CAREGIVER PERCEIVED SELF-EFFICACY AND SUPERVISION IN CHILDHOOD
UNINTENTIONAL INJURY PREVENTION: THE MODERATING ROLE OF
DEVELOPMENTAL KNOWLEDGE
A dissertation submitted
to Kent State University in partial
fulfillment of the requirements for the
degree of Doctor of Philosophy
by
Shanna M. Guilfoyle
August, 2009
Dissertation written by
Shanna M. Guilfoyle
B.A., University of Colorado at Boulder, 2000
M.A., Kent State University, 2005
Ph.D., Kent State University, 2009
Approved by
_____________________________, Chair, Doctoral Dissertation Committee
Beth Wildman
_____________________________, Members, Doctoral Dissertation Committee
Josefina Grau
_____________________________,
Manfred van Dulmen
_____________________________,
Diane Langkamp
Accepted by
_____________________________, Chair, Department of Psychology
Mary Ann Stephens
_____________________________, Dean, College of Arts and Sciences
John R. Stalvey
ii
TABLE OF CONTENTS
LIST OF TABLES ............................................................................................................. iv
CHAPTER
I
Page
INTRODUCTION ...................................................................................................1
Childhood Unintentional Injury Risk.......................................................................2
Incidence and Conceptualization .......................................................................2
The Attitude-Practice Gap .................................................................................4
Caregiver Supervision ..............................................................................................7
Self-Efficacy ............................................................................................................9
Knowledge of Child Development ........................................................................11
Self-Efficacy, Developmental Knowledge, and Parenting Practices ....................14
Parental Impact on Childhood Unintentional Injury .............................................16
Protection Motivation Theory ...............................................................................18
Objectives of the Current Study ............................................................................19
II
METHOD ..............................................................................................................22
Participants ............................................................................................................22
Procedure ...............................................................................................................24
Measures ................................................................................................................26
Demographic Information ...............................................................................26
Child Behavior ................................................................................................26
Caregiver Supervision ......................................................................................27
Childhood Unintentional Injury .......................................................................28
Developmental Knowledge .............................................................................30
Self-Efficacy ....................................................................................................31
Statistical Analysis Plan ........................................................................................32
Power Analysis ......................................................................................................34
iii
TABLE OF CONTENTS (Continued)
CHAPTER
III
Page
RESULTS ..............................................................................................................35
Descriptive Statistics .............................................................................................35
Demographic Characteristics .................................................................................35
Correlational Analyses ..........................................................................................35
Regression Analyses ..............................................................................................38
Mother-Father Caregiver Convergence on Main Study Variables .......................41
IV
DISCUSSION ........................................................................................................42
REFERENCES ..................................................................................................................50
APPENDICES ...................................................................................................................67
A
DEMOGRAPHIC QUESTIONNAIRE .................................................................68
B
STRENGTHS AND DIFFICULTIES QUESTIONNAIRE .................................71
C
PARENTAL SUPERVISION ATTRIBUTES PROFILE
QUESTIONNAIRE ...............................................................................................73
D
INJURY BEHAVIOR CHECKLIST ....................................................................76
E
INJURY ATTITUDES QUESTIONNAIRE ........................................................78
F
DEVELOPMENTAL KNOWLEDGE QUESTIONNAIRE .................................80
G
PARENT SENSE OF INJURY COMPETENCE .................................................82
iv
LIST OF TABLES
Table
Page
1
Caregiver Demographics Data ..............................................................................23
2
Descriptive Statistics for Mothers and Fathers ......................................................36
3
Inter-correlations Between Main Study Variables .................................................37
4
Summary of Hierarchical Regression Analysis for Maternal Caregivers .............39
v
CHAPTER I
INTRODUCTION
Childhood unintentional injury is the leading cause of death to children in the
United States (Heron, 2007; National Safety Council, 2004). Caregiver supervision is
often regarded as the most effective method of injury prevention (Morrongiello, 2005;
Peterson et al., 1986). However, constant supervision is neither realistic nor
developmentally appropriate, particularly as children mature. Caregivers seem to have
difficulty determining when and how to implement their supervisory practices, as injury
often occurs when caregivers are reportedly supervising their children (Morrongiello,
Ondejko, & Littlejohn, 2004b; Wills et al., 1997a, 1997b). Minimal research has been
dedicated to examining the cognitive attributions that may assist in explaining how
caregivers choose their supervisory practices. Examination of caregiver cognitions may
provide insight into the individual differences in caregiver supervision within the context
of injury prevention.
The developmental literature has examined cognitive characteristics of caregivers
that promote caregiver behavioral competence with their children and the healthy
development of children. Caregiver knowledge of child development and perceived selfefficacy have been identified as cognitive attributes that enhance caregiver behavioral
competence. Specifically, caregivers with more accurate developmental knowledge tend
1
2
to perceive themselves as more efficacious and, in turn, demonstrate greater behavioral
parenting competence (Conrad, Gross, Fogg, & Ruchala, 1992; Hess, Teti, & HusseyGardner, 2004). Such findings were hypothesized to generalize to other parenting
contexts, such as unintentional injury prevention.
The purpose of the current study was to examine the potentially individual and
interactive effects of caregiver perceived self-efficacy and caregiver developmental
knowledge on caregiver supervision using Protection Motivation Theory (PMT; Maddux
& Rogers, 1983; Prentice-Dunn & Rogers, 1986; Rogers, 1983) as a theoretical
framework. The current study was conducted to enhance the unintentional injury
literature by: (a) integrating prior findings from the child development literature, (b)
applying a sound theoretical framework to an area that has been largely atheoretical, and
(c) examining the relationship between caregiver cognitive attributions and supervision.
Childhood Unintentional Injury Risk
Incidence and Conceptualization
Unintentional injury, which the general public often refers to as accidents, causes
death to children more so than the next 10 leading causes of childhood mortality
combined in the United States (Heron, 2007; National Safety Council, 2004). Results
from epidemiological studies, such as the statistics outlined below (Danseco, Miller, &
Spicer, 2000), have called attention to the alarming incidence of childhood injury
morbidity and mortality rates (38 per 100,000 deaths). Annually, 20.6 million caregiverreported injuries occur to children. Per day, 56,000 nonfatal, medically attended,
3
childhood injuries are reported. The male fatal injury rate is approximately 50% higher
than the rate for females (30 per 100,000 versus 20 per 100,000, respectively; Danseco et
al., 2000). Boys also experience up to four times as many non-fatal injuries than girls
(Morrongiello & Hogg, 2004). Injury rates also vary by stage of development. Toddlers
are at higher risk for burns and poisonings (Agran, Anderson, Winn, Trent, & WaltonHaynes, 2003; Pickett, Streight, Simpson, & Brison, 2003) and early childhood-aged
children are at increased risk for lacerations, contusions, and fractures incurred during
sports and playground activities. Historically, injury researchers and caregivers often
considered accidents to be the plausible consequence of carelessness, stupidity or
indifference (Kronenfeld & Glik, 1995). Accidents were often believed to be nonpreventable and the result of fate. Once data identified the preventability of accidental
injury, the term accidental injury was re-conceptualized by injury researchers as
unintentional injury (i.e., injury not resulting from maltreatment or violence). However,
most caregivers continue to refer to unintentional injury as accidents.
Two injury prevention approaches have been presented in the literature: passive
and active strategies (Tremblay & Peterson, 1999). Passive strategies are
structural/environmental interventions, which typically require minimal parental effort
(e.g., employment of fire detectors, security gates, electrical outlet covers, and locked
cabinets containing hazardous substances). Active strategies often require consistent, or
repeated, actions by caregivers (e.g., supervision during bathing or kitchen activities).
Optimal injury control is conceptualized as the effective implementation of both passive
and active strategies (Peterson & Mori, 1985; Roberts, Fanurik, & Layfield, 1987), but
4
caregiver implementation of such efforts have not been particularly successful (Pless &
Arsenault, 1987). Such disappointing results have been attributed to the limited
application of psychological principles to injury prevention, which is intended to modify
behavior and increase learning (Finney et al., 1993; Gulotta & Finney, 2000; Peterson &
Saldana, 1996). As a result, recent efforts have attempted to better understand the
cognitive and behavioral etiology of injury prevention behaviors.
Proxies of unintentional injury have been developed to study childhood injury
because severe injuries occur at low base rates and are less likely to occur during direct
caregiver supervision (Peterson, Saldana, & Heiblum, 1996). The study of children’s
risk-taking behaviors (e.g., playing with sharp objects, running and jumping indoors,
climbing on furniture) (Boyer, 2006) is the most commonly used proxy of unintentional
injury. The examination of injury risk-taking behaviors, which have the potential to lead
to an injury event, allows researchers to study other constructs associated with injury
without necessarily requiring an injury to occur. Instead, behaviors associated with injury
events are examined. For instance, to better understand the etiology of unintentional
injury and injury risk, caregiver cognitions are vital to consider.
The Attitude-Practice Gap
Caregiver cognitions (e.g., knowledge, beliefs, attitudes, and perceptions) have
been a recent focus of examination within the injury literature. Cognitions guide
behaviors by providing an underlying framework for how caregivers view, perceive, and
ultimately rear their children (Ajzen, 1991; Holden & Buck, 2002). However, caregiver
cognitions are not always consistent with caregiver practices (i.e., behaviors). This
5
inconsistency has been identified as the attitude-practice gap in the unintentional injury
literature (Coffman, Martin, Prill, & Langley, 1998; Holden & Buck, 2002). Beliefs and
attitudes may have failed to predict caregiver safety practices because moderating factors
(i.e., caregiver, child, and environmental characteristics) have not been examined, nor
accounted for, in predictive analyses.
Caregivers seem to have little knowledge about the overwhelming epidemic of
unintentional injury morbidity and mortality rates and, in turn, do not believe they are
responsible for preventing such injury (Eichelberger, Gotschall, Feely, Harstad, &
Bowman, 1990; Morrongiello & Dayler, 1996). Few caregivers report being responsible
for teaching their children safety behaviors as they believe that “being careful” or
“vigilant” is sufficient to ensure child safety (Morrongiello & Dayler, 1996). Caregivers
who believe in the developmental benefits of minor injury tend to support popular
colloquialisms, such as “no pain no gain” and “once burned twice shy” (Lewis, DiLillo,
& Peterson, 2004; Morrongiello & Dayler, 1996). They tend to believe that children learn
to cope with pain and discomfort through experience and that unpleasant experiences lead
to avoiding future injury. However, no empirical evidence supports the educational
benefits of minor injury (Matheny, 1987).
