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Abstract
Background Millions of all-terrain vehicles (ATV) are used around the world for recreation by both adults and youth. This increase in use has led to a substantial increase in the number of injuries and fatalities each year. Effective strategies for reducing this incidence are clearly needed; however, minimal research exists regarding effective educational interventions.
Objective This study was designed to assess rural ATV riders' preferences for and assessment of safety messages.
Methods 13 focus group discussions with youth and adult ATV riders were conducted. 88 formative research participants provided feedback on existing ATV safety materials, which was used to develop more useful ATV safety messages. 60 evaluative focus group participants critiqued the materials developed for this project.
Results Existing ATV safety materials have limited effectiveness, in part because they may not address the content or design needs of the target population. ATV riders want educational and action-oriented safety messages that inform youth and adult riders about their responsibilities to learn, educate and implement safety behaviours (eg, appropriate-sized ATV, safety gear, solo riding, speed limits, riding locations). In addition, messages should be clear, realistic, visually appealing and easily accessible. Newly designed ATV safety materials using the acronym TRIPSS (training, ride off-road, impairment, plan ahead, safety gear, single rider) meet ATV riders' safety messaging needs.
Conclusions To reach a target population, it is crucial to include them in the development and assessment of safety messages. Germane to this particular study, ATV riders provided essential information for creating useful ATV safety materials.
- Adolescent
- advocacy
- ATV
- child
- community
- formative evaluation
- legislation
- MVTC
- public health
- qualitative research
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- Adolescent
- advocacy
- ATV
- child
- community
- formative evaluation
- legislation
- MVTC
- public health
- qualitative research
In the mid-1970s, all-terrain vehicles (ATV) were introduced as an equipment aid for agricultural work. In 2009, approximately 10.5 million ATVs were used in the USA.1 ATVs are now frequently used as recreational vehicles, causing a substantial number of injuries and deaths in young children.1 ,2 Between 2001 and 2009, approximately 1 186 600 people were treated in emergency departments (ED) and 5864 people died as a result of ATV-related injuries in the USA.1 In 2009, 25% of those injured were aged 16 years or younger. While the overall number of ED visits for ATV-related injuries among children under 16 years of age has decreased since a peak of 150 900 in 2007, there were still 131 900 ED visits during 2009 in the USA alone.1 Recent reports of increasing hospitalisations and injuries among children in the USA, Canada, Australia and New Zealand suggest that around the world children's exposure to these vehicles is common and risky.3–6
Effective strategies for reducing the incidence of ATV injuries and fatalities are clearly required. While descriptive studies of ATV injury are frequent, there is little research into effective educational interventions, and to our knowledge none have been guided by behavioural theories that might serve to make them more effective in reaching target groups. Focus groups were conducted to determine media messages that would resonate with ATV users regarding general knowledge and perceptions about riding safety. This methodology was chosen because of the ability of focus group participants to provide rich data and insight,7 and because focus groups have been shown to demonstrate utility in exploratory research.8 Facilitated discussions centered on the content and design of media messages that might impact safety behaviours. Using this input, safety materials were developed and additional focus group participants assessed the materials. The materials were developed to meet the educational needs of ATV users in different levels of readiness to alter behaviour, based on the stages of change behavioural model9 that has guided the development of the ATV safety programme.
Methods
Setting
The formative phase of research included a total of six focus groups in the five public health-designated regions of Arkansas. Six groups were conducted to have an equal number of group compositions: (1) children and adolescents 10–18 years who use ATVs and/or live in households with ATVs; (2) adult owners/users of ATV; and (3) groups with parent–adolescent dyads. Potential target communities were identified from emergency transport data from the Arkansas Department of Health, based on county-level rates of ATV-related ambulance runs, as a proxy for high levels of ATV use in the area. The availability of local contacts to assist the study team in facilitating project implementation further identified sites. Members of a multidisciplinary ATV workgroup (ie, representatives from medical institutions, the Arkansas Game and Fish Commission, the University of Arkansas Cooperative Extension Service 4-H programmes, ATV industry representatives, other interested parties) provided regional contacts that assisted the recruitment of participants and meeting logistics. Among these contacts were county-level health improvement coalitions affiliated with the Arkansas Department of Health, public schools and youth services. The focus groups were held in easily identifiable community venues arranged by local facilitators including community centres, health units and schools.
