compared with the comparison schools. Conclusions: ... years and by motor vehicle occupant and pedal cycle .... intervention teachers participated in a half-day training session to .... Vehicle repair costs: Accident costs for project planning and.
The Child Pedestrian Injury Prevention Project Mark Stevenson, Steve Jones, Donna Cross, Peter Howat, Margaret Hall Abstract Issue addressed: Australia has a higher child pedestrian fatality rate than both the United Kingdom and the United States (3.1/100,000 per year vs 2.4/100,000 per year for both the United Kingdom and the United States).''; In Western Australia the rate is even higher (3.2/100,000 per year) .1 The problem is particularly severe in the five- to nine-year age group.' Over the past ten years in Western Australia there has been no significant reduction in the mortality rate from child pedestrian injury, suggesting that these injuries will continue to represent a major child health problem unless efforts are directed at prevention. The problem is complex and multifactorial requiring action at a variety of levels and consisting of education. environment, engineering, and legislative changes. Methods: Three local government areas in metropolitan Perth were selected on the basis of their homogeneity of injury rates and sociodemographic characteristics. These areas were then randomly assigned to one of three experimental conditions: a school-based and community intervention; a school-based only intervention: and a comparison group. A cohort of six- to seven-year-old children from each of these areas is being observed for a period of three years, through Years 2, 3, and 4 of their schooling. Results: Results from the first year of the project demonstrate exceptionally high response rates from stUdents (97.6 per cent at baseline; 97.8 per cent at first year post-test), parents (89 per cent at baseline; 83.7 per cent at first year post-test) and teachers (100 per cent at baseline and first year post-test). Preliminary results for student outcomes indicate an improvement in childrens' reported road crossing behaviour in the intervention schools compared with the comparison schools. Conclusions: The results of the trial will determine the appropriateness of such a multifaceted approach for prevention of child pedestrian injury and the costs associated with it. So what? A multifaceted approach to injury prevention is required and educational or environmental strategies used alone will have limited long-term results.
Background From 1988 to 1992, pedestrian injury was the leading cause of injury-specific death in five- to nine-year-old Western Australian children. Childhood pedestrian injuries were exceeded only by drowning as the leading cause of death in children aged one to four years and by motor vehicle occupant and pedal cycle injuries as causes of death in children aged 10 to 14 years.' The child pedestrian fatality rate for Western Australian children aged one to 14 years of 3.2/100,000 per year' is higher than for children aged one to 14 years in Australia as a whole (3.1/100,000 per year). and is also higher than the rates for the United Kingdom' (2.4/100.000 per year) and the United States'' (2.4/100.000 per year) for children of the same age range. For children who survive the original crash, the injuries are severe. Pedestrian injuries account for approximately 10 per cent of all bed days for paediatric injury admissions in Western Australia. The average lengths of stay in hospital for children aged one to four. five to nine and 10 to 14 years are 6.6. 30.2 and 7.5 days respectively.' For the five- to nine-year age-group the average length of stay is four times longer than the average for burns. which accounted for the next longest length of stay. reflecting the severity of the injuries compared with other paediatric trauma. Hca/t/; Promotion Jnzmzal of Australia 1996:6(3J 32
Furthermore, a study by Harris, Schwaitzberg, Seman and Herrman found that three quarters of severely injured children were still disabled 12 months after injury.; Severe head injuries are present in more than 80 per cent of critically injured child pedestrians.; The effects on the families of injured children are equally profound. These effects include behavioural problems in uninjured siblings and greater pressures on marital relationships.·· In addition to the heavy social and emotional burden intrinsic to such injuries, both direct costs such as the cost of rehabilitation, and indirect costs, arising from the number of person-years of life lost and the loss of earning capacity. will be considerable. In fact, Andreassen estimated the direct costs of a pedestrian injury in urban or rural environments to be 889,000 and 8104,000, respectively.'': The lack of any significant reduction in the mortality rates from child pedestrian injury in Western Australia over the past decade suggests that these injuries will continue to represent a major child health problem if efforts are not directed at prevention.' However. at present then~ are few well-established prevention strategies. The prevention of child pedestrian injury is a multifactorial problem as recognised by Haddon· and others.": For example. primary prevention. that is. the
avoidance of the pedestrian/motor vehicle contlict, involves factors such as the amount of time the child spends in the road environment. the child's behaviour. the driver and the vehicle. and features in the road environment which may predispose or protect the child from being involved in a collision. :VIany of these factors offer opportunities for intervention. prompting the question: how does one set priorities for prevention? One answer to this question is to examine how often these factors are associated with the incidence of child pedestrian injury. This is the notion of attributable proportions. Attributable proportions provide a systematic approach to prevention as they take into account both the strength of effect and the frequency of its presence. This concept for attempting to prevent these injuries developed from a knowledge of epidemiological theory and health promotion practice. A case-control study involving 100 injured and 400 noninjured child pedestrians aged one to 14 years was conducted between December 1991 and December 1993 in Perth, Western Australia. Aspects of the child's social and physical environments, measures of his or her behaviour, cognitive skills and 'habitual' exposure to the road environment, as well as his or her knowledge of road safety, were recorded. The specific details of this study have been published elsewhere. 1u 2 The results from the case-control study indicated that the volume of traffic encountered by the child during his or her exposure to the road environment, the presence of visual obstacles and footpaths on the child's street of residence, as well as the child's behaviour, independently predicted the likelihood of pedestrian injury. The findings from the study also highlighted a number of inadequacies in the current school-based road safety education programs. For example, only 30 and 40 per cent of case and control children, respectively, reported receiving pedestrian skills training in the actual road environment. The findings from the case-control study and the need to undertake an intervention that was adequately implemented and rigorously evaluated led to the development of a three-year community intervention trial which is being undertaken in Perth, Western Australia by the Centre for Health Promotion Research, Curtin University. This project, called the Child Pedestrian Injury Prevention Project (CPIPP) is funded by the Western Australian Health Promotion Foundation, Main Roads Western Australia and the Traffic Board of Western Australia.
