Abstract
Purpose:
Road accidents are the leading cause of non-disease-related deaths among teenagers in Cambodia. However, Cambodian schools continue to lack road safety education programmes and standardised guidelines. This study evaluated the effects of a customised comprehensive road safety educational programme for older elementary school students in Cambodia.
Design:
We conducted a road safety educational programme at an elementary school in Cambodia. The programme consisted of seven parts and included content related to pedestrian and vehicle (car, motorcycle and bike) safety.
Methods:
We used a mixed method to evaluate changes in knowledge, attitudes and practices following the programme. For the quantitative evaluation, we conducted a quasi-experimental study using a nonequivalent control group pre-test–post-test design involving 52 students. The experimental group comprised fourth graders (aged 10 years) and the control group consisted of fifth graders (aged 11 years). For the qualitative evaluation, we conducted focus group interviews with six participants from the experimental group.
Results:
Post-test road safety knowledge (Z = −2.79; p = .005) and attitudes (Z = −2.05, p = .041) improved significantly in the experimental group. Qualitatively, three themes were identified: participants acquired new insights into road safety, they adopted more positive attitudes and they made an effort to practise road safety.
Conclusion:
This pilot study demonstrated a possible positive effect of a road safety educational programme, suggesting that, following additional verification, it could be used to improve road safety for older elementary school students in Cambodia.
Introduction
Road accidents were the sixth cause of disability-adjusted life years in 2019 and are the primary cause of non-disease-related fatalities (World Health Organization, 2021). Globally, 1.35 million people died from road accidents in 2016 (World Health Organization, 2020), causing both physical and economic losses. Traffic-related mortality rates are reportedly 8.3 per 100,000 in high-income countries and 27.5 per 100,000 (threefold higher) in low-income countries (World Health Organization, 2020). Moreover, traffic-related death rates are the highest among people aged 5–29 years and are the primary cause of death in the 5- to 14-year-old age group (World Health Organization, 2018). Therefore, children in low-income countries are particularly vulnerable to these kinds of deaths.
In 2019, road accidents ranked the 10th most common cause of death in Cambodia and were the highest non-disease-related cause of death (Institute for Health Metrics and Evaluation, 2020). The Cambodian government established a national road safety strategy in 2011 that aimed to cut traffic-related mortality rates by half by 2020 while strengthening legal regulations (Organisation for Economic Co-operation and Development/International Transport Forum, 2014). As a result of such efforts, the total number of accident cases gradually decreased from 2014 to 2019, but the number of serious injuries remains high, especially among young people aged 11–25 years (United Nations Development Programme, 2021). In addition, the road safety infrastructure is inadequate and public awareness of road safety is low (Kitamura et al., 2018).
Solving this problem requires not only added infrastructure but also educational measures to improve road safety awareness among vulnerable individuals. School-aged children are at a particularly high risk of accidents (World Health Organization, 2015). Generally, behaviours and healthy habits learned during the school-age years tend to be maintained throughout the lifespan (Pender et al., 2015); thus, it is crucial to provide appropriate safety education during these formative years. The Cambodian government has proposed that road safety education is covered in the life skills component of the regular curriculum (Kitamura et al., 2018; Ministry of Youth, Education and Sports, 2017). However, to the best of our knowledge, these topics are only described in general terms and lack an educational perspective and standardised guidelines. Most schools in Cambodia cannot employ dedicated health education instructors because budgets and manpower are limited, leaving road safety education to general teachers. Therefore, it is necessary to develop and provide educational standards for them to use.
To date, the number of studies on road safety educational programmes in developing countries is small. Only one such study for elementary school students has been conducted in Cambodia, in which Ederer et al. (2016) evaluated an educational programme to encourage helmet wearing. Although there have been overseas assistance projects on road safety education, only safety when riding motorcycles – the primary mode of transportation in Cambodia – has been addressed (Asia Injury Prevention Foundation, 2018). This is inadequate, as 38% of accidents among children worldwide involve pedestrians, and 36%, 14% and 6% are passenger, motorcycle rider and bicycle rider accidents, respectively (World Health Organization, 2015). Therefore, a more comprehensive road safety education programme is required.
