446374

et alJournal of Primary Care & Community Health

© The Author(s) 2010

Reprints and permission:

JPCXXX10.1177/2150131912446374Novak

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Journal of Primary Care & Community Health

Evaluation of a Standardized All-Terrain 4(1) 8­–13

© The Author(s) 2013
Reprints and permission:
Vehicle Safety Education Intervention sagepub.com/journalsPermissions.nav
DOI: 10.1177/2150131912446374

for Youth in Rural Central Illinois http://jpc.sagepub.com

Joshua A. Novak1, John W. Hafner2,3, Jean C. Aldag2,

and Marjorie A. Getz4

Abstract
Background: Although research investigating all-terrain vehicle (ATV) riders and ATV injury patterns has led to
support for legislative and educational efforts to decrease injuries in users younger than 16 years, there is little published
data regarding the utility of ATV safety education programs. This study investigates the effectiveness of a standardized
adolescent ATV safety program in changing the safety knowledge and safe ATV riding practices reported by rural Central
Illinois youths. Methods: A convenience sample of 260 rural Central Illinois middle and high school students received an
ATV safety presentation with both didactic and interactive features during the 2009-2010 school year. Preintervention
and postintervention surveys were distributed and collected by teachers. Survey questions consisted of multiple-choice
questions pertaining to demographics, ATV safety knowledge, and ATV riding practices. More than 200 surveys were
collected prior to the intervention and 165 surveys were collected 12 to 24 weeks after the intervention. Percentages
are reported, with differences in nominal variables tested by χ2 test and interval variables by t test. Results: Following
the intervention, there was a significant increase in the correct response rate for ATV safety knowledge questions (45.2%
vs 56.2%, P < .001). For adolescents who reported riding ATVs, both safety gear use (11.8% to 21.2%, P = .05) and
helmet use (25.4% to 29.0%, P = .56) increased; changes were not significant. Adolescent ATV riders reporting 2 or more
accidents showed a slight nonsignificant decrease (25.2% vs 23.4%, P = .77) between the time of the pretest and posttest.
Conclusion: This safety program was effective at increasing ATV safety knowledge but demonstrates limited effect on
safe riding practices.

