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Health Psychol. Author manuscript; available in PMC 2017 May 01. Published in final edited form as: Health Psychol. 2016 May ; 35(5): 454–464. doi:10.1037/hea0000273.
A Randomized Trial Evaluating Child Dog-Bite Prevention in Rural China through Video-Based Testimonials Jiabin Shen1, Shulan Pang2, and David C. Schwebel1 1
Department of Psychology, University of Alabama at Birmingham, USA
2
School of Public Health, Hebei United University, China
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Abstract Objective—Dog-bite injuries pose significant threat to children globally. School-aged children are especially at risk because of their cognitively immature tendency toward low perceived vulnerability to bites, and this risk is elevated further for school-aged children living in rural China due to the large number of stray dogs, all potential rabies carriers, present in their communities.
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Methods—This randomized controlled trial evaluated whether viewing an educational video of testimonials would change safety knowledge, perceived vulnerability, and simulated behaviors with dogs among a sample of 280 third and fourth graders living in rural China. Participants were randomly assigned to view either an educational video of testimonials on dog-bite prevention (treatment) or an educational video of testimonials on drowning prevention (comparison). Safety knowledge, perceived vulnerability to dog bites, and simulated behavior with dogs using a dollhouse model were assessed both before and after exposure to the video of testimonials. Results—Children who watched the educational video of testimonials on dog-bite prevention had increased safety knowledge, higher perceived vulnerability, and less risky simulated behaviors with dogs compared to the comparison group. Mediation analysis revealed that the intervention successfully changed children's simulated behaviors with dogs through greater safety knowledge and increased perceived vulnerability. Conclusions—Results suggest the incorporation of testimonials into injury prevention programs has potential for broad global dissemination. The fact that both increased knowledge and heightened perceived vulnerability mediated changes in simulated behavior suggests the dual roles of knowledge and appraisal on children's injury-risk behavior.
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Keywords dog-bite; injury; prevention; testimonial; child Over 100 million school-aged children ages 7-14 live in rural China. They have substantial risk for many adverse health effects (Wang et al., 2008), one of which is pediatric dog bite injuries. Researchers report that 30% of rural Chinese elementary school children ages 9-13 have experienced at least one dog-bite injury in their lives (Shen et al., 2013a). Among those
Corresponding Author: Jiabin Shen, Department of Psychology, University of Alabama at Birmingham, 1300 University Blvd, CH 415, Birmingham AL 35294 USA, Phone: (205) 934-8745, Fax: (205) 975-6110, [email protected].
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children, 54% of bites occur on public streets away from home, and 84% of bites occur without adults nearby (Shen et al., 2014). Dog bites result in both adverse physical and psychological consequences. Physical consequences can include acute and long-term medical treatment, painful and expensive rabies treatment, and physical restriction from routine activities and schoolwork (Eppley & Schleich, 2013; Shen et al., 2014). Psychologically, consequences can include fear, withdrawal, post-traumatic symptoms, and coping with permanent scarring, including on the face (Hon et al., 2007; Peters, Sottiaux, Appelboom, & Kahn, 2004). One recent study of 101 pediatric dog-bite cases in rural China found that pediatric dog-bite victims often developed behavioral withdrawal and psychological fear of dogs (Shen et al., 2014).
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Children have increased risk for dog bites compared to adults due to both smaller physical size and underdeveloped cognitive skills. Smaller size increases both risk and severity of bites, and children are especially vulnerable to bites on the neck or head (Hon et al., 2007; Mcheik, Vergnes, & Bondonny, 2000). Cognitively, children are more likely to engage in risky interactions with dogs and to behave impulsively and without accurate perception of their vulnerability to injury by dogs (Avner & Baker, 1991; Chouinard, 2007).
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The unique environment of rural China further heightens risk of child dog-bite injury. Many dogs run loose in rural Chinese villages, and children are exposed to dogs during long daily walks to and from school (Deng et al., 2004; Duan, 2008; Shen, Li, Xiang, Lu, & Schwebel, 2014). Risk from bites is amplified by the presence of rabies, which increased by 2000% among dogs in China from 1996 to 2006 and has not waned since (Si et al., 2008; Zhang, Jin, Sun, Sun, & Ruan, 2012). Furthermore, parental supervision of children in rural China is frequently insufficient because many young parents migrate to urban cities for higher-paid work (the China National Bureau of Statistics estimated 245 million migrants from rural to urban China in 2014), leaving children home with aging grandparents whose more limited mobility diminishes proper supervision of children, especially on public streets.
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Efforts to prevent pediatric dog-bite injuries are few globally, and almost non-existent in rural China. In fact, a 2009 systematic review of pediatric dog-bite injury prevention programs uncovered just two studies that met inclusion criteria of randomized controlled trials or controlled before-after studies and evaluated the effectiveness of educational interventions for preventing dog bites with behavioral outcomes in populations under 20 years old (Dupperrex, Blackhall, Burri, Jeannot, 2009). Intervention programs that are reported in the literature focus primarily on teaching children basic knowledge and skills via one-way (adult to child) educational programs (Beaver, 2001; Chapman, et al., 2000; Dixon, Pomerantz, Hart, Lindsell, & Mahabee-Gittens, 2013; Spiegel, 2000), interactive classroom lesson plans (Szecsi, Barbero, Del Campo, & Toledo, 2010; Wilson, Dwyer, & Bennett, 2003) or animated computerized tasks (Meints & De Keuster, 2006, 2009; Schwebel et al., 2012). These studies yielded mixed results concerning transfer of knowledge, but very few have tested and successfully demonstrated a change in children's risky behaviors with dogs (Schwebel, 2012). An alternative strategy to improve children's safety with dogs is to increase children's perceived vulnerability toward risk from child-dog interactions. The role of perceived
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vulnerability is emphasized in multiple prominent theoretical models to explain healthrelated behavioral change, including the Health Belief Model (Janz & Becker, 1984), and research with school-age children confirms the role of low perceived vulnerability in children's injury risk behaviors (Morrongiello & Rennie, 1998). Previous research examining dog-bite risk among school-aged children in rural China also reported that children's low perceived vulnerability was associated with both self-reported risky interactions with dogs and history of dog-bite injury (Shen et al., 2013a).
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One effective strategy to alter individuals’ perceived vulnerability toward health-related behaviors is through the use of first-person testimonials that detail the antecedents, processes, and consequences of an adverse event (Slater & Rouner, 1996). Testimonialbased interventions might be especially persuasive in the context of training children to be safe with dogs, as testimonials concerning dog bite incidents can elicit strong emotional arousal among children, a strategy that may improve the potential for behavior change (De Wit, Das, & Vet, 2008; Loewenstein, Weber, Hsee, & Welch, 2001). The current study used a repeated-measures randomized controlled trial design to evaluate the efficacy of a video-based testimonial intervention on reducing children's risks of dog-bite injury. We hypothesized that children who watched the dog-bite testimonials would demonstrate more safety knowledge, higher perceived vulnerability and less risky simulated behaviors with dogs than children in the comparison group (Hypothesis 1). Further, we hypothesized that both safety knowledge and perceived vulnerability would mediate the effect of intervention on children's simulated behaviors with dogs, with watching dog-bite testimonials leading to increased knowledge and increased perceived vulnerability, which would in turn lead to less risky simulated behaviors with dogs (Hypothesis 2).
