TY - JOUR
AU - Kagan, Richard, J.
AB - Abstract Burn prevention is not taught in Amish schools despite significant cultural risks for burn injuries related to scalds, ignition of clothing, and ignition of highly flammable materials. A culturally appropriate and acceptable burn prevention teaching tool was previously developed and pilot-tested in one Amish school. The purpose of this study was to perform further evaluation of this burn prevention teaching tool for Amish children. Following institutional review board approval, private schools were recruited via invitation in Amish newsletters. A teaching tool, which includes a magnetic story board, burn safety curriculum, and test questions, was provided to each school. Teachers obtained parental permission and informed assent for the children to participate. Teaching was guided by the curriculum and involved arranging magnetic pieces to illustrate and tell stories about burn hazards. The children were challenged to rearrange the magnets for a safer situation. Pretests and posttests were used to capture baseline knowledge and measure improvement. Scores were expressed as a percentage of the 33 test items answered correctly. Teachers provided recommendations and a written evaluation of the tool's usefulness. The participants were 294 students from 15 private Amish schools across eight states. Test scores were significantly improved by the lessons, without regard to gender or grade groups. Teachers valued the tool and recommended no changes. This multicenter study demonstrated that a culturally appropriate burn prevention teaching tool was highly effective for improving burn prevention knowledge among Amish school children. These results support expansion of burn prevention education to other Amish communities. The Amish are well known as the plain people. Their culture is centered on the family, home, and church community in a nonmechanized, farming lifestyle similar in many ways to that of the pioneers. They rely on basic resources (wood, coal, and kerosene) for lighting and heating their homes as well as cooking and preserving food. They intentionally segregate themselves from the rest of society to avoid worldly evils, foregoing connection to public utilities, including electricity and water supplies. Private schools help to limit exposure of Amish children to the outside world. Formal education for the Amish is simple, sound, and practical. Although “Amish High German” is spoken at home, English is spoken in school.1 The standard curriculum includes the 4 “Rs” of reading, writing, arithmetic, and religion and does not include science.2 Responsibility for work and putting the needs of others before one's own are essential elements of the education provided by Amish teachers in their private, one-room schools.3 Because the Amish believe that the “English” (ie, non-Amish) are highly educated and corrupt, they isolate themselves from the rest of society and limit their education to the eighth grade.4 Burns to the Amish are related to rudimentary chores involving scalding water, open flames, and highly flammable liquids. Amish children are given chores as they approach school age assuming responsibility for more work as they grow.5 Very young children working alongside their parents are exposed to the same hazards as their parents. In our experience, most burns to Amish children are caused by scalds. Ignition of clothing is more likely among the Amish because of the long styles they wear and the open flames they encounter. Ignition of highly flammable materials occurs nearly twice as often as compared with non-Amish children. Education is warranted, as we have seen that burns to Amish children also tend to be more extensive than similar injuries to the non-Amish.6 Although the causes of burn injuries among the Amish are unique, they are also preventable. We accepted the challenge to cross the cultural barrier to provide educational materials that reflect traditional Amish practices and address the social differences of the Amish community.5,7 Importantly, the new resource needed to be culturally sensitive (low-tech and nonelectrical) to reach this tenaciously traditional population. The development of a burn prevention teaching tool (©2009 Shriners Hospitals for Children, Cincinnati, OH) in cooperation with one Amish community has been previously reported.8 The durable 2 × 3 foot dry-erase storyboard displays a colorful background of the typical Amish environment with a dollhouse view of the inside of the house. The moveable magnetic images provide teachers and children the means to display burn hazards and rearrange the magnets for a safer situation. The teaching tool also includes a curriculum to guide lessons with sample illustrations that are particularly helpful for younger, inexperienced teachers. The intent is for the children to have fun while they learn about burn prevention with their teachers who are themselves products of an eighth-grade education with no additional training for their teaching role.4 Pilot testing of this tool in one private Amish school demonstrated a highly significant improvement in test scores.9 The purpose of this study was to evaluate the effectiveness of the same tool in a larger sample as measured by improvement in students' test scores and feedback from the teachers. METHODS Following institutional review board approval, teachers of private Amish schools were recruited by advertised invitations in several Amish newsletters. Teachers who volunteered were instructed, and the requirements for human research were addressed by obtaining verbal parental permission and student assent. Burn prevention