J Neurosurg Pediatrics 9:562–568, 9:000–000, 2012

Impact of an injury prevention program on teenagers’ knowledge and attitudes: results of the Pense Bem–Caxias do Sul Project Clinical article Asdrubal Falavigna, M.D., Ph.D.,1 Alisson Roberto Teles, M.D., 2 Maíra Cristina Velho, M.D., 3 Gregory Saraiva Medeiros, 4 Carolina Travi Canabarro, 4 Gustavo Lisbôa de Braga, 4 Daniel Ongaratto Barazzetti, 4 Viviane Maria Vedana, M.D., 5 and Fabrício Diniz Kleber, M.D. 6 Department of Neurology and Neurosurgery, University of Caxias do Sul; 2Department of Neurosurgery, Complexo Hospitalar da Santa Casa de Misericórdia de Porto Alegre- Hospital São José, Porto Alegre; 3Department of Neurosurgery, Hospital Beneficência Portuguesa, Porto Alegre; 4Liga Acadêmica Multidisciplinar de Neurologia e Neurocirurgia da Universidade de Caxias do Sul—LAMNN UCS, Caxias do Sul; 5University of Caxias do Sul; and 6Department of Neurology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil 1

Object. Trauma is the leading cause of mortality and morbidity in children, young people, and working-age adults. Because of the high incidence of intentional and unintentional injuries in young people, it is necessary to implement injury-prevention programs and measure the efficacy of these initiatives. The authors evaluated the effectiveness of an injury-prevention program in high school students in a city in southern Brazil. Methods. In a randomized controlled study, 1049 high school students were divided into a control group and intervention group. The study was conducted in the following 3 stages: a questionnaire was applied 1 week before the educational intervention (P0), shortly after the intervention (P1), and 5 months later (P3). In the control group, a questionnaire based on the Pense Bem Project was applied at the 3 time stages, without any intervention between the stages. Results. The postintervention analysis evidenced a slight change in knowledge about unintentional spinal cord and brain injuries. Regarding attitudes, the only significant improvement after the intervention lecture was in the use of helmets, which remained high 5 months later. A substantial number of students only partially agreed with using safety behaviors. The only significant postintervention change was the major agreement to check swimming pool depth before entering the water (P0 89% and P1 97.8%, p < 0.001; P2 92.8%, p = 0.005). Conclusions. An educational intervention based on a single lecture improved students’ knowledge of traumatic brain and spinal cord injuries, but this type of intervention did not modify most attitudes toward injury prevention. Clinical trial registration no.: U1111-1121-0192. (http://thejns.org/doi/abs/10.3171/2011.12.PEDS11169)

Key Words    •    injury prevention    •    spinal cord injury    •    traumatic brain injury    •    education    •    Pense Bem Project    •    ThinkFirst    •    trauma

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rauma is the leading cause of mortality and disability in children, youth people, and working-age adults. According to the WHO, mortality in people between the ages of 15 and 44 years accounts for almost 50% of the world’s injury-related deaths. In 2000, more than 5 million people died of unintentional (for example, motor vehicle accidents, drowning, or falls) and intentional injuries (for example, assault, suicide, or war related).21 In Brazil, 40% of deaths provoked by external

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causes occur in individuals 10–30 years of age (http:// www2.datasus.gov.br/). In addition to the high mortality rate, millions suffer other nonfatal health consequences due to injuries, which has severe implications for the victims, families, and dependents. The costs of treatment, prolonged hospitalization, and long-term rehabilitation, in addition to the lost productivity costs, represent tens of billions of dollars per year.7,21 As the WHO Regional Office for Europe reported, if all countries in Europe had J Neurosurg: Pediatrics / Volume 9 / May 2012