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METHODS Participants
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Power analysis was performed a priori and minimum sample size calculated based on the following two procedures. First, an estimated effect size of d = 0.33 for the intervention effect was determined based on results from a similar video-based intervention study of playground safety in Canada (Morrongiello & Matheis, 2007a). It was determined that 76 participants would be required to detect the expected effect size for Hypotheses 1 with a power of .99 (2 tails, alpha=.01; Cohen, 1988) using G*Power 3.1; our anticipated sample from any single school in rural China was much larger. Second, using the bias-corrected bootstrap method, it was determined that 120 participants were required to achieve power of .80 for the mediation analysis of Hypothesis 4 (Fritz & MacKinnon, 2007). Again, the anticipated sample from any single school in rural China was larger than this. In the present study, 280 children in Grades 3 and 4 at an elementary school in rural Zhejiang Province, China, participated (mean age = 10.03 years, median age = 10.00, SD = 0.83; Interquartile range = 1.13; 48.9% boys; 92% Han Chinese ethnicity). Inclusion criteria were all students enrolled in either Grade 3 or 4 at the participating school at the time of study, and no exclusion criteria applied. The sample reported annual household income of
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less than US $8,000 (~Chinese RMB 48,000) and 85% of primary caregivers had fewer than 10 years of formal education. Measures
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Demographics—Demographic information was collected from both parents and children pre-intervention. Children reported their age, gender, ethnicity (Han vs. other), dog ownership, dog exposure frequency, and daily risky practice with dogs. Dog ownership was assessed with a single item, ‘Does your family keep dogs now?’, which was answered ‘Yes’ or ‘No’. Dog exposure frequency was also assessed with a single item, ‘How often do you usually interact with dogs?’, which children responded to using a range from 1 (I've never interacted with dogs) to 6 (at least once a day). Daily risky practice with dogs was assessed using an 8-item instrument. Items were answered on a 5-point scale and both internal reliability (Cronbach alpha = .73) and factorial validity (Confirmatory factor analysis supported unidimensionality of the measure, χ2/df = 3.81, p < .05, Standardized Root Mean Square Residual (SRMS) = .06, CFI = .85) were adequate. The final score was an average across items (possible range = 1-5). Primary caregivers reported child dog-bite history (‘How many times has your child been bitten (scratched) by a dog?’; due to skewness, answers were dichotomized to bite history vs. none for analysis), household income and educational background. A socioeconomic status (SES) composite was computed as the mean of standardized scores from household income and the primary caregiver's education. Table 1 shows descriptive data.
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Child knowledge about dog safety—The child-dog interaction safety knowledge questionnaire is a 24-item measure of children's safety knowledge around dogs. We developed this questionnaire for use in pilot research with similar age groups of children in rural China and it demonstrated adequate external validity (significant correlation with risk perception, r = −.43, p < .01; and risky interactions with dogs, r = −.23, p < .01) (Shen et al., 2013a). In the present study, the measure had inadequate psychometric properties, so WLSMV-based factor analysis was conducted and revealed 6 items that did not load well onto the primary construct of interest. Thus, a modified 18-item instrument was analyzed. It demonstrated adequate test-retest reliability (r = .58, p < .001) and factorial validity (confirmatory factor analysis supported unidimensionality of the measure (χ2/df = 1.65, p < . 05; SRMR=0.12; CFI=0.81). Given the dichotomous nature of the scale items, ordinal coefficient theta was computed as a measure of internal reliability (Fabrigar, Wegener, MacCallum, & Strahan, 1999; Zumbo, Gadermann, & Zeisser, 2007) and it demonstrated adequate internal consistency, theta = .63. The questionnaire assesses children's knowledge about ‘dos’ and ‘don'ts’ when encountering dogs in typical daily scenarios in rural China. An example item is, “If you see stray dogs displaying unusual behavior like wandering around here and there aimlessly and easily getting irritated and angry, you should: A. Ignore it; B. Explore/Play with the dog to understand better what is going on; C. Yell at the dog, or else tease it; D. Walk away from the dog quickly; E. Immediately report to an adult” The correct answer is D. Participants were scored correct (1) or incorrect (0) for each item and the final composite score was the percentage of correct responses (0-100%), with higher scores indicating greater knowledge.
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Perceived vulnerability to dog bites—The child-dog interaction perceived vulnerability questionnaire is a 12-item measure of children's perceived vulnerability toward child-dog interactions. Also developed in pilot research (Shen et al., 2013a), it has adequate internal reliability (Cronbach's α = .77) and construct validity (confirmatory factor analysis supported unidimensionality of the measure, χ2/df = 3.04, p < .05; SRMS = .07; CFI = .76). An example item is, “I can run faster than unknown dogs so as to avoid their biting me.” Items are scored on a 5-point scale, with higher scores indicating greater perceived vulnerability. Final scores were averaged across all items (possible range = 1-5).
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Simulated behaviors with dogs—The dollhouse task assessed children's risky behaviors with dogs by asking children to act out what to do in simulated real-life situations involving dogs. The measure was based on a model used previously in the US that had adequate psychometric properties (Schwebel, Morrongiello, Stewart, & Bell, 2012), but was adapted to the rural Chinese context. It included eight situations that create the greatest risk for dog bites to children, as identified in pilot research (Shen et al., 2014). An example scenario is as follows: “Researcher acts out child doll [gender-matched to participant] walking on the street in front of the dollhouse while a stray dog approaches from behind the child. Say: ‘(Child's Name) is playing outside his/her house. A stray dog comes along the street toward (Child's Name). What will (Child's Name) do now?’” Children's verbal and behavioral responses to each scenario were recorded verbatim and then coded as safe (0), moderate (0.5) or unsafe (1) by the researcher using an objective written coding system. Inter-rater reliability was obtained by a second researcher who did not communicate with the first and was excellent (kappa>.95) in pilot testing with 60 participants.
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Quantifying risk in simulated situations is necessarily inexact but we treated the dollhouse task measure analytically as a ratio scale, such that risk intervals were considered equal across measures and across scores. Thus, the leap from a score of 0 to a score of 0.5 was conceptualized to be equal to the leap in risk from 0.5 to 1. Similarly, risk of a bite for a score of 0.5 was conceptualized to be equal across all scenarios. Given this assumption, children's final scores were computed as the average safety across the eight scenarios and ranged from 0 to 1, with higher scores indicating riskier simulated behaviors with dogs. Internal reliability was borderline (Cronbach's alpha = .65). Intervention
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The intervention comprised a 36-minute video displaying scripted testimonials of actual dog-bite experiences. Four adult actors, all native Mandarin speakers unfamiliar to the participants, presented the testimonials. Unlike what might be done with research in Western cultures, we chose adults to present the testimonials rather than peers because as part of a collectivist culture, Chinese children respect and admire adult authorities (Chen, Greenberger, Farruggia, Bush, & Dong, 2003; Ma, Shek, Cheung, & Lam, 2000). Pilot research in rural China confirmed that children learned dog safety lessons more effectively from adults than from peers or siblings (Shen, et al., 2013b). The four presenters were representative of the interpersonal environment with which children in rural China interact in terms of age (younger and older adults), gender ratio (3 females and 1 male, as mothers are
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more likely to care for children and school teachers are mostly female), and societal roles (school teacher, parents, grandparents).