lessons were guided by the teaching curriculum and enhanced by visual displays on the board. Written tests were used to capture baseline knowledge and measure improvement. Pretesting was done before the lessons began and then followed by posttesting approximately 1 month (range, 1 day to 6 months) later. Finally, the teachers were asked to complete a written evaluation of the tool's usefulness. There was no direct contact between the researcher and the parents or children during this study in a conscious effort to minimize intrusion from outsiders. Tests were given and lessons taught by Amish teachers in private, one-room schools with students in grades 1 to 8. Testing was designed to be stress-free, with the option to answer “not sure” for any question, to discourage guesswork and to help the teacher easily identify student learning needs. The tests were written on two grade levels (grades 1 to 4 and grades 5 to 8) in a familiar true/false, multiple choice format requiring 33 responses to 25 questions. There were a few differences in word choices simplified for the younger children, but the concepts being tested were the same for all. Tests given before and after the lessons were scored as percent correct. This was all accomplished in the normal classroom setting by making use of story time and rainy day recesses to avoid interfering with daily lessons, in replication of the pilot study. The teachers used the burn prevention curriculum as a guide for basic fire and burn safety topics applicable to most Amish homes. Lessons were made interesting and interactive by sharing stories of family and friends who had been burned and by manipulation of magnetic pieces on the storyboard. Typical burn hazards involving lighters, stoves, kerosene heaters, gasoline-powered engines, and hot liquids used for canning, butchering, mopping, washing clothes, and making lye soap were among those illustrated on the board. Explanations were given to help the children understand why there were dangers and how to react to various situations. For example, as illustrated in Figure 1, it would be safer to move the child away from the ironing board, the washing machine motor, and the hot water heater; to keep the kerosene lamp away from the edge of the table; to place the candle away from the curtain; and certainly to keep matches away from the hay. Lessons were enhanced by the visuals for fire safety topics such as smoke detectors, fire extinguishers, fire escape plans, and the “stop, drop and roll” process. The teaching guide provided suggested illustrations for the storyboard and served as a checklist to ensure all important information was discussed. The children were encouraged to help each other review, so the older children set up hazards and challenged the younger children to rearrange the magnetic figures for safety. Figure 1. Open in new tabDownload slide Sample illustrations on magnetic board. Reprinted with permission.9 Figure 1. Open in new tabDownload slide Sample illustrations on magnetic board. Reprinted with permission.9 The mean pretest and posttest scores were compared for general improvement, using the paired t-test and repeated measurements analysis of variance (RM ANOVA). In addition, each of the 33 items was individually evaluated to identify improvement in specific knowledge. A test for paired proportions was used to determine statistical significance for percent differences in correct response to each question over time.10 RESULTS Teachers from 15 private Amish schools in eight states (Figure 2) volunteered to participate during the 2010 to 2011 school term. The average class size was 21, with a maximum of 46 students. For testing purposes, the eight grades were split into two groups corresponding to the reading levels of the two test versions. Students were fairly evenly distributed between gender groups and grade levels with slightly more female than male students and more students in the upper grades (5–8) than in the lower grades (1–4). Figure 2. Open in new tabDownload slide Distribution of 15 study sites. Figure 2. Open in new tabDownload slide Distribution of 15 study sites. There was 302 grade-school students who participated in the study. Eight students were excluded from the analysis. Of those, three special education students were dropped when their teacher indicated that their test results would not likely provide meaningful information. Five additional students were dropped due to absence for either the pretesting or the posttesting. The final analysis was based on 294 students who participated in the lessons and completed both tests. Table 1 lists the test results and participant demographics grouped by grade level. Tests were scored as the percentage of the 33 items answered correctly. Statistical analysis using the paired t-test demonstrated a highly significant improvement in the mean class test scores over time (P < .0001), for both grade-level subgroups as well as the aggregate of students. Table 1. Effect of lessons on mean test scores by grade groups Open in new tab Table 1. Effect of lessons on mean test scores by grade groups Open in new tab The overall difference between the pretests and posttests was highly significant, without regard to gender or grade. The class average improved 21 points, from 64 to 85% correct. There was a wide range of differences between pretest and posttest scores for individual students. Negative differences (a drop in an individual student's test score by as much as 32% on posttesting) were attributed to additional students, identified after the analysis to have special educational needs. Even with their data included, the overall