Perceptions of injury risk also impact caregiver injury prevention practices.
Simulation heuristics, which represent plausible injury events that are visualized in the
mind of a caregiver in a given location with their child, have been applied to predict
caregiver cognitions prior to injury prevention behaviors. Caregivers engage in a
“perceptual sweep” in novel situations to assess or judge potential injury risks and the
6
subsequent behaviors necessary to prevent injury (Kahneman & Tversky, 1973; Tversky
& Kahneman, 1974, 1980). Availability heuristics utilize recollections of prior injury
events to evaluate current injury risk. In partial support of availability heuristics, one
study detected a link between judged risk and number of recalled near-injuries and/or
actual injuries (Garling, 1989). This association was not attributed to personal
experiences, but rather to heuristics and cognitive schemas stemming from perceptions of
past experiences. As such, general knowledge of injury risk was not necessarily based on
past injury events, which is consistent with the notion that past injury experiences may
not be reliable predictors of caregiver risk perceptions (Garling, 1989; Glik, Kronenfeld,
& Jackson, 1993; Peterson, Ewigman, & Kivlahan, 1993). In turn, injury heuristics
appear to guide cognitions that contribute to injury risk perception and subsequent injury
prevention practices.
Caregivers implement more effective injury prevention strategies when they
accurately perceive and anticipate injury risk (Holden, 1983; Valsiner, 1985). Findings
suggest that mothers anticipate between 57-67% of their children’s injuries (Garling &
Garling, 1995). Perceived risk for injury tends to be lower during direct parent-child
interactions, but anticipation of injury tends to increase when children are in close
proximity to a potential injury-causing agent (Garling & Garling, 1995). However, this
effect does not seem to be as strong for older children as for younger children nor in
rooms considered to be less dangerous (e.g., living room, bedroom; Garling & Garling,
1993). Taken together, caregiver knowledge and perceptions need to be considered in
models predicting unintentional injury risk (Brown, Roberts, Mayes, & Boles, 2005).
7
Caregiver supervision provides a context to examine the relative impact of caregiver
cognitions on injury prevention behaviors.
Caregiver Supervision
Caregiver supervision has been identified as the most effective method of injury
prevention (Morrongiello, 2005; Peterson et al., 1986). To appropriately supervise,
caregivers must be able, ready, and willing to perform (Bishai, Mahoney, DeFrancesco,
Guyer, & Gielen, 2003; Wills et al., 1997a). When such efforts are compromised,
inadequate supervision is often cited as a primary contributor to unintentional injury
morbidity and mortality (Garbarino, 1988; Landen, Bauer, & Kohn, 2003). However,
unintentional injury has been found to also occur when caregivers are reportedly
supervising their children (Morrongiello et al., 2004b; Rimsza, Schackner, Bowen, &
Marshall, 2002; Wills et al., 1997a, Wills et. al, 1997b).
Historically, caregiver supervision was not initially defined by researchers or was
defined by caregivers or witnesses to injury events via reports and interviews (Harrell,
2003). When asked to define supervision, caregivers often respond with statements, such
as “be there,” “watch or oversee,” or “instruct, explain use” (Pollack-Nelson & Drago,
2002). Additionally, past interpretations of supervision were often drawn from proxies of
supervision (i.e., injury implies inadequate supervision, knowledge of a child’s location).
Behavioral conceptualizations of supervision drive current definitions with three critical
dimensions of supervision identified: attention, proximity, and continuity (Saluja et al.,
2004). For example, an empirically derived taxonomy of supervision has been presented
(Morrongiello et al., 2004a, 2004b): (1) no supervision, (2) intermittent listening from an
8
out of view location, (3) intermittent physical monitoring from an out of view location,
(4) constant listening from an out of view location, and (5) constant watching and
listening. Maximal supervision is considered to be constant watching and listening from
close physical proximity. Supervision is jeopardized when such behaviors decrease. For
children during early childhood, caregivers tend to supervise by being close-by and onhand when needed, instead of consistently being directly engaged with their children
during supervision (Pollack-Nelson & Drago, 2002). However, it is unclear how
caregivers determine their supervisory practices to prevent injury to their children.
As children mature, caregivers generally adapt their supervisory practices from
constant supervision for infants and toddlers to intermittent supervision for children
during early childhood, who typically have internalized safety practices to some degree.
Supervision behaviors tend to vary with child age, child temperament, child gender, and
particularly with environmental context (Morrongiello, Corbett, McCourt, & Johnston,
2006a, 2006b; Schwebel, Brezausek, Ramey, & Ramey, 2004). However, the association
between supervision and injury risk is unclear due to discrepant findings, with some
studies finding that supervision protects children from injury risk (Harrell, 2003; Landen
et al., 2003; Morrongiello & House, 2004) and others not detecting a link (Morrongiello,
2005; Morrongiello & Lasenby, 2006). At present, the literature suggests that supervision
seems to be a protective factor against injury only when risk is low. During high injury
risk events, supervision does not protect against injury (Dal Santo, Goodman, Glik, &
Jackson, 2004; Garling & Garling, 1993; Glik et al., 1993; Morrongiello et al., 2004a,
2004b; Peterson, Cook, Little, & Schick, 1991). Another study found that physical
9
proximity was the only effective supervision strategy to prevent injury (Morrongiello &
House, 2004). However, caregivers often have misperceptions of household hazards and
injury risk. For example, in locations perceived by caregivers as low risk (e.g., bedrooms,
family rooms, yards), supervision tends to be low. In locations perceived by caregivers as
high risk (e.g., bathrooms, kitchens), supervision tends to be high, particularly for young
children (Morrongiello et al., 2004a, 2004b; Peterson et al., 1991). Interestingly, injury
risk is low in rooms perceived as more dangerous (e.g., bathroom, kitchen), likely
because caregivers supervise more in such areas (Peterson et al., 1991). More generally,
when caregivers increase their supervisory practices, their perceptions of risk decrease.
As such, the underlying attributes of caregiver supervision, such as caregiver perceptions,
knowledge, and attitudes, likely impact caregiver supervisory practices (Morrongiello &
House, 2004) and may be integral to understanding supervisory behaviors.
Self-Efficacy
Self-efficacy theory, which is theoretically grounded within social cognition
theory, posits that perceived self-efficacy captures an individual’s judgments and
perceptions of their ability to execute behaviors necessary to regulate prospective life
events (Bandura, 1977, 1982, 1989, 1999). For caregivers to perceive themselves as
efficacious, several factors have been identified: (1) knowledge of appropriate child care
responses, (2) confidence in own abilities to implement tasks, and (3) belief that children
will appropriately respond and that others in the social milieu (e.g., peers, family) will be
supportive of such efforts (Coleman & Karraker, 1997). A distinction exists between
outcome expectations and self-efficacy expectations when evaluating motivations for
10
action behaviors (Bandura, 1999). An outcome expectation involves an individual’s
estimate that a given behavior will lead to a certain outcome. An efficacy expectation is
the belief that one can successfully execute an action required to produce a particular
outcome. This distinction is necessary because both outcome expectation and efficacy
expectation are theoretically intertwined, as presumed success is based upon the
perceived ability to execute actions leading to a specific successful outcome (Bandura,
1977, 1982).
Accurate appraisals of one’s own capabilities have functional benefits (Bandura,
1982). Before executing an action, if one perceives they possess the capability to execute
the action, then they are more likely to attempt to perform the behavior. If perceived
efficacy is low, then the action is often avoided. Some literature suggests that individuals
with high-perceived self-efficacy cognitively process information more readily by
engaging in more analytical thinking (Bandura, 1989). In turn, self-efficacy may
influence motivation to develop more creative and challenging parenting strategies, such
as in the context of unintentional injury. A presumption is that caregiver perceived selfefficacy will generalize across behaviors and environmental context. However, some
evidence suggests that self-efficacy is context-specific (Harter, 1993; Leerkes &
Crockenberg, 2003; Teti & Garland, 1991).
A paucity of literature examining efficacy exists within the context of
unintentional injury. Findings from the developmental literature provide a strong
empirical basis for exploring the impact of caregiver perceived self-efficacy on injury
prevention, and more specifically, caregiver supervision. However, a distinction between
11
caregiver efficacy in preventing injury and caregiver perceived self-efficacy in injury
prevention is necessary. For example, child-based strategies (e.g., “be careful”) have
been found to be least effective in preventing injury compared to parent-based or
environmental-based strategies (Morrongiello et al., 2004a, 2004b). Such a finding could
be attributed to caregiver developmental knowledge, such that caregivers understand that
toddlers do not have the ability to independently execute child-based prevention
strategies. However during the years of early childhood, children do not have the
cognitive ability to independently implement safety practices without the supervision of
adults, but they often can recall safety rules and have more advanced motor ability. Such
advancements can mislead caregivers to believe they can implement more child-based
intervention strategies. Although this remains an empirical question, efficacious injury
prevention efforts likely differ from caregiver perceived efforts to effectively prevent
injury.
Knowledge of Child Development
Caregiver knowledge and subsequent expectations of children impact how
caregivers understand, interpret and react to their children’s behaviors (Goodnow, 2002;
Miller, 1988; Sigel, 1986). Efforts to explore the associations between caregiver
developmental knowledge, parenting, and child outcomes exist in the developmental
literature. Adequate knowledge of child development consists of knowledge about
children’s physical, cognitive and socio-emotional development. Specifically, maternal
developmental knowledge has been positively linked to developmentally appropriate
home and learning environments and parent and child competence (Benaisch & Brooks-
12
Gunn, 1996; McGillicuddy-DeLisi, 1985; Stern & Alvarez, 1992; Stevens, 1984a,
1984b). However, unrealistic expectations of normative child development can lead
caregivers to overestimate child abilities, which can place children at risk for injury
(Schwebel & Bounds, 2003). The injury field has built upon such findings to presume
that caregiver developmental knowledge guides supervisory practices.