The Child Pedestrian Injury Prevention Project (CPIPP) The CPIPP intends to bring together the triumvirate of health education, environment and legislation as an example of health promotion in action. Health promotion, is by popular definition, the "combination of educational and environmental supports for actions and
conditions of lh•ing conducice to health". The CPIPP is a comprehensive program aimed at modifying children's behaviour in the road environment. as well as the road environment to which they are exposed, to reduce pedestrian injuries in fiveto nine-year-old children. It combines both educational and behavioural interventions including school-based student, parent, teacher and community education and a variety of environmental interventions. The interventions are based on relevant components of behavioural learning theories and involve aspects of community development to ensure the active involvement of schools and their communities. The CPIPP has been developed using rigorous planning procedures. Epidemiological. psychosocial. environmental, educational and demographic information for the target group was identi1ied. 11 This information was organised and prioritised using a modified version of Green and Kreuter's PRECEDEPROCEED framework. 1' The framework enabled a comprehensive summary model to be developed that identified the relevant risk, predisposing, enabling, and reinforcing factors, and their various relations!J.ips. A paper which details the application and adaptation of the PRECEDE-PROCEED model to the CPIPP is in submission. 15
CPIPP research design Three local government areas in metropolitan Perth (a city of 1.2 million pt;ople), Western Australia were selected based on !llJury rates and their sociodemographic characteristics. The injury rates were identified through previous epidemiological research. 11 The local government areas were randomly assigned to one of three conditions: Intervention 1 (school-based, community and environmental interventions), Intervention 2 (school-based interventions only), and comparison (no intervention other than schools being provided with nutritionrelated educational materials). A cohort of six- to seven-year-old children from each of these local government areas is being observed for a period of three years; that is, through Years 2, 3 and 4 of their schooling. A total of 47 schools, 2440 six- to seven-yearold students and a parent or guardian (n=2440), 106 teachers of the six- to seven-year-old students, and 1845 community residents comprise the total sample for the first year of the study (see Figure 1). Baseline measures for all components of the CPIPP were undertaken during May, 1995 and the first year post-test was conducted in November, 1995. Further measurements will occur in November 1996 and 1997.
School-based intervention The aim of the school-based intervention is to increase five- to nine-year-old students' and their parents' pedestrian-related knowledge, attitudes, skills and behaviour. The school-based intervention comprises Health Promotion journal of Australia 1996;6 (3) 33
two components: classroom curriculum and 'ho~e· activities. The classroom activities address pedestnan safety-related knowledge, affective education, social skill development (including decision making and assertive communication), and simulation and practise of pedestrian safety behaviours. A key focus of the classroom lessons are activities that provide students with pedestrian skills training in the actual road environment or a simulated road outside the classroom. Learning activities have been integrated with the Education Department of Western Australia's Health Education Kindergarten to Year 10 Syllabus (five to 15 years of age) and the Western Australian Student Outcome Statements. These strategies are student centred, interactive, actively involve parents, and provide cross-curricular applications for teachers. Prior to initiating the school-based program all intervention teachers participated in a half-day training session to familiarise them with the classroom materials and to enhance their skills to deliver the program content. Ongoing post-training support to teachers is provided to ensure and enhance implementation of the pedestrian safety lessons.
Community/environmental intervention The aim of the community intervention is to decrease the speed and volume of vehicular traffic, thereby reducing children's exposure to the risk of injury. The community and environmental component of the project involves only one intervention group
(Intervention 1) and comprises a number of discrete, yet inter-related, interventions and strategies (see Figure 1). A critical component of the communityI environmental intervention development process has been the establishment of a Community Road Safety Advisory Committee. This committee includes representatives from local government (traffic engineer and councillor), the regional health authority, community policing, schools, Main Roads Western Australia, transport organisations and service clubs. The committee actively engages the community and other interested groups in road safety initiatives through a combination of approaches, including community meetings, informational seminars, community health and safety events, lobbying and advocacy. It is anticipated that as a result of the recommendations and actions proposed by the Community Road Safety Advisory Committee, and the impact of other project strategies, engineering changes will be initiated within Intervention Group 1. Possible changes in