There are no road safety education programmes that include diverse topics in elementary schools in Cambodia; thus, this study developed and assessed the effects of such a programme developed for teachers for use in educating senior elementary school students in the country.
Methods
A mixed-methods design was used to evaluate the effects of the educational programme; a quasi-experimental research design was utilised for a quantitative assessment, and focus group interviews were undertaken for qualitative evaluation.
Road safety programme overview
The road safety programme was developed using the ADDIE (Analysis, Design, Development, Implementation and Evaluation) instructional design model to advance knowledge, attitudes and safe practices with respect to road safety among Cambodian elementary school children. Educational needs were assessed by evaluating the participants’ characteristics, performing a literature review and conducting both a needs survey and an environmental analysis. Accordingly, educational topics, methods and media were selected to be included in the programme. Local elementary school teachers and experts from Cambodia participated in reviewing the programme during its development. A total of three reviews and revisions were made to focus and tailor the level of contents for teachers and students. The final version of the educational programme was developed by the authors in South Korea and translated from Korean into Khmer to make it accessible to local teachers in Cambodia.
The goal of this programme was to ‘teach children [. . .] competences to comply with road safety rules, and practice these in their daily lives for their own and others’ safety’. The learning outcomes sought by the study were correct knowledge of and positive attitudes towards and the ability to keep road safety within four categories: safety on the way to and from school, compliance with road signs, two-wheeler safety, and automobile safety.
The programme covered various educational content related to road safety. It consisted of seven parts and engaged with pedestrian and vehicle safety relevant to the transport students often use to commute to school. The parts were: ‘Safe Commuting to School’, ‘Signs’, ‘Safe Bike Riding’, ‘Causes and Prevention of Motorcycle Road accidents’, ‘Understanding Motor Vehicles and Drivers’, ‘Motor Vehicle Accidents and How to Prevent Them’ and the ‘Proper Use of the Seat Belt’. Strategies for promoting knowledge, positive attitudes and practices were outlined in line with the topics covered in each chapter. The activities included in the educational programme included: ‘sharing the experience of being involved in or witnessing a car crash’, ‘promising each other to follow safety rules’, ‘writing a pledge of road accidents prevention’ and ‘talking about the lessons of the chapter topics’. In addition, field training was provided to promote behaviours such as ‘wearing a helmet’ and ‘practising accident prevention behaviours when commuting’.
Prior to delivering the programme to children, we organised a programme application workshop to strengthen Cambodian schoolteachers’ ability to implement the road safety educational programme. In the workshop, the researcher (B.A.) explained the purpose and importance of road safety education, how the programme had been developed, the educational background to the programme and the application of the programme. Three teachers who participated in the workshop taught the road safety programme to a group of grade 4 (aged 10 years) elementary school students from an Elementary School located in Kampong Speu Province in June and July 2019. Although the school principal and other teachers recognised the programme’s importance, since the current elementary school curriculum includes little or no road safety education, the road safety education was delivered as a stand-alone subject in cooperation with researchers. Seven 40-minute sessions were held.
Participants
The necessary number of participants for each of the experimental and control group was 27 (calculated for an effect size of 0.5, an α of .05 and power of 0.7 using the G*power version 3.1.9.7 program). The experimental group comprised 31 fourth grade students who attended the educational programme. Thirty-one fifth grade students (aged 11 years) from the same school comprised the control group. Students from a different year group had to be used as the control group because there was only one class per grade. The data from five students from each group had to be deleted due to absences or other reasons; hence, the final analysis included 26 students per group. For the qualitative evaluation, volunteer students from the experimental group were interviewed. A group of six students (two boys and four girls) was interviewed in a classroom where students felt comfortable with the involvement of a Khmer-Korean language interpreter.