Highly educated mothers have been found to actively seek out developmental
information, via books and physicians, more so than less educated mothers (Deutsch,
Ruble, Fleming, Brooks-Gunn, & Stangor, 1988; Rivara & Howard; 1986; Vukelich, &
Kliman, 1985). In turn, they have more exposure to accurate developmental information.
In a sample of affluent, white, married, and well-educated adults, participants were 6077% accurate on knowledge of normative child development (Yankelovich, & DYG,
Inc., 2000). However, a sizeable proportion of adults were not accurate. Inaccurate
developmental knowledge likely contributes to caregivers’ difficulty identifying and
implementing developmentally appropriate parenting practices, such as supervision.
Similarly, Reich (2005) found that 65% of caregivers answered developmental questions
accurately, yet they often overestimated their children’s abilities. Mothers with lower
education, ethnic minority status, and support by public assistance for childcare scored
significantly lower on developmental knowledge than their higher educated, more
affluent counterparts. Although maternal education is often a strong predictor of
developmental knowledge, this association was not as robust as in prior findings (Rivara
& Howard, 1986). As such, other demographic variables, such as socio-economic status
(SES) or race/ethnicity, may need to be further explored to provide a more
13
comprehensive understanding of the impact of developmental knowledge on parenting
and injury prevention.
Caregiver knowledge of child development, particularly the knowledge of skill
level necessary for safe completion of tasks, seems to influence children’s injury risk.
Increased developmental knowledge has been linked to decreased injury risk (Rivara &
Howard, 1982). As children mature, they develop advancing cognitive skills (i.e., causal
reasoning) in conjunction with greater physical and verbal abilities (Coppens, 1986). In
turn, caregivers begin to rely on their children’s developing abilities to better predict
outcomes of engaging in high-risk situations and to then choose appropriate safety
practices.
The discrepancy between children’s actual abilities and caregiver perceptions or
misperceptions of childhood developmental abilities is linked to caregivers
unintentionally creating unsafe environments for their children during early childhood
(Hunt & Paraskevopoulos, 1980; Schwebel & Bounds, 2003). For example, gun-owning
caregivers have been found to be generally unaware that children develop the physical
capacity to reach and discharge guns much earlier than learning the potential
consequences of such an action. Consequently, guns are often not secured within homes
(Farah, Simon, & Kellermann, 1999). Therefore, young children may be able to handle
guns before understanding causal reasoning. Parents also tend to support the notion that
children in kindergarten or 1st grade cannot reliably and independently cross streets
without adult supervision. Yet, they report allowing their young children to crossresidential streets and walk to school alone (Rivara, Bergman, & Drake, 1989; Vinje,
14
1981). Such findings likely stem from caregiver perceptions that children are either too
old to have a safety measure employed or children are able to cope with the hazardous
situation (Wortel, de Gues, Kok, & van Woerkum, 1994). Such findings suggest that
developmental knowledge may moderate the association between caregiver perceived
self-efficacy and supervision to prevent unintentional injury.
Self-Efficacy, Developmental Knowledge, and Parenting Practices
Maternal behavioral competence and quality of mother-child interactions often
have been used as outcome variables to assess parenting ability in the developmental
literature. Although a theoretical link between caregiver efficacy and competence exists
(Bandura, 1977, 1989), empirical evidence has been inconsistent. Several reasons may
contribute to such inconsistencies: (1) variance in measurement methods, (2) lack of
differentiation between actual and perceived efficacy, and (3) caregiver developmental
knowledge not being consistently accounted for in most analyses. Despite such concerns,
two studies have linked caregiver perceived self-efficacy, knowledge of child
development, and parenting competence (Conrad et al., 1992; Hess et al., 2004). Their
empirical framework may provide a model for understanding supervision as an
unintentional injury prevention strategy.
Conrad and colleagues (1992) differentiated between caregiver actual and
perceived self-efficacy by positing that the inter-relationships between caregiver
developmental knowledge, confidence (i.e., perceived self-efficacy), and competence
could be curvilinear (Conrad et al., 1992). Specifically, the authors hypothesized: (1) a
positive association would be detected between developmental knowledge and
15
confidence, and (2) an interaction effect between knowledge and confidence would
predict the quality of mother-toddler interactions (i.e., given adequate knowledge,
maternal confidence would be positively associated with the quality of mother-toddler
interactions). The curvilinear effect was supported. When mothers, who were
predominantly well-educated, married Caucasian women, possessed higher levels of
accurate developmental knowledge, a positive association between confidence and
mother-toddler interaction quality was stronger. However, a negative link between
confidence and mother-toddler interaction quality was detected when mothers had lower
levels of accurate developmental knowledge. This effect was conceptualized as the
naively confident mother (Davis, 1989). Naively-confident caregivers are those
possessing little knowledge of child development who demonstrate lower levels of
behavioral competence, but perceive themselves as efficacious in their parenting ability.
To have high levels of parenting behavioral competence, caregivers most often need to
have high levels of developmental knowledge and perceived self-efficacy.
Hess and colleagues (2004) also examined the independent and interactive effects
of maternal perceived self-efficacy and developmental knowledge on the behavioral
competence of African-American (66.2%) and Caucasian (32.3%), low-income mothers
with their medically at-risk infants. The authors hypothesized that developmental
knowledge would moderate the association between maternal self-efficacy and maternal
behavioral competence with their infants. Consistent with prior research (Conrad et al.,
1992; Donovan & Leavitt, 2002; Leerkes & Crockenberg, 2003), self-efficacy and
developmental knowledge did not independently predict behavioral competence.
16
However, developmental knowledge did moderate the association between maternal
perceived self-efficacy and behavioral competence. Self-efficacy was positively linked to
behavioral competence when developmental knowledge was high. Consistent with the
concept of the naively confident mother, the association between self-efficacy and
competence was inversely associated when developmental knowledge was low.
The naively confident parent identified in the aforementioned studies raises the
question of whether the naively confident parent exists within the context of unintentional
injury, particularly when self-report measures of caregiver supervision attitudes and
practices are utilized. Studies have found that parents often feel that they are able to
prevent injury, but do not feel responsible to do so (Eichelberger et al., 1990;
Morrongiello & Dayler, 1996). Furthermore, some preventive efforts perceived by
parents as effective have been found to be ineffective (e.g., “be careful”; Morrongiello et
al., 2004b).
Paternal Impact on Childhood Unintentional Injury
Despite the well-documented finding that fathers are key contributors to child
development (Lamb, 2004), mothers have dominated the majority of injury research
(Morrongiello, 2005; Schwebel & Gaines, 2007). As such, little is known about the
extent to which maternal influences on unintentional injury extend to paternal influences.
Similar to mothers, fathers have been found to competently and sensitively interact with
their young children (Lamb, 2004). A caregiver’s emotional bond, despite biological
relationship of caregiver or child gender, has been consistently detected as a powerful
predictor of positive child development (Silverstein & Auerbach, 1999). However,
17
several findings suggest that mothers and fathers may have differential influences on
injury prevention: (1) mothers and fathers may differentially interact with their children
(Lamb, 2004), (2) fathers are more likely than mothers to support the notion that children
benefit from minor unintentional injury (Lewis et al., 2004; Morrongiello & Dayler,
1996). Such beliefs may explain why fathers, compared to mothers, tend to intervene
more slowly during high-risk situations (Morrongiello & Bradley, 1997).
Caregivers, particularly fathers, have been found to be more protective of girls
and allow more risk-taking behaviors with boys. Such findings are consistent with results
suggesting that mothers are more tolerant of boys’ risk taking behaviors than girls
(Morrongiello & Dawber, 2000). To explain such phenomena, Morrongiello and Dayler
(1996) found that mothers attributed injury occurring to boys to uncontrollable causes,
such as innate male characteristics and bad luck. In contrast, injuries to girls were
attributed to controllable causes, such as disregard of safety practices and carelessness.
Mothers tend to report feeling powerless to intervene when boys are engaging in highrisk behaviors, but report feeling more powerful to intervene with girls (Morrongiello &
Hogg, 2004). Similar to mothers, fathers may also not intervene during high-risk
behaviors in boys and may want to protect girls (Morrongiello & Bradley, 1997).
However, their reasons for refraining from intervention for boys may differ from mothers
(i.e., support of the developmental benefits of minor injuries). Although speculation,
fathers may be more apt to delay interventions for boys due to the perception of the
developmental benefits of unintentional injury, but may implement more injury
18
prevention practices with girls to protect them from injury. In turn, fathers may supervise
less consistently and frequently compared to mothers.
Protection Motivation Theory
With the exception of the Health Belief Model (HBM; Becker, 1974; Peterson,
Farmer, & Kashani, 1990), few theories have been integrated into injury research. In turn,
the fields of injury prevention and health education have been somewhat segregated
(Trifiletti, Gielen, Sleet & Hopkins, 2005). The HBM attempts to explain and predict
health behaviors and is comprised of four components: perceived susceptibility,
perceived severity, perceived benefits, and perceived barriers. Similar to the HBM, the
PMT emphasizes the cognitive processes associated with attitudinal and behavioral
change. Both theories are functions of expectancy-value theories. However, the PMT was
developed to explain fear appeals by examining two cognitive appraisal processes that
underlie preventive behaviors when confronted with a risk or hazard: threat appraisal and
coping appraisal.
Threat appraisal assesses factors that maximize or minimize the likelihood of
engaging in protective behavior, alter undesired behaviors, or both. The types of intrinsic
and extrinsic rewards gained from engaging in the preventive behavior and the perceived
severity of, and vulnerability to, the presenting threat guide the threat appraisal process.
When threat is assessed, potential methods for coping with the threat are also considered.
Coping appraisal assesses response efficacy (i.e., perceived adequacy of response), selfefficacy (i.e., perceived ability to perform), and the costs associated with employing a
preventive response. The distinction between outcome expectations and perceived self-
19
efficacy expectations highlights the integration of Self-Efficacy Theory into PMT
(Bandura, 1977, 1989). Individual motivation to engage in preventive behavior is the
summation of the threat and coping appraisal processes. PMT underscores the interactive
psychological states that guide behavioral intentions and the cognitive processes that
influence behavior.
