ORIGINAL ARTICLE

On the Road With Injury PreventionAn Analysis of the Efficacy

of a Mobile Injury Prevention Exhibit
Mariann Manno, MD, Allison Rook, MPS, EdM, Amanda Yano-Litwin, BS, Louise Maranda, MVZ, MSc, PhD,
Andrew Burr, DO, and Michael Hirsh, MD

Background: To assess the effectiveness of a mobile injury prevention

vehicle (mobile safety street [MSS]) with a hands-on curriculum on instruction and retention of safety knowledge compared with traditional classroom
safety curriculum among grade 5 elementary school children.
Methods: Grade 5 students (n 1,692) were asked to participate in the
study as either the intervention group (MSS experience) or the comparison
group (traditional classroom safety curriculum). Each student in the intervention group was asked to complete a series of three surveys. The first
survey was given before the MSS visit (Fall 2009), the second immediately
following the MSS visit (Fall 2009), and a third given 6 months after the
MSS visit (Spring 2010) to measure knowledge retention. Students in the
comparison group were asked to complete two surveys. The first survey was
given at the same time as the intervention group (Fall 2009) and the second
was given after the completion of the traditional classroom safety curriculum
(Spring 2010).
Results: Students scored on average 5.67 of 10 (5.56 5.80) before any
safety instruction was given. After MSS instruction, mean scores showed a
significant increase to 7.43 of 10 (7.16 7.71). Such increase was still
measurable 6 months after the intervention 7.34 (7.04 7.66). The comparison group saw a significant increase in their mean scores 6.48 (6.10 6.89),
but the increase was much smaller than the intervention group.
Conclusions: Community-based injury prevention programs are essential to
reducing preventable injury and deaths from trauma. This study demonstrates
that a hands-on program is more effective than traditional methods for
providing safety knowledge.
Key Words: Safety, Education, Interactive.
(J Trauma. 2011;71: S505S510)

nintentional injury remains the leading cause of death

among children older than 1 year, adolescents, and
young adults.1 The cause of injury varies with age. Among
school-aged children, motor vehicle crashes, drowning, and
Submitted for publication January 29, 2011.
Accepted for publication September 28, 2011.
Copyright 2011 by Lippincott Williams & Wilkins
From the Division of Pediatric Emergency Medicine/Department of Pediatrics
(M.M.), Division of Pediatric Surgery/Department of Surgery (A.R., A.B.,
M.H.), Division of Clinical Research/Department of Pediatrics (L.M.),
UMassMemorial Childrens Medical Center, Worcester, Massachusetts.
Supported by Wal-Mart, Ford Motor Company, Department of Public Health of
the City of Worcester, Hoche Scofield Foundation.
Presented at Forging New Frontiers: Making Communities Safe for Children &
Their Families Injury Free Coalition for Kids 15th Annual Conference,
November 1214, 2010, Chicago, Illinois.
Address for reprints: Mariann Manno, MD, 55 Lake Avenue North, Worcester,
MA 01655; email: mannom@gmail.com.
DOI: 10.1097/TA.0b013e31823a49bc

burns account for most fatal injuries; falls and bicycle and
pedestrian crashes are responsible for most nonfatal injuries.2
In addition, children who live in poverty are at greater risk for
injury and live in environments where they are simultaneously exposed to multiple safety hazards.3 There is evidence
that risky behaviors increase with age in school-aged children
and that children who have a history of injuries are more
likely to report risky behaviors.4
Schools are a constant and important part of childrens
lives and an obvious venue for teaching safety behaviors.
School-based interactive injury prevention programs have
reported positive results in improved knowledge among students in areas of bike and pedestrian safety, falls, playground
safety, fire safety, and poisoning when compared with traditional methods of instruction.57 This is consistent with literature that has shown shorter periods of time spent in more
active learner-to-learner interactions are more productive
than longer periods of more passive teacher-driven sessions.8
Successful injury prevention education has occurred
through multifaceted approaches that include hands-on learning, visual aids, creative writing, and verbal interaction.
Inquiry-based instruction allows children to develop critical
reasoning skills, superior to declarative methods where children are simply provided with the correct answer.9 One
mobile safety center reported that their mobile nature offered
them the ability to provide urban families greater access to
personalized, low-cost injury prevention education.10
Our mobile safety street (MSS) is an injury prevention
program that seeks to incorporate proven effective strategies to
enhance the learning of safety behaviors of fifth-grade students.
It is a mobile exhibit that travels to the schools, maximizing
efficiency in the students school day and creating a familiar
environment in which students learn. The MSS curriculum has
been developed to parallel the safety and health curriculum that
is required by the Department of Education in Massachusetts. It
uses a hands-on, learner-centered method of instruction best
suited to the learning style of grade school boys and girls. The
purpose of this project is to test the effectiveness of the MSS
curriculum and compare it with a traditional classroom safety
curriculum among grade 5 elementary school children.