Keywords
all-terrain vehicle, ATV, education, youth, injury prevention

Introduction
The all-terrain vehicle (ATV) was introduced in America in
the 1970s and has gained in popularity with an estimated
5.6 million ATVs in the United States and 2364 million
driving hours in 2001.1 ATVs are designed with large, low-
pressure tires to be used on rugged, irregular terrain. The
rider straddles atop the engine using a handlebar configura-
tion to steer a vehicle with most engine sizes greater than
400 cm3, vehicle weights up to 600 pounds, and vehicle
speeds up to 75 miles per hour.2-4 Studies using US
Consumer Product Safety Commission data have shown
that young ATV riders are at higher risk for injury and
death. Among ATV users, riders who are younger than
16 years encompass only 18% of users but represent 28%
of ATV-related injuries and 18% of ATV-related deaths.5
ATV drivers younger than 16 years have almost 4 times the
risk for injury compared with riders older than 16 years.
When compared with ATV riders older than 45 years, riders
younger than 16 years have 12 times the risk of injury.3
Some authors posit that this risk is because of children’s
lack of physical strength, higher order cognitive abilities,
and the potential speed achievable by ATVs; this latter fac-
tor can make ATV operation more difficult than the
operation of automobiles.2,6 These factors make ATV
1
David Geffen School of Medicine, University of California, Los Angeles,
Los Angeles, CA, USA
2
University of Illinois College of Medicine at Peoria, Peoria, IL, USA
3
OSF Saint Francis Medical Center/Children’s Hospital of Illinois, Peoria,
IL, USA
4
Methodist Medical Center, Peoria, IL, USA
Corresponding Author:
John W. Hafner, Department of Surgery, OSF Saint Francis Medical
Center/Children’s Hospital of Illinois, Department of Emergency
Medicine, 530 NE Glen Oak Avenue, Peoria, IL 61637, USA
Email: jhafner@pol.net
Novak et al. 9
operation inherently dangerous, and many researchers have
advocated for increased education programs and legislation
to decrease the national ATV injury epidemic affecting this
young population.
This study begins the process of determining if educa-
tional activities are effective in decreasing this injury risk.
A collaborative, pilot project was developed between the
Children’s Hospital of Illinois/OSF Saint Francis Medical
Center and the Peoria County Sheriff’s Office to provide an
ATV education and safety demonstration to rural students
of Central Illinois, known as the Rural Youth ATV Safety
Education Program. We sought to determine the effective-
ness of this program for improving users’ ATV knowledge
and safety practices.
Methods
The study used a descriptive research strategy with a one
group pretest/posttest design. Pretest and posttest question-
naires surveyed participants’ knowledge about ATV safety,
personal safety practices, ATV use patterns, and descrip-
tions of ATV-related crashes and injuries. Rural middle and
high schools throughout 3 counties of West-Central Illinois
were approached for participation in the program.
Administrators from 1 rural middle school and 2 rural high
schools agreed to participate. The convenient sample con-
sisted of the students present on the pretest/intervention day
and then the posttest day. The institutional review board
would not allow personal identifiers to match the students
who were present on both days.
The intervention consisted of a standardized Microsoft
PowerPoint lecture highlighting ATV usage and mechan-
ics, injury risk factors, and recommended safety practices,
coupled with a “hands-on” safety demonstration of relevant
safety gear and ATV operation using full-sized ATVs and
equipment. The intervention was conducted on school
property, during scheduled class time. Prior to the interven-
tion, pretest surveys were completed during homeroom
class periods. Postintervention surveys were mailed to the
school at least 12 weeks after the presentation and distrib-
uted by teachers to the same students who had previously
participated.
Questions on the survey included student demographic
information, ATV use patterns, ATV safety knowledge,
protective equipment use, and history of ATV-related inju-
ries and crashes. Community was defined as a rural area/not
a farm, farm, small town (<10 000 people), or a city (>10
000 people). ATV safety knowledge questions were based
on Illinois ATV regulations and adapted from several
sources. ATV safety knowledge questions included identi-
fying the appropriate locations to ride ATVs (trails and non-
paved surfaces), affirming that ATVs were not designed to
carry passengers, identifying the correct type of helmet,
identifying the recommended ATV size for participant’s
age group, and identifying adolescent developmental char-
acteristics that lead to higher injury rates (insufficient
strength, cognitive abilities, and motor skills for adult-sized
machines). Participants were queried about routine helmet
and safety gear use (5-category, ordinal scale, using “always”
to “never” as anchor points) and were asked if they had ever
participated in an ATV safety course. Participants were
asked to report any ATV crashes that occurred during the
previous 6 months. If a participant indicated that they had
been involved in a crash, a follow-up query asked if they
had required medical attention.
A pilot study, performed in the previous year, allowed
the questions to be evaluated and modified for clarity and
responses to be grouped in categories. The pre and post
responses were primarily analyzed using those respondents
who reported having driven or ridden on an ATV over the
past 6 months (riders). For the purposes of analysis, ordinal
scale responses were grouped into representative dichoto-
mous categories (“always” and “mostly” were grouped as
positive responses; “neutral,” “not often” and “never” were
grouped as negative responses). Chi-square tests or
Fischer’s exact tests were used to examine differences
between groups for nominal variables and t tests were used
for interval variables. A significance level was accepted at
P < .05. Student responses were combined into aggregate
preintervention and postintervention categories because our
institutional review board approval did not allow for indi-
vidual respondent matching. The primary outcome for the
study was collective ATV safety knowledge improvement
(percentage change in the aggregate correct responses of
the 5 ATV safety knowledge questions).
Results
The educational intervention was presented to rural Central
Illinois adolescent youths at 3 sites that consisted of 2 high
schools and 1 middle school. Of the participants, 207
responded to the preintervention survey (51.2% male, mean
age 13.1 years), whereas 165 (55.5% male, mean age
13.2 years) completed the postintervention survey. Table 1
gives the characteristics of riders (drivers and passengers)
and nonriders. Riders and nonriders were similar in age and
school grade. Whereas the largest proportion of riders
(55.8%) resided in small towns, of the 116 that reported
living on a farm, 92.2% were riders. This contrasted with
74.6% of the 213 respondents living in a small town and
54.3% of the 35 respondents living in a city being riders. A
larger percentage of riders (56.6%) compared with nonrider
families (3.8%) owned an ATV. Of the riders, 82.8%
reported riding an ATV within the past 6 months.
Among all riders students increased significantly in their
overall knowledge from the preintervention survey to pos-
tintervention survey (45.2% vs 56.2% correct; P < .001) on
the 5-knowledge-item test. The individual components of
10 Journal of Primary Care & Community Health 4(1)

