Accident Analysis and Prevention 147 (2020) 105773

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Accident Analysis and Prevention

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Effectiveness of a school-based road safety educational program for lower

secondary school students in Denmark: A cluster-randomized
controlled trial
Anders Bo Bojesen , Signe Boe Rayce *
VIVE – The Danish Center for Social Science Research, Herluf Trolles Gade 11, 1052, København K., Denmark

A R T I C L E I N F O A B S T R A C T

Keywords: Road accidents are one of the leading causes of death and injuries among adolescents and young adults. Road
Road safety education safety education programs aim to promote safe traffic behavior through information, skills training or fear ap­
Victim testimonials peals. During the last decade, an intervention type using victim testimonials has been developed. These types of
Adolescents
programs aim to promote road safety by connecting a personal narrative of choices and consequences to the
Cycling
Seatbelt use
beliefs and behaviors of the audience. Studies on the effectiveness of this type of road safety programs among
Pre-drivers youngsters who are not yet drivers are still limited.
This study used a cluster-randomized and controlled trial design to examine the effect of a Danish school-based
road safety educational program using testimonials for students in lower secondary schools in Denmark on a)
knowledge of risks factors in traffic and b) two types of behavior specifically relevant for the pre-driver target
group: seatbelt use and safe bicycle behavior. Our analysis sample comprised 1007 students from 57 schools with
a matched baseline and four-month follow-up response.
Linear regression analyses suggest a small positive effect on the students’ knowledge of the three most
important risk factors in traffic but not on the age group most at risk. Concerning seatbelt use or overall cycling
behavior no effect was found, although a small positive effect was found on helmet use. Neither was the
effectiveness modified by gender, parental educational background, or risky cycling behavior at baseline.
Although classroom-based interventions using testimonials may have the potential to increase knowledge of
risk factors in traffic among adolescents, translating knowledge into safe traffic behavior is challenging. More
studies are needed on how to further adapt the intervention to an age group who are not yet drivers. Such
research may focus on mechanisms of change including the age-specific relevance of the ambassador’s testi­
monial and on employing strong elements of action guidance.

1. Introduction
Injuries sustained in traffic are the main cause of severe injuries
among adolescents in Denmark (Ekström et al., 2017; Laursen and
Schaarup, 2017; Møller et al., 2012). Despite an increasing focus on road
safety through the last decades, adolescents are still over-represented in
traffic-related accidents among 0− 18 year olds, particularly as moped
riders and bicyclists, (Ekström et al., 2017; Laursen and Schaarup,
2017). This age dependent increase in injuries is similar in other western
countries (OECD, 2006). Globally, road accidents are the primary cause
of death among children and young adults (WHO, 2018). The increased
risk is closely related to: the lack of experience as agents in traffic,
cognitive and emotional factors related to the brain not yet being fully
developed, intense social dynamics at work among adolescents, negative
peer pressure, and to the use of alcohol and drugs (Buckley et al., 2014;
Hatfield and Fernandes, 2009; OECD, 2006; Rosenbloom et al., 2008;
Weston and Hellier, 2018; Romer et al., 2014).
The importance of preventing traffic injuries in general and the
recognition that children and adolescents are particularly vulnerable is
reflected by the extent of road safety campaigns and programs launched
in many western countries (Classen et al., 2019; Richmond et al., 2013;
Pressley et al., 2016). Some programs focus on practical skills and
knowledge of traffic rules (Richmond et al., 2013; Pressley et al., 2016);
other programs use a cognitive approach aiming to improve knowledge

* Corresponding author.
E-mail address: sbo@vive.dk (S.B. Rayce).