MATERIALS AND METHODS

Curriculum Design
A comprehensive elementary school injury prevention
curriculum was developed and piloted by the Injury Free

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The Journal of TRAUMA Injury, Infection, and Critical Care Volume 71, Number 5, November Supplement 2, 2011

Figure 1. Learning stations at MSS. (A) Urban pedestrian safety, (B) suburban pedestrian safety, (C) home safety, and (D)
bus safety.

Coalition for Kids (IFCK) in Worcester, MA. The MSS curriculum was adapted from the standard classroom health curriculum used by Worcester Public Schools, the Michigan Model for
Comprehensive School Health Education. The same safety information was taught in two different waysat MSS and in the
classroom. This study was designed to compare the effectiveness of the hands-on MSS curriculum in improving and retaining safety knowledge with what is achieved through the standard
classroom health education. The MSS curriculum uses applied
S506

learning techniques including problem-solving, role-playing,

and hands-on activities. MSS is a 40-foot mobile safety unit that
includes four separate learning stations within the school bus and
safety trailer (Fig. 1). MSS travels to each school and is set up
on school property lending to the realistic nature of the
students experience. Instruction at each station includes
10-minute lessons that focus on specific pedestrian, home,
and bus passenger safety using visual simulations and
hands-on activities (Fig. 2).
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The Journal of TRAUMA Injury, Infection, and Critical Care Volume 71, Number 5, November Supplement 2, 2011

Efficacy of a Mobile Injury

Prevention Exhibit

Figure 2. Safety knowledge and behaviors covered at MSS.

Survey Design
We developed a 14-question survey that focused on
important safety behaviors emphasized in both the schoolbased and MSS curricula. The evaluation tool from the
Michigan Model is available in open-ended question format
only. We adapted this tool and created multiple choice questions. For example, the Michigan Model evaluation regarding
calling 911 asks the student to describe how to make an
emergency phone call. A correct student response would be
to dial 911, state his or her name and address, and tell the
nature of the emergency. We adapted this on the survey as
multiple choice question 5 (Fig. 3).

Study Design
This study followed a randomized block design. The 33
elementary schools in the Worcester Public School system
were placed in homogenous blocks based on socioeconomic
and demographic data reported by each school. The percentage of enrolled students who are eligible for government
subsidized lunch was the primary criterion and served as a
proxy for household income. Using this criterion, the 33
elementary schools were matched into 16 pairs, excluding 1
school because the reported demographic and socioeconomic
data were widely divergent from the other schools. A discrepancy of 10% in the criterion was determined as an
2011 Lippincott Williams & Wilkins

acceptable variance. Only one matched pair exceeded the

10% variance in the category of percentage of students
eligible for government subsided lunch (10.5% variance).
One of the two schools in each of the 16 matched pairings
was randomly assigned to participate in the MSS educational
curriculum.

Intervention and Comparison Groups

All grade 5 students (n 1,692) were asked to participate in the study as either the intervention group (who
received the MSS experience) or the comparison group (who
received traditional classroom safety education). Before receiving MSS, each child in the intervention group took a
written safety knowledge survey. During the next health
class, each student participated in the MSS 30-minute to
40-minute curriculum. Students completed a written safety
knowledge survey immediately after participating in MSS to
assess changes in their safety knowledge. Six months later,
students completed a follow-up survey to evaluate retention
of safety knowledge following their MSS experience. Students in the comparison group completed a baseline survey at
the same time as the intervention group. They participated
in their regularly scheduled health class and safety curriculum. They took a follow-up survey after the completion of the
traditional classroom safety education curriculum. After the
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The Journal of TRAUMA Injury, Infection, and Critical Care Volume 71, Number 5, November Supplement 2, 2011

Figure 3. MSS survey.

data collection period was completed, the comparison group

schools received the MSS educational curriculum so students
attending comparison group schools were not deprived of
participating in the MSS program.