Table 1. Characteristics of Survey Responders

Riders, n = 290 Nonriders, n = 80 P
Age in years; mean (SD) 13.21 (1.27) 13.00 (1.51) .250
No. of years of ATV riding experience; mean (SD) 4.16 (2.59)  
Grade; mean (SD) 7.76 (1.30) 7.68 (1.57) .704
Gender 57.9% male 36.3% male .001
Living location; % .001
 Farm 37.5 11.4  
  Small town 55.8 68.4  
 City 6.7 20.3  
ATV report family ownership; % 56.6 3.9 <.001
Abbreviation: ATV, all-terrain vehicle.

Table 2. Percentage Correct of All-Terrain Vehicle (ATV) Safety Knowledge Items by ATV Riders
Percentage Correct Responses
ATV Safety Knowledge Item Pre, n = 155 Post, n = 129 P
All knowledge questions in aggregate 45.2 56.2 <.001
Correct location for ATV usage 30.1 37.7 .209
Standard ATV not designed for passenger 46.8 73.3 <.001
Correct ATV helmet type 73.9 82.3 .117
Developmental characteristics associated with injuries 36.5 43.2 .279
Correct engine size for 14-year-old 37.7 43.2 .401

Table 3. Changes in All-Terrain Vehicle (ATV) Riding Behavior Among ATV Riders
Percentage Responses
  Pre, n = 137 Post, n = 108 P
Participation in formal ATV safety course 3.6 4.6 .753
Two or more crashes in pre- and post-intervention periods 25.2 23.4 .765
Wearing helmet “always” or “most of time” 25.4 29.0 .561
Wearing safety gear “always” or “most of time” 11.8 21.2 .052