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Each of the four testimonials was nine minutes long and was scripted to accomplish standardized learning objectives: (1) introduction of who the speaker is (teacher, parent, grandparent); (2) introduction about the child victim's background and circumstances; (3) antecedents/circumstances of the dog-bite incident (i.e., how the child got bit, what the child was doing, what the dog was doing); (4) consequences of the incident (i.e., gravity of the injury, how the child was treated, what happened to the dog after the bite); (5) mistakes, decisions, and actions the child victim made, including perception of invulnerability the child may have had, plus alternative cognitions/behaviors that would have been safer; and (6) a summary of safety lessons learned from this incident. To enhance the educational effect and hold children's attention during the video session, the testimonials were edited to incorporate background melodies fitting the story and illustrative pictures, texts and video clips to create a vivid and emotion-arousing lesson. Both visual and audio cues were provided between each of the four testimonial stories also. Anecdotally, child attention was excellent while viewing the videos. The testimonials were scripted but all described actual bites described in the literature (Shen et al., 2014) among children of the same age as the target population in rural Chinese culture. The comparison group watched scripted testimonials of identical length and structure on drowning risk, another significant public health risk among rural Chinese children (Guo, 2010; Zhang, Chen, Deng, Xu, & Hu, 2003). Procedure
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IRB approval was obtained from University of Alabama at Birmingham and written consent from participating school officials. Signed informed consent was obtained from students’ caregivers and signed informed assent from students. All children in grades 3-4 (100%) at the participating school participated in the study. As shown in Figure 1, there was no attrition throughout the study, although only 276 (99%) children completed the preintervention dollhouse task due to scheduling conflicts at the time of the study. The study lasted three weeks. In week 1, all participating children completed the child-dog interaction safety knowledge and perceived vulnerability questionnaires in their classroom, and then were taken individually in randomized order to a quiet and private room to complete the simulated behavior assessment using the dollhouse task. Intervention group membership was assigned subsequently, so both researchers and participants were masked to group membership during pre-tests.
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Implementation of the intervention commenced one week later. Testimonial videos were delivered to children at individual desktop computers with headphones. Each child was randomly assigned to watch one of the two testimonial videos using a 1:1 randomization scheme. Random assignment occurred within the same classrooms to reduce clustering influences in data analysis. In the final week of the study, the post-test was administered following the same procedure as the pre-test (knowledge and perceived vulnerability questionnaires completed in classroom, and individualized assessment of simulated behavior
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in the dollhouse task in a separate room). Researchers administering post-tests were masked to group membership. Data Analysis Plan
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Initial analyses were performed to examine descriptive data and intercorrelations between and among outcome variables at both pre- and post-test, along with demographic variables. Independent samples t-test and chi-square tests were performed next to examine group differences on demographic and outcome measures. Following this, the effects of the intervention on children's safety knowledge, perceived vulnerability and simulated behaviors were tested respectively using stepwise linear regression models, controlling for preintervention test scores and demographic variables. All of those analyses were conducted using SPSS 21.0. The final step of the analysis was to evaluate the mediational roles of safety knowledge and perceived vulnerability in the effect of intervention on children's behavioral changes using bias-corrected bootstrapping methods. This analysis was conducted using Mplus 6.0.
RESULTS
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Thirty-one (11%) of the 280 participants had missing data on at least one variable. Together, the missing data constituted 0.3% of total data points. Four participants (1%) missed the predollhouse task due to scheduling conflicts. Five participants (2%) were missing the Parent Questionnaire due to unavailability of literate caregivers. Other missing data occurred in the Child Questionnaire, most likely because children overlooked items at the bottom of a page while turning to the next page. Relations between missingness and other variables were examined using bivariate correlation analysis, and missingness was not significantly correlated with any of the variables of interest in this study. Since far less than 5% of data points were missing, and missing data points were distributed across variables and across participants, pairwise deletion and estimations (e.g. imputation) are likely to produce similar results (Tabachnick & Fidell, 2013). Therefore, pairwise deletion was applied to all missing data.
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Descriptive statistics for all variables of interest appear in Table 1, both for the full sample and for each group. As expected given the randomization scheme, no statistical difference was found between the groups on most demographic variables. The only difference occurred on the exposure frequency to dogs measure, in which children in the intervention group reported somewhat less frequent exposure to dogs than those in the comparison group (χ2 (5) = 16.16, p < .05). Given this result, we controlled for exposure to dogs in all subsequent analyses. The safety knowledge, perceived vulnerability and simulated behavior in the dollhouse task measures also did not differ statistically prior to intervention. Table 2 presents a correlation matrix including the major outcome variables plus demographic variables. No evidence of multicollinearity between predictor variables emerged. Intervention condition was significantly correlated with children's safety knowledge (r = .38, p < .01), perceived vulnerability (r = .33, p < .01), and simulated risky behaviors with dogs in the dollhouse task (r = −.34, p < .01) in post-intervention tests, but not in pre-intervention tests. Dog-bite history was not correlated significantly with any of the
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demographic or outcome measures, so we analyzed children with and without dog-bite history together in the main analyses. Our first primary hypothesis was that children in the intervention group would have greater knowledge, higher perceived vulnerability and safer simulated behavior with dogs following the intervention compared to children in the comparison group. Descriptive statistics shown in the shaded section of Table 1 support this hypothesis. One way to interpret the results is that the intervention group benefited from a 13% reduction in risk (−0.13 point difference from pre-behavior to post-behavior in the dollhouse task) compared to the comparison group, without adjusting for baseline functioning or other factors. To reinforce descriptive findings on the simulated behavior task, Figure 2 illustrates the change in responses among both groups from pre-intervention to post-intervention.
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Three stepwise linear regression analyses were then performed to further evaluate the intervention effect on the three outcomes with respective post-intervention scores (knowledge, perceived vulnerability, simulated behavior) as the dependent variables, training condition as an independent variable, and respective pre-test scores and demographic factors (age, gender, ethnicity, SES, dog-bite history, exposure frequency to child-dog interactions, dog ownership, and daily risky practice with dogs) as control variables entered in the first step of analysis. For each outcome, we computed the adjusted effect size (adjusted Cohen's d) of the intervention by subtracting the pre-intervention effect size from the postintervention effect size (Durlak, 2009).
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Table 3 shows the effect of the intervention on safety knowledge. Covariates in the first step accounted for 22% of the variance in the outcome, R2 = .22, F (9, 254) = 7.75, p < .001. No demographic variables were predictive of post-intervention safety knowledge, but children with more pre-intervention safety knowledge had more post-intervention safety knowledge (B = .45, SE = .07, 95% CI = [.32, .58], β = .39, t = 6.81, p < .001). In the second step, training condition accounted for a significant proportion of the variance, R2 change = .14, F (1, 253) = 56.84, p < .001. Children in the intervention group had significantly more safety knowledge about dogs compared to the comparison group (B = 12.46, SE = 1.65, 95% CI = [9.20, 15.71], β = .39, t = 7.54, p < .001). The adjusted Cohen's d for the intervention effect on safety knowledge was 0.85 (pre-intervention Cohen's d = −0.04, post-intervention Cohen's d = 0.81).