Data collection instrument
A data collection instrument was developed to assess knowledge, attitudes and practices based on the components of the education programme (Supplemental file 1). This instrument was evaluated by experts for content validity. The knowledge component consisted of nine items, with 1 (correct) or 0 (incorrect) points assigned to each response. The total score was calculated and converted into a percentage. Discrimination between knowledge items ranged between .22 and .50. The attitudes and practices sections consisted of 9 and 12 items, respectively; both were measured using a 5-point Likert-type scale in which the possible responses were ‘strongly disagree’, ‘disagree’, ‘neutral’, ‘agree’ or ‘strongly agree’. The mean score for all items was calculated. Cronbach’s alpha values for the attitudes and practices components were .622 and .808, respectively.
For the qualitative evaluation, a series of questions were asked about (any) changes after attending the programme. The questions were as follows:
1) Why is it important to practise road safety?
2) Have you experienced any changes after participating in the programme? If so, what changes have you observed following the programme?
3) Have you acquired new information through the programme? If so, what new information did you learn about road safety?
4) Has the programme changed your attitudes towards road safety? If so, how do you think about road safety after the programme?
5) Have you ever practised what you have learned through the programme? If so, how do you practise the things you learned from the programme in your daily life?
Data collection
Pre-test and post-test questionnaires were administered immediately before the first class and immediately after the last class, respectively. Students were not told the correct answers for the knowledge items after the pre-test.
Focus group interviews were conducted 1 month after the classes had ended to collect qualitative data, aided by an interpreter. The entire interview process was recorded with participants’ consent.
Data analyses
Quantitative data were analysed using SPSS 21.0. The Shapiro–Wilk test was used to assess whether the data satisfied the assumption of a normal distribution for each of the three variables (knowledge, attitudes and practices), in which case a parametric test was performed. If the data were not normally distributed, a non-parametric test was performed.
First, the difference in knowledge scores between the experimental and control groups was compared using a Quade test to correct for differences in pre-test scores. Differences in attitudes and practices scores between the two groups were then compared using independent t-tests. Second, pre- and post-test scores for knowledge, attitudes and practices within the groups were compared using Friedman tests. Third, differences in knowledge, attitudes and practices with respect to road safety education between the groups were compared using independent t-tests or Mann–Whitney tests.
The qualitative data were analysed using thematic analysis. First, transcribed data were read several times to achieve familiarity with overall content and flow and to elucidate the main characteristics. Second, meaningful statements were highlighted and assigned codes. Third, these codes were linked to establish potential themes. The entire dataset was reviewed again to ensure that no potential themes had been overlooked. Fourth, potential themes were reviewed to ensure they fully represented the codes and were relevant to the entire dataset. Then, the themes were assessed to ascertain that the concepts they represented were clearly distinct from one another, after which the themes were named. Finally, the analysed themes and interpretations were described.
Ethical issues
Ewha Womans University Institutional Review Board (no. 149-16) approved this study. The project’s aims, methods and ethical issues pertaining to the study were explained to participants, who voluntarily agreed to participate. In addition, we obtained written informed consent from all participants and their parents.
Quantitative findings
Test of participant homogeneity
Sex, personal road accident experience, family road accident experience and possession of motor vehicle/motorcycle/bike were homogeneous between groups. However, commuting mode of transport (x2 = 11.33, p < .035) and commuting time (U = 222.50, p < .032) were different between the two groups. Regarding mode of commuting, 46.2% of the experimental group used a bicycle, while 30.8% of the control group drove a motorcycle by themselves. In addition, while pre-test attitudes and practices were similar, pre-test knowledge in the control group was significantly higher than that in the experimental group (U = 99.50, p < .001) (Table 1).
General characteristics of participants including pre-test knowledge, attitudes and practices with respect to road safety (N = 52).