the test are listed in Table 2. Students gained significant Discussion

improvement in recognizing that an ATV is not designed to
carry passengers (P < .001). Although the remaining 4 items
were more frequently answered affirmatively in the posttest
compared with the pretest, there was no significant differ-
ence for the correct location for ATV usage, correct helmet
type, risk of injury compared with adult rider and correct
engine size.
None of the changes in the 4 ATV riding behaviors
among those reporting to have ridden in the last 6 months
were significant for the pretest–posttest differences (see
Table 3). A slightly larger proportion reported 2 or more
crashes in the preperiod than in the postperiod. The partici-
pation in other ATV safety courses, always or most of the
time wearing a helmet or safety gear increased slightly from
the pretest to the posttest.
Investigations of ATV-related injuries have shown the risk of
injury is higher for young ATV riders. One study has demon-
strated children have 4.7 times the risk compared with adults for
involvement in a right-sided rollover, even when excluding
collision crashes.7 The high risk of injury for ATV riders
younger than 16 years is also shown through ATV-related hos-
pitalizations and the associated cost impact. From 2000 to 2004
there were an estimated 58 254 hospitalizations related to ATVs
and of these admissions, 30% were younger than 18 years. The
highest rate of ATV-associated hospitalization per 100 000
population was in the younger than 18 years age-group.8 In a
study comparing the years 1997 to 2000, an estimated $70 mil-
lion in hospital charges accrued related to ATV injuries,
with 20% of the charges being paid by public insurance.9
Novak et al. 11
These injury risks to adolescent ATV riders and their
subsequent public health impact have led to advocacy
efforts to decrease ATV-related injuries. The American
Academy of Orthopaedic Surgeons, the American Academy
of Pediatricians, and the Canadian Association of Pediatric
Surgeons have issued policy statements that include limit-
ing the operation of ATVs to a minimum age of 16 years.10-12
However, several studies have pointed out that similar
enacted legislation has not been effective. For example, a
study examining pediatric ATV incidents in Utah, another
examining the short-term legislative impact in North
Carolina, another describing injury patterns in Florida; as
well as studies that compare states with the greatest and
least ATV-related pediatric mortality with established state
legislation, have all demonstrated that legislation in isola-
tion is ineffective at preventing ATV-related injuries and
mortality.13-17 Winfield et al17 have advocated for legisla-
tion that promotes safety education and certification through
knowledge and skill testing as an alternative to restrictive
use legislation.
Determining the best strategy for implementing ATV
educational programs has been investigated previously.
Research using several focus groups investigated what type
of education programs adults and teenagers view positively.
Inclusion of ATV safety education in youth forums at
school or as part of driver education programs was viewed
most positively by these focus groups.18 Of interest, find-
ings from this research suggest that restricting age limit to
those 16 years old and older was viewed negatively and
would fail to affect the reality of ATV use. A study at the
national convention for the Future Farmers of America
found that nearly half the participants did not have ATV
training available to them and suggested frequent danger-
ous behaviors that should be the focus of educational inter-
ventions.19 It also has been shown that community-based
prevention programs effectively increase safety knowledge
and decrease injuries associated with various injury mecha-
nisms, including drowning, traffic injuries, residential fires,
bicycle accidents, tap water burns, and car accidents.20-26
Our ATV safety program was modestly effective at
increasing ATV-related safety knowledge collectively.
Several of the topics covered in the current intervention
have been shown to be important safety topics to address
with adolescent ATV riders.19 However, individual safety
issues, such as riding in the correct location, appropriate
helmet type and usage, and adolescent developmental char-
acteristics addressed in this ATV education intervention did
not show significant knowledge improvement amongst ado-
lescent ATV riders. Although addressed in the educational
intervention, there were no knowledge changes noted for
riders younger than 16 years using a recommended youth-
sized ATV. This issue should be strongly addressed in any
future interventions as nearly 90% of injuries to young
ATV riders occur while using an adult-sized ATV.27,28 One
possible way to address this safety issue is by focusing edu-
cational interventions on parents, as they represent the
group actually purchasing the ATVs.
Even with an overall increase in safety knowledge, our
nonsignificant changes in riding practices and crash rates
demonstrate that youth behavior is more difficult to impact
than knowledge. The results from this study indicate that