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Table 4 shows the effect of the intervention on perceived vulnerability. Covariates in the first step accounted for 34% of the variance in the outcome, R2 = .34, F (9, 262) = 15.29, p < . 001. No demographic variables were predictive of post-intervention perceived vulnerability, but children with higher pre-intervention perceived vulnerability had higher postintervention perceived vulnerability (B = .50, SE = .05, 95% CI = [.40, .60], β = .53, t = 9.76, p < .001). In the second step, training condition accounted for a significant proportion of the variance, R2 change = .10, F (1, 261) = 41.97, p < .001. Children in the intervention group had significantly higher perceived vulnerability about child-dog interactions compared to the comparison group (B = .35, SE = .05, 95% CI = [.24, .45], β = .31, t = 6.48, p < .001). The adjusted Cohen's d for the intervention effect on perceived vulnerability was 0.63 (preintervention Cohen's d = 0.07, post-intervention Cohen's d = 0.70).
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Table 5 shows the effect of the intervention on children's simulated behaviors with dogs in the dollhouse task. Covariates in the first step accounted for 42% of the variance in the outcome, R2 = .38, F (9, 257) = 17.22, p < .001. No demographic variables were predictive of post-intervention simulated behaviors with dogs except for dog exposure (B = .01, SE = . 01, 95% CI = [.00, .02], β = .12, t = 2.00, p = .047). Children who had riskier preintervention behaviors with dogs demonstrated riskier post-intervention simulated behaviors with dogs (B = .59, SE = .05, 95% CI = [.49, .69], β = .60, t = 11.57, p < .001). In the second step, training condition accounted for a significant proportion of the variance, R2 change = . 08, F (1, 256) = 37.31, p < .001. Children in the intervention group demonstrated significantly less risky simulated behaviors with dogs compared to the comparison group (B = −.11, SE = .02, 95% CI = [−.14, −.07], β = −.29, t = −6.11, p < .001). The adjusted Cohen's d for the intervention effect on reducing risky simulated behaviors was 0.63 (preintervention Cohen's d = 0.11, post-intervention Cohen's d = 0.74).
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The final step of the analysis was to test whether perceived vulnerability mediated the effect of the intervention on children's simulated behaviors with dogs. The bootstrapping method with 95% bias-corrected confidence estimates and 10,000 bootstrap resamples (MacKinnon, Lockwood, & Williams, 2004; Preacher & Hayes, 2004, 2008) was applied to test a twomediator model with training condition as the independent variable, post-test scores on simulated behaviors with dogs as the dependent variable, and post-test scores on safety knowledge and perceived vulnerability as two parallel mediators, controlling for pre-test scores on knowledge, perceived vulnerability and simulated behaviors, and demographic variables. Results are presented in Figure 3. The mediation role of perceived vulnerability was supported by the significant indirect effect from intervention condition to simulated behavior via perceived vulnerability (B = −.02, SE = .01, 95% CI = [−.04, −.007], β = −.06). Children who watched the testimonial video on dog-bite prevention had significantly higher perceived vulnerability (B = .36, 95% CI = [.25, .47], β = .33, t = 6.51, p < .001), which led to less riskier simulated behaviors with dogs (B = −.06, 95% CI = [−.10, −.02], β = −.18, t = −2.82, p = .01). The mediation role of safety knowledge was also supported by the significant indirect effect from intervention condition to simulated behavior via safety knowledge (B = −.02, SE = .01, 95% CI= [−.04, −.003], β = −.06). Children who watched the testimonial video on dog-bite prevention had significantly more safety knowledge (B = 12.62, 95% CI = [9.40, 15.76], β = .39, t = 7.74, p < .001), which led to less riskier simulated behaviors with dogs (B = −.002, 95% CI = [−.003, 100 million children in rural China), even small behavior changes can result in large reduction of the public health burden. One future direction that might improve the intervention's efficacy would be to consider incorporation of live testimonials presented by actual people rather than videotaped stories. Such an experience might influence children's emotions and thus behaviors more dramatically, although it also would increase the economic and labor cost of the intervention.
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Implications of this study are many; we highlight three. First, in terms of public health implications, over 100 million school-aged children live in rural China, all at significant risk of dog-bite injuries and rabies infection. This short-term efficacy study offers preliminary evidence of an intervention program that has potential to reduce dog-bite injury risk, including for children who have a history of previous dog bite. Second, the study has implications to behavioral science and injury prevention. Grounded in health behavior change theory, the positive results remind us how grounded theory-based interventions can be effective to change long-standing health-related habits and ultimately to reduce risk. Finally the adoption of mediation analysis to consider not just if an intervention works but also how it works is critical to health behavior intervention development. We discovered behavioral change was mediated both by increased knowledge and increased perceived vulnerability among the sample. Another way to frame this mediational effect is that testimonials influenced both cognition and perception-induced emotion (Morrongiello & Matheis, 2007b). Future work evaluating health-related interventions should target both knowledge and perceived vulnerability to improve the efficacy of intervention programs, and should also try to parse out the relative contributions of the two elements on children's behavioral change at different ages/developmental stages.
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In conclusion, this study developed and evaluated a video-based testimonial intervention to reduce pediatric dog-bite injury risk in rural China. The positive findings have implications for future research and consideration of how interventions such as this one may be used throughout China and also translated to other cultures and regions with high rates of pediatric dog-bite injury.
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Acknowledgments Thanks to my dissertation committee members Dr. Samuel Cartner, Prof. Michele Forman, Dr. Sylvie Mrug, and Dr. Despina Stavrinos for insightful guidance on this project. Thanks to Prof. Forman and her team at the UAB Media Commons for support of the development of the testimonials. Thanks to Jinhong Guo, Hui Xu, and Manhong Yao for assisting with data collection. The research was partially supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under Award Number R21HD075960, American Psychological Association Division 38 (Health Psychology), Clinton Global Initiative University, and UAB Sparkman Center for Global Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the above-mentioned agencies and institutions.
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Author Manuscript Author Manuscript Author Manuscript Figure 1.
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The CONSORT Flowchart Diagram of Study Enrollment
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Distribution of Children's Responses in the Dollhouse Simulated Behavior Task by Visit and Group
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Mediation Model: Safety Knowledge and Perceived Vulnerability Mediating the Relation between Intervention Condition and Children's Simulated Behavior in the Dollhouse Task
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Table 1
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Descriptive Data Overall (N=280)
Intervention (N=143)
Control (N=137)
p
10.03 (.83)
10.03 (.82)
10.02 (.84)
.87
135 (48.90)
67 (47.20)
68 (50.70)
.55
256 (91.80)
133 (93.00)
123 (90.40)
.44
19 (6.90)
10 (7.00)
9 (6.70)
== College
5 (1.80)
2 (1.40)
3 (2.20)
149 (54.40)
75 (53.20)
74 (55.60)
.44
55 (20.00)
28 (19.90)
27 (20.10)
.95
Never
61 (21.80)
33 (23.10)
28 (20.40)
Once every few years
37 (13.20)
25 (17.50)
12 (8.80)
>=once a year, < once a month
17 (6.10)
14 (9.80)
3 (2.20)
>=once a month, =once a week, < once a day
46 (16.40)
17 (11.90)
29 (21.20)
At least once a day
96 (34.30)
44 (30.80)
52 (38.00)
116 (41.40)
57 (39.90)
59 (43.10)
.59
1.80 (.60)
1.77 (.58)
1.83 (.61)
.38
48.01 (14.21)
47.76 (13.86)
48.26 (14.60)
.77
3.79 (.61)
3.81 (.60)
3.77 (.62)
.62
.33 (.19)
.32 (.19)
.34 (.19)
.33
60.89 (16.09)
66.78 (14.81)
54.74 (15.09)
Health Psychol. Author manuscript; available in PMC 2017 May 01. Published in final edited form as: Health Psychol. 2016 May ; 35(5): 454–464. doi:10.1037/hea0000273.