The PMT offers a more comprehensive and specified model than the HBM. In
particular, the PMT provides an explicit inclusion of personal mastery (i.e., self-efficacy).
To effectively implement a preventive behavior, an individual must believe they can
perform the behavior. Caregivers with a strong sense of self-efficacy will likely be able to
overcome threat appraisal variables (e.g., vulnerability to injury) to implement a
preventive behavior. Furthermore, PMT predicts behavior without a cue to action,
whereas the HBM typically involves a cue to action (e.g., injury occurrence.). This
distinction seems particularly integral to the study of injury prevention. One study
applied the HBM to examine parental teaching and environmental interventions to
prevent unintentional injury (Peterson et al., 1990). The HBM did not significant predict
injury prevention behaviors. However, variables from PMT were supported, specifically,
injury prevention efficacy and parental efficacy, which in the context of PMT is response
efficacy and self-efficacy, respectively. As such, the PMT served as the theoretical
framework for the current study.
Objectives of the Current Study
The aforementioned literature calls attention to the need to further examine
caregiver cognitive attributions that influence the supervisory practices chosen by
20
caregivers to prevent injury to their children. To address this limitation, findings within
the developmental literature regarding caregiver behavioral competence was applied and
tested within the context of childhood unintentional injury in the current study. Prior
research suggests that the association between caregiver perceived self-efficacy and
behavioral competence is dependent upon caregiver developmental knowledge. This
model was generalized to predict caregiver supervision to prevent childhood injury. The
current study aimed to: (1) examine the independent and potentially interactive effects of
caregiver perceived self-efficacy and developmental knowledge on caregiver supervision,
and (2) assess whether mothers and fathers differed on the main study variables. The
following hypotheses were tested in the current study:
Hypothesis 1: Caregiver supervision would be negatively associated with childhood
unintentional injury risk.
Hypothesis 2: Caregiver knowledge of child development would be positively
associated with caregiver supervision.
Hypothesis 3: Caregiver perceived self-efficacy would be positively associated with
caregiver knowledge of child development.
Hypothesis 4: Caregiver perceived self-efficacy would be positively associated with
caregiver supervision.
Hypothesis 5a: Caregiver knowledge of child development would moderate the
association between caregiver perceived self-efficacy and supervision.
Hypothesis 5b: Some evidence in support of the naively confident caregiver would be
detected.
21
Hypothesis 6: Mothers would report significantly greater levels of supervision and
lower levels of injury-related attitudes compared to fathers.
Exploratory analyses were conducted to examine differences between
mothers and fathers on perceived self-efficacy and developmental
knowledge.
CHAPTER II
METHOD
Participants
Primary caregivers were recruited from pediatric primary care offices and local
message boards as part of a larger study examining unintentional injury and caregivers of
children 2 to 10 years. Of the 855 caregivers approached for study participation in the
larger study, 527 were eligible and 374 consented to study participation (70.97%).
Common reasons for study non-completion included inconvenience and disinterest in
research. For the purpose of the current study, participation criteria included being 1) an
English-speaking primary caregiver of a child ranging in age from 2 to 5 years and 2)
informed consent. Exclusion criteria included caregivers of children younger than 2
years, older than 5 years of age, and non-primary caregivers. The final sample for the
current study was comprised of 123 caregivers. Caregiver demographic data are
presented in Table 1. The children reported on by their caregivers had a mean age of 3.5
years (SD = 1.2), were primarily Caucasian (80.8%; African-American 13.3%; Other
5.8%), and had an equal distribution of boys (50.4%) and girls (49.6%).
22
23
Table 1.
Caregiver Demographic Data (N = 123)
______________________________________________________________________
n
%
M (SD)
Range
______________________________________________________________________
Female
95
77.2
Male
28
22.8
Age
30.5 (6.6) 18-48
Relation to Child
Biological Parent
113
91.9
Step-parent/Caregiver Spouse
3
2.4
Grandparent
2
1.6
Other
5
4.1
a
Ethnicity
Caucasian
79
81.4
African-American
16
16.5
Other
2
2.1
a
Education
High School Degree/Some High School
36
31.1
College Degree/Some College
59
50.9
Advanced Degree/Some Graduate School
21
18.1
a, b
Insurance Status
Medicaid-HMO
45
38.7
Private Insurance
67
57.8
Fee for Service
4
3.4
_______________________________________________________________________
Note.
a
Sub-groupings do not equal total sample size due to missing data.
Rates were comparable to prior data from the same pediatric offices (45.3%).
b
24
Procedure
Prior to data collection, approval from the Institutional Review Board (IRB) was
obtained and research assistants were trained to approach parents and collect data in the
pediatric primary care waiting rooms. Two recruitment phases were implemented to
target eligible primary caregivers. The initial recruitment phase occurred in the waiting
rooms of 4 community-based (i.e., urban and suburban) pediatric primary care offices
affiliated with Children’s Hospital Medical Center of Akron in northeastern Ohio.
Research assistants approached caregivers presenting with children in our targeted age
range; caregivers were then provided a brief description of the study and, consent was
obtained if eligibility criteria was met and the caregiver agreed to participate. For
caregivers who had multiple children within the targeted age range, protocol required that
the caregiver report on the child with the next upcoming birthday. Consented participants
completed the assessment packet either in the waiting room or while waiting for the
pediatrician in the examination room, or caregivers were given a business reply envelope
to complete the packet at a later time and return via mail.
To facilitate recruitment of caregiver dyads, all consented participant caregivers
presenting in the waiting rooms were asked to provide name and contact information of
one other primary caregiver of the targeted child (e.g., mother, father, step-parent,
grandparent), if appropriate. The author and co-primary investigator contacted the
additional primary caregivers via telephone to inform them of the study and answer any
questions. If the additional primary caregivers expressed interest in learning more about the
study, they were sent study materials (i.e., introduction letter, written consent form,
25
assessment packet, business reply envelope). Within approximately one week after packets
were mailed, the co-primary investigators contacted them again to ensure receipt of the
packet, answer any questions, and assess progress if the additional primary caregiver
expressed interest in participating in the study. Informed consent information was included
in the packet and was verbally discussed during the initial contact. One additional followup phone call occurred approximately two weeks after initial contact if the consent form
and assessment packet were not returned.
In response to poor recruitment and in an attempt to maximize study participation,
two modifications to the IRB approved study protocol occurred approximately half way
through the study, after obtaining approval for an IRB change to study protocol. The first
change was to the reimbursement system. The initial 69 participants of the current sample
received a $10 Wal-Mart gift card after primary investigators confirmed receipt of all study
materials. After the change to the study protocol, the remaining 54 participants of the
current sample were entered into three lotteries for reimbursement for their time and effort:
(1) One out of every 20 participants received $30, (2) One out of every 50 participants
received $40, and (3) One out of every 80 participants received $50. The second
modification included the ability for caregivers to complete the assessment packet via the
internet, which offered easy access to study information and allowed caregivers to
complete the study at their convenience. Participants were informed of the study website
via the telephone contact or via local public message boards. All data was collected
anonymously.
26
Measures
Demographic Information
Demographic Questionnaire (See Appendix A). A demographic questionnaire
was developed for the current study. Information obtained from this questionnaire
included: caregiver and child age, gender, race/ethnicity, caregiver relationship to child,
education level, insurance information, time spent with child, and name and contact
information of another primary caregiver when appropriate.
Child Behavior
Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997, 2001; Goodman
& Scott, 1999) (See Appendix B). The SDQ is a brief, psychometrically valid assessment
tool to measure caregiver perceptions of recent emotional and behavioral problems in
children ranging from toddlers to adolescents. The SDQ consists of 25-items with a threepoint response format for each item (0 = not true, 1 = somewhat true, 2 = certainly true)
and five subscales, each comprised of 5 items: Prosocial Behavior (e.g., helpful to
others), Peer Problems (e.g., solitary play), Hyperactivity (e.g., fidgets), Emotional
Symptoms (e.g., fearful) and Conduct Problems (e.g., temper tantrums). A Total
Difficulties Score is computed by summing the scores of all scales, with the exception of
the Prosocial Scale. Scores can range from 0 to 40. The subscales have a mean internal
consistency reliability coefficient of 0.71, mean 6-month test-retest reliability coefficient
of 0.62, a stable subscale factor structure and strong criterion validity for predicting
27
psychological disorders (Goodman, 2001). For the current sample, internal reliability for
mothers ranged from
= .49 - .79 on the SDQ subscales and
score. Internal reliability for fathers ranged from
= .71 for the SDQ total
= .25 - .82 on the SDQ subscales and
= .75 for the SDQ total score.
Caregiver Supervision
Parent Supervision Attributes Profile Questionnaire (PSAPQ; Morrongiello &
House, 2004) (See Appendix C). The PSAPQ is a psychometrically sound measure
assessing injury risk in children 2 to 5 years of age due to inadequate supervision. The
focus of the PSAPQ is not only supervisory behaviors, but also caregiver beliefs and
attitudes likely associated with injury related supervision. The PSAPQ consists of 29
statements and caregivers are asked to judge each statement on a five-point scale (1 =
strongly disagree to 5 = strongly agree). Higher scores reflect increased cognitions and
behaviors associated with greater supervision. To test criterion-related validity, PSAPQ
scores were compared to naturalistic observations of caregiver supervisory strategies and
child injury ratings (Morrongiello & House, 2004). As a result, four subscales with
adequate internal consistency have been identified: 1) Protectiveness (9 items,
= 0.78;
e.g., I think of all the dangerous things that could happen), 2) Supervision (9 items,
0.77; e.g., I know exactly what my child is doing), 3) Risk Tolerance (8 items,
=
= 0.79;
e.g., I let my child take some chances in what he/she does), and (4) Belief that Fate
Controls Child’s Health (3 items,
= 0.78; e.g., When my child gets injured it is due to
bad luck). Test-retest reliabilities for each subscale over a one-month period of time were
28
good (>0.70). Results from a confirmatory factor analysis indicated that the PSAPQ also
exhibits both adequate convergent and discriminant validity (Morrongiello & Corbett,
2006). The following are the Cronbach’s alpha coefficients for the PSAPQ subscales for
the current sample of mothers and fathers, respectively: Protectiveness ( = .74; .73),
Supervision ( = .69; .72), Risk Tolerance ( = .73; .84), and Belief that Fate Controls
Child’s Health ( = .70; .76).