https://doi.org/10.1016/j.aap.2020.105773
Received 20 December 2019; Received in revised form 2 September 2020; Accepted 3 September 2020
Available online 15 September 2020
0001-4575/© 2020 Elsevier Ltd. All rights reserved.
A.B. Bojesen and S.B. Rayce
and understanding of risk factors in traffic through information, and in
some cases, also demonstrations (e.g. testing reaction time) (Twisk et al.,
2014; Pressley et al., 2016). Other types of programs use fear appeals as
a central incentive to reduce risky traffic behavior. By focusing on the
dreadfulness of traffic accidents often resulting in severe injury or death,
these programs aim to motivate youngsters to behave safely in traffic
(Lewis et al., 2007; Ruiter et al., 2014). While fear may have an effect on
attitude, intention, and behaviors in general (Witte and Allen, 2000), the
effect most likely depends on perceived efficacy in handling the threat
(Peters et al., 2013; Ruiter et al., 2014) and to which degree the indi­
vidual feels susceptible to the threat (Ruiter et al., 2014). If information
about coping mechanisms is not provided as part of an intervention, a
fear-appeal approach may have no or even the opposite effect such as
risk-denial or increased risky behavior (Carey et al., 2013; Feenstra
et al., 2014). In a study comparing five short road safety interventions
targeted adolescents, Twisk et al. (2014) did not find significantly
different effects on behavior dependent on whether the intervention
used a cognitive or a fear-appeal approach.
During the last decade, a new type of programs with a stronger focus
on establishing emotional ties to people affected by traffic accidents has
been launched. By using testimonials by either a person (or a relative)
who has been involved in a traffic accident, and subsequently a dialog
between this person and the youngsters, these interventions seek to
affect the youngsters emotionally but also to facilitate cognitive reflec­
tion on own behavior and responsibility in traffic (Cuenen et al., 2016).
To date, effect studies of road safety programs using testimonials among
youngsters are relatively limited. None of the existing studies are based
on a randomized controlled study design and the studies show mixed
results. Although the majority of studies find positive effects of these
programs on some beliefs or socio-cognitive variables (Feenstra et al.,
2014; Poulter and McKenna, 2010; Cuenen et al., 2016) or behavior,
(King et al., 2008; Twisk et al., 2014; Cuenen et al., 2016) others find no
or only a small effect of such interventions on behavior (Glendon et al.,
2014; Feenstra et al., 2014; Twisk et al., 2014). Two studies even found a
negative effect (Feenstra et al., 2014; Glendon et al., 2014).
In many European countries, besides being a passenger in a car the
bicycle is one of the primary means of transportation among youngsters
who are not yet old enough to drive. Therefore, use of seatbelt and
cycling behavior are two key outcomes in this age group. However, only
three studies focus on the effect of road safety programs using testimo­
nials on behavior among students not yet allowed to drive (Cuenen et al.,
2016; Feenstra et al., 2014; Twisk et al., 2014). While two of these
studies encompassed cycling behavior in an overall measure of risky/­
safe behavior, we have found only one study focusing specifically on
risky cycling behavior (Feenstra et al., 2014). This study found positive
effects on risk perception and relative attitude towards traffic safety but
the intervention group was also more positive towards traffic violations
at follow-up. No effect was found on risky cycling behavior.
In summary, little is known on the effect of road safety programs
using testimonials among youngsters, especially in the pre-driver pop­
ulation. Additionally, there is little knowledge on whether the effects of
such programs differ within certain subgroups of young people. Besides
age, the risk of injuries in traffic is modified by gender with young males
having a substantially higher risk for injuries in traffic (OECD, 2006) and
being more likely to report lower perceived risk about unsafe driving
and more risky attitudes towards driving (Glendon et al., 2014)
compared to females. Therefore, it may also be possible that the effect of
road safety programs differs depending on gender. Only one of the
studies evaluating the effect of using testimonials among pre-drivers
(Cuenen et al., 2016) tested whether the effect on behavior was modi­
fied by gender. They found a significant interaction with boys being
more likely to benefit from the intervention than girls. In addition,
youngsters with a lower socio-economic background have a greater risk
of experiencing traffic injuries compared to peers with a higher
socio-economic background (WHO, 2007; Laflamme et al., 2010).
Studies also find that youngsters who perceive their parents as being less
2
Accident Analysis and Prevention 147 (2020) 105773
committed to safety or who witness risky traffic behavior from their
parents have an increased risk of taking risks themselves (Alonso et al.,
2018; Taubman Ben-Ari et al., 2014). However, only one of the studies
using testimonials examined whether the effect of the road safety pro­
gram was modified by factors related to family socio-economic back­
ground (Cuenen et al., 2016).
Therefore, the purpose of this study was to evaluate the effect of a
road safety program (Road Safety LIVE) targeting the oldest students in
lower secondary school in Denmark. Using testimonials, this program
aims to provide the students with better insight into and understanding
of the consequences of accidents in traffic and thereby motivate them to
make safer choices in traffic. More specifically, using a cluster-
randomized controlled study design the aims of this study were: 1) to
examine the effect of the LIVE intervention on the students’ knowledge
of a) the most important risk factors in traffic and b) the age group most
at risk and 2) to examine the effect on two behavioral outcomes spe­
cifically relevant for youngsters not yet driving: a) seat belt use and b)
cycling behavior. Furthermore, an aim was to examine whether these
two behavioral outcomes were modified by a) gender, b) parental
educational background and for c) risky cycling behavior at baseline.
2. Method
2.1. The Road Safety LIVE intervention and context
The Road Safety LIVE intervention (LIVE) is an educational program
using testimonials targeted at lower secondary school students, students
in upper secondary school and pre-vocational short-term educational
programs. This evaluation only considers the program targeted students
in the 8th–10th grade of lower secondary school (13–17 year-olds).
Denmark has ten years of compulsory education (0th –9th grade)
where lower secondary school refers to the 7th – 10th grade, with the