The evaluative research focus groups included seven discussions with hunter education instructors, public school teachers, 4-H (ie, a youth development programme for the 109 land-grant universities in the USA) leaders and youth ATV riders in Louisiana and South Carolina. These states were chosen as sites based on previous interest expressed by various collaborative organisations in each state and because both states share a rural, agriculturally based economy similar to Arkansas. These focus groups were held in easily identifiable community venues arranged by local facilitators including community centres and restaurants.
Participant selection
The formative research participants were recruited using a purposive, case sampling strategy via flyer postings in key locations; community contacts facilitated study awareness by word of mouth. Interested parties contacted project staff by telephone to complete screening procedures before inclusion in the study.
Exclusion criteria included inappropriate age range, not residing in a targeted county, or lack of ATV use in the previous 12 months. The goal was to target active ATV adult riders (ie, adults 18 years or older who rode an ATV for any reason within the previous 12 months who had children they were responsible for communicating with about ATV safety) and active ATV youth riders. Therefore, adults without children or grandchildren who use ATVs were also excluded. Participants were not asked about the settings or purpose of their ATV use as safety recommendations are the same regardless. A total of 95 callers was screened for participation; only one was ineligible. A total of 94 was invited to participate, and 88 (93%) actually attended the focus group sessions (13 adult men, 14 adult women, 33 male youth and 28 female youth). Weather-related rescheduling conflicts resulted in the non-attendance of six participants.
During a 3-month period, a total of six focus groups was held: two with adult/youth dyads, one with male youths, one with female youths, and one each with adults and youth of both sexes. Youth participants ranged in age from 10 to 16 years (M=13.3 years) while adult participants ranged from 20 to 59 years (M=42.5 years). All participants were white, and 46 (52%) were male.
The evaluative research participants were recruited from a convenience sample. Adult participants in Louisiana were recruited from public school teachers who utilised the project-specific materials in their classrooms. This particular parish system requires health teachers to provide 10 h of ATV safety per school year. Adult participants in South Carolina were recruited from the Department of Natural Resources, which incorporated the use of the materials in their standardised hunter education classes. Multiple sessions were conducted in both states to accommodate participants from different geographical communities. Youth participants in both states were recruited through the 4-H organisation. Inclusion criteria for adult participants were based on the use of the ATV safety toolkit in at least one class before the focus group discussion. Exclusion criteria for youth included inappropriate age range or lack of ATV use in the previous 12 months.
During a 2-month period, seven evaluative focus groups were held with available participants: two with youth and five with adults. Each focus group included both sexes. Youth participants included 10 male and 14 female 4-H members while adult participants included 21 men and 15 women (15 teachers, 14 hunter education instructors and seven 4-H leaders).
Formative group participants were paid a small stipend, and both formative and evaluative focus group members received a meal for participation. Institutional review board approval was received, and informed consent was waived for this project. Before each session, moderators explained participants' confidentiality rights and gave the option to leave at any time, which no-one chose.
Data collection
Semi-structured moderator guides were developed, pilot-tested and utilised to facilitate discussion during each 2-h group session. Each audio-recorded focus group was conducted by a trained moderator and assistant moderator. The assistant moderator documented field notes during the sessions. A debriefing session between the moderator and assistant moderator was held after each group discussion to discuss themes that emerged during the sessions.
