10-19 years) as well as to children under 10 years old. This result is consistent with epidemiological studies that find the inci- dence of RS to be stable for children 10-19 years old but reduced for younger children.4 Increased emphasis of the RS warning for teenagers seems warranted. Furthermore, the degree to which teenagers self-medicate is not known nor is their use (or intended use) of aspirin known. Informational programs directed to both teenagers and their parents would appear appropriate. In March of 1986, the Food and Drug Administration began requiring manufacturers of aspirin- containing drug products to revise their labeling to include the RS warning.5
ACKNOWLEDGMENTS The views expressed are those of the authors and do not reflect the policy
of the Food and Drug Administration. Data for this study were collected under FDA Contract #223-85-6010. We would like to express our thanks to Dr. Evelyn Gordon for her help in questionnaire design, to the Westat Corporation for their aid in data collection, and to Dr. Janet Arrowsmith for providing background information and editorial assistance.
AJPH December 1986, Vol. 76, No. 12 1 423
MORRIS AND KLIMBERG
products. Federal Register, December 28, 1982; 47:57886-57901. 2. Centers for Disease Control: Reye syndrome-Ohio, Michigan. MMWR
1980; 29:532-539. 3. Taylor J, Gustafson TL, Johnson CC, et al: Antipyretic use among children
during the 1983 influenza season. Am J Dis Child 1985; 139:486-488. 4. Barrett MJ, Huritz ES, Schonberger LB, et al: Changing epidemiology of
Reye Syndrome in the United States. Pediatr 1986; 77:598-602. 5. Food and Drug Administration: Labeling for oral and rectal over-the-
counter aspirin and aspirin-containing drug products; final rule. Federal Register, March 7, 1986; 51:8180-8182.
Eight Health Agencies Win 'Model Standards' Community I Recognition Awards
Eight health agencies received community recognition awards, during the American Public Health Association's 114th annual meeting in Las Vegas, for their efforts in implementing preventive health programs in their communitites. These programs, based on the Model Standards: A Guide for Community Preventive Health Services, are designed to reduce preventable illness, disability, and death. The health agencies so recognized are:
* Colorado Department of Health * Delaware Division of Public Health * Hartford Health Department (Connecticut) * Health Officers Association of California/Alameda County Department of Public Health * Gateway District Health Department (Kentucky) * Jefferson County Department of Health (Alabama) * Onondaga County Health Department (New York) * Tulsa City-County Health Department (Oklahoma) These agencies, selected from proposals submitted by health departments nationwide, have begun
three-year projects in which they use the Model Standards as a tool for identifying and addressing health problems in their communities. In each program area, community-specific objectives, action plans, and data tracking systems to monitor the impact of these efforts on the public's health are being developed. The projects also place special emphasis on involving the public, private, and voluntary sectors in solving local public health problems.
The Model Standards Project is a collaborative effort of the American Public Health Association, the Centers for Disease Control, Association of Schools of Public Health, Association of State and Territorial Health Officials, National Association of County Health Officials, and US Conference of Local Health Officers. Funding is provided by CDC through a cooperative agreement with APHA.
Model Standards: A Guide for Community Preventive Services, 2nd edition, 1985, may be ordered from the American Public Health Association, 1015 15th Street, NW, Washington, DC 20005. Cost is $8 (APHA members) and $10 (nonmembers) in the US and Canada; $15 elsewhere.
1424 AJPH December 1986, Vol. 76, No. 12
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