Evaluation of kiosk-based tailoring to promote household safety behaviors in an urban pediatric primary care practice

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Abstract

We tested a kiosk-based tailoring intervention with a sample of 144 parents of young children using a two-group randomized controlled design to evaluate the kiosk. Intervention group parents (n = 70) answered 50 questions at a practice-based kiosk and they and their child's physician received immediate feedback reports of their injury prevention needs. Four weeks later, both control (n = 74) and intervention parents completed a telephone interview. Safety knowledge, beliefs, and practices were compared at follow-up. Compared to control group parents, intervention group parents were more knowledgeable about the inappropriateness of young children riding in the front seat of a car (16% versus 5%, p < 0.05), less likely to believe that teaching a child to mind you is the best way to prevent injuries (64% versus 86%, p < 0.05), and more likely to report that they “have syrup of ipecac” (34% versus 9%, p < 0.001) and “know how to use” it (24% versus 4%, p < 0.002). This study provides further support for the use of tailored communication to address the prevention of injuries to young children but calls for continued investigation in the area.

Introduction

Injuries are the leading cause of morbidity and mortality for children in the United States [1]. Injuries requiring medical attention affect approximately one quarter of all children each year [2], [3] with a disproportionate burden on poor and minority populations [4]. Racial disparities in injury rates, however, have been attributed to living in impoverished housing conditions rather than ethnicity [5], [6]. National household survey data suggest that parents’ reported safety behaviors, such as having smoke alarms, also vary by ethnicity, education, and income [7]. Parents of lower socioeconomic status have been found to underestimate their children's risks for injury, and be less likely to take precautions to prevent childhood injuries [8]. Our own previous research, conducted in Baltimore [9], found that having a lower income and living in substandard housing was associated with implementing fewer safety behaviors.

The evidence is strong that many safety behaviors such as using smoke alarms and car safety seats can reduce injury risk [10], [11]; their use has been recommended by the American Academy of Pediatrics [12]. However, much less is known about how best to promote these behaviors, especially among low-income urban populations. Health maintenance visits offer important opportunities for implementing safety interventions, especially since pediatric anticipatory guidance includes injury prevention as a key topic for physician–caregiver discussion [13]. A recent review of interventions in clinical settings found that counseling combined with access to safety products improved parents’ safety behaviors [14], which is consistent with our earlier work specifically with low income families [15]. However, even in interventions with demonstrated effectiveness, many children remain unprotected or inadequately protected, indicating a strong need for the development of innovative, clinically based programs. We focus on home (fire/burn, poison and fall prevention) and child passenger safety topics in this study because of their contribution to the pediatric injury problem and the availability of effective countermeasures to mitigate against these injuries.

Tailoring, a process of creating individualized communication, is an assessment-based approach in which individuals provide personal data related to a given health outcome. Those data are then used to determine the most appropriate information or strategies to meet each person's unique needs [16]. Culturally based constructs, such as spirituality, collectivism, time-orientation (e.g., present versus future), and racial pride have been shown to be associated with health-related knowledge and behavior [17], [18] and reactions to educational materials [19], and are now being used to tailor messages to individuals [20], [21]. New communication technologies have made it not only possible but also practical to collect individual-level data from large populations and use that information to customize educational and behavior change materials to an individual's unique needs.

An important theoretical basis for tailoring comes from Petty and Cacioppo's [22] Elaboration Likelihood Model, which states that people are more likely to actively and thoughtfully process information if they perceive it to be personally relevant. The model is based on the premise that under many conditions, people are active information processors, considering messages carefully, relating them to other information they have encountered, and comparing them to their own past experiences [23], [24]. Studies have shown that messages processed in this way (i.e., elaborated upon) tend to be retained for a longer period of time and are more likely to lead to permanent attitudinal change [25], [26]. Tailored messages have been found to stimulate greater cognitive activity (e.g., elaboration) than non-tailored messages.

To our knowledge, only one study has been published in which computer tailoring was used to promote child safety with families seen in pediatric primary care settings [27]. Results of the Baby, Be Safe study demonstrated the superiority of tailored communication in reducing injury risk relative to generic materials in a socio-economically diverse sample. Given the limited but promising research on computer tailoring and child safety and the growing evidence for effectiveness of tailoring for other health problems [28], [29], [30], additional tailoring research on child safety applications, especially among highly vulnerable, low-income urban populations, is timely and important. The aims of this paper are to: (1) describe the development and feasibility of implementing a computer tailored injury prevention intervention in a busy urban primary care practice, and (2) report the results of the program's impact on parents’ home and child passenger safety knowledge, beliefs, and behaviors.

Section snippets

Setting

The study took place in an urban hospital-based academic primary care practice. The practice provides medical care to children from birth to 12 years of age. Post-graduate level (PL) physicians (PL-1 = 16, PL-2 = 15, PL-3 = 17) were identified as the primary care providers for each patient; faculty pediatricians supervise their care. The practice's waiting room housed both the SafetyLand kiosk, used by study parents to complete the assessment, and the SafetyLand resource center, used by those who

Sample

A total of 218 parents or guardians of children in the study age range presented to the primary care practice for a well child visit during the study data collection period (see Fig. 3). Sixty-five parents were missed by the study recruiter for the following reasons: the recruiter was already occupied with another study participant (n = 41), the recruiter was not in the practice waiting room (n = 6), or the parent was not in the waiting room long enough to be recruited (n = 18). Nine parents refused

Discussion

Tailoring safety messages for low-income populations through the computer kiosk experience is feasible. Based on our prior qualitative research, we were able to develop the computer safety assessment to reflect the attitudes, beliefs and behaviors of our patient population. More importantly, the computer-tailoring program allowed us to use an individual parent–child dyad's unique attributes to determine the child's risk for specific injuries and to create personalized safety messages for

Conclusions

This study provides further support for the use of tailored communication to address the prevention of injuries to young children. A computer-tailored educational kiosk can be effectively incorporated into a busy clinical setting to enhance pediatricians’ counseling on childhood injury prevention. Both the safety assessment and the tailored messages derived from it can be written to reflect the attitudes, beliefs and values important to a low-income urban population. Widely accepted by both

Acknowledgements

The authors would like to thank Vanya Jones for her valuable contributions to the physician training, data collection, and SafetyLand staffing. We are also grateful to the patients and physicians who participated in this study. This study was funded by the National Center for Injury Prevention and Control (R49CCR302486).

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