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Behaviors Related to Unintentional and Intentional Injuries Among High School Students -- United States, 1991

During 1988, injuries were the leading cause of death among persons aged 15-19 years in the United States (CDC, unpublished data, 1988). Of all deaths in this age group, 42% were motor-vehicle related, 13% were due to homicide, 13% to suicide, and 11% to other types of injuries and adverse effects. This report presents 1991 self-reported data on the prevalence of selected behaviors (i.e., attempted suicide, physical fighting, weapon-carrying, safety-belt use, motorcycle-helmet use, and bicycle-helmet use) associated with these causes of death among 9th-12th-grade students in the United States.

Data were collected from two school-based components of CDC's Youth Risk Behavior Surveillance System (1): 1) state and local Youth Risk Behavior Surveys (YRBSs) conducted by departments of education in 23 states* and 10 cities during the spring of 1991 and 2) the national YRBS conducted during the same period. The 33 state and local sites drew probability samples from defined sampling frames of schools and students in grades 9-12. Seventeen sites had adequate school- and student-response rates, which allowed computation of weighted results of known precision; 16 sites had overall response rates below 60% or unavailable documentation, which precluded making estimates of known precision. The national survey used a three-stage sample design to obtain a sample of 12,272 students representative of students in grades 9-12 in the 50 states and the District of Columbia.

For the state and local surveys, school-response rates ranged from 48% to 100%; student-response rates ranged from 44% to 96% (2); and state and local sample sizes ranged from 369 to 5834 students. Students in most samples were distributed evenly across grades and between sexes, and the racial/ethnic characteristics of the samples varied. The school-response rate for the national survey was 75%, and the student-response rate was 90%. Suicide Attempts

Of students participating in the state and local surveys, 14%- 35% (median: 27%; national prevalence: 29%) had thought seriously about attempting suicide, 9%-22% (median: 17%; national prevalence: 19%) had made a specific plan to attempt suicide, 5%-12% (median: 8%; national prevalence: 7%) actually attempted suicide, and 1%-5% (median: 2%; national prevalence: 2%) made a suicide attempt that resulted in an injury or poisoning that had to be treated by a doctor or nurse (Table 1). In all sites, female students were more likely than male students to report having thought seriously about attempting suicide, made a suicide plan, attempted suicide one or more times, and made a suicide attempt that required medical attention. Physical Fighting and Weapon-Carrying

Of students participating in the state and local surveys, 34%- 56% (median: 42%; national prevalence: 42%) had been in at least one physical fight during the 12 months preceding the survey (Table 2). In every site, male students were more likely than female students to report having been in a physical fight. The 12-month incidence rate** for physical fighting ranged from 102 incidents per 100 students to 202 incidents per 100 students (median: 140; national incidence: 137 per 100 students).

Of participating students, 16%-39% (median: 26%; national prevalence: 26%) carried a weapon such as a gun, knife, or club at least 1 day during the 30 days preceding the survey; among students who carried a weapon, 5%-41% (median: 11%; national prevalence: 11%) most often carried a handgun (Table 2). In every site, male students were more likely than female students to have carried a weapon. The 30-day incidence rate** for weapon-carrying ranged from 62 to 164 incidents per 100 students (median: 110; national incidence: 107 per 100 students). Safety-Belt and Helmet Use

Of students participating in the state and local surveys, 7%- 54% (median: 22%; national prevalence: 28%) "always" used safety belts when riding in a car or truck driven by someone else (Table 3). Among students who rode motorcycles, 10%-59% (median: 36%; national prevalence: 39%) "always" wore motorcycle helmets. Among students who rode bicycles, 0.2%-3% (median: 1%; national prevalence: 1%) "always" wore bicycle helmets. Rates of safety-belt, motorcycle-helmet, and bicycle-helmet use were similar for female and male students in most sites.

Reported by: J Moore, EdD, Alabama State Dept of Education. J Campana, MA, San Diego Unified School District; M Lam, MSW, San Francisco Unified School District. D Sandau-Christopher, State of Colorado Dept of Education. J Sadler, MPH, District of Columbia Public Schools. D Scalise, MS, School Board of Broward County; N Gay, MSW, School Board of Dade County, Florida. R Stalvey, MS, Georgia Dept of Education. J Schroeder, Hawaii Dept of Education. J Pelton, PhD, Idaho Dept of Education. B Johnson Biehr, MS, Chicago Public Schools. J Harris, MEd, Iowa Dept of Education. N Strunk, MS, Boston Public Schools. R Chiotti, Montana Office of Public Instruction. J Owens-Nausler, PhD, Nebraska Dept of Education. B Grenert, MEd, New Hampshire State Dept of Education. D Chioda, MS, Jersey City Board of Education; D Cole, MEd, New Jersey State Dept of Education. K Meurer, MS, New Mexico State Dept of Education. G Abelson, CSW, New York City Board of Education; A Sheffield, MPH, New York State Education Dept. P Ruzicka, PhD, Oregon Dept of Education. C Balsley, EdD, School District of Philadelphia; M Sutter, PhD, Pennsylvania Dept of Education. M del Pilar Cherneco, MPH, Puerto Rico Dept of Education. J Fraser, EdD, South Carolina State Dept of Education. M Carr, MS, South Dakota Dept of Education and Cultural Affairs. E Word, MA, Tennessee State Dept of Education. P Simpson, PhD, Dallas Independent School District. L Lacy, MS, Utah State Office of Education. S Tye, PhD, Government of the Virgin Islands Dept of Education. B Nehls-Lowe, MPH, Wisconsin Dept of Public Instruction. B Anderson, Wyoming Dept of Education. National Center for Injury Prevention and Control; Div of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report can be used to plan and evaluate broad national, state, and local interventions for injury prevention and to monitor progress toward achieving national health objectives for the year 2000 (objectives 6.2, 7.8, 7.9, 7.10, 9.12, and 9.13) (3). However, because the quality of the samples varied among the state and local surveys, data across sites may not be comparable.