Childhood Unintentional Injury
Injury Behavior Checklist (IBC; Speltz, Gonzales, Sulzbacher, & Quan, 1990)
(See Appendix D). The IBC is a measure assessing risky behaviors associated with
childhood injury occurring in children 2 to 5 years of age. Risk-taking behaviors are
defined as encouraged behaviors that have some probability of undesirable results
(Boyer, 2006). Adult respondents are asked to respond to items outlining risky child
behaviors and to rate their child’s frequency of engaging in each behavior within the past
6 months. The rating system is a 5-point scale, ranging from 0 to 4 (0 = not at all, 1 =
very seldom (i.e., has happened once or twice), 2 = sometimes (about once a month), 3 =
pretty often (about once a week), 4 = very often (more than once a week). The IBC score
is the total sum of the 24 items and scores can range from 0 to 96. The IBC demonstrates
adequate reliability, with an internal consistency of .87 and a one-month test-retest
correlation of .81. The IBC has adequate discriminant validity, as the IBC has been found
to discriminate children with two or more injuries from those children with one injury or
less (p < .001) (Speltz et al., 1990). The IBC has also demonstrated good convergent
29
validity with school-age children (up to 9 years of age). Internal consistency with this
population was higher ( = .92) than those reported by Speltz and colleagues (1990). The
IBC demonstrated adequate reliability in the current sample for mothers ( = .87) and for
fathers ( = .91).
Injury Attitudes Questionnaire (IAQ; Lewis et al., 2004) (See Appendix E). The
IAQ assesses parental attitudes towards children’s unintentional injuries. Participants are
asked to indicate their level of agreement with 14 statements using a 7-point Likert scale
(1-very strongly disagree to 7-very strongly agree). Scores are tallied along two subscales:
Toughening and Learning. The Toughening subscale includes 6 items consistent with the
notion that injuries help children endure physical or emotional pain (e.g., Injuries can help
my child learn to handle physical pain better). The Learning subscale contains 8 items
related to the educational benefits of injury (that injuries serve as a punishment for
inappropriate and/or unsafe behaviors; e.g. A few minor injuries could be good for my child
because they can help him/her learn to be more cautious). The total IAQ score is the
average score of the 14 items. The IAQ has high internal consistency for the total score (
= .88) and the two subscales: Learning subscale ( = .80) and the Toughening subscale (
= .88) (Lewis et al., 2004). Test-retest reliability for the total measure was .84, .80 for the
Learning subscale and .77 for the Toughening subscale. The internal reliability for the
current sample ranged from ( = .83-.89) for mothers and ( = .87 – .96) for fathers.
30
Developmental Knowledge
Developmental Knowledge Questionnaire (DKQ) (Appendix F). The DKQ was
created for this study to assess caregiver knowledge about normative child development.
The DKQ was primarily modified from a self-administered questionnaire developed to
examine the link between parental knowledge of child development and injury risks
(Rivara & Howard, 1982). The self-administered questionnaire from Rivara and Howard
(1982) was predominantly based upon the Denver Developmental Screening Test
(Frankenburg & Dodds, 1967) and the Framingham Safety Studies (Bass & Mehta,
1980). The Rivara and Howard (1982) questionnaire was chosen because of its brevity
compared to other measures of developmental knowledge (Larsen & Juhasz, 1986).
Caregiver developmental knowledge is conceptualized as a caregiver’s understanding of
developmental norms and milestones, processes of child development, and familiarity
with caregiving skills (Benasich & Brooks-Gunn, 1996). Participants respond to 20
statements using a three-point scale, ranging from 1 = Agree, 2 = Disagree, 3 = No
Opinion. To calculate an accuracy total score, each correct item is given 1 point with
scores ranging from 0 to 20, with a score of 20 equating to 100% accuracy. Higher scores
reflect more accurate developmental knowledge. Internal reliability for the current
sample was adequate for both mothers ( = .75) and fathers ( = .74).
Self-Efficacy
Parent Sense of Injury Competence (PSIC) (Appendix G). The PSIC was adapted
for the present study from the well-validated Parent Sense of Competence Scale (PSOC)
31
to specifically address caregiver perceived competence in the prevention of childhood
unintentional injury. Based upon a principal-components analysis of the PSOC, two
dimensions were identified (Johnston & Mash, 1989). The satisfaction dimension reflects
parenting frustration, anxiety, and motivation. The efficacy dimension reflects perceived
competence, problem-solving ability, and capability as a parent (Johnston & Mash,
1989). The PSIC was modified from the PSOC to assess caregivers’ view of their
competence specific to injury prevention. The following definition of perceived selfefficacy was utilized in the present study: Beliefs and judgments about one’s competency
or ability to be successful in the parenting role to prevent unintentional injury to their
children (Hess et al., 2004). On the PSIC, parents rate the degree to which each of the 16
statements applies to him or herself using a 6-point Likert-type scale, ranging from 1
(Strongly Agree) to 6 (Strongly Disagree). Scores range from 16 to 96, with higher scores
reflecting higher perceived self-efficacy in preventing unintentional injury. Examples of
statements are as follows: “My actions as a parent can protect my child from accidents,” “I
meet my own personal expectations for ensuring my child’s safety from injuries.” The
PSOC internal consistency (Cronbach’s alpha) is adequate: PSOC total score (.79);
satisfaction score (.75); and efficacy score (.76) (Johnston & Mash, 1989). Ohan, Leung,
& Johnston (2000) assessed internal consistency separately for mothers (both scales had
alphas of .80) and fathers (efficacy: .77; satisfaction: .80). Test-retest correlations over a
6-week period ranged from .46 to .82 (Gibaud-Wallston & Wandersman, 1978).
Adequate convergent and divergent validity has also been established with the PSOC
32
(Ohan, et al., 2000). The PSIC demonstrated good internal consistency in the current
study for both mothers and fathers, respectively: Satisfaction ( = .59; .58), Efficacy
( = .71; .78), and PSIC Total score ( = .78; .72).
Statistical Analysis Plan
Descriptive analyses, including means and standard deviations, were calculated
for each of the main study measures (i.e., PSAPQ, PSIC, DKQ, IBC, IAQ). Due to the
low reliability of the PSAPQ total score, subsequent analyses employed the PSAPQ
supervision subscale score, which is a more concise representation of caregiver
supervision and the subscale had adequate reliability. Variable distributions were
assessed for skewness and kurtosis. First, caregiver and child demographic characteristics
were examined in relation to caregiver supervision for both mothers and fathers. A
disproportionate amount of caregivers were Caucasian and had either private insurance or
Medicaid/HMO. As such, insurance status, which was used as a proxy for socioeconomic status (SES), and ethnicity were dichotomized (i.e., Caucasian versus nonCaucasian, private insurance/fee for service versus Medicaid/HMO). Student’s t-tests
were utilized to examine the impact of caregiver and child sex, ethnicity, and insurance
status on supervision. Bivariate correlations were conducted to assess the influence of
child behavior and caregiver and child age on supervision. A one-way univariate analysis
of variance (ANOVA) test was used to examine the impact of caregiver education on
supervision. Any analyses with significant findings (i.e., p ≤ .05) were considered
covariates in subsequent analyses.
33
Second, bivariate correlations were conducted to assess the inter-correlations
among the main study variables. Third, Baron and Kenny (1986)’s statistical
recommendations for testing moderation were implemented. To examine caregiver
developmental knowledge as a moderator of the association between perceived selfefficacy (i.e., predictor variable) and supervision (i.e., criterion variable)., a regression
model was considered. The assumption of independence for regression analysis was
violated in the current study, as some participants were part of caregiver dyads who
reported on the same child (e.g., mother-father dyads). As a result, two parallel
hierarchical linear regression analyses were specified and conducted for mothers and
fathers. For each of the regression analyses, the predictor and moderator variables were
centered before entry into the regression models (Aiken & West, 1991; Holmbeck, 1997).
To center variable scores, which results in a sample mean of zero for each variable,
sample means were subtracted from each individual variable score. The centered
moderator and predictor variables were multiplied to create an interaction variable (i.e.,
DKQ Total score x PSIC Total score). Evidence of a moderation effect was detected if
the interaction term was statistically significant at a .05 criterion.
The final analysis included a subset of participants who reported on the same
child and matched as part of a dyad (e.g., mother-father dyads). Paired-samples t-tests
were conducted to examine the convergence between mothers and fathers on knowledge
of child development, perceived self-efficacy, supervision, and injury-risk behaviors and
attitudes. Effect size statistics (d) were calculated for each paired samples t –tests. SPSS
15.0 (SPSS Inc., Chicago, IL) was employed to analyze study hypotheses.
34
Power Analysis
Two separate power analyses (i.e., mothers and fathers) were conducted on the
primary study hypothesis examining developmental knowledge as a moderator of the link
between perceived self-efficacy and supervision. Given a small effect size prediction
(f 2= .15), sufficient power (.96) was detected for mothers, but not for fathers (.50)
(Cohen, 1992). As such, the father analyses are considered exploratory in nature and
should be interpreted with caution. A final power analysis was conducted to examine
group differences between mothers and fathers on the main study variables. Power was
insufficient (.63) for the paired samples t-tests and should also be considered exploratory
and interpreted cautiously (Cohen, 1992).
CHAPTER III
RESULTS
Descriptive Statistics
Means and standard deviations for main study variables (i.e., perceived selfefficacy, developmental knowledge, supervision, and injury-risk attitudes and behaviors)
appear in Table 2.
Demographic Characteristics
Caregiver and child demographic and behavioral characteristics were examined in
relation to caregiver supervision using Student’s t-tests and bivariate correlations,
respectively. Caregiver supervision scores did not differ significantly based on caregiver
and child gender, child behavior, caregiver educational status, insurance status, or
ethnicity, but did vary significantly for child (r = -.31, p < .01) and caregiver age (r = .21, p < .05). No caregiver or child demographic characteristics were significantly
associated with caregiver supervision by fathers.