A Randomized Trial Evaluating Child Dog-Bite Prevention in Rural China through Video-Based Testimonials Jiabin Shen1, Shulan Pang2, and David C. Schwebel1 1
Department of Psychology, University of Alabama at Birmingham, USA
2
School of Public Health, Hebei United University, China
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Abstract Objective—Dog-bite injuries pose significant threat to children globally. School-aged children are especially at risk because of their cognitively immature tendency toward low perceived vulnerability to bites, and this risk is elevated further for school-aged children living in rural China due to the large number of stray dogs, all potential rabies carriers, present in their communities.
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Methods—This randomized controlled trial evaluated whether viewing an educational video of testimonials would change safety knowledge, perceived vulnerability, and simulated behaviors with dogs among a sample of 280 third and fourth graders living in rural China. Participants were randomly assigned to view either an educational video of testimonials on dog-bite prevention (treatment) or an educational video of testimonials on drowning prevention (comparison). Safety knowledge, perceived vulnerability to dog bites, and simulated behavior with dogs using a dollhouse model were assessed both before and after exposure to the video of testimonials. Results—Children who watched the educational video of testimonials on dog-bite prevention had increased safety knowledge, higher perceived vulnerability, and less risky simulated behaviors with dogs compared to the comparison group. Mediation analysis revealed that the intervention successfully changed children's simulated behaviors with dogs through greater safety knowledge and increased perceived vulnerability. Conclusions—Results suggest the incorporation of testimonials into injury prevention programs has potential for broad global dissemination. The fact that both increased knowledge and heightened perceived vulnerability mediated changes in simulated behavior suggests the dual roles of knowledge and appraisal on children's injury-risk behavior.
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Keywords dog-bite; injury; prevention; testimonial; child Over 100 million school-aged children ages 7-14 live in rural China. They have substantial risk for many adverse health effects (Wang et al., 2008), one of which is pediatric dog bite injuries. Researchers report that 30% of rural Chinese elementary school children ages 9-13 have experienced at least one dog-bite injury in their lives (Shen et al., 2013a). Among those
Corresponding Author: Jiabin Shen, Department of Psychology, University of Alabama at Birmingham, 1300 University Blvd, CH 415, Birmingham AL 35294 USA, Phone: (205) 934-8745, Fax: (205) 975-6110, [email protected].
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children, 54% of bites occur on public streets away from home, and 84% of bites occur without adults nearby (Shen et al., 2014). Dog bites result in both adverse physical and psychological consequences. Physical consequences can include acute and long-term medical treatment, painful and expensive rabies treatment, and physical restriction from routine activities and schoolwork (Eppley & Schleich, 2013; Shen et al., 2014). Psychologically, consequences can include fear, withdrawal, post-traumatic symptoms, and coping with permanent scarring, including on the face (Hon et al., 2007; Peters, Sottiaux, Appelboom, & Kahn, 2004). One recent study of 101 pediatric dog-bite cases in rural China found that pediatric dog-bite victims often developed behavioral withdrawal and psychological fear of dogs (Shen et al., 2014).
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Children have increased risk for dog bites compared to adults due to both smaller physical size and underdeveloped cognitive skills. Smaller size increases both risk and severity of bites, and children are especially vulnerable to bites on the neck or head (Hon et al., 2007; Mcheik, Vergnes, & Bondonny, 2000). Cognitively, children are more likely to engage in risky interactions with dogs and to behave impulsively and without accurate perception of their vulnerability to injury by dogs (Avner & Baker, 1991; Chouinard, 2007).
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The unique environment of rural China further heightens risk of child dog-bite injury. Many dogs run loose in rural Chinese villages, and children are exposed to dogs during long daily walks to and from school (Deng et al., 2004; Duan, 2008; Shen, Li, Xiang, Lu, & Schwebel, 2014). Risk from bites is amplified by the presence of rabies, which increased by 2000% among dogs in China from 1996 to 2006 and has not waned since (Si et al., 2008; Zhang, Jin, Sun, Sun, & Ruan, 2012). Furthermore, parental supervision of children in rural China is frequently insufficient because many young parents migrate to urban cities for higher-paid work (the China National Bureau of Statistics estimated 245 million migrants from rural to urban China in 2014), leaving children home with aging grandparents whose more limited mobility diminishes proper supervision of children, especially on public streets.
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Efforts to prevent pediatric dog-bite injuries are few globally, and almost non-existent in rural China. In fact, a 2009 systematic review of pediatric dog-bite injury prevention programs uncovered just two studies that met inclusion criteria of randomized controlled trials or controlled before-after studies and evaluated the effectiveness of educational interventions for preventing dog bites with behavioral outcomes in populations under 20 years old (Dupperrex, Blackhall, Burri, Jeannot, 2009). Intervention programs that are reported in the literature focus primarily on teaching children basic knowledge and skills via one-way (adult to child) educational programs (Beaver, 2001; Chapman, et al., 2000; Dixon, Pomerantz, Hart, Lindsell, & Mahabee-Gittens, 2013; Spiegel, 2000), interactive classroom lesson plans (Szecsi, Barbero, Del Campo, & Toledo, 2010; Wilson, Dwyer, & Bennett, 2003) or animated computerized tasks (Meints & De Keuster, 2006, 2009; Schwebel et al., 2012). These studies yielded mixed results concerning transfer of knowledge, but very few have tested and successfully demonstrated a change in children's risky behaviors with dogs (Schwebel, 2012). An alternative strategy to improve children's safety with dogs is to increase children's perceived vulnerability toward risk from child-dog interactions. The role of perceived
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vulnerability is emphasized in multiple prominent theoretical models to explain healthrelated behavioral change, including the Health Belief Model (Janz & Becker, 1984), and research with school-age children confirms the role of low perceived vulnerability in children's injury risk behaviors (Morrongiello & Rennie, 1998). Previous research examining dog-bite risk among school-aged children in rural China also reported that children's low perceived vulnerability was associated with both self-reported risky interactions with dogs and history of dog-bite injury (Shen et al., 2013a).
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One effective strategy to alter individuals’ perceived vulnerability toward health-related behaviors is through the use of first-person testimonials that detail the antecedents, processes, and consequences of an adverse event (Slater & Rouner, 1996). Testimonialbased interventions might be especially persuasive in the context of training children to be safe with dogs, as testimonials concerning dog bite incidents can elicit strong emotional arousal among children, a strategy that may improve the potential for behavior change (De Wit, Das, & Vet, 2008; Loewenstein, Weber, Hsee, & Welch, 2001). The current study used a repeated-measures randomized controlled trial design to evaluate the efficacy of a video-based testimonial intervention on reducing children's risks of dog-bite injury. We hypothesized that children who watched the dog-bite testimonials would demonstrate more safety knowledge, higher perceived vulnerability and less risky simulated behaviors with dogs than children in the comparison group (Hypothesis 1). Further, we hypothesized that both safety knowledge and perceived vulnerability would mediate the effect of intervention on children's simulated behaviors with dogs, with watching dog-bite testimonials leading to increased knowledge and increased perceived vulnerability, which would in turn lead to less risky simulated behaviors with dogs (Hypothesis 2).