During each formative research session, participants were shown a variety of print and electronic media pertaining to ATV safety. Due to time constraints, only key portions illustrating the format and quality of electronic media were utilised. Media pieces utilised during the discussions were a representative sample of nationally available ATV safety materials from a variety of sources, including ATV manufacturers, academic institutions and community organisations. Materials selected and topics discussed focused on appropriate vehicle selection, helmet use, avoiding riding with passengers and training before ATV use, all of which are associated with safer vehicle use by both manufacturers and public health advocates. A total of 36 print and electronic materials was identified; of these, 13 print and six electronic materials were used. Materials were selected by a committee comprised of study staff and members of the local ATV safety workgroup based on the relevance of material, compliance with current safety recommendations, the reading level of printed materials and placement in the stages of change behavioural model.
Information gathered from the formative research focus groups was utilised to develop materials (ie, brochures, posters, curriculum) to be utilised in a toolkit to accompany an ATV safety DVD titled ‘A trip unplanned.’ These materials were then assessed by the evaluative research participants.
Data analysis
Following accepted qualitative analytical techniques, audio-recorded focus groups were transcribed and managed using HyperRESEARCH version 2.03, a content analysis software package for qualitative research. Given the limited research in this area, a grounded theory approach was used to code data, with the data dictating the development of major and minor themes.10 Grounded theory is a qualitative research design that allows researchers to generate explanations about phenomena, given that a shared view of the phenomena is expressed by a large number of participants; therefore, the explanation is grounded in the data.11
The moderator was the lead coder designated to analyse the transcripts. Other team members read journaling notes to confirm codes were consistent with debriefing discussions and field notes. Any disagreements were discussed until consensus was reached. During the constant comparative coding process, it was determined that data saturation was achieved when no new ideas emerged from the data. After all data had been collected and coded, another research team member not involved with the initial analysis (MB) coded all the data to determine reliability (Scott's π=0.93).12
Results
The purpose of the formative focus groups was to explore issues surrounding ATV use, safety, formatting of media messages and venues for delivery. The evaluative focus groups assessed the newly developed ATV safety materials for usefulness and likeability.
Formative focus group suggestions
Results of the formative focus groups were organised into a coding tree with four major thematic areas emerging: (1) safety concerns; (2) behaviour modifications; (3) material design; and (4) message delivery. When applicable, subthemes were identified based on age group differences (ie, adults, youth). Only the information related to desired message content (ie, addressing safety concerns) and design are addressed in this report.
Message content
Discussions with participants centered on safety concerns about ATV use, which dictated what participants felt would be most effective when represented in safety educational materials. Both adults and youth expressed concerns, but the foci differed. Adult participants were mainly concerned with the improper use of ATV by youth, including excessive speed, lack of training, multiple riders, paved surface use and lack of safety equipment use. Additional safety concerns mentioned by adult participants included lack of adult supervision for young riders, lack of safe places to ride and the possibility of crashes (see table 1 for adult themes and examples). While most of the discussion centered on educating youth about how to be responsible for safe riding behaviours, adults did note their own responsibility for safety through supervision and education as well as the recognition of environmental constraints.
Adults' primary focus topics for ATV safety messages
The youth, however, mainly focused on the lack of licensing requirements or regulations governing ATV use for young people. They placed the onus of the responsibility on lawmakers. Youth were also concerned about the lack of proper ATV use, safety equipment use, understanding of injury risks and machine design and safety practices by their parents (see table 2 for youth themes and examples). They did recognise their responsibility to be educated and practice safe riding behaviours, but also argued that parental role modelling needs to illustrate safety.
Youths' primary focus topics for ATV safety messages
Participants also suggested that messages should be educational and action-oriented including the need for hands-on training, awareness-raising messages, skill builders, proper use and statistics (see table 3 for themes and examples). More specifically, hands-on training messages should include information regarding shifting gears, riding on specific terrain and maintaining control of the ATV and allow riders to perform the behaviours properly. Awareness-raising messages should target the potential risks and consequences associated with ATV use, whereas skill-building messages should provide information on assessing readiness to ride along with visual guidelines for better understanding how to select ATVs and accessories (eg, choosing appropriate-sized ATV). Some argued that riders simply were not aware of proper safety procedures. Proper ATV use messages should discuss safety gear, passengers, speed and appropriate size of ATVs. Participants recognised the most common injury-causing behaviours and want messages to address those issues in particular. Finally, participants felt that some messages should emphasise the statistics surrounding ATV use, paying particular attention not only to deaths but also injuries. They believed that some riders' belief that they were not vulnerable to crashes or injury needed to be addressed by raising awareness of the likelihood and seriousness of injuries.