Data Analysis
Descriptive statistics were calculated to establish a
baseline evaluation of intervention and comparison groups.
Variables include gender, socioeconomic status as determined by eligibility for free and reduced lunch, and age for
each of the intervention and comparison groups. Also recorded were the total number of students who completed each
survey and their mean score, with its associated 95% confidence interval.
A two-way analysis of variance (ANOVA) was then
performed to compare means (grade of 10) within groups,
adjusting for gender and age. Log transformation was performed to account for the lack of normality for the measured
outcome. Success rates for each question were compared
separately for boys and girls and between tests using a 2
analysis. Ninety-five percent confidence intervals were constructed around differences between means and percentages.

RESULTS
Inspection of baseline values of gender, age, and socioeconomic status showed that the intervention and comparS508

ison groups were comparable, with the presence or absence of

the MSS intervention as the only significant difference between groups (Table 1).
Table 2 reports the number of students present and their
mean test scores within each group studied. Test scores are
the average number of right answers of 10 questions adjusted
for age, exponentiated from results obtained with one-way
ANOVA done on log-transformed data. As can be seen,
children scored on average 5.67 of 10 (5.56 5.80) before any
safety instruction was given. Once the MSS program was
performed, mean scores showed a significant increase to 7.43
of 10 (7.16 7.71). Such increase was still measurable 6
months after the intervention. Children who were submitted
to the regular school curriculum also saw a significant increase in their mean scores, but the increase was much
smaller than for the MSS group.
In Table 3, mean test scores are stratified over gender
and adjusted for age. Means are exponentiated from results
obtained with a two-way ANOVA done on log-transformed
data. Again, results show that the increase in test scores is
larger for the MSS intervention than for the regular school
curriculum and that boys seem to perform better than girls
with hands-on experiences.
Individual question analysis indicates that questions 1,
5, 11, 13, and 14 show no measurable change in responses
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The Journal of TRAUMA Injury, Infection, and Critical Care Volume 71, Number 5, November Supplement 2, 2011

TABLE 1.

Efficacy of a Mobile Injury

Prevention Exhibit

Baseline Comparison of Studied Groups

Variable
Gender (% males)
Age of males
(yr, mean, 95% CI)
Age of females
(yr, mean, 95% CI)
Social economic status, % eligible for government subsidy

Intervention Group
n1415

Comparison Group
n155

P*

50.5

44.5

0.10

10.09 10.0010.18

10.26 10.1810.34

10.48 10.3710.59
60.8

10.52 10.3810.66
65.7

0.023

CI, confidence interval.

* From 2 test to compare 2 proportions.

Thirty-four students from the intervention group and one student from the non-intervention group did not indicate their gender.

TABLE 2.

Test Scores Adjusted for Age

Test Group
At baseline
After MSS intervention
6 months after MSS
intervention
School curriculum
(comparison)

Mean Test Score*

1354
425
336

5.67 5.565.80
7.43 7.167.71
7.34 7.047.66

154

6.48 6.106.89

* Mean 95% Confidence Interval.

TABLE 3.
in Score)

intervention and the testing done 6 months later (percent

change 3.4%, p 0.465), but all results remain significantly higher than for the nonintervention school curriculum
program (percent change 11.4% between baseline and
school program, p 0.041; 16.7% between the intervention
and the school curriculum, p 0.007; and 20.1% between the
6 months postintervention evaluation and the school curriculum, p 0.001).
Boys responses to question 7 are similar to the girls
responses to question 3 stated above, except for the percent
change between baseline and intervention which seems to be
nonexistent (percent change 0.6%, p 0.866).

