Parents frequently receive a great deal of information on various health-related topics, and providers must address numerous health-related concerns during the course of a brief well-child visit. Concerns about injury prevention may become secondary to more immediate and apparent issues such as immunizations or nutrition. Moreover, parent recall of anticipatory guidance decreases as the number of topics addressed increases [33
]. Thus, an intervention that could efficiently and effectively provide injury prevention information could have considerable utility in pediatric practice. Findings from this study support the efficacy of individually tailored injury prevention information for promoting adoption of injury prevention measures by parents of young children. Those receiving tailored information were more likely to adopt an injury prevention behavior than those receiving generic information. This effect was observed specifically among those with a lower education level. As health promotion interventions are often more effective with higher educated populations, a program that is effective for those with less education may be of particular value.
Those receiving tailored information were also more likely to adopt a higher impact behavior, such as consistently using the car seat or not leaving a child alone in the tub. This suggests that for simple behaviors (e.g. using outlet covers, a low-cost one-time behavior), generic information may be sufficient, whereas more complicated behaviors (e.g. installing and using car seats, a higher-cost and ongoing behavior) benefit from a tailored approach. Thus, the use of individually tailored injury prevention information may be a useful method to enhance the provision of effective injury prevention education in the pediatric primary care environment.
This study adds to a growing body of evidence that tailoring can be effective in promoting health-related behaviors for a range of issues among parents of young children, including immunization [34
], nutrition [35
] and injury prevention [11
]. One explanation for effects of tailored health communication, based on the Elaboration Likelihood Model [37
], suggests that individuals are more motivated and likely to process information when they perceive it to be personally relevant. In support of this explanation, studies have shown that tailored information stimulates greater cognitive activity about the health topic of interest than nontailored information [38
]. This in-depth processing, or ‘elaboration', is thought to lead to greater and more lasting changes in attitudes, which in turn may facilitate changes in behavior [39
]. Although this study did not assess parents’ processing of the injury prevention information, the finding that tailored materials were more likely to be read is consistent with this explanation. In models of communication and persuasion effects, paying attention to a stimulus is an important prerequisite to understanding [41
]. Another explanation of tailoring effects is that the expectation of customization—for example, simply telling an individual they will be receiving individualized information—leads to more positive evaluations of the materials [42
]. However, the lack of differences between the perceived persuasiveness of the tailored and generic materials does not support this explanation.
Contrary to expectations, the addition of provider-directed tailored feedback did not enhance intervention effectiveness. Previous research has indicated positive outcomes associated with provider recommendations for behavior change [14
]. However, the provision of provider tailored feedback in this study did not result in greater provider discussion of injury prevention recommendations, according to parent reports. The lack of effect observed in this study may indicate a need for more extensive training regarding use of the program or may suggest that programs need to be integrated more fully or differently into standard office protocols. While the providers reported discussing the tailored information with most parents, few parents recalled such discussion. This discrepancy is common when comparing patient and provider reports of communication [45
] and could be the result of a social desirability reporting bias among the health care providers or could reflect parents' not remembering these discussions. Thus, it cannot be determined from this study whether increased or systematic provider–parent interaction would result in greater behavior change.
A notable strength of this study is that it was conducted with a lower socioeconomic status sample. Injury prevention and other health promotion interventions may be especially challenging with this population, given the degree of environmental stressors and competing priorities that are often present. These populations are more difficult to reach, especially through traditional print media. By providing highly relevant and targeted information, a tailored approach may be more successful in overcoming impediments to the effectiveness of print health-related information. For practices serving lower income and less educated populations, an effective, low-cost, low-intensity intervention that can be integrated into the existing health care system could have particular appeal and utility.
The selection of this study population resulted in a low follow-up response rate, however. During the time in which the study was conducted, the population served by the participating clinics consisted of 28–50% families with young children living below the poverty level [46
]. While this suggests that public health programs are very much needed, this population is also harder to follow-up since participants are less likely to have regular access to phones and may often change housing. The low follow-up rate is also a function of many advances in telephone capabilities. With caller ID, call blocking and other phone options, there has been a decrease in the response percentages of telephone surveys. The 2000 Summary Data Quality Report of the Behavioral Risk Factor Surveillance System [47
] shows that median response rates have declined steadily from 63.2% in 1996 to 48.9% in 2000. In 2003, the overall response rate for the Behavioral Risk Factor Surveillance System in Missouri was 54.2%, modestly higher than our follow-up response rate of 51%. This response rate is an important limitation of this study, adversely affecting power and of concern for internal validity. However, the treatment groups did not differ in follow-up rates and very minimal demographic differences between responders and nonresponders were observed. Moreover, the differences observed would have more likely created a bias in the direction of not observing a treatment effect, as those with a college education showed the least treatment effect. As such, we conclude that the response rate is not a significant threat to the internal validity of this study.
The rates of injury prevention adoption in this sample were lower than in our pilot study [11
], likely affected by the nature of the current study population. This along with the lower follow-up rate reduced the statistical power of this study, limiting more extensive analyses. As multiple outcomes were assessed, analyses included the use of multiple significance tests. However, between-group findings regarding reading of the information and adoption of injury prevention behavior demonstrated similar patterns, suggesting that results are likely attributable to differences in the information rather than chance.
The use of T-IPI integrated within the pediatric primary care environment may be an effective and efficient way to enhance the provision of injury prevention anticipatory guidance and increase the use of safety practices by parents of young children. However, despite the demonstrated efficacy of tailored information compared with generic, adoption of injury prevention behaviors as a result of the information occurred in less than half of the recipients. Greater rates of behavior change will likely require more intensive efforts than unsolicited provision of information. Future work in this area should continue to explore avenues by which the health care provider could increase parent activation and further enhance the effectiveness of this form of print media.