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Randomized Trial of Enhanced Anticipatory Guidance for Injury Prevention
Andrea Carlson Gielen, ScD, ScM;
Modena E. H. Wilson, MD, MPH;
Eileen M. McDonald, MS;
Janet R. Serwint, MD;
John S. Andrews, MD;
Wei-Ting Hwang, BS;
Mei-Cheng Wang, PhD
Arch Pediatr Adolesc Med. 2001;155:42-49.
ABSTRACT
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Objective To develop and evaluate an injury prevention anticipatory guidance training
program for pediatric residents.
Design Thirty-one residents were randomly assigned to an intervention or control
group. Both groups attended a 1-hour seminar about injury prevention and the
American Academy of Pediatrics TIPP (The Injury Prevention Program) materials.
The intervention group also received 5 hours of experiential instruction on
injury prevention content and counseling skills (SAFE Counseling Framework).
Families with infants from birth to age 6 months were enrolled in the study
(N = 196); they were followed up until the child was aged 12 to 18 months.
Data were collected by means of baseline and follow-up interviews, audiotapes
of medical visits, parent exit surveys, and home observations.
Setting A hospital-based continuity clinic that serves families living in low-income,
inner-city neighborhoods.
Outcomes Physician counseling and parent satisfaction, knowledge, beliefs, and
behaviors.
Results Parents seen by physicians in the intervention group received significantly
more injury prevention counseling for 5 of the 6 safety practices, and they
were significantly more satisfied with the help their physicians provided
on safety topics. They were no less satisfied with their physicians' counseling
on other anticipatory guidance topics. Parents' knowledge, beliefs, and home
safety behaviors did not differ between the 2 groups.
Conclusions The frequency and impact of pediatric counseling can be enhanced by
experiential training that targets specific injury hazards. Because low-income
families face many barriers to carrying out the recommended safety practices,
supplemental strategies are needed to ensure safer homes.
INTRODUCTION
INJURIES ARE the leading health threat to children in the United States.1 Approximately one quarter of all children experience
a medically attended injury each year.2, 3
Every year there are more than 4 million injuries in the preschool-aged population,
and fatal injuries claim more of these young lives than do childhood diseases.4, 5, 6 In addition to the human
suffering, such injuries are expensive to society and to families. Miller7 estimated the annual lifetime cost of all injuries
to children aged 14 years and younger in 1991 to be $180 billion. In 1997,
a single pediatric hospitalization for a preschool-aged child was estimated
to cost $2600 for poisonings, $2900 for falls, $12 000 for scalds, and
$22 000 for burns (D. Bishai, MD, MPH, PhD, M.E.H.W., and A.C.G., unpublished
data, 1999).
Many injuries can be prevented by modifying children's environments
and teaching parents safety practices. Pediatricians are in a unique position
to encourage and support such injury prevention efforts. Not only do pediatricians
have continuing access to parents, but parents rate them as an important source
of information on injury prevention.8 Injury
prevention counseling is included in the anticipatory guidance standards of
care of the American Academy of Pediatrics (AAP),9
in the US Preventive Services Task Force Guide to Clinical Preventive Services,10 and in the national health objectives.11
A recent Delphi technique survey12 of 23 pediatric
injury prevention experts also provided support for the importance of counseling
and indicated consensus on high-priority safety topics.
Bass and colleagues13 reviewed the literature
on the effectiveness of pediatric injury prevention counseling programs. Between
1964 and 1991, only 20 published studies were found to be of sufficient scientific
rigor to evaluate this type of intervention. Of 7 studies that used an experimental
study design, 5 demonstrated positive results, including improved knowledge,
better home safety practices, and increased reported car seat use. In studies
using quasi-experimental designs, positive outcomes included increased parental
knowledge, improved safety practices (use of auto restraints, ipecac, and
smoke alarms), and reductions in injuries (motor vehicle crashes and falls).
Miller and Galbraith14 estimated that pediatric
injury prevention counseling for parents of preschool-aged children could
save society $880 per child.