the Rural Youth ATV Safety Education Program may be an
effective first step to a much broader, community-based
intervention that is needed to affect the safety knowledge
and riding behavior of rural Central Illinois youths. A com-
mon element of successful adolescent bicycle helmet pro-
motion programs is the use of multiple strategies targeted at
different audiences to address the pivotal barriers.29,30 ATV
safety educational interventions should not only target rural
youths but also aim to influence the knowledge and behav-
ior of the parents of these young operators, as well as com-
munity leaders and organizations. Although many injury
prevention programs have included education and the dis-
tribution of discounted or free safety equipment, implemen-
tation of similar strategies for an ATV safety campaigns
will be more difficult, given the use of the vehicles on pri-
vate property, the diversity of vehicle types, the relatively
high costs of recommended motorcycle helmets, and the
low use of safety equipment at baseline.18 In addition, effec-
tive safety knowledge transfer is not likely a linear process,
but rather that it is an interactive, multidirectional process,
that benefits from multiple interconnected interventions.31
Therefore, using a wide variety of interventions and tech-
niques (ie, hands-on training, safety courses, social marketing,
safety regulation) may yield the best effect on adolescent
ATV injury prevention.
Limitations of this study include the convenience sample
and the inability to match preintervention and postinterven-
tion surveys to individual participants. Given the lack of
previously published ATV safety programs in this popula-
tion, we felt this enrollment model would provide basic data
and trends regarding the intervention. As the present study
was limited because of the convenient sample, a larger, ran-
domized trial based on a power analysis needs to be con-
ducted. As we were seeking self-reported information
regarding risky behavior, it was felt that self-identification
might have deterred individuals from truthfully completing
the survey. This limited tracking those participants that
dropped out of the study and prevented the matching of
individual results on pretests and posttests. Although
absences and students not returning the postintervention
surveys account for the differences in numbers of surveys,
the similarities in sample demographics from the preinterven-
tion to the postintervention surveys suggests that the popu-
lation of students who received the educational intervention
and completed the preinterventional and postinterventional
12 Journal of Primary Care & Community Health 4(1)
survey were similar. The study participants were all from
rural Central Illinois and regional differences in ATV oper-
ation and legislation may limit the generalizability of the
results. We inquired into ATV crashes and related injuries;
however, this study was underpowered to determine if the
intervention caused any change in ATV-related injuries
or fatalities. The sporadic nature of ATV-related injuries
requires a much larger population base beyond the scope of
this investigation.
Conclusions
In conclusion, our Rural Youth ATV Safety Education
Program was effective at increasing ATV safety knowledge
in rural Central Illinois youths. However, affecting the
behavior of young ATV operators was not successful and
represents a much more challenging initiative. In the future,
the design and implementation of a community-based,
multi-agency ATV injury prevention intervention might
benefit by targeting not only youths but also their parents to
improve its impact.
Authors’ Note
This study was presented as a poster at the 138th American Public
Health Association Annual Meeting and Exposition, Injury Control
and Emergency Services Section, Denver, Colorado, November 2010.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article:
Funding for this study was provided through a Robert Wood
Johnson Grant for the Injury Free Coalition for Kids of Peoria.
References
1. Levenson MS. All-terrain vehicle 2001 injury and exposure
studies. Bethesda, MD: US Consumer Product Safety Com-
mission; 2003. http://www.cpsc.gov/library/foia/foia03/os/
atvex2001.pdf. Accessed February 20, 2009.
2. Scutchfield SB. All-terrain vehicles: injuries and prevention.
Clin Orthop Relat Res. 2003;409:61-72.
3. Rodgers GB, Adler P. Risk factors for all-terrain vehicle
injuries: a national case-control study. Am J Epidemiol.
2001;153:1112-1118.
4. Yuma PJ, Maxson RT, Brown D. All-terrain vehicles and
children: history, injury burden, and prevention strategies.
J Pediatr Health Care. 2006;20:67-70.
5. Garland S. 2009 annual report of ATV-related deaths and
injuries. Bethesda, MD: US Consumer Product Safety
Commission; 2010. http://www.cpsc.gov/library/foia/foia11/
os/atv2009.pdf. Accessed March 11, 2011.
6. Brown RL, Koepplinger ME, Mehlman CT, Gittelman M,
Garcia VF. All-terrain vehicle and bicycle crashes in chil-
dren: epidemiology and comparison of injury severity. J
Pediatr Surg. 2002;37:375-380.
7. Brandenburg MA, Brown SJ, Archer P, Brandt EN Jr.
All-terrain vehicle crash factors and associated injuries in