Impact of an injury prevention program the same death rate from injuries as the countries with the lowest rates, some 500,000 lives could be saved each year.16 Most injuries are not fatal and could be prevented with different strategies, including improving environmental characteristics (for example, roadway infrastructure), vector (for example, vehicles), and hosts (for example, human behavior).10,11 Globally, several programs have been created with the aim to decrease traumatic brain and spinal cord injuries in young people through a change in behavior: ThinkFirst,15 Safety Makes Sense,3 and the Harlem Hospital Injury Prevention Program.9 These surveys show a significant increase in knowledge regarding the potential for injury and creating awareness, which are both necessary and effective first steps for injury prevention. The “Pense Bem” Project (in English, “Think Well”), inspired by the ThinkFirst Program, was developed by the Brazilian Society of Neurosurgery in 1995. The project’s aim is to develop educational campaigns in society, providing information about traumatic brain and spinal cord injuries with the purpose of modifying risk behaviors and reducing the incidence of injuries in Brazil (http://www.sbn.com.br/). Furthermore, the Pense Bem Project is already being applied in a Brazilian city and has shown a reduction in the severity of trauma in traffic accidents (primarily traumatic brain injuries) since the program was implemented.14 Because of the high incidence of intentional and unintentional injuries among young people, it is necessary to implement injury prevention programs and measure their efficacy. Thus, the objective of this study was to assess the effectiveness of an educational intervention based on the Pense Bem Project in improving teenagers’ knowledge and attitudes concerning injury prevention in Caxias do Sul City—the Pense Bem–Caxias do Sul Project.

Methods Study Design

This international clinical trial is registered in Brazil at the National System of Ethics and Research (no. U11111121-0192). This controlled and randomized trial was held in public and private schools in Caxias do Sul, a southern Brazilian city. Two of the 35 schools in the city were excluded because they consisted of students with special needs, and 10 schools were randomly selected among the remaining schools. The schools were divided into the following 2 groups: 5 schools (477 students) represented the control group, and 5 schools (572 students) represented the intervention group. The sample consisted of all students in the second year of high school. The researchers contacted the schools in advance and scheduled days to do the survey. The study was submitted to the University of Caxias do Sul Ethics and Research Committee and began after approval was received. It was performed between March and August 2008. The exclusion criteria were as follows: students who had not taken the written informed consent to be signed by the person responsible

J Neurosurg: Pediatrics / Volume 9 / May 2012

for them and students who were not present when the questionnaire was distributed the first time. This survey was designed in the following 3 stages: pretest stage (before the educational intervention lecture; P0) at baseline; 1 week after testing (P1); and 5 months after testing (P2). In the control group, a questionnaire based on the Pense Bem Project was applied at the 3 time stages, without any intervention between the stages. In the intervention group, the questionnaire was distributed at the same 3 times, but at the P1 stage the questionnaire was distributed after an intervention lecture administered by the researchers. Intervention

The intervention was presented in audiovisual form and was divided into 2 periods: initially, a video was shown with an unintentional injured young victim, who reported the experience of being injured and the impact on his lifestyle and his family life; then, a brain and spinal cord trauma prevention lecture was given based on the Pense Bem Project. The researchers gave the lecture; they were previously trained by the research coordinator to standardize the lecture. The lecture consisted of a session in basic anatomy and physiology of the cranial structures (for example, cerebral lobes and brainstem) and of the spinal cord, with the possible complications caused by trauma (sensory disability, aphasia, tetraplegia, death caused by a fall, and vital signs of brainstem damage). Then, the age-related risk was presented, as well as the main causes of neurotrauma with examples from daily life (falls from a height, diving in shallow water, and automobile accidents). Finally, general guidelines were given about attitudes toward prevention of neurotrauma (never drink and drive [take a taxi or bus, or call your parents to pick you up]; and follow this rule: everyone must wear a seat belt in your car). The lecture time was approximately 60 minutes.

Instrument

The assessment instrument was developed by the Neurology and Neurosurgery Multidisciplinary Academic League (LAMNN) of the Medical Course at the University of Caxias do Sul based on the lecture proposed by the Pense Bem Project (http://www.sbn.com.br/). The questionnaire was composed of questions in the following 4 areas: 1) demographic aspects; 2) knowledge of the topics discussed in the lecture; 3) attitudes; and 4) opinions about trauma prevention. In addition to the basic demographic aspects, such as age and sex, there were general questions asking if the student usually used a car, bike, motorcycle, skateboard, or rollerblades. Basic knowledge about traumatic brain and spinal cord injuries was evaluated by simple-choice objective questions approaching the main etiology, risk age, meaning of tetraplegia, function of the cerebral lobes, prognosis of traumatic brain and spinal cord injuries, and importance of seat belts. Next, there were objective questions about the frequency of use (never, sometimes, or always) of protective equipment and if the student usually accepts a ride with an intoxicated driver. Finally, there were 5 statements concerning drink563

