Overall, parents' injury prevention score was only modestly related to theoretical determinants of behavior; however, the magnitude of these relations differed significantly by age of the child and birth order. Both outcome expectations and social norms were more strongly related to injury prevention behavior among parents of preschool children (ages 2–4) than among parents of infants and toddlers. It may be that parenting experiences during the child's early years shape the development of outcome expectations and social norms, and these constructs gain influence based on experiences. Attitudes, however, were more predictive for parents of first born children than parents of later born children. It is possible that parenting experience diminishes the influence of attitudes, as behavior becomes more influenced by experience and expected outcomes. Overall, then, the potential determinants were most strongly associated with injury prevention behavior among parents of first born preschool children.
The findings of this study suggest the utility of an audience segmentation strategy for child injury prevention that distinguishes first time parents from parents of multiple children, and also considers children's age. A good segmentation strategy has at least four key characteristics. First, it will identify distinct subgroups that are truly different with respect to the outcomes of interest. Second, these subgroups will be large enough in size or population proportion to justify allocation of resources to reach its members. Third, in order to assure that these groups can be reached with targeted communication, methods of identifying members of different audience segments should exist, be fast and easy to use, and reliable. Finally, the unique characteristics of each audience segment should provide clear opportunities and directions for targeting health information content and/or delivery channels. The proposed strategy meets all four criteria.
Although audience segmentation is recognized as a best practice in health communication, its application in many public health and injury prevention efforts has been relatively unsophisticated.30
Historically, public health educators have relied on risk status and/or demographic characteristics in defining target audiences. For example, potential target audiences for car injury prevention among infants and toddlers might vary by parent risk behavior,31
or demographics, such as parent age34
or socioeconomic status.35
For obvious reasons, parents are identified most often as the target audience for health communication about child injury prevention. However, assuming homogeneity within such a broadly defined category (that is, parents) may not be justified. If subgroups of parents differ in systematic ways with respect to injury prevention beliefs and behaviors, different intervention approaches may be indicated.
Findings from this study suggest intervention strategies based on a social cognitive approach may be most effective with parents of first born children. Early work with these parents should emphasize the development of social norms and attitudes that are supportive of injury prevention behavior, including messages that establish injury prevention measures as an integral part of parenting; provide a sense of control over the occurrence of injuries; and promote supervision and training as necessary, but not sufficient for injury prevention. Establishing parents' injury prevention behavior patterns during a child's infancy and as the child becomes a toddler may facilitate the development of positive outcome expectations for injury prevention behavior as the child develops. It is possible that outcome expectations develop primarily out of parenting experience; if so, intervening to influence early behavior patterns is especially important. During the early childhood years, fostering parents' positive outcome expectations appears to be a promising approach, as does assisting parents to identify and manage barriers to injury prevention behavior that they encounter.
Intervention approaches for experienced parents may be especially challenging, as social cognitive determinants were less associated with behavior for these parents, regardless of child age. Findings would suggest some utility in building positive outcome expectations, reducing barriers (primarily for parents of younger children), and promoting protective social norms (primarily for parents of older children). However, these measures may not be sufficient to affect behavior change. In working with these parents, it may be important to first assess injury prevention practices with previous children; then promote maintenance of previous preventive behavior, determine receptivity to changes from any previous risk behavior, and assess factors inhibiting these changes.
Several limitations to the study should be noted. The sample was predominantly of lower socioeconomic status from a limited geographical area, and so findings may not generalize to other populations. Data are cross sectional; thus we could not assess longitudinal or reciprocal relations between attitudes/beliefs and behavior. It should also be noted that subgroup analyses increase the chance of Type I error, and therefore the results have been interpreted cautiously to account for the possibility of such error. Injury prevention behavior was assessed by self report, and may be prone to social desirability bias. However, survey administration was conducted via computer kiosk, providing privacy to encourage honest responding. In addition, many of the safety behaviors assessed, such as consistency of car seat use or avoidance of choking risk foods, could not be assessed through single observations. Thus, self report remains the most practical method for assessing a broad spectrum of injury prevention behaviors.
- Theorized social cognitive determinants of behavior were related to parent report of injury prevention practices, but degree of association ranged from modest to substantial within subgroups based on age and birth order of the child.
- Outcome expectations and social norms were more strongly related to injury prevention behavior among parents of preschool children than among parents of infants and toddlers, while attitudes were more predictive for parents of first born children than parents of later born children.
- An audience segmentation strategy for child injury prevention that distinguishes first time parents from parents of multiple children, and also considers the children's age, may enhance effectiveness of injury prevention efforts.
- Prevention approaches with experienced parents may be particularly challenging.
Findings from this study provide guidance for the development of programs targeting different groups of parents and their use of injury prevention practices. They also speak to the difficulties faced in the design of such programs. Typically, the most effective behavioral intervention efforts are those that modify key theoretical determinants of behavior. However, in this study, these determinants were only modestly associated with injury prevention behaviors for some subgroups. Considering that previous studies addressing potential determinants of injury prevention behavior have also found relatively weak relations,22,25,28,36
further work to elucidate the determinants of injury prevention behavior is needed. Currently, modifiable attitudes and beliefs that most effectively influence parents' injury behavior are not sufficiently understood to optimally design effective prevention programs. Continued work using theory driven research and preventive intervention, with refinement and advancement of health communication strategies, is needed to realize the full benefit of active injury prevention strategies.