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METHODS Participants
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Power analysis was performed a priori and minimum sample size calculated based on the following two procedures. First, an estimated effect size of d = 0.33 for the intervention effect was determined based on results from a similar video-based intervention study of playground safety in Canada (Morrongiello & Matheis, 2007a). It was determined that 76 participants would be required to detect the expected effect size for Hypotheses 1 with a power of .99 (2 tails, alpha=.01; Cohen, 1988) using G*Power 3.1; our anticipated sample from any single school in rural China was much larger. Second, using the bias-corrected bootstrap method, it was determined that 120 participants were required to achieve power of .80 for the mediation analysis of Hypothesis 4 (Fritz & MacKinnon, 2007). Again, the anticipated sample from any single school in rural China was larger than this. In the present study, 280 children in Grades 3 and 4 at an elementary school in rural Zhejiang Province, China, participated (mean age = 10.03 years, median age = 10.00, SD = 0.83; Interquartile range = 1.13; 48.9% boys; 92% Han Chinese ethnicity). Inclusion criteria were all students enrolled in either Grade 3 or 4 at the participating school at the time of study, and no exclusion criteria applied. The sample reported annual household income of
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less than US $8,000 (~Chinese RMB 48,000) and 85% of primary caregivers had fewer than 10 years of formal education. Measures
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Demographics—Demographic information was collected from both parents and children pre-intervention. Children reported their age, gender, ethnicity (Han vs. other), dog ownership, dog exposure frequency, and daily risky practice with dogs. Dog ownership was assessed with a single item, ‘Does your family keep dogs now?’, which was answered ‘Yes’ or ‘No’. Dog exposure frequency was also assessed with a single item, ‘How often do you usually interact with dogs?’, which children responded to using a range from 1 (I've never interacted with dogs) to 6 (at least once a day). Daily risky practice with dogs was assessed using an 8-item instrument. Items were answered on a 5-point scale and both internal reliability (Cronbach alpha = .73) and factorial validity (Confirmatory factor analysis supported unidimensionality of the measure, χ2/df = 3.81, p < .05, Standardized Root Mean Square Residual (SRMS) = .06, CFI = .85) were adequate. The final score was an average across items (possible range = 1-5). Primary caregivers reported child dog-bite history (‘How many times has your child been bitten (scratched) by a dog?’; due to skewness, answers were dichotomized to bite history vs. none for analysis), household income and educational background. A socioeconomic status (SES) composite was computed as the mean of standardized scores from household income and the primary caregiver's education. Table 1 shows descriptive data.
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Child knowledge about dog safety—The child-dog interaction safety knowledge questionnaire is a 24-item measure of children's safety knowledge around dogs. We developed this questionnaire for use in pilot research with similar age groups of children in rural China and it demonstrated adequate external validity (significant correlation with risk perception, r = −.43, p < .01; and risky interactions with dogs, r = −.23, p < .01) (Shen et al., 2013a). In the present study, the measure had inadequate psychometric properties, so WLSMV-based factor analysis was conducted and revealed 6 items that did not load well onto the primary construct of interest. Thus, a modified 18-item instrument was analyzed. It demonstrated adequate test-retest reliability (r = .58, p < .001) and factorial validity (confirmatory factor analysis supported unidimensionality of the measure (χ2/df = 1.65, p < . 05; SRMR=0.12; CFI=0.81). Given the dichotomous nature of the scale items, ordinal coefficient theta was computed as a measure of internal reliability (Fabrigar, Wegener, MacCallum, & Strahan, 1999; Zumbo, Gadermann, & Zeisser, 2007) and it demonstrated adequate internal consistency, theta = .63. The questionnaire assesses children's knowledge about ‘dos’ and ‘don'ts’ when encountering dogs in typical daily scenarios in rural China. An example item is, “If you see stray dogs displaying unusual behavior like wandering around here and there aimlessly and easily getting irritated and angry, you should: A. Ignore it; B. Explore/Play with the dog to understand better what is going on; C. Yell at the dog, or else tease it; D. Walk away from the dog quickly; E. Immediately report to an adult” The correct answer is D. Participants were scored correct (1) or incorrect (0) for each item and the final composite score was the percentage of correct responses (0-100%), with higher scores indicating greater knowledge.
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Perceived vulnerability to dog bites—The child-dog interaction perceived vulnerability questionnaire is a 12-item measure of children's perceived vulnerability toward child-dog interactions. Also developed in pilot research (Shen et al., 2013a), it has adequate internal reliability (Cronbach's α = .77) and construct validity (confirmatory factor analysis supported unidimensionality of the measure, χ2/df = 3.04, p < .05; SRMS = .07; CFI = .76). An example item is, “I can run faster than unknown dogs so as to avoid their biting me.” Items are scored on a 5-point scale, with higher scores indicating greater perceived vulnerability. Final scores were averaged across all items (possible range = 1-5).
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Simulated behaviors with dogs—The dollhouse task assessed children's risky behaviors with dogs by asking children to act out what to do in simulated real-life situations involving dogs. The measure was based on a model used previously in the US that had adequate psychometric properties (Schwebel, Morrongiello, Stewart, & Bell, 2012), but was adapted to the rural Chinese context. It included eight situations that create the greatest risk for dog bites to children, as identified in pilot research (Shen et al., 2014). An example scenario is as follows: “Researcher acts out child doll [gender-matched to participant] walking on the street in front of the dollhouse while a stray dog approaches from behind the child. Say: ‘(Child's Name) is playing outside his/her house. A stray dog comes along the street toward (Child's Name). What will (Child's Name) do now?’” Children's verbal and behavioral responses to each scenario were recorded verbatim and then coded as safe (0), moderate (0.5) or unsafe (1) by the researcher using an objective written coding system. Inter-rater reliability was obtained by a second researcher who did not communicate with the first and was excellent (kappa>.95) in pilot testing with 60 participants.
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Quantifying risk in simulated situations is necessarily inexact but we treated the dollhouse task measure analytically as a ratio scale, such that risk intervals were considered equal across measures and across scores. Thus, the leap from a score of 0 to a score of 0.5 was conceptualized to be equal to the leap in risk from 0.5 to 1. Similarly, risk of a bite for a score of 0.5 was conceptualized to be equal across all scenarios. Given this assumption, children's final scores were computed as the average safety across the eight scenarios and ranged from 0 to 1, with higher scores indicating riskier simulated behaviors with dogs. Internal reliability was borderline (Cronbach's alpha = .65). Intervention
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The intervention comprised a 36-minute video displaying scripted testimonials of actual dog-bite experiences. Four adult actors, all native Mandarin speakers unfamiliar to the participants, presented the testimonials. Unlike what might be done with research in Western cultures, we chose adults to present the testimonials rather than peers because as part of a collectivist culture, Chinese children respect and admire adult authorities (Chen, Greenberger, Farruggia, Bush, & Dong, 2003; Ma, Shek, Cheung, & Lam, 2000). Pilot research in rural China confirmed that children learned dog safety lessons more effectively from adults than from peers or siblings (Shen, et al., 2013b). The four presenters were representative of the interpersonal environment with which children in rural China interact in terms of age (younger and older adults), gender ratio (3 females and 1 male, as mothers are
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more likely to care for children and school teachers are mostly female), and societal roles (school teacher, parents, grandparents).