C: control group; E: experimental group; M: mean; SD: standard deviation.
Fisher’s exact test.
Mann–Whitney test.
Knowledge
When post-test scores were compared between the two groups after statistically correcting for differences in pre-test results, knowledge was significantly higher in the control group than in the experimental group (F = 13.53, p = .001). On the intra-group comparison, knowledge of the experimental group was significantly improved (Z = −2.79, p = .005), as was the post-test knowledge score of the control group (Z = −2.20, p = .028) (Table 2). With respect to knowledge in each of the road safety domains, commuting safely to school (U = 276.0, p = .191), compliance with road signs (U = 314.5, p = .676) and motor vehicle safety (U = 242.0, p = .065) were not significantly different between the two groups, while knowledge of motorcycle safety (U = 202.0, p = .001) was significantly higher in the control group (Table 3).
Intra- and inter-group comparison of differences in knowledge, attitudes and practices pre- and post-road safety education (N = 52).
C: control group; E: experimental group; M: mean; SD: standard deviation.
Quade test. The mean of the residuals was −5.15 ± 12.34 and 5.15 ± 7.16 for the experimental and control groups, respectively.
Comparison of differences between groups in knowledge, attitudes and practices pre- and post-road safety education (N = 52).
C: control group; E: experimental group; M: mean; SD: standard deviation.
The score of range of each domain of knowledge is 0–11.11 points for safe commute to school, 0–22.22 points for compliance with traffic signs, 0–22.22 points for motorcycle safety and 0–44.44 points for motor vehicle safety.
Mann–Whitney test.
Attitudes
Road safety attitudes were not significantly different between the two groups in inter-group comparison (t = 1.10, p = .278). On intra-group comparisons, the post-test score of the experimental group was significantly higher than the pre-test score (Z = −2.05, p = .041), while there was no significant difference in the control group (Z = −0.93, p = .354) (Table 2). With respect to attitudes on the road safety domains, all domains including safe commute to school (U = 337.5, p = .993), compliance with road signs (U = 243.5, p = .079), motorcycle safety (U = 278.5, p = .267) and motor vehicle safety (t = 0.35, p = .730) were not significantly different between the two groups (Table 3).
Practices
Road safety practice was not significantly different between the two groups in inter-group comparison (t = 1.13, p = .265). On intra-group comparison, there were no significant differences between the experimental (Z = −1.68, p = .093) and control groups (Z = −0.21, p = .903) (Table 2). With respect to practice on each of the road safety domains, practising safe commuting to school (U = 216.5, p = .023) was significantly higher in the experimental group than in the control group. There were no significant differences in compliance with road signs (U = 291.0, p = .378), motorcycle safety (t = 1.07, p = .288) or motor vehicle safety (t = 0.85, p = .398) between the two groups (Table 3).
Qualitative findings
Qualitative interviews identified 46 meaningful statements from which we developed six categories, which were then combined into three main themes.
New instruction on road safety
Participants reported learning new things from the road safety education programme. In particular, they reported learning safe behaviour with which to protect themselves.
Interest in newly learned contents
As a result of the programme, participants reported learning about road signs, road safety rules and safely crossing the street; they noted that the newly learned contents were sometimes surprising to them: Studying road safety makes us think about experiences that we have not studied before. I did not understand road safety rules . . . I am now able to understand many of the road safety rules. (Student B) One interesting thing I learned was road safety compliance. (Student C) I want to learn more about road signs. (Student D)
Road safety behaviour
Participants learned about road safety behaviours to help protect themselves, for example: Before attending the programme, I did not know the meanings of the road signs and how to behave . . . I learned how I should behave. (Student A) I learned that I have to look left and right for safety when I cross the street. (Student C) I learned about safely riding a bicycle. For example, I need to stay on the right side of the road when I bike, and I should not be playing around with my friends. (Student D)
Positive attitude towards road safety
Participants showed a positive attitude towards road safety, saying that compliance with road safety prevents accidents and helps keep themselves and others safe. In addition, they expressed fear of road accidents and had negative feelings about not complying with road safety.