Despite the endorsement of professional guidelines and evidence of its
potential effectiveness, pediatric counseling is still not widely practiced.15, 16, 17 In an analysis of
178 audiotaped well-child visits with pediatric residents, only 47% mentioned
injury prevention, and when an injury topic was discussed, only 1.08 minutes
was devoted to it.17 Thompson18
noted that the potential for counseling as an intervention is underappreciated
by physicians, who often lack skills in the application of patient behavioral
change strategies. A national survey19 of pediatric
residency programs found that injury prevention was less frequently taught
than other disease prevention topics. Residency training programs can play
an important role in enhancing pediatricians' counseling skills and increase
the amount and quality of injury prevention anticipatory guidance they provide
their families.
The purpose of this study was to develop and evaluate an injury prevention
anticipatory guidance training program for pediatric residents. The ultimate
goal of the program was to improve parents' safety practices for the prevention
of burns, falls, and poisoning among children aged 0 to 2 years living in
low-income, inner-city neighborhoods. The specific safety practices included
using smoke detectors, lowering hot water temperatures, eliminating baby walkers,
using stair gates, storing poisons safely, and having syrup of ipecac in the
home. These safety practices were selected because they are recommended topics
in the AAP TIPP (The Injury Prevention Program) materials, there is evidence
of their effectiveness for reducing injury risk, and they address injury problems
that are especially important in low-income neighborhoods. We hypothesized
that enhanced anticipatory guidance (EAG) training of pediatric residents
would result in their providing more injury prevention counseling, which in
turn would positively impact parents' satisfaction with their pediatric visit
and their safety knowledge, beliefs, and home safety practices.
PARTICIPANTS AND METHODS
DESIGN
This study was undertaken in a pediatric continuity clinic in a large
urban teaching hospital. Forty-four first- and second-year pediatric residents
were invited to participate via a letter from the clinic director (J.R.S.)
and the director of general pediatrics (M.E.H.W.), and written consent was
obtained from the 31 residents (70%) who agreed to participate. A table of
random numbers was used to assign 18 participating residents (58%) to the
intervention group (IG) and 13 (42%) to the control group (CG). Both groups
were invited to attend a standard 1-hour seminar on the problem of injuries
and an overview of the AAP TIPP that was offered annually by the director
of general pediatrics. Each resident received a complete AAP TIPP packet to
keep. Because the residents' schedules did not permit them all to attend the
seminar, the TIPP packets were distributed by mail to those who could not
attend (8 residents in the IG and 9 in the CG). Copies of TIPP safety sheets
were also available in the clinic throughout the study. The IG residents also
received training in EAG, as described in the "EAG Intervention" subsection.
The family's study group status (IG or CG) was determined based on their pediatrician's
study group assignment. Families are routinely assigned to a pediatric resident
on a random basis, and that resident remains their primary care provider as
long as the family attends the clinic or until the resident graduates. Families
with children from birth to age 6 months were enrolled in the study during
a clinic visit by the study interviewer, who was in the clinic on a daily
basis. Written informed consent was obtained in accordance with the hospital's
institutional review board, which approved the study.
DATA COLLECTION
Families completed a baseline interview at study enrollment and were
then followed up until their child was aged 12 to 18 months. Each clinic visit
was audiotaped, and parents completed a brief exit survey that included questions
about satisfaction with the visit. All visits were included because it was
not uncommon for parents to miss a well-child visit and then appear for an
acute care visit shortly thereafter, in which case some well-child care (eg,
anticipatory guidance) might have been included. At the 12-month well-child
visit, parents completed a 15-minute follow-up interview about their safety
knowledge, beliefs, and practices. Parents who were not reached at 12 months
(because they did not return for the appointment or were missed by the study
interviewer) were interviewed at their next well-child visit, which occurred
at either 15 or 18 months. Home observation was scheduled to occur within
2 weeks of the follow-up interview. A community health worker who received
special training in the study protocol and home safety conducted the observations.
Data for the present analysis are taken from the baseline interview, parent
exit surveys, audiotapes, and home observations.
Families were compensated $10 for each completed interview and for home
observation. At the time of home observation, the community health worker
provided instructions about correcting identified hazards, educational materials,
and free home safety supplies (syrup of ipecac, 9-V battery, 911 and poison
control telephone stickers, outlet plug covers, and a home safety booklet).
SAMPLE
Based on sample size calculations for moderate effect sizes, 
= .05 and ß = .20, we sought to enroll 100 families in each study group.