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Each of the four testimonials was nine minutes long and was scripted to accomplish standardized learning objectives: (1) introduction of who the speaker is (teacher, parent, grandparent); (2) introduction about the child victim's background and circumstances; (3) antecedents/circumstances of the dog-bite incident (i.e., how the child got bit, what the child was doing, what the dog was doing); (4) consequences of the incident (i.e., gravity of the injury, how the child was treated, what happened to the dog after the bite); (5) mistakes, decisions, and actions the child victim made, including perception of invulnerability the child may have had, plus alternative cognitions/behaviors that would have been safer; and (6) a summary of safety lessons learned from this incident. To enhance the educational effect and hold children's attention during the video session, the testimonials were edited to incorporate background melodies fitting the story and illustrative pictures, texts and video clips to create a vivid and emotion-arousing lesson. Both visual and audio cues were provided between each of the four testimonial stories also. Anecdotally, child attention was excellent while viewing the videos. The testimonials were scripted but all described actual bites described in the literature (Shen et al., 2014) among children of the same age as the target population in rural Chinese culture. The comparison group watched scripted testimonials of identical length and structure on drowning risk, another significant public health risk among rural Chinese children (Guo, 2010; Zhang, Chen, Deng, Xu, & Hu, 2003). Procedure
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IRB approval was obtained from University of Alabama at Birmingham and written consent from participating school officials. Signed informed consent was obtained from students’ caregivers and signed informed assent from students. All children in grades 3-4 (100%) at the participating school participated in the study. As shown in Figure 1, there was no attrition throughout the study, although only 276 (99%) children completed the preintervention dollhouse task due to scheduling conflicts at the time of the study. The study lasted three weeks. In week 1, all participating children completed the child-dog interaction safety knowledge and perceived vulnerability questionnaires in their classroom, and then were taken individually in randomized order to a quiet and private room to complete the simulated behavior assessment using the dollhouse task. Intervention group membership was assigned subsequently, so both researchers and participants were masked to group membership during pre-tests.
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Implementation of the intervention commenced one week later. Testimonial videos were delivered to children at individual desktop computers with headphones. Each child was randomly assigned to watch one of the two testimonial videos using a 1:1 randomization scheme. Random assignment occurred within the same classrooms to reduce clustering influences in data analysis. In the final week of the study, the post-test was administered following the same procedure as the pre-test (knowledge and perceived vulnerability questionnaires completed in classroom, and individualized assessment of simulated behavior
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in the dollhouse task in a separate room). Researchers administering post-tests were masked to group membership. Data Analysis Plan
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Initial analyses were performed to examine descriptive data and intercorrelations between and among outcome variables at both pre- and post-test, along with demographic variables. Independent samples t-test and chi-square tests were performed next to examine group differences on demographic and outcome measures. Following this, the effects of the intervention on children's safety knowledge, perceived vulnerability and simulated behaviors were tested respectively using stepwise linear regression models, controlling for preintervention test scores and demographic variables. All of those analyses were conducted using SPSS 21.0. The final step of the analysis was to evaluate the mediational roles of safety knowledge and perceived vulnerability in the effect of intervention on children's behavioral changes using bias-corrected bootstrapping methods. This analysis was conducted using Mplus 6.0.
RESULTS
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Thirty-one (11%) of the 280 participants had missing data on at least one variable. Together, the missing data constituted 0.3% of total data points. Four participants (1%) missed the predollhouse task due to scheduling conflicts. Five participants (2%) were missing the Parent Questionnaire due to unavailability of literate caregivers. Other missing data occurred in the Child Questionnaire, most likely because children overlooked items at the bottom of a page while turning to the next page. Relations between missingness and other variables were examined using bivariate correlation analysis, and missingness was not significantly correlated with any of the variables of interest in this study. Since far less than 5% of data points were missing, and missing data points were distributed across variables and across participants, pairwise deletion and estimations (e.g. imputation) are likely to produce similar results (Tabachnick & Fidell, 2013). Therefore, pairwise deletion was applied to all missing data.
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Descriptive statistics for all variables of interest appear in Table 1, both for the full sample and for each group. As expected given the randomization scheme, no statistical difference was found between the groups on most demographic variables. The only difference occurred on the exposure frequency to dogs measure, in which children in the intervention group reported somewhat less frequent exposure to dogs than those in the comparison group (χ2 (5) = 16.16, p < .05). Given this result, we controlled for exposure to dogs in all subsequent analyses. The safety knowledge, perceived vulnerability and simulated behavior in the dollhouse task measures also did not differ statistically prior to intervention. Table 2 presents a correlation matrix including the major outcome variables plus demographic variables. No evidence of multicollinearity between predictor variables emerged. Intervention condition was significantly correlated with children's safety knowledge (r = .38, p < .01), perceived vulnerability (r = .33, p < .01), and simulated risky behaviors with dogs in the dollhouse task (r = −.34, p < .01) in post-intervention tests, but not in pre-intervention tests. Dog-bite history was not correlated significantly with any of the
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demographic or outcome measures, so we analyzed children with and without dog-bite history together in the main analyses. Our first primary hypothesis was that children in the intervention group would have greater knowledge, higher perceived vulnerability and safer simulated behavior with dogs following the intervention compared to children in the comparison group. Descriptive statistics shown in the shaded section of Table 1 support this hypothesis. One way to interpret the results is that the intervention group benefited from a 13% reduction in risk (−0.13 point difference from pre-behavior to post-behavior in the dollhouse task) compared to the comparison group, without adjusting for baseline functioning or other factors. To reinforce descriptive findings on the simulated behavior task, Figure 2 illustrates the change in responses among both groups from pre-intervention to post-intervention.
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Three stepwise linear regression analyses were then performed to further evaluate the intervention effect on the three outcomes with respective post-intervention scores (knowledge, perceived vulnerability, simulated behavior) as the dependent variables, training condition as an independent variable, and respective pre-test scores and demographic factors (age, gender, ethnicity, SES, dog-bite history, exposure frequency to child-dog interactions, dog ownership, and daily risky practice with dogs) as control variables entered in the first step of analysis. For each outcome, we computed the adjusted effect size (adjusted Cohen's d) of the intervention by subtracting the pre-intervention effect size from the postintervention effect size (Durlak, 2009).
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Table 3 shows the effect of the intervention on safety knowledge. Covariates in the first step accounted for 22% of the variance in the outcome, R2 = .22, F (9, 254) = 7.75, p < .001. No demographic variables were predictive of post-intervention safety knowledge, but children with more pre-intervention safety knowledge had more post-intervention safety knowledge (B = .45, SE = .07, 95% CI = [.32, .58], β = .39, t = 6.81, p < .001). In the second step, training condition accounted for a significant proportion of the variance, R2 change = .14, F (1, 253) = 56.84, p < .001. Children in the intervention group had significantly more safety knowledge about dogs compared to the comparison group (B = 12.46, SE = 1.65, 95% CI = [9.20, 15.71], β = .39, t = 7.54, p < .001). The adjusted Cohen's d for the intervention effect on safety knowledge was 0.85 (pre-intervention Cohen's d = −0.04, post-intervention Cohen's d = 0.81).