A. Falavigna et al. ing and driving, knowing the depth of swimming pools, lakes, or rivers before diving, and the importance of seat belts and safety equipment in the other means of conveyance, and the students had to choose how much they agreed with the statements (“I completely agree,” “I partially agree,” or “I disagree”). Completing the questionnaire took approximately 10 minutes. The questionnaire was translated to an English version (Appendix). Statistical Analysis

All statistical analyses were conducted using SPSS 18.0 for Windows (SPSS, Inc.). Categorical variables are presented as a proportion. The continuous variables were submitted to the Kolmogorov-Smirnov test to verify a normal distribution and are presented as the mean ± SD. To compare categorical data between the 2 groups, bivariate analysis was performed using the chi-square test. The Mann-Whitney U-test was performed to assess differences in the quantity of correct answers about knowledge at each time period (P0, P1, and P2) and age. Paired analyses with Wilcoxon test were conducted to compare mean corrected answers about knowledge during the stages (P0 vs P1, P1 vs P2, and P0 vs P2). The Z-test was used to verify differences in the attitudes and opinions concerning injury prevention between P0 and P1 and between P0 and P2 in the control and intervention groups. Statistical significance was accepted at a p value of < 0.05.

Results

One thousand forty-nine students completed the questionnaire: 45.4% (n = 477) of the students in the control group and 54.3% (n = 572) of those in the intervention group. The general characteristics of the sample are described in Table 1. At the P1 stage, 4.3% of the intervention group and 8.5% of the control group could not be contacted. At the P2 stage, 10.3% of intervention group and 12.7% of control group were lost to follow-up. Knowledge of Injury Prevention

Concerning knowledge of traumatic brain injury, both groups exhibited deficiencies in pretest results. The

number of correct answers at each stage in the survey is shown in Fig. 1. In the intervention group, acquired knowledge initially increased after the intervention, but diminished 5 months later, remaining higher than at the P0 stage (p < 0.001). The control students had significantly improved scores at the P2 stage than at P1 (p < 0.001). Comparing the number of correct answers concerning injury knowledge, there was no statistically significant intergroup difference at P0, but at the P1 and P2 stages the number of correct answers was higher in the intervention group (p < 0.001). The increase in knowledge of occipital lobe function was significant after the intervention, and this higher level of knowledge was sustained after 5 months. Regarding safety belt use, we observed that knowledge in both groups was similar at the P0 stage (control group 97.1%, intervention group 97.7%; p = 0.49) and did not change throughout the remaining months. Attitudes Regarding Injury Prevention

The proportion of students in the intervention group who use safety equipment on bikes always or sometimes increased at the P1 stage (P0 8.6%, P1 14.5%; p = 0.039) and was maintained at the P2 stage (17.7%, p = 0.034) (Table 2). The high school students reported more frequent use of safety equipment on skateboards and rollerblades at the P2 stage (P0 28%, P1 33.6% [p = 0.460]; P2 40.4% [p = 0.037]). However, the proportions of students who always or sometimes ride in a car with someone who has ingested alcohol increased slightly (P0 36.9%, P1 38.9% [p = 0.561]; P2 42.1% [p = 0.046]) (Table 2). The analyses of control group data did not demonstrate any difference regarding attitudes toward injury prevention at the P1 and P2 stages (Table 2).

Opinions Regarding Injury Prevention

In the intervention group, the students’ opinions about not accepting a ride from someone who had ingested alcohol changed after the lecture (P0 95.6% and P1 98.5%—that is, students who partially agreed or com-

TABLE 1: Summary of general characteristics in the subject sample Subject Group* Characteristic

Total*

Control

Intervention

p Value

no. of subjects 1049 477 572 mean age (yrs) 16.15 ± 0.75 16.25 ± 0.81 16.07 ± 0.69