Between November 1, 1994, and July 31, 1995, 224 eligible families were approached
in the clinic waiting room and invited to participate in the study. To be
eligible, the parent or guardian accompanying the child had to be assigned
to a participating resident, English speaking, and living with the child.
The child had to be 6 months or younger and free of any serious medical problem
that the physician thought would preclude his or her participation. Before
each clinic session, a study interviewer reviewed the clinic registrar's list
of patients with scheduled well-child visits to identify eligible families
and then approached those who appeared for their appointments in the waiting
room. A total of 196 families (88%) were enrolled (120 in the IG and 76 in
the CG); 3 families were ineligible and 25 (11%) declined to participate.
No further information was collected from families who declined. Of those
enrolled, 117 IG families (6.5 per resident) and 73 CG families (5.6 per resident)
who completed at least 1 subsequent medical visit that was audiotaped are
included in these analyses. Data analyzed from these families include 411
audiotaped visits (3.5 per patient) and 462 exit surveys (4.0 per patient)
completed in the IG and 281 audiotaped visits (3.8 per patient) and 321 exit
surveys (4.4 per patient) completed in the CG.
EAG INTERVENTION
The IG residents received 5 hours of training in the 6 safety practices
being addressed and in communication skills for counseling parents. The training
took place in two 2 -hour evening sessions held in pediatric faculty
homes. The experiential training program, led by pediatric and health education
faculty, included an introduction to a SAFE Counseling Framework, which was
developed by five of us (A.C.G., M.E.H.W., E.M.M., J.R.S., and J.S.A.) for
this project (Table 1); practice
in role plays and homework assignments; and reinforcement with printed materials
that summarized the framework and the injury content tailored to the age of
the child. For each safety practice, residents were provided with specific
strategies to discuss with their families (Table 2). Demonstration skill stations were also set up for each
of the 6 safety practices, and residents spent approximately 15 minutes at
each station, during which time faculty presented didactic material on the
associated injury problem and demonstrated or discussed use of the safety
products and allowed residents time to practice use or installation of the
device and to ask questions. Additional background information about the theoretical
underpinnings of the counseling intervention can be found in the publications
of Gielen and McDonald20 and Sleet and Gielen.21
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Table 1. SAFE Communication Framework
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Table 2. Safety Practices and Strategies
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MEASURES
Counseling
Discussion of the targeted safety practices was assessed by audiotaping
all medical visits with study physician-parenting dyads. Two research assistants
listened to the audiotapes and coded every use of any of the communication
skills (Table 1) and every mention
of a safety strategy (Table 2).
We then tallied the total number of communication skills and the total number
of safety strategies mentioned across all medical visits for each parent and
for each safety practice.
Satisfaction
After each medical visit, parents completed an exit survey that included
questions about the extent to which they believed their pediatrician had helped
them with each of 4 anticipatory guidance topics: feeding, growth and development,
behavior, and safety. Answer options were scored from 0 (did not discuss)
to 4 (helped a great deal). Responses were tallied for each topic for all
visits and averaged for each parent.
Knowledge
The follow-up interview included 12 agree/disagree items that were use
to measure general knowledge of injuries (2 items) and specific knowledge
about poisons (3 items), falls (4 items), and burns (3 items). Items were
developed by us (A.C.G., M.E.H.W., E.M.M., J.R.S., and J.S.A) to reflect the
most important information for physicians to communicate to parents for each
of the injury topics of interest. A draft version containing additional items
was pilot tested in the clinic before the start of the study, and only items
with sufficient variation were retained in the final questionnaire (Table 3).
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Table 3. Knowledge, Beliefs, and Safety Practices Reported at Follow-up
by Study Group
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Beliefs
The EAG was also expected to shift families' beliefs about how injuries
occur, how they can best be prevented, and how strongly their pediatrician
feels about home safety. The follow-up interview included 5 agree/disagree
items that were used to measure these dimensions of beliefs (Table 3).