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Table 4 shows the effect of the intervention on perceived vulnerability. Covariates in the first step accounted for 34% of the variance in the outcome, R2 = .34, F (9, 262) = 15.29, p < . 001. No demographic variables were predictive of post-intervention perceived vulnerability, but children with higher pre-intervention perceived vulnerability had higher postintervention perceived vulnerability (B = .50, SE = .05, 95% CI = [.40, .60], β = .53, t = 9.76, p < .001). In the second step, training condition accounted for a significant proportion of the variance, R2 change = .10, F (1, 261) = 41.97, p < .001. Children in the intervention group had significantly higher perceived vulnerability about child-dog interactions compared to the comparison group (B = .35, SE = .05, 95% CI = [.24, .45], β = .31, t = 6.48, p < .001). The adjusted Cohen's d for the intervention effect on perceived vulnerability was 0.63 (preintervention Cohen's d = 0.07, post-intervention Cohen's d = 0.70).
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Table 5 shows the effect of the intervention on children's simulated behaviors with dogs in the dollhouse task. Covariates in the first step accounted for 42% of the variance in the outcome, R2 = .38, F (9, 257) = 17.22, p < .001. No demographic variables were predictive of post-intervention simulated behaviors with dogs except for dog exposure (B = .01, SE = . 01, 95% CI = [.00, .02], β = .12, t = 2.00, p = .047). Children who had riskier preintervention behaviors with dogs demonstrated riskier post-intervention simulated behaviors with dogs (B = .59, SE = .05, 95% CI = [.49, .69], β = .60, t = 11.57, p < .001). In the second step, training condition accounted for a significant proportion of the variance, R2 change = . 08, F (1, 256) = 37.31, p < .001. Children in the intervention group demonstrated significantly less risky simulated behaviors with dogs compared to the comparison group (B = −.11, SE = .02, 95% CI = [−.14, −.07], β = −.29, t = −6.11, p < .001). The adjusted Cohen's d for the intervention effect on reducing risky simulated behaviors was 0.63 (preintervention Cohen's d = 0.11, post-intervention Cohen's d = 0.74).
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The final step of the analysis was to test whether perceived vulnerability mediated the effect of the intervention on children's simulated behaviors with dogs. The bootstrapping method with 95% bias-corrected confidence estimates and 10,000 bootstrap resamples (MacKinnon, Lockwood, & Williams, 2004; Preacher & Hayes, 2004, 2008) was applied to test a twomediator model with training condition as the independent variable, post-test scores on simulated behaviors with dogs as the dependent variable, and post-test scores on safety knowledge and perceived vulnerability as two parallel mediators, controlling for pre-test scores on knowledge, perceived vulnerability and simulated behaviors, and demographic variables. Results are presented in Figure 3. The mediation role of perceived vulnerability was supported by the significant indirect effect from intervention condition to simulated behavior via perceived vulnerability (B = −.02, SE = .01, 95% CI = [−.04, −.007], β = −.06). Children who watched the testimonial video on dog-bite prevention had significantly higher perceived vulnerability (B = .36, 95% CI = [.25, .47], β = .33, t = 6.51, p < .001), which led to less riskier simulated behaviors with dogs (B = −.06, 95% CI = [−.10, −.02], β = −.18, t = −2.82, p = .01). The mediation role of safety knowledge was also supported by the significant indirect effect from intervention condition to simulated behavior via safety knowledge (B = −.02, SE = .01, 95% CI= [−.04, −.003], β = −.06). Children who watched the testimonial video on dog-bite prevention had significantly more safety knowledge (B = 12.62, 95% CI = [9.40, 15.76], β = .39, t = 7.74, p < .001), which led to less riskier simulated behaviors with dogs (B = −.002, 95% CI = [−.003, 100 million children in rural China), even small behavior changes can result in large reduction of the public health burden. One future direction that might improve the intervention's efficacy would be to consider incorporation of live testimonials presented by actual people rather than videotaped stories. Such an experience might influence children's emotions and thus behaviors more dramatically, although it also would increase the economic and labor cost of the intervention.
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Implications of this study are many; we highlight three. First, in terms of public health implications, over 100 million school-aged children live in rural China, all at significant risk of dog-bite injuries and rabies infection. This short-term efficacy study offers preliminary evidence of an intervention program that has potential to reduce dog-bite injury risk, including for children who have a history of previous dog bite. Second, the study has implications to behavioral science and injury prevention. Grounded in health behavior change theory, the positive results remind us how grounded theory-based interventions can be effective to change long-standing health-related habits and ultimately to reduce risk. Finally the adoption of mediation analysis to consider not just if an intervention works but also how it works is critical to health behavior intervention development. We discovered behavioral change was mediated both by increased knowledge and increased perceived vulnerability among the sample. Another way to frame this mediational effect is that testimonials influenced both cognition and perception-induced emotion (Morrongiello & Matheis, 2007b). Future work evaluating health-related interventions should target both knowledge and perceived vulnerability to improve the efficacy of intervention programs, and should also try to parse out the relative contributions of the two elements on children's behavioral change at different ages/developmental stages.
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In conclusion, this study developed and evaluated a video-based testimonial intervention to reduce pediatric dog-bite injury risk in rural China. The positive findings have implications for future research and consideration of how interventions such as this one may be used throughout China and also translated to other cultures and regions with high rates of pediatric dog-bite injury.
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Acknowledgments Thanks to my dissertation committee members Dr. Samuel Cartner, Prof. Michele Forman, Dr. Sylvie Mrug, and Dr. Despina Stavrinos for insightful guidance on this project. Thanks to Prof. Forman and her team at the UAB Media Commons for support of the development of the testimonials. Thanks to Jinhong Guo, Hui Xu, and Manhong Yao for assisting with data collection. The research was partially supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under Award Number R21HD075960, American Psychological Association Division 38 (Health Psychology), Clinton Global Initiative University, and UAB Sparkman Center for Global Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the above-mentioned agencies and institutions.
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The CONSORT Flowchart Diagram of Study Enrollment
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Distribution of Children's Responses in the Dollhouse Simulated Behavior Task by Visit and Group
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Mediation Model: Safety Knowledge and Perceived Vulnerability Mediating the Relation between Intervention Condition and Children's Simulated Behavior in the Dollhouse Task
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Table 1
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Descriptive Data Overall (N=280)
Intervention (N=143)
Control (N=137)
p
10.03 (.83)
10.03 (.82)
10.02 (.84)
.87
135 (48.90)
67 (47.20)
68 (50.70)
.55
256 (91.80)
133 (93.00)
123 (90.40)
.44
19 (6.90)
10 (7.00)
9 (6.70)
== College
5 (1.80)
2 (1.40)
3 (2.20)
149 (54.40)
75 (53.20)
74 (55.60)
.44
55 (20.00)
28 (19.90)
27 (20.10)
.95
Never
61 (21.80)
33 (23.10)
28 (20.40)
Once every few years
37 (13.20)
25 (17.50)
12 (8.80)
>=once a year, < once a month
17 (6.10)
14 (9.80)
3 (2.20)
>=once a month, =once a week, < once a day
46 (16.40)
17 (11.90)
29 (21.20)
At least once a day
96 (34.30)
44 (30.80)
52 (38.00)
116 (41.40)
57 (39.90)
59 (43.10)
.59
1.80 (.60)
1.77 (.58)
1.83 (.61)
.38
48.01 (14.21)
47.76 (13.86)
48.26 (14.60)
.77
3.79 (.61)
3.81 (.60)
3.77 (.62)
.62
.33 (.19)
.32 (.19)
.34 (.19)
.33
60.89 (16.09)
66.78 (14.81)
54.74 (15.09)