improvement was significant. There were also a significant grade-level difference (P < .0001) by RM ANOVA. Both grade-level subgroups showed significant improvement in their test scores by more than 21 points. The mean percent correct increased from 60 to 81 in the lower grades and from 68 to 89 in the upper grades. There were significant grade-level differences for both the pretest scores (60 for the lower vs 68 for the upper grades) and for the posttest scores (81 for the lower vs 89 for the upper grades). Both male and female students showed a significant overall improvement in scores over time. No statistically significant gender difference was found (P = .14) by RM ANOVA. Effective lessons are reflected by those items with the most conversions from errors on the pretest to correct answers on the posttest. The correct response rates showed significant improvement (P < .05) for 22 (67%) of the 33 items (Table 2). Some examples include knowledge of how to react if the house is on fire by calling for help, feeling a door before opening it, and crawling beneath any smoke to get outside. Similar improvement was seen for other very basic concepts. A significant number of children learned that plain lye can burn the skin; some cleaners cause fumes that can burst into flames; one should not throw a spray can into a trash fire; the only purpose for gas is to run a motor and if one's clothes catch fire, he or she should not run for help. Overall, general knowledge acquisition was confirmed. Table 2. Effectiveness of lessons measured by change in itemized test scores Open in new tab Table 2. Effectiveness of lessons measured by change in itemized test scores Open in new tab The teachers' evaluations of the burn prevention teaching tool were all favorable. Most of the teachers strongly agreed that the teaching board was interesting, effective, and easy to use. All teachers indicated they would recommend this tool, and some provided names for referrals. Others indicated they would share their board with teachers in their community. Examples of impromptu comments from the teachers' evaluations include these statements: The huge colorful board caught the children's attention and the moveable pieces fired their imagination. The students had fun, learned important lessons and continued to use the teaching tool at every opportunity. It made it more real to see in pictures what can happen. Everyone had ideas about how these poor board people could improve their safety habits. Just having the board on the wall had made the children more aware of the dangers of carelessness. DISCUSSION It is estimated that more than 273,700 Amish are residing in 456 settlements. Within the settlements are 2007 smaller church districts with approximately 1500 private schools serving 40,000 Amish students.11 Many youth who are exposed to burn risks on a daily basis could benefit from structured safety education in the Amish culture. This burn prevention teaching tool has the potential to become part of their tradition, mounted on the walls of their private schools for a constant reminder. This study provided a tool that encouraged and enabled 15 Amish communities to teach burn safety to their school-age children. This effort was an initial step intended to introduce formal burn prevention education and hopefully initiate heightened awareness in a challenging population through their school children in a new tradition of burn prevention education. Although knowledge deficits persisted after the lesson, these would hopefully be addressed through continuing education during each subsequent school term to reinforce knowledge and correct any misconceptions. Future research could capture long-term retention of knowledge and changes in behavior of students in their home environment. While this depth of inquiry by outsiders into the Amish ways would likely be too intrusive at this time, we do not discount the possibility as relationships continue to evolve. Other limitations were recognized within the study as performed. The effectiveness of lessons may have been influenced by factors extraneous to the teaching tool under evaluation. Additional data were requested from the teachers including their years of teaching experience, time spent on lessons for this study, as well as currency of textbooks, and other classroom resources. The response was fragmented. While 40% (n = 6) of the teachers provided all requested information, the majority of 87% (n = 13) responded to only some of the questions with two preferring not to provide any of the requested details about classroom circumstances. Therefore, data were not sufficient to determine any effect of site-specific variables on the test results. Thirteen teachers provided their years of teaching experience and the publication dates for the classroom resources. The mean length of teaching experience (for 13 teachers) was 7.2 (range, 2–20) years, and the average length of time spent on the burn prevention lessons (for 6 teachers) was 32 hours. Some schools used more textbooks than others. The broad range of publication dates for schoolroom resources are delineated in Table 3. Encyclopedias were available in most schools with an average age of 30 years (5–57 year range). Textbooks were published as far back as 1968 (reading), 1963 (history), and 1928 (arithmetic). The most recent additions to the repertoire of subjects was a 1999 vocabulary textbook in one school and health textbooks (1997–2008) in five schools. Most often, the textbooks used in Old Order Amish schools are dated if not archaic, having been donated by public schools updating with new textbook editions.4,12 