Safety Practices
Each of the 6 safety practices was assessed by self-report at baseline
and follow-up and by home observation. To avoid influencing parents with the
baseline interview, only a few general questions were included to assess self-reported
safety practices at baseline. All were dichotomous answer options (yes/no),
unless otherwise noted, and included (1) having a working smoke detector,
(2) being able to provide the temperature of the hot water, (3) having a stair
gate, (4) planning to use or using a baby walker, (5) keeping poisons locked
or latched (all, most, some, or none), and (6) having syrup of ipecac. These
questions were repeated at the follow-up interview.
During home observations, smoke alarms and tap water temperatures were
tested. Observers recorded whether there were stairs in the home and, if so,
whether there was a stair gate or door at the top and bottom of every set
of stairs. Parents were asked if they had a baby walker (with wheels), and
those that were produced by the parent or observed during the home visit were
recorded. Observers asked where cleaning supplies, medicines and vitamins,
hair and nail care products, and other hazardous materials were kept and then
inspected these locations, recording what the substance was and whether it
was stored in a place that was locked or latched. Parents were asked if they
had syrup of ipecac, and, if so, the observer recorded its expiration date
and storage location.
In the analysis, each safety practice was treated first as a dichotomous
variable—"safe" or "unsafe." Criteria used to be counted as safe for
each practice were any working smoke detector, hot water temperature of 120°
or less, no baby walker, all stairs protected with a gate or door, any poisons
kept locked or latched, and at least 1 unexpired bottle of syrup of ipecac.
Decisions about the criteria were made based on balancing what would offer
the most protection with what families were actually doing. For example, no
families kept all their poisonous substances locked, so we considered a home
safe if any poisonous substances were kept locked or latched.
A total safety score variable was also constructed, counting the number
of safe practices in each home for 4 safety practices: stair gates, poison
storage, ipecac, and smoke alarm. Baby walkers were not included because by
the time of home observation children were beyond the age at which walkers
are typically considered an issue and we could not be confident that simply
because we did not observe a walker none was present. Hot water temperatures
were not included because most families in both study groups had safe water
temperatures even though they did not report having tested or turned it down,
suggesting that this issue was addressed structurally in these homes rather
than because of any intervention on our part.
Sociodemographic and Family Variables
The baseline interview included items assessing parents' age, ethnicity,
education, employment, number of children and adults living in the household,
and whether any of the respondents' children had ever experienced an injury
that required medical attention.
STATISTICAL ANALYSIS
Bivariate analyses, including t tests and  2 statistics, were used to compare IG and CG parents at baseline and
to compare families who completed the study (ie, had a home observation) with
those who did not on sociodemographic characteristics and baseline safety
practices to identify potential sources of bias and control variables. We
evaluated the impact of the intervention on physician counseling and parent
satisfaction using all available exit surveys and audiotapes. We then examined
changes in parents' knowledge, beliefs, and practices using data from the
subset of families who completed the study (ie, had a home observation). Hypothesis
testing included examining IG vs CG differences in (1) the number of communication
skills used and safety strategies mentioned (using 2 statistics),
(2) parent satisfaction (using t tests), (3) parent
knowledge and beliefs (using 2 statistics), and (4) parents'
safety practices (self-reported and observed).
To evaluate differences in observed safety practices, we first used 2 statistics for overall, unadjusted comparisons of each safety practice
and the total safety score. Second, we used logistic regression analyses to
examine the effect of the intervention on each safety practice, adjusting
for actual exposure to the counseling and testing for potential confounders
using the socidemographic and family variables. Finally, we used polytomous
logistic regression to analyze the total safety score, adjusting for exposure
and testing for potential confounders. For all adjusted analyses, exposure
to the counseling was treated as a categorical variable, with number of safety
strategies mentioned divided into tertiles (ie, low, medium, and high exposure).
When comparisons between the IG and the CG resulted in statistically
significant differences, we reran the analyses using the generalized estimating
equation (GEE) to confirm the finding. The GEE provides a more accurate estimate
of the SE in the case of a repeated-measures design such as ours (eg, satisfaction
surveys at each visit). This step is not needed when the traditional analysis
for independent observations finds no statistically significant association
because the adjustment in GEE widens the confidence interval, making it even
less likely to find significant differences. We assumed that the underlying
correlational structure was exchangeable in performing the GEE analyses.