Comparison of Test Results (the Increase

Test Group Comparisons

Between baseline and MSS
intervention
Between baseline and 6 mo after
MSS intervention
Between baseline and school
curriculum
Between MSS intervention and
school curriculum
(comparison)

DISCUSSION
Males

Females

1.28 1.211.36

1.30 1.231.37

1.22 1.131.31

1.26 1.191.34

1.04 0.951.16

0.86 0.800.93

1.23 1.101.34

1.12 1.021.22

* Mean difference 95% Confidence Interval.

with and without intervention or before and after intervention. Girls answers to question 4 show a significant increase
in correct responses between baseline and intervention (percent change 36.2%, p 0.001), a slight decrease between
intervention and the testing done 6 months later (percent
change 4.0%, p 0.098), and all results are significantly
higher than for the comparison school curriculum program
(percent change 16.4% between baseline and school program, p 0.004; 21.2% between the intervention and the
school curriculum, p 0.001; and 15.8% between the 6
months postintervention evaluation and the school curriculum, p 0.002). Boys answers to question 4 followed the
same pattern. Answers to questions 2, 3, and 12 also show the
same trend for both boys and girls.
Girls responses to question 3 show no change in
correct responses between baseline and intervention (percent
change 5.3%, p 0.157), a slight increase between
2011 Lippincott Williams & Wilkins

Injury is the leading cause of death for children in the

United States. Unintentional childhood injuries disproportionally affect families challenged by poverty.1 The goal of
this work was to examine the effect of an interactive method
of instruction on a mobile safety vehicle in teaching safety
behaviors to fifth-grade students and compare these results
with a traditional health education curriculum. Our findings
support previous studies which show that the use of a handson, multifaceted curriculum, like the mobile safety vehicle,
had a positive effect on the retention of injury prevention
knowledge within the community.8,11,12
Mean test scores illustrated that the MSS approach
made an immediate and delayed posttraining improvement in
the intervention group over the comparison group. These
findings could be attributed to the fact that the MSS curriculum uses a more interactive, hands-on approach to the safety
curriculum resulting in more knowledge gained and better
retention of that knowledge by the MSS students.
Although girls scored higher than boys in all three
surveys done with the intervention group, boys showed a
greater improvement in scores than girls. This could be
explained by the fact that boys in our intervention cohort age
(mean, 10.09 years) have been shown to benefit from learning
activities that require some physical activity, such as those
they experienced during MSS.13
The practical realities of partnering with a large public
school system presented several challenges. These included
the following: (1) relying on public school health educators
outside of our injury prevention group; (2) instruction time
available to MSS in the course of the school day; (3) teacher
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The Journal of TRAUMA Injury, Infection, and Critical Care Volume 71, Number 5, November Supplement 2, 2011

and student reassignment and student absenteeism; and (4)

traveling to public schools. Health educators taught both the
traditional classroom curriculum and assisted in teaching in
MSS. This may have altered the delivery of the schoolbased curriculum and altered scores in the comparison
group. Detailed in-services regarding survey administration were conducted by the IFCK Worcester staff for all
health teachers before the initiation of the study. However,
administration of surveys was not observed by IFCK
Worcester staff, so individual characteristics of teachers
could have impacted the method of administration of some
surveys and the survey results.
MSS functioned on the schools regular schedules; this
imposed limitations on instructional time. Educators did not
always have time to address all topics completely. Questions
6, 8, 9, and 10 are related to topics that were not consistently
taught. We eliminated these questions from our analysis and
analyzed the remaining 10 questions. Finally, teacher and
student reassignments occur throughout the school year. Substitute teachers assigned midyear to a class may not have
participated in in-service training about MSS and survey
administration. Similarly, it is unknown how many students
switched between comparison and intervention groups when
they were transferred from one school to another throughout
the course of the study. In addition, outside factors such as
illness or student absenteeism could not guarantee that each
student participated in each phase of the intervention or
comparison group.
MSS is an outdoor exhibit that is limited by weather
conditions, restricting its availability to the early fall and
spring months. MSS was not able to visit 5 (of 16) schools in
the intervention group because there was no safe place for
MSS to park and set up (two schools) and cancellations
because of inclement weather (three schools). This contributed to the skew in socioeconomic status that was observed
when we analyzed this characteristic of the intervention and
comparison groups (60.8% vs. 65.7%).

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CONCLUSION
MSS is an innovative, interactive, and effective approach to teaching safety behaviors. The positive results
seen in this study suggest that mobile safety units such as
MSS are an important way to impart knowledge about
safety behaviors to grade school students living in lowincome urban environments where children are at the
greatest risk of injury.
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