Table 3. Classroom resources—age and publication dates Open in new tab Table 3. Classroom resources—age and publication dates Open in new tab Community characteristics included acceptance of newer safety concepts and overall awareness of appropriate fire safety responses before introduction of our burn prevention efforts. All of the 13 teachers responding to this segment of the evaluation believed that their communities would accept smoke detectors and fire extinguishers. Only five (38%) of those teachers thought their communities would accept bathtub thermometers. Six (46%) of the respondents believed their community was aware of fire escape plans and nine (69%) thought their students knew when and how to stop, drop, and roll. These results are generalizable to the Old Order Amish communities represented, but not necessarily to all Amish communities. In fact, the tool was rejected on two separate occasions by members of Swartzentruber groups, the most conservative or “lowest order” of Amish sects. Two Swartzentruber men (an Amish school board member and the father of a burn patient treated at our hospital) simply refused the burn prevention teaching board because they “would not use something like that” in their schools. In addition to the lack of universal acceptability, the teaching tool does not comprehensively address the burn risks to all Amish across North America. Although Amish groups are united by history, they are divided by the ordinung (rules for living and acceptable practices that regulates everything from clothing to technology), which varies among the hundreds of Amish settlements.12 For example, “wick lamps” fueled by oil or kerosene are used for home lighting in the low-order community in southeast Indiana where the teaching tool was developed. In contrast, most of the Amish of Holmes County, Ohio (the largest Amish settlement) use floor lamps powered by 12-volt car batteries for lighting in the home. Many higher-order Amish groups of Lancaster (Pennsylvania) use propane to fuel their indoor lights. Both of the latter types of lamps were excluded from the teaching tool because they are forbidden by the ordinung of the most conservative groups. We wanted the tool to address topics that are common among the Amish population, and particularly applicable to the lower Amish orders that are most in need of safety education. Future work could address the burn risks of more progressive Amish communities to supplement the teaching guide and design additional magnetic pieces that could be used as each community deems appropriate. CONCLUSION This multicenter study substantiates the findings of our pilot study, demonstrating that the teaching tool is highly effective for improving burn prevention knowledge among Amish children. Importantly, the tool was accepted as culturally appropriate and useful by the teachers. Expanded use of this tool to other Amish communities seems warranted and will provide the culturally sensitive burn prevention education necessary to increase burn awareness among Amish school children. ACKNOWLEDGMENTS We acknowledge the Amish teachers who took the time and put forth the effort to evaluate this tool in their schools. We thank Laura James, MS, for her statistical support and the International Association of Fire Fighters—Burn Foundation for funding this effort to increase burn awareness among Amish children. REFERENCES 1. Hostetler JA Amish society. 19934th ed Baltimore, MD Johns Hopkins University Press. 2. Fischer SE, Stahl RK The Amish school. 19972nd ed Intercourse, PA Good Books. 3. Ediger M. What is Amish in Old Amish education. Descriptive report. Educational Resources Information Center (ERIC). 1987:ED 278579. 4. Jared E. The educational journey of an Amish woman. Teacher Educator. 2001;36:235–247 available from http://dx.doi.org/10.1080/08878730109555269; accessed March 29, 2012. 5. Jones PJ, Field WE. Farm safety issues in Old Order Anabaptist communities: unique aspects and innovative intervention strategies. J Agric Saf Health. 2002;8:67–81. 6. Rieman MT, Hunley M, Woeste L, Kagan RJ. Is there an increased risk of burns to Amish children?. J Burn Care Res. 2008;29:742–9. 7. Burgus S, Rademaker A. Testing a novel child farm safety intervention for Anabaptist audiences. J Agromedicine. 2007;12:63–70. 8. Rieman MT, Kagan RJ. Development of a burn prevention teaching tool for Amish children. J Burn Care Res. 2012;33:259–64. 9. Rieman MT, Kagan RJ. Pilot testing of a burn prevention teaching tool for Amish children. J Burn Care Res. 2012;33:265–71. 10. Hossein A. Statistical thinking for managerial decisions. Merrick School of Business, University of Baltimoree available from http://home.ubalt.edu/ntsbarsh/Business-stat/otherapplets/PairedProp.htm#rmenu; accessed February 20, 2012. 11. Amish population trends 2012, one-year highlights. Young Center for Anabaptist and Pietist Studies, Elizabethtown College available from http://www2.etown.edu/amishstudies/Population_Trends_2012.asp; accessed September 3, 2012. 12. Johnson-Weiner KM Train up a child: Old Order Amish and Mennonite schools. 2007 Baltimore, MD The Johns Hopkins University Press. Footnotes 1 Presented in part at the 44th annual meeting of the American Burn Association, April 24–27, 2012. Copyright © 2012 by the American Burn Association
TI - Multicenter Testing of a Burn Prevention Teaching Tool for Amish Children
JF - Journal of Burn Care & Research
DO - 10.1097/BCR.0b013e318278169a
DA - 2013-01-01
UR - https://www.deepdyve.com/lp/oxford-university-press/multicenter-testing-of-a-burn-prevention-teaching-tool-for-amish-g4r6vMANqQ
SP - 58
EP - 64
VL - 34
IS - 1
DP - DeepDyve
ER -