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Childhood Injury Prevention Interventions
Skills Training Programs
Background
Street crossing is a complex series of actions, with as many as
26 tasks needed to negotiate traffic safely. Pedestrian skills training programs
have long been the mainstay of interventions to reduce child pedestrian injuries.
These training programs are of variable length and intensity and have occurred both
in school settings as well as community settings. One study found 159 different
programs intended for children.2 Evaluations of these programs which
we have considered here consist of both changes in injury rates, as well as changes
in pedestrian behavior. We have not included evaluations based solely on changes
in knowledge, attitudes, or reported behavior change, since these correlate poorly
with actual behavior change. Our 1997 review included studies which evaluated
educational programs using simulated or model traffic situations. For this 2001
update we excluded studies using these "artificial" outcomes. (Renaud
1989, Nishioka 1991, Thomson 1998).
Review of pedestrian skills training programs:
Author | Roberts et al., 1995 |
Study design and target population | Case control study.
Auckland New Zealand
Cases: (n=54) children killed or hospitalized by pedestrian
injury occurring on journey home from school
Controls: (n=157) Random sample of children who walk to and
from school. |
Intervention | Adult accompaniment on school-home
journey for children ages 5-15. |
Outcomes | Deaths and hospitalized injuries.
Study period January 1992 to March 1994. |
Results | Reduced risk of injury for children
who had an adult walk them home from school.
OR=0.31, (0.07-1.49).
Adjusted for age, sex and SES. |
Study quality and conclusions | Having adults accompany children appears
to reduce risk of injury. Presence of adults should be accounted for when evaluating
pedestrian injury rates on basis of exposure. |
Author | Rivara et al., 1991 |
Study design and target population | Controlled trial
229 children aged 5-9 years (kindergarten to Grade 4) in 3
public elementary schools in Seattle |
Intervention | 6 session curriculum based on modeling
and positive reinforcement, training in real traffic environment, parent booklet
to reinforce school program. |
Outcomes | Pre-test and post-test observations
of children as they walked home from school evaluating if they walked on sidewalk,
stopped before crossing, looked before crossing, and kept on looking. |
Results | Not Walking on sidewalk: OR=0.39,
0 .04-2.45
Not Stopping before crossing: OR=0.53, 0.27-1.03
Not Looking before crossing: OR=0.34, 0.18-0.66
Not Keep on looking: OR=0.24, 0 .11-0.54. |
Study quality and conclusions | The addition of the parent component
helped to improve behavior. However, even after the intervention, approximately
50% of K-1 children and 50-70% of Grade 2-4 children still had unsafe behavior. |
Author | Young and Lee, 1987 |
Study design and target population | Before-after design
5 year old children, Edinburgh. Group 1, n=23; group 2, n=15 |
Intervention | Group 1 received series of training
sessions on 1-way street; group 2 series of sessions on 2-way street |
Outcomes | Percent of subjects crossing with
too short of gap ("tight fits") between self and vehicle; percent
of subjects with missed opportunities for crossing |
Results | Single lane roads: No effects
on "tight fits"; reduction in number of missed opportunities (OR=0.69,
0.18-2.67)
Two lanes: Reduction in "tight fits" (OR=0.76, 0.14-4.11);
no effect on missed opportunities. |
Study quality and conclusions | Artificial training and testing situation.
Results indicate potentially modest effect, although sample size very small.
|
Author | Rothengatter, 1984 |
Study design and target population | Non-randomized controlled trial: parent-trained
group, research assistant-trained group, control group
307 children 4-6 years old in the Netherlands |
Intervention | Practical training in the real-world
environment, supplemented with social learning and behavior modification techniques.
Utilized parents and kindergarten teachers. |
Outcomes | Traffic behavior at end of intervention
and 4 months later |
Results | Children <5 yrs: Crossing incorrectly
reduced by 98% with assistant training (OR=0.02, 0.00-0.19); reduced by 63%
with parent training (OR=0.37, 0.11-1.22).
Children>5 yrs: Crossing correctly at junctions reduced
by 57% with assistant training (OR=0.43, 0 .14-1.27) and by 58% with parent
training (OR=0.42, 0.41-1.26). |
Study quality and conclusions | Training appeared to improve crossing
behavior, with training by parents almost as good as training by research assistants.
Children knew they were being observed so that this should
be viewed as optimal behavior. |
Author | Van der Molen et al., 1983 |
Study design and target population | Before-after design
63 pre-school children in the Netherlands |
Intervention | Training in crossing streets, crossing
near parked cars, and crossing at intersections.
Consisted of four 10-15 minute training sessions per task. |
Outcomes | Observations of children crossing
real streets.