Correlational Analyses
Bivariate correlations between main study variables are documented in Table 3.
For mothers, a significant negative correlation was detected between supervision and
35
36
Table 2.
Descriptive Statistics for Mothers (n = 95) and Fathers (n = 28)
______________________________________________________________________
Mothers
Fathers
______________________________________________________________________
Mean
SD
Mean
SD
______________________________________________________________________
PSIC
Satisfaction
36.3
6.0
36.9
5.2
Efficacy
37.7
5.3
38.1
5.4
Total
73.9
10.2
75.0
9.3
DKQ
Total
11.2
3.4
10.4
3.5
PSAPQ
Supervision
3.56
0.52
3.42
0.48
Protectiveness
3.78
0.62
3.62
0.58
Belief in Fate
1.85
0.79
1.80
0.63
Risk Tolerance
2.79
0.60
3.07
0.66
Total
3.04
0.35
2.98
0.33
IBC
Total
22.2
12.0
22.1
13.7
IAQ
Toughening
2.6
1.0
3.4
1.3
Learning
3.8
1.0
4.4
1.0
Total
3.3
0.9
4.0
1.1
______________________________________________________________________
37
Table 3.
Inter-correlations Between Main Study Variables
____________________________________________________________________________________________
1
2
3
4
5
6
7
8
9
10
11
12
____________________________________________________________________________________________
1.
PSIC-Sat
---
.65**
.92**
.16
.12
-.01
-.49**
-.07
-.14
-.24*
-.10
-.19
2.
PSIC-Eff
.56**
---
.90**
-.01
.38**
.27**
-.33**
-.04
-.15
-.27** -.12
-.22*
3.
PSIC Total
.88**
.89**
---
.10
.27**
.14
-.46**
-.06
-.16
-.28** -.12
-.22*
4.
DKQ
.01
.09
.06
---
-.15
-.09
-.31**` .01
.13
-.26*
-.03
-.16
5.
PSAPQ-Sup
.15
.26
.23
-.23
---
.58**
-.09
-.23*
.11
-.24*
-.38**
-.37**
6.
PSAPQ-Pro
.02
.31
.19
-.15
.82**
---
.06
-.12
-.06
-.14
-.25*
-.24*
7.
PSAPQ-Fate
-.28
-.02
-.17
.00
-.30
-.18
---
.15
-.03
.46**
.30**
.44**
8.
PSAPQ-Risk
-.11
.08
-.02
.16
-.29
-.03
.48*
---
.12
.25*
.27**
.31**
9.
IBC
-.19
-.31
-.28
-.08
-.12
-.04
-.31
-.08
---
.04
.01
.02
10. IAQ-Tough
-.42*
-.15
-.32
.21
-.30
-.22
.56**
.62**
-.09
---
.47**
.82**
11. IAQ-Learn
-.20
-.06
-.15
.28
-.27
-.22
.48**
.60**
.01
.78**
---
.89**
12. IAQ Total
-.33
-.11
-.24
.26
-.30
-.23
.55**
.66**
-.04
.94**
.95**
---
________________________________________________________________________________________________________
Note. Correlations for mothers (n = 95) are presented above the diagonal. Correlations for fathers (n = 28) are presented below the
diagonal.
attitudes specific to injury risk, but supervision was not significantly associated with
reported injury-risk behaviors. Perceived self-efficacy was significantly positively
correlated with supervision and protectiveness. Developmental knowledge was not
significantly associated with supervision or perceived self-efficacy, but significant
negative correlations were found between developmental knowledge and beliefs that
child safety is a matter of fate or luck and that minor injury can have developmental
benefits (i.e., “toughening up”). Caregiver belief in fate was also negatively correlated
with perceived self-efficacy and satisfaction in preventing injury. Beliefs in the
developmental benefits of minor injury and that children can learn from minor injury
were significantly associated in the expected directions with supervision, protectiveness,
38
belief in fate, and risk tolerance. For fathers, moderate, but significant, correlations were
found between injury beliefs and attitudes. Beliefs in risk tolerance and that child safety
is a matter of fate were positively associated with beliefs in “toughening up” and that
children can learn from experiencing minor injury. A negative correlation was detected
between satisfaction in preventing injury and beliefs in “toughening up”.
Regression Analyses
To ascertain if caregiver developmental knowledge moderated the association
between perceived self-efficacy and supervision, parallel hierarchical multiple regression
analyses were conducted for both mothers and fathers following Baron and Kenny
(1986)’s recommendations for testing moderation. For the mother-based analysis, ages of
both the mother and child were identified as covariates (i.e., significantly negatively
correlated with supervision) and were subsequently controlled for in the regression
analysis. On the first step, covariates (i.e., caregiver and child age) were entered.
Centered developmental knowledge and perceived self-efficacy variables (i.e., resulting
in a sample mean of zero for both variables) were entered on the second step. Perceived
self-efficacy, but not developmental knowledge, entered the model as a significant
independent predictor of caregiver supervision. On the third step, the multiplicative
interaction term created from the centered developmental knowledge and perceived selfefficacy variables was entered. The interaction was a statistically significant predictor of
caregiver supervision (R2 change = .06, F(1, 86) = 6.76, p < .01) (see Table 4). Six
percent of the variance in maternal caregiver supervision was accounted for by the
interaction of perceived self-efficacy and developmental knowledge.
39
Table 4.
Summary of Hierarchical Regression Analysis for Maternal Caregivers
________________________________________________________________________
R
∆ R2
df
∆F
p
________________________________________________________________________
Step 1
.34
.11
2, 89
5.68
.01
Child age
-.29**
Parent age
-.14
Step 2
.46
.10
2, 87
5.67
.01
Efficacy
Knowledge
.25**
-.09
Step 3
Interaction
.52
.06
1, 86
6.76
.01
-.25**
_______________________________________________________________________
Note. ** p < .01.
Following the recommendations suggested by Cohen, Cohen, West, & Aiken
(2003), the interaction effect was further examined. Predicted values of caregiver
supervision were calculated from both perceived self-efficacy and developmental
knowledge scores. Specifically, standard deviations were added and subtracted from each
score (i.e., perceived self-efficacy and developmental knowledge). Subsequent scores
created high and low groups for both variables (i.e., low, high perceived self-efficacy;
low, high developmental knowledge). The interaction effect is illustrated in Figure 1.
Caregivers with low developmental knowledge and low perceived self-efficacy had lower
supervision scores. Similarly, caregivers with high developmental knowledge and high
40
45
Low Developmental Knowledge
Medium Developmental Knowledge
Supervision
High Developmental Knowledge
40
35
Low
Medium
Perceived Self-Efficacy
Figure 1. Developmental Knowledge as a Moderator
High
41
perceived self-efficacy had lower supervision scores. Higher supervision scores were
reported by caregivers with low developmental knowledge and high perceived selfefficacy or by caregivers with high developmental knowledge and low perceived selfefficacy.
The result of the regression analysis predicting caregiver supervision by fathers
was non-significant (R2 change = .01, F(1, 24) = 0.15, p < NS).
Mother-Father Caregiver Convergence
on Main Study Variables
Paired t-tests indicated that fathers had significantly higher scores on the IAQ
Toughening (t(13) = -2.35, p < .05) and Total (t(13) = -2.41, p < .05) scales compared to
mothers. No significant differences were found between mothers and fathers on the other
main study variables.
CHAPTER IV
DISCUSSION
The current study is the first to examine caregiver developmental knowledge as a
moderator of the association between perceived self-efficacy and supervision in a sample
of both mothers and fathers. As hypothesized, the comprehensive model proposed in the
current study was supported for mothers, but not for fathers. This finding highlights the
complex nature of determining supervisory practices and the importance of applying a
multifaceted approach to understanding caregiver decisions within injury prevention.
Most notably, the interactive effect of both developmental knowledge and perceived selfefficacy on supervision behaviors supports the need for continued investigation of
caregiver characteristics and their subsequent relationships to injury prevention strategies,
which has been largely neglected within the injury literature. Models of studying injury
prevention that consider complex interactions between caregiver cognitions and
behaviors may elucidate upon the attitude-practice gap currently identified in the injury
literature.
The finding in the present research that the relationship between caregiver
perceived self-efficacy and supervisory practices varied with amount of developmental
42
43
knowledge suggest that caregiver perceptions of their ability to prevent injury and their
developmental knowledge base influence how they supervise their children. In part,
mothers reporting fewer supervisory strategies tended to have either “low” or “high”
levels of developmental knowledge and perceived self-efficacy. Although mothers with
low levels of both knowledge and efficacy were expected to report decreased supervision
practices, mother with high levels of both knowledge and efficacy were not. The
likelihood that the low and high groups may have different reasons for use of less
supervision highlights the complexity involved in predicting supervision from caregiver
perceptions of their effectiveness and knowledge of normative child development.
Mothers with little knowledge of child development, such as the ability to identify
adequate self-regulatory safety skills in children at various ages, may have difficulty
identifying when supervision is necessary or what type of supervision is developmentally
appropriate. When these mothers also feel ineffective in keeping their children away from
harm, they may lack confidence to appropriately supervise. As a result, even when
supervision is deemed necessary, these mothers may be less likely to intervene and
supervise. One could further speculate that these caregivers may evaluate an environment
(i.e., simulation heuristic) and, based on their poor developmental knowledge, determine
that intermittent to low supervision is appropriate when their child is able to verbalize
safety rules (Morrongiello, Midgett, & Shields, 2001) and in a room perceived to be
“safe” (e.g., bedroom, family room, yard) (Morrongiello et al., 2004a, 2004b). For these
caregivers, low levels of perceived self-efficacy may not be particularly critical when the
perceived need to intervene is minimal. However, over-reliance on caregiver perceptions
44
of “safe” environments can be harmful (Morrongiello et al., 2004a, 2004b, 2006a,
2006b), particularly if risk is not appropriately assessed. Support for this interaction
effect is similar to prior findings within the context of general parenting strategies
(Conrad et al., 1992; Hess et al., 2004). For example, prior data in the developmental
literature has found that mothers of infants that have low knowledge of normative child
development and low perceived self-efficacy were more likely to demonstrate lower
parenting competence (Conrad et al., 1992; Hess et al., 2004).