RESULTS
ENROLLED SAMPLE
Baseline Characteristics
Parents in both study groups were most often the child's mother (96%)
and were generally young (mean age, 24 years). At enrollment, babies were
aged 1.90 months on average in the IG compared with 1.86 months in the CG.
Living arrangements for most families included having more than one adult
in the home (73% in the IG and 80% in the CG), 5 or more people in the home
(56% in the IG and 64% in the CG), and only 1 other child younger than 5 years
(68% in the IG and 63% in the CG). Few mothers were employed (12% in the IG
and 15% in the CG) or married (14% in the IG and 17% in the CG), and approximately
one third had less than a high school education (37% in the IG and 33% in
the CG). Almost one third of families had a household income of less than
$5000 (33% in the IG and 26% in the CG). None of these differences in sociodemographic
characteristics between IG and CG parents were statistically significant (P>.05 by 2 or t
tests).
Parents in the 2 study groups did not differ significantly on reported
experiences with child injury or current safety practices at baseline (P>.05 by 2 or t
tests). When asked if any of their children had been injured seriously enough
to need medical care, 22% of IG and 18% of CG parents said yes. Most parents
reported having a working smoke detector (93% in the IG and 92% in the CG).
Only 3% of each study group reported knowing the temperature of their hot
water. Slightly more than one third of each group (38%) reported keeping all
poisons in places that locked or latched, although few parents reported having
syrup of ipecac (12% in the IG and 16% in the CG). Most parents reported having
a stair gate (81% in the IG and 84% in the CG) and planning to use a baby
walker (72% in the IG and 65% in the CG).
Clinic Visits
On average, IG residents had 6.72 families enrolled (with 29.89 visits)
and CG residents had 5.85 families enrolled (with 28.77 visits) during the
study. The proportion of visits that were for well-child care was 83% in the
IG and 82% in the CG. Based on the length of the audiotapes, the average length
of the visits is estimated to be 26 minutes in the IG and 24 minutes in the
CG. None of these differences between the IG and the CG were statistically
significantly different by t or 2
tests.
Counseling
The mean ± SD number of mentions of safety strategies across
all safety practices was 9.4 ± 6.8 (range, 0-30) in the IG and 3.7
± 3.2 (range, 0-15) in the CG. On average, for all safety practices,
the mean ± SD number of communication skills used was 15.1 ±
11.3 (range, 0-44) in the IG and 6.0 ± 5.5 (range, 0-26) in the CG.
When analyzed for each safety practice, parents receiving care from physicians
in the IG were significantly more likely than those seen by CG physicians
to have safety strategies mentioned and SAFE Communication Framework skills
used for every practice except poison storage (Table 4). The GEE analysis confirmed the significant 2 test results, using GEE for binary logistic models (Table 4).
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Table 4. Families Receiving Counseling That Included Recommended Safety
Strategies and SAFE Communication Skills*
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Satisfaction
Parents in the IG rated the help they received with safety topics significantly
higher than parents in the CG, and they did not differ in their ratings on
any of the other anticipatory guidance topics (Table 5). Both groups were generally very satisfied (scoring >3.5
on scales that ranged from 0-4) with the amount of help they received with
all 4 anticipatory guidance topics. A linear GEE model confirmed the significant t test results (Table
5).
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Table 5. Mean Satisfaction Scores by Study Group and Anticipatory Guidance
Topics*
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HOME OBSERVATION SAMPLE
Of those enrolled in the study, 80 (67%) and 56 (74%) in the IG and
the CG, respectively, completed home observation. Reasons for not completing
home observation included parents moving out of the area, disenrolling from
care at the clinic, declining further participation in the study, or being
lost to follow-up despite multiple attempts to find usable telephone numbers
or addresses. Families who completed home observation were compared with those
who did not on sociodemographic characteristics, previous child injury experience,
and safety practices reported at baseline. No differences were found in the
CG; in the IG, completers were more likely to be unemployed (92% vs 80%; 2 = 4.04, P = .04) and to be the only adult
living in the home (33% vs 15%; 2 = 4.18, P = .04). The average age of the children at the time of home observation
was 14.4 months in the IG and 14.2 months in the CG, which was not statistically
significantly different by t test.
Knowledge and Beliefs at Follow-up
Parents in the IG and the CG did not differ on any of the knowledge
and beliefs measured (Table 3).