Proportion of children stopping at the curb, looking left, right,
and backward. |
Results | Stopping increased from 46% to 63%
(OR for not stopping=0.49, 0.23-1.06); looking to left increased from 35% to
46% (OR for not looking left=0.63, 0.29,-1.37); looking right increased from
41% to 60% (OR for not looking right=0.46, 0.21-1.00); looking backward increased
from 3% to 18% (OR for not looking backward=0.15, 0.02-0.77). Greatest improvement
was on streets with low density traffic. |
Study quality and conclusions | This is a strong intervention from
the Gronigen group, involving parents teaching their children as well. It appears
to have been somewhat effective, although after the intervention many children
still had poor skills. There was no long term follow-up to see the decay of
the intervention effects. |
Author | Fortenberry and Brown, 1982 |
Study design and target population | Tine series design
6-7 year old children in 4 cities in Alabama |
Intervention | School-based educational program |
Outcomes | Ratio of the number of pedestrian
accidents in 6-7 year olds to all age groups for 2 years before and 2 years
after the training program. |
Results | 12% of the pedestrian accidents before
the intervention were to 6-7 year olds compared to 8% after (p<0.01). Pedestrian
injuries decreased by 33.8% in the 4 intervention cities compared to no change
in rest of the state (OR=0.66, 0 .45-0.96) |
Study quality and conclusions | One of the few studies to show a reduction
in pedestrian injuries from a school program. The data quality appears reasonable.
Unfortunately, this program has never been replicated. |
Author | Limbourg and Gerber, 1981 |
Study design and target population | Controlled trial
658 children 3-6 years old in Germany |
Intervention | Behavioral training of parents consisting
of film and video who in turn trained children; control group shown other film
or no treatment |
Outcomes | Pre- and post-intervention observations
of pedestrian crossing skills of the children in real streets, including distraction
by ball going into street. Two outcomes were: stopping at the curb and looking
both ways before crossing |
Results | Experimental group less likely not
to stop at the curb than the control group both with distraction (OR=0.31, 0
.19-0.48 ) and without distraction (OR=0.36, 0.21-0.68). In other words, training
reduced risk of not stopping at curb by 69% and 64% respectively.
Experimental group less likely not to look both with distraction
(OR=0.55, 0.36-0.84) and without distraction (OR=0.57, 0.35-0.94). In other
words, training reduced the risk of not looking before crossing by 45% and
43% respectively. |
Study quality and conclusions | At baseline only 8-15% stopped at
curb and only 20-25% looked before crossing. Significant placebo effect, especially
for non-distracted crossing.
Study results appear to be valid, although probably represent
optimal behavior. |
Author | Yeaton and Bailey, 1978 |
Study design and target population | Before and after design.
12 children in grades K-3 (ages 5-9) at each of 2 schools |
Intervention | Training session (average of 16 minutes),
using modeling and practice, each day for 3 days. |
Outcomes | Observation of children crossing "generalization"
street. |
Results | Wide variation from day-to-day on
pedestrian behavior. No discernible immediate effect in 2nd-3rd grade, but some
effect for kindergarten-1st grade students. |
Study quality and conclusions | No control groups. Behavior on training
street much better than on test street. Effects faded over time; one of the
only studies to have a 1 year f/u. |
Summary of pedestrian skills safety training programs
There were no randomized controlled trials of the effect of pedestrian
training programs. With the exception of the Fortenberry
study7, and the Roberts
1995 study, all of the studies examined pedestrian behavior
as their outcome and did not examine the effect of the programs on pedestrian injuries.
Some of the studies used more artificial situations to evaluate the impact of the
training program than others. The effectiveness of the interventions varied considerably,
from achieving near perfect pedestrian crossing skills to others in which about
one-half of the children even after the intervention did not cross the streets correctly.
The effectiveness of the interventions varied considerably, from achieving
near perfect pedestrian crossing skills to others in which about one-half of the
children even after the intervention did not cross the streets correctly.
An example of a comprehensive (multi-modal) program is the Children's Village,
a life safety education facility for children evaluated by Gielen
et al 1996. Programs included a broad array of educational approaches, such
as individual instruction, audiovisual materials, behavior modification techniques,
modeling, simulations, training in real street situations, and mass media campaigns.
The evaluations suggest that: 1) educational approaches can increase children's
knowledge of pedestrian safety; 2) training in real street situations has potential
for changing unsafe behaviors; and parent e ducation component needed to maximize
success. Unfortunately the evaluation used self-reported outcomes, not observed
behaviors. This approach, while promising, requires the commitment of substantial
resources. The authors point out that neither their study nor the published literature
has linked improved knowledge to increased safety skills which should be measured
by observed behavior or changes in injuries.
Child pedestrian injuries and deaths have decreased over the past 20 years. Several
studies h ave indicated that a change in travel patterns (i.e. less walking and
biking) is a major contributor to reduction in deaths.(DiGuiseppi 1997, Roberts 1995 , Roberts 1993, MacPherson 1998) These changes in exposure patterns
need to be tak e n into account in evaluations of pedestrian training programs which
use changes in injuries as an outcome measure. Changes in transport policy to encourage
walking and cycling for short trips and bus, train, air trips for longer distances
should be consi dered, (Roberts 1995). This would include environmental changes
to make walking safer and a philosophical shift to value pedestrian and cyclists'
convenience over that of motor vehicle drivers.
Recommendations on pedestrian skills safety programs
The programs do appear to improve child pedestrian crossing skills
and can therefore be recommended. Programs which are multi-modal and programs which
use parents are likely to be most successful in altering behavior. However, they
are not panaceas and are not the complete answer to the pedestrian injury problem.
Recommendations for future research
There is a need for a rigorous randomized controlled
trial to test the effectiveness of pedestrian skills training programs. Ideally,
these should be done in large communities in which the outcome of interest could
be pedestrian-motor vehicle collisions. At the least, the outcome should be observed
pedestrian behavior and street crossing skills in the real world environment, in
which the child is unaware he or she is being observed.
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