Unexpectedly, mothers with high levels of both developmental knowledge and
perceived self-efficacy engaged in low levels of supervision. Given our knowledge that
caregivers use varying levels of supervision (Morrongiello et al., 2004a, 2004b;
Morrongiello & House, 2004), along with other safety practices (e.g., Morrongiello &
Kiriakou, 2004), the current data may actually capture a more accurate representation of
how caregivers realistically supervise. Although not assessed in the current study, these
mothers may also implement passive injury prevention practices that are used in a
complementary fashion with supervision to prevent injury (Morrongiello & Kirakou,
2004). In effect, caregivers that have adequate developmental knowledge and believe
they can effectively prevent injury to their children (i.e., high perceived self-efficacy)
may use more developmentally appropriate supervision practices. For example, these
caregivers may use less constant supervision (i.e., greater reliance on more intermittent
listening and less physical monitoring) and more passive prevention (e.g., security gates),
particularly as children mature. More than half of our sample reported having at least
some college education, suggesting that these caregivers may have had the financial
45
means to implement passive injury prevention strategies, along with intermittent to low
levels of constant supervision. A flourishing safety product industry is available to
caregivers who possess the financial means to “safety proof” their homes with products
such as security gates, cabinet latches, and electrical safety plates. These safety strategies
are often viewed as complementary tools to supervision.
However, the data did not lend support to the “naively confident” caregiver, as
identified in the developmental literature (Hess et al., 2004). The current data suggest that
caregivers report higher levels of supervision when they have differing levels of
developmental knowledge and perceived self-efficacy (e.g., low developmental
knowledge and high perceived self-efficacy). Possibly, high, constant supervision is
utilized to compensate for low levels of knowledge of child development or perceptions
of low self-efficacy. Although speculation, other moderating and/or mediating constructs
not considered in the current study could contribute to such findings (e.g., lack of access
to safety products to be used complementary to supervision).
The interaction model tested in the current study is somewhat consistent with
prior research within the developmental literature (Conrad et al., 1992; Hess et al., 2004).
However, discrepancies between current and past findings may be attributed to context
specifics and sampling effects. Within the current study, the conceptualization and
measurement of self-efficacy was developed to be specific to the context of unintentional
injury prevention and supervision to prevent injury is simply one facet of a broad
conceptualization of “parenting practices”. In other words, the model was initially
developed within the context of examining mother-child interactions (Conrad et al., 1992;
46
Hess et al., 2004), but was applied within the specific context of childhood unintentional
injury in the current study. One could speculate that the model may manifest differently
in various contexts (i.e., generic parenting skills versus parenting specific to injury
prevention) and with the use of different methodologies (e.g., observations versus selfreport). As a result, the current conceptualizations of self-efficacy and supervision likely
better capture the interrelations among these constructs within the context of
unintentional injury prevention.
The current data is also similar to prior literature examining caregiver personality
attributes and parenting styles and their associations with supervision. Specifically,
caregivers high in conscientiousness tend to supervise more consistently and have
children with lower injury risk than those low in conscientiousness (Morrongiello &
House, 2004; Morrongiello et al., 2006b). A similar trend has been detected for
caregivers low in permissive parenting styles (Morrongiello, Corbett, Lasenby, Johnston,
& McCourt, 2006). As a result, more comprehensive models of injury prevention that
examine caregiver characteristics may benefit from the inclusion of personality attributes,
along with beliefs, attitudes, and knowledge.
The need for further consideration of a multifaceted approach to injury prevention
became even more apparent when examining caregiver dyads. Consistent with prior
literature, fathers supported the notion of “toughening up” more so than mothers (Lewis
et al., 2004). Interestingly, supervision practices did not differ between mothers and
fathers. These data suggest that, despite differing perspectives on the developmental
benefits of minor injury, mothers and fathers from the same family were found to have
47
similar levels of supervision. Given that fathers believe that children who experience
minor injury are more likely to internalize safety practices and become more cautious,
fathers were hypothesized to report less supervision practices than mothers. Lack of
support for this finding is contrary to one study examining paternal supervisory practices
(Morrongiello & Bradley, 1997). However, the current data suggest that fathers continue
to supervise their children at levels similar to mothers who do not support the notion of
the developmental benefits of minor injury. Given our knowledge from the
developmental literature that mothers and fathers may differentially interact with their
children (Lamb, 2004; Lewis & Lamb, 2003), one could speculate that this difference in
interaction style also applies to their supervision strategies. Possibly, fathers may engage
in more direct, physical play (Lamb, 2004; Lewis & Lamb, 2003) when supervising their
children. On the other hand, mothers may implement more intermittent, but frequent
physical and auditory monitoring. Despite potential use of different supervision
strategies, both mothers and fathers likely share an ultimate goal of adequate supervision
to prevent injury to their children.
As a first study to examine the interrelations between perceived self-efficacy,
developmental knowledge and supervision within the context of injury prevention, there
were several limitations to the current research with implications for future directions.
The study was comprised of a convenience sample of caregivers who were primarily
Caucasian, middle-class females. Current findings and trends suggest that a larger sample
of fathers may have captured similar, but potentially unique, characteristics between
mothers and fathers. Continued examination of caregiver dyads may be useful when
48
studying both mothers and fathers. Additionally, the cross-sectional design utilized single
method data collection (i.e., self-report). This methodology could have potentially
introduced biased reporting and other methodologies may have been more effective in
capturing actual supervisory behaviors and injury risk (i.e., diary methods, simulated
hazard environments) (Brown et al., 2005; Morrongiello et al., 2005). Given the limited
knowledge of how ethnic minority and economically disadvantaged caregivers perceive
injury risk, and in turn, attempt to prevent injury, future research with a larger, more
ethnically diverse sample of caregivers are important next steps in the field of injury
prevention. And finally, the burgeoning field of injury lacks breadth in the number of
psychometrically-sound assessment methods that capture caregiver beliefs, attitudes, and
perceptions. For example, the current measure of developmental knowledge (i.e., DKQ)
was adapted from other measures, has not yet been submitted to rigorous psychometric
testing, and may contribute to the mixed findings for developmental knowledge. Injuryspecific measures are critical to enhancing the field and to better understanding how
caregivers attempt to prevent injury.
Taken together, the current study offers an innovative model of examining the
interactive effects of caregiver perceptions and knowledge on injury prevention
strategies. Most importantly, the results highlight the complex nature of studying
childhood unintentional injury prevention, particularly the integral role of caregiver
characteristics when examining supervisory practices. A multifaceted approach to
understanding the process of implementing supervision strategies, specifically how
caregivers consider the interplay between individual (i.e., both caregiver and child) and
49
environmental factors (i.e., both active and passive prevention strategies) (Finney et al.,
1993), may serve as a useful approach in future research (Kendrick, Barlow, Hampshire,
Stewart-Brown, & Polnay, 2008). Perhaps the attitude-practice gap has gained
prominence because more complex models of caregiver cognitions and behaviors have
not yet been applied within the unintentional injury literature. This gap may decrease as
more comprehensive models of conceptualizing injury prevention develop. For example,
the current model could be improved upon by further consideration of caregiver
characteristics that have already been linked to supervision practices, such as personality
attributes (Morrongiello & House, 2004; Morrongiello et al., 2006b) and parenting styles
(Morrongiello et al., 2006). Continued examination of caregiver beliefs, knowledge, and
practices specific to injury prevention is critical to 1) conceptualizing injury within a
broader context of potentially modifiable familial factors and, 2) developing effective
primary and secondary interventions to promote child safety across the developmental
life span.
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APPENDICES
67
APPENDIX A
DEMOGRAPHIC QUESTIONNAIRE
68
69
Child Characteristics
Child’s age: _____
Child’s grade in school: _____
Child sex (select one):
 Female
 Male
Child race/ethnicity:  African-American  Asian/Pacific Islander  Caucasian  Hispanic
 Other _______________
Parent Characteristics
Parent age: _____
Parent sex (select one):
 Female
 Male
Parent race/ethnicity:  African-American  Asian/Pacific Islander  Caucasian  Hispanic
 Other ______________
Relationship to child:
 Biological parent
 Adoptive parent
 Partner of child’s mother or father
 Grandparent
 Step-parent (legally adopted)
 Step-parent (not adopted)
 Other (please indicate): _________________
Do you currently live with this child?
 Yes, 100% of the time
 Yes, but I share custody with another parent
 No, I do not live with the child
Does this child have another significant primary caregiver in his or her life (someone he or she would
identify as a mother or father)?
If No, please skip to next section.
If Yes, may we contact this person? 

Yes 
 No
If Yes, please provide a name and contact information for this person (if there is more
than one person, please select the person that fulfills most roles typical of a father or
mother):
Name:_________________
Relationship to child:
 Mother

 Step-mother

Father
Grandmother


 Step-father
 Grandfather
How much time (in hours) do you spend with your child on the following days?
Average weekday ____________ (time, in hours)
Average weekend day ____________
How much time (in hours) does the person you identified above spend with your child on the
following days?
Average weekday ____________ (time, in hours)
Average weekend day ____________
70
Education level (please select the highest completed level):
 Some High School
 Completed High School / GED
 Some College/Professional School
 Bachelor/Associates/Professional Degree
 Some Graduate School
 Graduate or Advanced Degree
What is your type of Medical Insurance Coverage?
Medicaid
Medicaid-HMO
Private Insurance
Self Pay
APPENDIX B
STRENGTHS AND DIFFICULTIES QUESTIONNAIRE
71
72
Strengths and Difficulties Questionnaire
For each item, please mark the box for Not True, Somewhat True or Certainly True. It would
help us if you answered all items as best you can even if you are not absolutely certain. Please
give your answers on the basis of the child’s behavior over the last six months or this school year.