Positive role of road safety
Participants described the expected benefit from practising road safety and expressed a positive attitude towards doing so, stating that road safety behaviour not only protects themselves and their friends but also allows them to be considerate of each other: Complying with road safety every day helps keep us safe and avoid traffic jams. (Student A) I understood road safety. I can help save my friends from accidents. (Student B) Complying with road safety allows us to care for and love each other. (Student C) Complying with road safety keeps us safe when we drive. (Student E)
Fear of road accidents
Participants expressed a fear of road accidents after witnessing neighbours not complying with road safety rules or when being non-compliant themselves. They expressed a negative attitude towards the consequences of non-compliance with road safety rules: I am very scared when I see a friend who does not comply with road safety rules. (Student A) When I do not comply with road safety rules, I am scared I’ll be in a road accident. (Student D) Not adhering to road safety rules myself is as horrible as seeing a friend violating road safety rules. (Student F)
Efforts to practice road safety
Participants reported practising the road safety norms they had learned through the programme so as to protect themselves and their families.
Practising road safety in daily life
Participants specifically listed the safety behaviours they practised in their own lives following the programme and explained the behavioural changes they had made: Since attending the programme, I cross the street using crosswalks. (Student A) Since the programme, I practise safe behaviours by not riding my bike too fast. (Student B) Since attending the programme, I wear a helmet whenever I ride my motorcycle. I ride my bike slowly and follow the traffic lights. (Student F)
Spreading road safety awareness to neighbours
Finally, participants shared the information they had learned with people around them. They stated that they would tell others about the negative consequences of non-compliance with road safety regulations and would share their knowledge to promote safer behaviour in others: When my parents or friends do not comply with road safety, I will tell them they will be fined by the police and they may die if an accident occurs. (Student A) When I see my friends and family not complying with road safety rules, I will tell them what I learned. (Student B) I told my younger sibling to not stay behind cars or cross the street outside of a crosswalk. (Student F)
Discussion
This study developed a locally relevant road safety educational programme for senior elementary school students in Cambodia and attempted to verify its effectiveness. To the best of our knowledge, this is one of the first attempts in Cambodia to implement a road safety education programme addressing a range of relevant issues. The education programme was developed using the ADDIE instructional design model and was tailored for and tested in elementary schools in Cambodia.
Prior to intervention, the elementary school we worked in did not offer road safety education. We expected the experimental and control groups to have similar backgrounds and learning curves. However, we found a priori differences between groups, most likely because the control group was a year older than the experimental group. The control group had more exposure to traffic, and even without specific road safety education, they were likely to have received more informal road safety education from their parents or neighbours (Oxley et al., 2007). In addition, the difference between two groups may perhaps be explained by their different modes of commuting and the commuting time. A higher percentage of fifth- than fourth-grade students commuted to school by motorcycle and had longer commute times, suggesting that those students had to travel relatively longer distances. Thus, the control group had been more exposed than the experimental group to situations in which road safety needed to be taken into consideration.
The corrected post-test knowledge score was higher in the control group than in the experimental group, which suggested that participating in the pre-test may have served to educate the control group students, who already had relatively more experience in riding motorcycles. Moreover, the benefits of testing were likely overstated by using the same instruments to assess post-test knowledge (Gray et al., 2018); hence, future studies should use different items with similar difficulty and discrimination for each test to test knowledge, to prevent such an effect. Intra-group comparisons of pre- and post-test knowledge revealed that the experimental group improved significantly. This is consistent with findings in previous studies (Bachman et al., 2015; Hatfield et al., 2019) in which significant differences were observed between pre- and post-test knowledge of road safety rules following bicycle safety education. However, the control group also showed improvements in post-test knowledge score, suggesting the need for additional research to assess the effectiveness of this educational programme on road safety knowledge.