More than three quarters of parents knew that injuries are the leading cause
of death for children. In most cases, parents were knowledgeable about the
hazards and prevention strategies, except that few parents knew that putting
medicines on a high shelf was inadequate. Almost half of the sample (45%)
thought that injuries were not preventable, and most ( 60%) agreed that
teaching a toddler to mind is the best way to prevent injuries.
Safety Practices
Although most parents (80%) thought that the pediatrician felt strongly
about childproofing, few families had tested the temperature of their hot
water or reported having taken steps to prevent poisonings (Table 3). Almost all parents (96%) reported having a working smoke
detector.
In the analysis of observed safety practices (Table 6), the IG and CG families did not differ on any of the safety
practices or on the total safety score in the overall bivariate comparisons.
There was considerable variation across the safety practices. For example,
virtually all families had tap water temperatures at or below 49°C (120°F),
whereas almost none stored poisons safely. Families stored poisonous substances
in an average of 3 locations, most frequently in the bathroom and most often
behind an unlocked door. Only 2 comparisons were in the expected direction,
although not statistically significant: 36% of IG vs 30% of CG families had
stairs that were protected by a gate or door; and 59% of IG vs 50% of CG parents
had at least 1 working smoke alarm.
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Table 6. Frequency of Safety Practices Observed During Home Visits
by Study Group
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In the logistic regression analyses that included an adjustment variable
for exposure to the intervention (ie, the number of safety strategies mentioned
by the physician), for the IG relative to the CG, the odds ratios for each
safety practice were 1.56 (95% confidence interval [CI], 0.70-1.37) for working
smoke alarm, 1.56 (95% CI, 0.67-3.66) for protected stairs, 0.47 (95% CI,
0.09-1.80) for locked poisons, and 0.47 (95% CI, 0.12-1.78) for syrup of ipecac.
Results did not change when we used other measures of exposure to the intervention
or tested for potential sociodemographic confounders.
The total safety score was fairly evenly distributed in both groups,
with approximately one third of families practicing none, 1, and 2 or more
of the recommended safety practices (Table
6). In the polytomous logistic regression analysis that included
the exposure adjustment variable, the odds ratio for the IG relative to the
CG for practicing 1 vs none of the safety practices was 1.26 (95% CI, 0.42-3.80)
and for practicing 2 or more vs none was 1.19 (95% CI, 0.37-3.87).
COMMENT
This is the first study, to our knowledge, to examine the impact of
enhancing pediatric anticipatory guidance training on counseling parents about
child safety. The results indicate that there are substantial benefits to
such training in the context of clinical settings that serve low-income, inner-city
families. Not only did IG residents provide significantly more injury prevention
counseling than CG residents, but their families were more satisfied with
the safety help they received. Moreover, parents were no less satisfied with
the amount of help their pediatricians provided on other routine anticipatory
guidance topics, suggesting that improved attention to safety topics can be
achieved without compromising the attention given to other important concerns.
It is possible that the satisfaction levels parents in the EAG group reported
on these other anticipatory guidance topics was a result of their physicians'
improved global communication skills that generalized to other counseling
topics. Future analyses of the audiotaped visits might be able to shed light
on this issue. We conclude that the potential impact of the AAP TIPP materials,
which both groups of residents received, can be enhanced with additional training
that targets specific injury hazards and uses "hands-on" approaches to learning
about the safety practices recommended to families.
We found the impact of the EAG to be insufficient to support significant
behavioral changes in the families, although in 2 cases (smoke alarms and
protected stairs) the differences between IG and CG families were in the predicted
direction. In the analyses of total number of safety practices, the adjusted
odds ratios also favored the IG, but the differences were not statistically
significant. Although these results might be attributable in part to the study's
relatively small sample size, it is also likely that low-income families face
many barriers to carrying out pediatric advice that can be overcome only by
supplementing counseling with other supportive services, such as improved
access to affordable safety supplies. This hypothesis is supported by other
research, including a survey of low-income families in Baltimore, Md,22 and a recent childhood injury prevention intervention
trial in England.23
The parental knowledge, beliefs, and prevalence of injury hazards found
in this study may provide useful information for planning injury prevention
programs for low-income families in urban areas. For example, virtually all
families reported having a working smoke detector, yet only half actually
did have one when we conducted home observations. A substantial proportion
of families also did not know that smoke detector batteries should be changed
at least twice a year. That families think they are protected when they are
not is of particular concern in the context of low-income neighborhoods, where
the risk of house fires is high. In addition, these results underscore the
importance of including observed behaviors when evaluating injury prevention
programs.