Objectives 6.2 and 7.8 are to reduce by 15% the incidence of injurious suicide attempts that required medical attention among adolescents aged 14-17 years. Based on results from the 1991 national YRBS, the annual prevalence of injurious suicide attempts will need to be reduced from 2.0% to 1.4% by the year 2000 to meet the objectives. Only two sites have met these objectives. Objective 7.9 is to reduce by 20% the incidence of physical fighting among adolescents aged 14-17 years; based on the 1991 national YRBS, the 12-month incidence must decline from 137 to 110 or fewer episodes per 100 students by the year 2000. Only one site has met this objective.

Objective 7.10 is to reduce by 20% the incidence of weapon-carrying by adolescents aged 14-17 years. To meet this objective by the year 2000, the 30-day incidence rate must be reduced from 107 to 86 or fewer episodes per 100 students. Six sites have met this objective. Objective 9.12 is to increase to at least 85% the proportion of motor-vehicle occupants who use occupant-protection systems, and objective 9.13 is to increase use of helmets to at least 80% among motorcyclists and at least 50% among bicyclists. In all 33 sites, the prevalence of safety-belt, motorcycle-helmet, and bicycle-helmet use is substantially below these objectives.

Comprehensive health education programs in elementary, middle, and secondary schools may help meet the national health objectives. These programs should include information about the warning signs of suicide and suicide-prevention services, teach nonviolent conflict-resolution skills, discourage physical fighting and weapon carrying, and promote the use of safety belts and helmets to prevent motor-vehicle injuries (3). Other strategies that have been employed in the school setting to reduce weapon-carrying are random locker searches, walk-throughs with metal detectors, and policies requiring clear plastic or mesh book bags so that weapons cannot be concealed easily (4).

Complementary educational and legal strategies are needed at the community level, including decreasing the cultural acceptance of violence (5); decreasing aggressive behavior between parents and children (6); reducing the exposure of children and adolescents to violence in the media (7); and improving the recognition of children and adolescents at high risk for assaults (5). Gatekeeper training and screening programs can help identify youth at risk for suicide and refer them to mental health services (8).

Legislation that requires safety-belt and helmet use among adolescents and adults is needed in every state (3). National health objective 9.14 calls for the enactment and enforcement of laws requiring safety-belt and helmet use for persons of all ages. Increasing the use of safety belts, the use of motorcycle and bicycle helmets, and the practice of other safety precautions among adolescents will require cooperative efforts by local and state health, traffic-safety, and education officials; families; medical practitioners; retailers; community agencies serving youth; and legislators.


  1. Kolbe LJ. An epidemiological surveillance system to monitor the prevalence of youth behaviors that most affect health. Health Educ 1990;21:44-8.

  2. CDC. Participation in school physical education and selected dietary patterns among high school students -- United States, 1991. MMWR 1992;41:597-601,607.

  3. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

  4. Office of Juvenile Justice and Delinquency Prevention. Weapons in schools. Washington, DC: US Department of Justice, Office of Juvenile Justice and Delinquency Prevention, 1989.

  5. National Committee for Injury Prevention and Control. Injury prevention: meeting the challenge. Am J Prev Med 1989;5(suppl):192-

  6. Widom CS. The cycle of violence. Science 1989;244:160-6.

  7. National Institute of Mental Health. Television and behavior: ten years of scientific progress and implication for the eighties, summary report. Vol 1. Rockville, Maryland: National Institute of Mental Health, 1982.

  8. CDC. Youth suicide prevention program: a resource guide. Atlanta: US Department of Health and Human Services, Public Health Service, CDC (in press).

    • The District of Columbia, Puerto Rico, and the Virgin Islands are categorized as states for funding purposes. ** The incidence rate was calculated by adding the number of times each student reported being in a physical fight during the 12 months preceding the survey or carrying a weapon during the 30 days preceding the survey and dividing this sum by the total number of students. The number of physical fighting or weapon-carrying episodes per student was then multiplied by 100 to determine the incidence rate per 100 students. Students who replied that they had fought 2 or 3 times were assigned a physical fighting frequency of 2.5; 4 or 5 times, 4.5; 6 or 7 times, 6.5; 8 or 9 times, 8.5; 10 or 11 times, 10.5; and 12 or more times, 12. Students who replied that they carried a weapon 2 or 3 times were assigned a weapon-carrying frequency of 2.5; 4 or 5 times, 4.5; and 6 or more times, 6.

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