Qualitative assessment showed that the programme provided an opportunity for children to acquire an understanding of new topics they have never learned before. This indirectly suggests the need for new road safety educational programmes that include various topics related to the main causes of local road accidents, in addition to motorcycle safety. This is a topic covered by existing road safety education in Cambodia (Asia Injury Prevention Foundation, 2018; Ederer et al., 2016). Moreover, participants reported learning proper road safety behaviours, showing that the knowledge they acquired could be applied and suggesting a shift towards a higher cognitive domain (Bloom, 1956).
There was no difference in attitudes towards road safety between the groups before and after the programme. However, intra-group comparisons of pre- and post-test attitudes showed a significant difference only in the experimental group, demonstrating the benefits of the educational programme. This particular finding was consistent with data from Adams et al. (2014), wherein the attitudes of their experimental group changed significantly following helmet safety education. Although there was a significant difference only in intra-group comparison of attitudes, considering that attitudes are difficult to change with short-term education (Kelly and Barker, 2016), it is expected that there may be inter-group differences in attitudes if the educational period is prolonged. In addition, to achieve a lasting positive attitude towards road safety, the instructional period should be prolonged, perhaps by gradually introducing more advanced programmes every school year. Qualitatively, we observed that the participants thought positively about complying with road safety rules and negatively about disobeying them, suggesting a positive attitudinal impact of the education programme.
There were no differences in intra- and inter-group comparisons of road safety practices pre- and post-test; thus, we found no overall road practice effects of the programme. Hatfield et al. (2019) also found no significant change in practice after imparting road safety education, whereas Ederer et al. (2016) did. However, we found a significant difference within the ‘safe commuting to school’ domain. Commuting to school is a daily task; thus, participants likely had the opportunity to immediately apply what they learned in the programme, leading to differences within thus domain. Intra-group comparison of road safety practices pre- and post-test revealed that the p-value for the experimental group (p = .093) was much lower than that of the control group (p = .903). Long-term intervention may be needed to lead to significant change in the practice of road safety. The qualitative assessment showed that they seemed to change their real-life road safety practices, suggesting that the programme may have influenced them. Moreover, participants made efforts to promote road safety awareness in others in order to protect both themselves and their neighbours.
Limitations
This study had some limitations. First, there was limited power to detect significant differences as the study included only 26 participants per group, which was less than intended sample size of 27. In addition, the number of participants in the focus group interview was limited, and only one focus group took place. Second, homogeneity between the two groups could not be confirmed. Due to local conditions, it proved difficult to select a control group similar to the experimental group. As this was a pilot study, further assessment is necessary to establish the effects of this road safety education programme, preferably using a randomised controlled trial design with a sufficient number of participants. Finally, as this study was based on self-report, we cannot offer an assessment of actual changes in attitudes and practices. Other data collection methods such as direct observation should be considered in further studies.
Conclusion
As a pilot study, this elementary school-based road safety educational programme showed promise as way of imparting knowledge and affecting the attitudes in Cambodian children. Although the programme needs further evaluation, it has undergone systematic educational development and local application. It also meets Cambodia’s needs, and local teachers can apply the programme as part of their curriculum. The programme can be utilised to overcome the lack of professional health educators in Cambodian elementary schools. Therefore, following additional verification, the programme could be deemed useful for educational purposes.
Supplemental Material
sj-docx-1-hej-10.1177_00178969221090584 – Supplemental material for Evaluation of a road safety educational programme for senior elementary school students in Cambodia: A pilot study
Supplemental material, sj-docx-1-hej-10.1177_00178969221090584 for Evaluation of a road safety educational programme for senior elementary school students in Cambodia: A pilot study by Bomi An and Sook Ja Yang in Health Education Journal
Footnotes
Acknowledgements
We thank Ewha-Srang School in Cambodia for helping us to conduct this study.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
Supplemental material
Supplemental material for this article is available online.
References
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