The virtual absence of poison prevention strategies (safe storage and
syrup of ipecac) suggests a potentially high priority area for intervention.
Messages need to address the widespread misconception that putting medicines
on a high shelf will keep them safely out of the reach of children. Our families
also stored poisonous substances in an average of 3 different locations throughout
their homes, making it even more difficult to maintain proper storage over
time. Prevention messages should include recommendations to reduce the number
of places such items are kept to make safe storage easier.
Two thirds of the sample had stairs that were unprotected by a stair
gate or door, representing a substantial fall hazard to infants and toddlers.
One third of the sample continued to have a baby walker in their home, which
might be an underestimate because some additional walkers may not have been
visible to the home observer. Parents' knowledge about fall hazards was generally
high, suggesting that other barriers and facilitators to eliminating them
need to be explored (eg, difficulty in obtaining stair gates and perceived
benefits of using baby walkers).
This study was implemented in a large urban teaching hospital clinic
that serves low-income inner-city families, which has implications for understanding
the results. First, we were able to use random assignment of physicians to
study groups, which is a strength of the design and should ensure comparability
between the groups. However, a smaller proportion of the CG attended the initial
training seminar compared with the IG, which suggests that there might have
been differences between the groups on variables that we did not measure that
could account for our results (eg, knowledge and enthusiasm about injury prevention).
We do not believe that this is a major threat in this study because all physicians
received a complete TIPP packet and TIPP materials were widely available in
the clinic. Also, there were no systematic differences between the study groups
on any of the other indicators of potentially greater concern (eg, number
of visits and length of visits). A second issue concerns generalizability
of the results to other settings. Because the participating physicians were
first- and second-year pediatric residents, results cannot be widely generalized
to other practitioners or settings, such as pediatricians who have been in
practice for several years or who serve middle class, suburban populations.
Nevertheless, low-income families are an important audience for injury prevention
because of their elevated injury risk and because many receive care in residency
training settings. Such settings should consider incorporating EAG along with
other strategies to better promote childhood injury prevention.
Enhanced anticipatory guidance seems to be an effective strategy for
improving parent satisfaction, an important outcome of medical care in its
own right, especially in the current managed care climate. The EAG training
that we provided successfully in this project may serve as a useful model
to other pediatricians and health care providers. Because pediatricians are
expected to provide injury prevention, anticipatory guidance routinely provides
a strong rationale for developing the most effective counseling. For those
who serve low-income families, however, additional strategies that help parents
act on their pediatrician's advice are necessary.
AUTHOR INFORMATION
Accepted for publication August 15, 2000.
This study was supported by grant MCJ-240638 from the Maternal and Child
Health Bureau (Title V, Social Security Act), Health Resources and Services
Administration, US Department of Health and Human Services, Rockville, Md.
We thank the participating physicians and parents for making the study
possible and David Bishai, MD, MPH, PhD, Debra Roter, PhD, Larry Wissow, MD,
MPH, Susan Larson, MS, and Mary Kay Oberle, BA, for advice and technical assistance.
From the Department of Health Policy and Management and the Center
for Injury Research and Policy (Dr Gielen and Ms McDonald) and the Department
of Biostatistics (Ms Hwang and Dr Wang), Johns Hopkins University, School
of Public Health, and the Department of Pediatrics, Johns Hopkins University
School of Medicine (Drs Wilson, Serwint, and Andrews), Baltimore, Md. Dr Wilson
is now with the American Academy of Pediatrics, Elk Grove Village, Ill. Dr
Andrews is now with Starship Children's Health, Auckland, New Zealand.
Corresponding author: Andrea Carlson Gielen, ScD, ScM, Center for
Injury Research and Policy, Johns Hopkins University, School of Public Health,
624 N Broadway, Baltimore, MD 21205 (e-mail: agielen{at}jhsph.edu).
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