Considerate of other people’s feelings
Not
True
_
Somewhat
True
_
Certainly
True
_
Restless, overactive, cannot stay still for long
_
_
_
Often complains of headaches, stomach-aches or sickness
Shares readily with other children, for example toys,
treats, pencils
Often loses temper
_
_
_
_
_
_
_
_
_
Rather solitary, prefers to play alone
_
_
_
Generally well behaved, usually does what adults request
_
_
_
Many worries or often seems worried
_
_
_
Helpful if someone is hurt, upset or feeling ill
_
_
_
Constantly fidgeting or squirming
_
_
_
Has at least one good friend
_
_
_
Often fights with other children or bullies them
_
_
_
Often unhappy, depressed or tearful
_
_
_
Generally liked by other children
_
_
_
Easily distracted, concentration wanders
Nervous or clingy in new situations, easily loses
confidence
Kind to younger children
_
_
_
_
_
_
_
_
_
Often lies or cheats
_
_
_
Picked on or bullied by other children
Often offers to help others (parents, teachers, other
children)
Thinks things out before acting
_
_
_
_
_
_
_
_
_
Steals from home, school or elsewhere
_
_
_
Gets along better with adults than with other children
_
_
_
Many fears, easily scared
_
_
_
Good attention span, sees work through to the end
_
_
_
APPENDIX C
PARENTAL SUPERVISION ATTRIBUTES PROFILE QUESTIONNAIRE
73
74
Parent Supervision Attributes Profile Questionnaire
Half of the
Time
Most of
the Time
All of the
Time
1. I make him/her keep away from anything that could be
dangerous.
2. I let him/her learn from his/her own mishaps.
1
2
3
4
5
1
2
3
4
5
3. Whether or not my child gets injured is largely a matter of fate.
1
2
3
4
5
4. I keep an eye on my child’s face to see how he/she is doing.
5. I stay close enough to my child that I can get to him/her
quickly.
6. I let my child experience minor mishaps if what he is doing is
lots of fun.
7. I feel very protective of my child.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
8. I keep a close watch on my child.
9. I wait to see if he/she can do things on his/her own before I get
involved.
10. I warn him/her about things that could be dangerous.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
11. When my child gets injuries it is due to bad luck.
12. I make sure I know where my child is and what he/she is
doing.
13. I can trust my child to play by himself/herself without
constant supervision.
14. I let my child take some chances in what he/she does.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
15. I have my child within arm’s reach at all times.
16. I try things with my child before leaving him/her to do them
on his/her own.
17. I say to myself that I can trust him/her to play safely.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
18. I hover next to my child.
1
2
3
4
5
19. I feel fearful that something might happen to my child.
1
2
3
4
5
Never
Some of
the Time
Please read each statement below and select a response to indicate how often you think each is
true. There are no right or wrong answers. We simply want to know what is true for you! If you
have any questions please ask the interviewer.
75
20. I stay within reach of my child when he/she is playing on
dangerous equipment.
21. I let my child make decisions for himself/herself.
1
2
3
4
5
1
2
3
4
5
22. I feel a strong sense of responsibility.
23. I encourage my child to take risks if it means having fun
during play.
24. I think of all the dangerous things that could happen.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
25. I let my child do things for him/herself.
1
2
3
4
5
26. I know exactly what my child is doing.
1
2
3
4
5
27. I encourage my child to try new things.
28. Good fortune plays a big part in determining whether or not
my child gets injured.
29. I keep my child from playing rough games or doing things
where he/she might get hurt.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
APPENDIX D
INJURY BEHAVIOR CHECKLIST
76
77
Injury Behavior Checklist
Please circle the frequency your target child engages in each of the specified behaviors.
0 – Not at all
4 – very often
(more than
once a week)
1. Runs out into the street
0
1
2
3
4
2. Jumps off furniture or other structures
0
1
2
3
4
3. Jumps down stairs
0
1
2
3
4
4. Rides bike in unsafe areas
0
1
2
3
4
5. Runs or bumps into things
0
1
2
3
4
6. Falls down
0
1
2
3
4
7. Plays with fire
0
1
2
3
4
8. Puts fingers or objects near appliances or outlets
0
1
2
3
4
9. Leaves the house without permission
0
1
2
3
4
10. Refuses to use seat belt or to stay seated in car
0
1
2
3
4
11. Plays with sharp objects
0
1
2
3
4
12. Pulls/pushes over furniture or heavy objects
0
1
2
3
4
13. Falls out window or down stairs
0
1
2
3
4
14. Puts objects or nonfood items in mouth
0
1
2
3
4
15. Gets scratches, scrapes, bruises during play
0
1
2
3
4
16. “Takes chances” on play-ground equipment
0
1
2
3
4
17. Tries to climb on top of furniture or cabinets
0
1
2
3
4
18. Stands on chairs
0
1
2
3
4
19. Explores places that are off limits
0
1
2
3
4
20. Gets into dangerous substances
0
1
2
3
4
21. Plays carelessly or recklessly
0
1
2
3
4
22. Comes into contact with hot objects
0
1
2
3
4
23. Behaves carelessly in or around water hazards
0
1
2
3
4
24. Teases and/or approaches unfamiliar animals
0
1
2
3
4
APPENDIX E
INJURY ATTITUDES QUESTIONNAIRE
78
79
Injury Attitudes Questionnaire
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Very Strongly Agree
1. Injuries can help my child learn to handle physical pain
better.
2. Minor injuries can sometimes help my child build character
and stamina.
3. A few minor injuries could be good for my child, because
they can help him/her learn to be more cautious.
4. Being injured may help my child “toughen” up mentally.
5. Experiencing a few minor injuries may help my child
prepare better for life by teaching him/her how injuries
occur and can be avoided.
6. Sometimes it is better to let my child learn on his/her own,
even if it means getting hurt a little.
7. When it comes to my child, I believe the saying “No pain, no
gain.”
8. Being injured may help my child “toughen up” physically.
9. If my child never gets injured, he/she is more likely to turn
out to be a “wimp” or “wuss” as an adult.
10. My child can build character by taking sensible risks that
could result in some minor injuries (e.g., sports).
11. When it comes to my child, I believe that the “once burned,
twice shy” notion is correct.
12. After being injured, my child usually learns not to do the
same thing again.
13. My child’s injury experiences help him/her learn the
consequences of risky behavior.
14. Getting injured can help my child learn the limits of his/her
physical abilities.
Very Strongly Disagree
The following questions ask about parent’s attitudes about childhood unintentional injuries
(i.e., accidents). Please respond to each statement using the following scale:
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
1
2
2
3
3
4
4
5
5
6
6
7
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
APPENDIX F
DEVELOPMENTAL KNOWLEDGE QUESTIONNAIRE
80
81
DEVELOPMENTAL KNOWLEDGE QUESTIONNAIRE
DISAGREE
1. Creep or crawl up three steps by 3 months of age.
1
2
3
2. Walk independently between 12 to 18 months of age.
1
2
3
3. Have the ability to feed self by one year of age.
1
2
3
4. Independently walk up stairs by one year of age.
1
2
3
5. Often refuse to comply to commands by saying “no” by one year of age.
1
2
3
6. Say two-word phrases by one year of age.
1
2
3
7. Display imaginative behavior by three years of age.
1
2
3
8. Kick a ball by 18 months of age.
1
2
3
9. Recite their first and last name by 4 years of age.
1
2
3
10. Have self care skills by 18 months of age.
1
2
3
11. Can distinguish between fantasy and reality by 4 years of age.
1
2
3
12. Sing songs by 18 months of age.
1
2
3
13. Can jump on one foot by 3 years of age.
1
2
3
14. Can safely cross neighborhood streets alone by 5 years of age.
1
2
3
15. Can ride tricycles or bicycles with training wheels by 4 years of age.
1
2
3
16. Safely climb up and down ladders by 5 to 6 years of age.
1
2
3
17. Can recite their address and phone number by 5 years of age.
1
2
3
18. Recognize many letters and print some by 3 years of age.
1
2
3
19. Understand cause and effect by 3 years of age.
1
2
3
20. Can safely be left alone in a bathtub by 4 years of age.
1
2
3
21. Can babysit younger children by ten years of age.
1
2
3
22. In adolescence have better balance than children younger than 10 years of age.
1
2
3
23. Need constant supervision under the age of 10 years.
1
2
3
24. Begin to write school-related stories, by 6 years of age.
1
2
3
25. Understand abstract thinking (i.e., morality, religion) by ten years of age.
1
2
3
NO
OPINION
AGREE
The following statements reflect accurate and inaccurate normative physical and cognitive
developmental abilities that most children develop at various ages. Please respond to each
statement by circling the number (Agree = 1, Disagree – 2, No opinion = 3) that coincides with
your option of each statement. Begin each statement with “Most children . . .”
APPENDIX G
PARENT SENSE OF INJURY COMPETENCE
82
83
PARENT SENSE OF INJURY COMPETENCE SCALE
Disagree
Strongly
Disagree
Mildly
Agree
Mildly
Disagree
Agree
1. My actions as a parent can protect my child from
accidents.
2. Parenting is usually rewarding, but I am frustrated
as a parent with my child at his/her current age.
3. I often feel that my child is vulnerable to accidents
in my care/home.
4. Sometimes I feel that other parents are better able to
protect their children from accidents than I am.
5. My mother/father was better at ensuring a safe
environment for their children than I am.
6. New parents should model my abilities to ensure a
safe environment for their children.
7. Preventing children’s accidents is manageable and
easily solved.
8. How I feel about myself as a parent impacts my
ability to prevent accidents to my child.
9. Sometimes I feel I cannot keep my child safe from
accidental injuries when other parents are able to.
10. I meet my own personal expectations for ensuring
my child’s safety from injuries.
11. If anyone can prevent injuries to my child, I am the
one.
12. My talents and interests are in other areas, not in
protecting my child from accidents.
13. I feel thoroughly familiar with preventing
accidental injuries to my child.
14. If I were more interested in safety proofing my
home, I would be more motivated to do a better
job.
15. I have all of the skills necessary as a parent to
protect my child from most types of accidents.
16. Thinking about my child’s safety from injuries
makes me tense and anxious.
Strongly
Agree
The following statements reflect some parents’ opinions about their ability to protect their
children from injuries. Please read each item carefully and rate whether you feel it applies to you
by circling a number from 1 (strongly agree) to 6 (strongly disagree) on the scale.
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6