Educational and action-oriented messages
Message design
To understand material design styles acceptable to rural audiences, participants critiqued the content and appearance of various print and electronic materials. Conversations regarding content focused on the need for clarity and realism in messages, positive delivery style and targeted messages. Discussions of material appearance concentrated on modern design style and user-friendly layouts (see table 4 for content and appearance suggestions).
Desired ATV safety message design elements
Materials that demonstrate clarity should focus on scenarios with clearly defined storylines that do not send conflicting messages. Messages also need to be realistic, which can be demonstrated in numerous ways. For example, participants suggested including dirty machines, visible injuries and real-life statistics and personal stories. In addition, participants argued that more positive ATV use scenarios could enhance messages because riders may be more inclined to engage in safe behaviours if they see realistic positive outcomes as opposed to stopping unsafe behaviours because of negative outcomes. Finally, the messages need to be targeted to specific audiences (eg, youth riders, parents).
The appearance of material is as important as content and includes consideration of a design style that is visually appealing and a layout that is easy to use. Visually appealing material engages the audience, employs realistic and appropriate settings for the messages, utilises modern design of bold colour and real pictures/live shots, contains graphic injury/crash depictions if appropriate, and includes diversity in both rider and machine representation (eg, different sexes and ages of riders, non-racing type machines). Participants felt that user-friendly layouts should include visually identifiable key messages through the use of bold headings, bullet points or summaries. In addition, they suggested that material should have font styling that is large and easy to read, be concise and include easy-to-locate resource/contact information.
Evaluative focus group suggestions
Based on feedback received from the formative focus group discussions regarding already developed ATV safety information, the research team refined existing materials (ie, DVD) and developed new, more focused materials (ie, brochure, posters, curriculum) based on information received from formative focus group discussions to disseminate to ATV instructors, school teachers and youth. While different messages were developed, the majority of materials focused on the acronym TRIPSS (training, ride off-road, impairment, plan ahead, safety gear, single rider). The research team tried to address most of the issues raised by participants in the formative group discussions (eg, having training, riding in safe places, wearing proper safety equipment, not riding with passengers). Beyond the acronym, other suggestions were also addressed in the content such as recognising the appropriate size of ATV and raising awareness of the consequences of ATV crashes by reporting statistics of injuries and fatalities. Results suggest that the materials addressed the needs communicated by formative participants, and slight stylistic modifications were made based on evaluative responses.
Overwhelmingly, participants liked the message design and delivery of the ATV safety messages. They particularly liked the acronym TRIPSS, realistic images (eg, visualised themselves in the situation) and artistic elements (eg, colour, font). They believed that the message was easy to read and understand, and it reinforced messages already being communicated in other realms. One instructor said, “The message is just outstanding. I've been very impressed with them,” referring to the TRIPSS brochures. The 20-min DVD was particularly powerful and effective at reaching the target audience and beyond. One instructor shared that a girl approached her after viewing the video at a summer leadership camp asking where she could get a copy of the DVD and said, “I've got one of my best friends who is going to kill himself on an ATV if he doesn't change, and I'd like to show him that video.”
There was no criticism of the DVD, and it was even stated that the DVD could be used for an extended period of time (eg, ‘At least 10 years before you would even have to worry about it. It’ll last 10 years without a problem') because of its realism. Participants liked the DVD because the message was somewhat shocking yet realistic, and it provided information in an entertaining format. When discussing the DVD, an instructor said,“That wasn't the typical documentary with the guy who talks like telling me not to do things. It was actually a video, and the kids really enjoyed it. From 6th grade to senior [grade levels], they all seemed to enjoy it. It was just like they were watching a movie.”