patients presenting to a regional trauma center. J Trauma.
2007;63:994-999.
8. Helmkamp JC, Furbee PM, Coben JH, Tadros A. All-terrain
vehicle–related hospitalizations in the United States, 2000-
2004. Am J Prev Med. 2008;34:39-45.
9. Killingsworth JB, Tilford JM, Parker JG, Graham JJ, Dick RM,
Aitken ME. National hospitalization impact of pediatric all-
terrain vehicle injuries. Pediatrics. 2005;115:e316-e321.
10. American Academy of Orthopaedic Surgeons. All-terrain
vehicles position statement. http://www.aaos.org/about/
papers/position/1101.asp. Accessed February 14, 2009.
11. American Academy of Pediatrics Committee on Injury and
Poison Prevention. All-terrain vehicle injury prevention:
two-, three-, and four-wheeled unlicensed motor vehicles.
Pediatrics. 2000;105:1352-1354.
12. Trauma Committee of the Canadian Association of Pediatric
Surgeons. Canadian Association of Pediatric Surgeons’ posi-
tion statement on the use of all-terrain vehicles by children
and youth. J Pediatr Surg. 2008;43:938-939.
13. Cvijanovich NZ, Cook LJ, Mann NC, Dean JM. A population-
based assessment of pediatric all-terrain vehicle injuries.
Pediatrics. 2001;108:631-635.
14. Upperman JS, Shultz B, Gaines BA, et al. All-terrain vehicle
rules and regulations: impact on pediatric mortality. J Pediatr
Surg. 2003;38:1284-1286.
15. Keenan HT, Bratton SL. All-terrain vehicle legislation for
children: a comparison of a state with and a state without a
helmet law. Pediatrics. 2004;113:e330-e334.
16. Beidler SK, Kromhout-Schiro S, Douillet CD, Riesenman PJ,
Rich PB. North Carolina all-terrain vehicle (ATV) safety
legislation: an assessment of the short-term impact on
ATV-related morbidity and mortality. N C Med J. 2009;70:
503-506.
17. Winfield RD, Mozingo DW, Armstrong JH, et al. All-terrain
vehicle safety in Florida: is legislation really the answer? Am
Surg. 2010;76:149-153.
18. Aitken ME, Graham CJ, Killingsworth JB, Mullins SH,
Parnell DN, Dick RM. All-terrain vehicle injury in chil-
dren: strategies for prevention. Inj Prev. 2004;10:303-307.
19. Burgus SK, Madsen MD, Sanderson WT, Rautiainen RH.
Youths operating all-terrain vehicles—implications for safety
education. J Agromed. 2009;14:97-104.
20. Bennett E, Cummings P, Quan L, Lewis FM. Evaluation of a
drowning prevention campaign in King County, Washington.
Inj Prev. 1999;5:109-113.
Novak et al. 13
21. Durkin MS, Laraque D, Lubman I, Barlow B. Epidemiology
and prevention of traffic injuries to urban children and ado-
lescents. Pediatrics. 1999;103:e74.
22. Mallonee S, Istre GR, Rosenberg M, et al. Surveillance
and prevention of residential-fire injuries. N Engl J Med.
1996;335:27-31.
23. Thompson DC, Rivara FP, Thompson RS. Effectiveness of
bicycle safety helmets in preventing head injuries. A case-
control study. JAMA. 1996;276:1968-1973.
24. Bergman AB, Rivara FP, Richards DD, Rogers LW. The
Seattle children’s bicycle helmet campaign. Am J Dis Child.
1990;144:727-731.
25. Ebel BE, Koepsell TD, Bennett EE, Rivara FP. Use of child
booster seats in motor vehicles following a community cam-
paign: a controlled trial. JAMA. 2003;289:879-884.
26. Towner E, Dowswell T. Community-based childhood injury
prevention interventions: what works? Health Promot Int.
2002;17:273-284.
27. Goldcamp EM, Myers J, Hendricks K, Layne L, Helmkamp J.
Nonfatal all-terrain vehicle-related injuries to youths living
on farms in the United States, 2001. J Rural Health. 2006;22:
308-313.
28. General Accounting Office. All-terrain vehicles: how they
are used, crashes, and sales of adult-sized vehicles for chil-
dren’s use. GAO-10-418. April 10, 2010.
29. Morris BP, Trimble NE. Promotion of bicycle helmet use
among schoolchildren: a randomized clinical trial. Can J
Public Health. 1991;82:92-94.
30. DiGuiseppi CG, Rivara FP, Koepsell TD, Polissar L. Bicycle
helmet use by children. Evaluation of a community-wide hel-
met campaign. JAMA. 1989;262:2256-2261.
31. Ward V, House A, Hamer S. Developing a framework for
translating knowledge into action: a thematic analysis of the
literature. J Health Serv Res Policy. 2009;14:156-164.
Bios
Joshua A. Novak, MD, is currently a first-year resident physician
at UCLA Emergency Medicine Residency Program and conducted
this research as a medical student in the James Scholar Research
program at the University of Illinois College of Medicine at Peoria.
John W. Hafner, MD, MPH, is a clinical associate professor of
surgery in the Division of Emergency Medicine at the University
of Illinois College of Medicine at Peoria and serves as the Research
Director of the Emergency Medicine Residency Program.
Jean C. Aldag, PhD, is an adjunctive professor of preventative medi-
cine and is the Chairperson of the James Scholar Committee at the
University of Illinois College of Medicine at Peoria. For this project,
she worked with the project methodology and statistical analysis.
Marjorie A. Getz, MA, MPhil, serves as the Health Science
Program Coordinator for the Methodist School of Nursing and has
participated in multiple studies on community health initiatives
and injury prevention research as a core member of the Injury Free
Coalition for Kids of Peoria.