Although most of the print material images (ie, brochures, posters) were realistic (eg, muddy ATV), many wanted the image of the rider in the print materials also to be dirty. Also, although most liked the design features with the font style and colour choices, a concern for many people was the placement of the acronym, which originally had TRIPSS broken up across the page. Consistently, participant suggestions focused on minor stylistic choices (eg, colour of images, placement of words) and not on any content modifications. The message was strongly supported by participants; and based on their feedback, only slight stylistic modifications were made to improve readability.
Discussion
User input is critical in the development of effective educational materials.13 For challenging public health problems such as ATV-related injury, for which clear interventions are still evolving, educational materials must reflect both the limited safety evidence available and the real-world perspectives of the end-users. Focus group methodology can provide useful information about message content and message delivery to those planning injury prevention strategies. A previous study using this methodology examined adult and youth perceptions about ATV safety in general but did not focus on specific ATV safety media or message delivery as this study does.14 Qualitative methodologies have been used to inform injury prevention strategies for road safety, teen driving, booster seat use and teen dating violence.15–19 Our study demonstrates that rural ATV users are interested in improved safety and are willing to engage in a focus group setting to provide information that is practical and reflects their experiences.
Both the content and style of message delivery are important in crafting effective injury prevention messages.20 The formative participants helped message designers avoid developing and using messages and styles that would have been ineffective as well as present more compelling formats and styles. The target audience is vital in developing the content and style of message delivery. This was evident in this study as adults and youth reported different desired ATV safety topics.
Several key themes about message delivery for ATV safety were apparent in the focus groups. Participants perceived realism, clarity and personal stories to be important. Although messages with only direct, fact-based information can have modest effects, the use of narrative has been shown to be effective in a variety of settings.21 The use of narrative may better capture the attention of the target audience and possibly increase the chance of behaviour change. Health and safety messages with brief stories have been shown to be more effective than messages without such narratives. For example, an injury prevention safety message related to child swingsets was shown to be more effective when accompanied by a brief story of someone previously injured than without the narrative component.21 Wipe Out, a traumatic brain injury prevention intervention, is another example of the use of narrative to reinforce safety messages.22 Combining narratives with realism, as suggested by the focus group participants, has also been shown to be effective in safety training for miners,23 thus supporting the recommendations of the focus group participants.
The evaluative focus group participants offered additional suggestions for minor modifications to the newly developed ATV safety materials and provided support for the continued use of these more useful educational materials. These follow-up focus groups demonstrated the value of assessing target audience perceptions when developing safety messaging and how such messages can be adjusted to have more impact.
Conclusion
Focus groups of adult and youth ATV riders from rural environments were helpful in the development, refinement and assessment of the usefulness and likeability of a series of educational tools to promote safer use of ATVs. Combined as an ATV safety toolkit, the educational tools are appropriate for use in formal and informal ATV safety training environments as well as in schools. Widespread dissemination and further evaluation of the toolkit are required to assess fully its impact on ATV users' knowledge about appropriate use and, more importantly, any behaviour change resulting from this knowledge. Although educational interventions are an important first step, it is essential to emphasise the importance that safety education policy can have in changing behaviour and increasing safety. As noted by the youth, licensing and training requirements are lacking, yet desirable in the promotion of ATV safety.
What is already known on the subject
ATV injuries and fatalies are a growing national (and world) problem, especially among youth.
Little research has assessed ATV safety educational materials.
What this study adds
It provides both an evaluation assessment of existing ATV safety materials as well as an evaluation assessment of newly developed materials created based on the results of the formative research.
It offers evidence of the need to use target populations in the development and evaluation of safety messages.
References
Footnotes
Funding This work was supported by HRSA EMSC grant number H34MC08514. MEA also received support from NCRR grant number 1UL1RR029884.
Competing interests None.
Ethics approval Ethics approval was provided by the University of Arkansas.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Because this study was deemed exempt from consent, consent for data sharing was not obtained but the presented data are anonymised and risk of identification is low. No additional data are available. Information is available from MB.