10th grade being optional.
A LIVE session lasts 90-minutes and takes place in a classroom setting
during regular school hours. Schools contact regional coordinators at
The Danish Road Safety Council to arrange for one or more LIVE ses­
sions. The program is free of charge for any municipal school in the
target group (approximately 80 % of Danish primary and lower sec­
ondary school students attend municipal schools, which are financed
through taxes) but both municipal and private schools received LIVE
visits. and there are only simple requirements for teachers and schools
who want to participate. To facilitate dialog and interaction between the
LIVE ambassador and the students, only one or two classes can partici­
pate in a session, e.g. no more than approximately 50 students.
The LIVE intervention has three overall aims: 1) to increase knowl­
edge of risk factors, 2) improving attitudes towards risk-taking behav­
iors related to traffic and 3) promote safe behaviors in traffic. The main
component of the program is the story of an ambassador. Ambassadors
are adult road accident survivors (age range: 27− 50 year olds) injured as
a young person who are trained in executing the LIVE sessions. The
sessions are structured around the personal narrative of the ambassador
in the first part and a Q&A session in the second part. A teacher’s guide
and a pupil handout supplement the LIVE visit. The student handout is
specific to each ambassador and comprises reflection exercises to be
completed by the students before the visit as well as an introduction to
the format of the LIVE visit.
The ambassador introduces him or herself to the audience and then
describes his or her life before the accident. Emphasis is on who the
ambassador was as a person in lower secondary school, what he or she
enjoyed doing and his or her dreams for the future. The ambassadors will
typically ask questions about the students’ own experiences in traffic
and whether they know somebody who has been injured in a road ac­
cident. This part is intended to establish a personal connection between
the ambassador and the audience and to give the students an under­
standing that the ambassador’s life as a young person before the acci­
dent is reminiscent of the students’ lives. The ambassador then describes
A.B. Bojesen and S.B. Rayce
the accident and the circumstances of the accident in detail with images
from the scene of the accident. This part highlights the events, actions,
and choices made by the ambassador and other individuals, which led to
the accident. Since the ambassadors are often local, it is likely that the
students know the location of the accident. Apart from making the ac­
cident comprehensible, the purpose is to make clear links between
choices and the event of the accident. The ambassador deliberately
avoids a fear approach such as dramatizing the accident or scaring the
audience. Instead, the ambassador seeks to give an account of what
happened emphasizing that he or she was a person making some wrong
decisions and thereby in some way responsible for the accident. While
doing that the ambassador establishes and maintains a personal relation
to the audience. This seeks to enable the audience to identify with the
ambassador and reflect on their own attitudes and behaviors in traffic.
Overall, the approach used in the LIVE intervention aims to increase
students’ experience of being susceptible to threats in traffic, i.e. in­
crease their perceived susceptibility, but also to facilitate a feeling that
by making the right choices they themselves can reduce the risk of being
injured in traffic. Subsequently, the ambassador talks about how his or
her life has worked out since the accident, focusing on the consequences
of the accident and how the accident affected family, friends, and future.
Students are encouraged to prepare at least one question to the
ambassador. The ambassador may also ask students questions about
their attitudes, behaviors, and experiences in relation to risks in traffic
and provide guidance on action. As a final remark, the ambassador re­
peats the most important points and thanks the students for their
participation.
2.2. Design and data collection
This study used a cluster-randomized wait-list trial design. Partici­
pating schools were recruited in the summer of 2016 among Danish
schools who contacted The Danish Road Safety Council requesting a
LIVE visit. Ninety-four schools were included and randomly assigned to
either wait-list (n = 49) or to participation in the program (n = 45). The
randomization was conducted by VIVE – The Danish Center for Social
Science Research. The students completed an online questionnaire at
baseline and follow-up. The contact teacher of each school was
responsible for data collection at the school by making the questionnaire
link available to the students, preferably by providing time for
Fig. 1. Flow chart for the data collection.
3
Accident Analysis and Prevention 147 (2020) 105773
completing the questionnaire during the course of a lesson. The students
were informed that participation in the survey was voluntary and that
their answers were treated confidentially.
Fig. 1 illustrates the data collection. Baseline data were collected in
September 2016 before the LIVE visit took place. At baseline, 3,708
responses (control: 49 schools, n = 1805; intervention: 45 schools, n =
1903), were recorded. After removal of duplicates, responses with
missing identification data (e-mail or phone number), or blank response,
the baseline data comprised responses from 3,536 students. The LIVE
visits took place during October and November 2016 with most visits in
November. Follow-up data were collected between January and
February 2017, before the wait-list schools received their LIVE visit.
Thus, the follow-up questionnaire was typically completed two to three
months (Range: 1–4 months) after the LIVE visit. At follow-up, 1784
responses (control: 29 schools n = 857 intervention: 28 schools, n =
855) were recorded. After removal of duplicates and responses with
missing identification, follow-up data comprised 1,390 responses. Of the
3,536 valid baseline responses (control n = 1,724; intervention n =
1,812), 1,007 responses could be linked to a follow-up response using
self-reported phone numbers and email addresses. These 1,007 obser­
vations (control n = 480, intervention n = 527) constitute the analysis
sample. Since the number of students with access to the LIVE visit and
baseline questionnaire was not recorded, the exact response rate is not
known.
2.3. Measures
2.3.1. Outcome measures
Outcome measures included two outcomes of knowledge: a)
knowledge of the most important risk factors in traffic; b) knowledge of
the age group most at risk; and two outcomes of behavior: c) seat belt
use; and d) cycling behavior.
2.3.1.1. Knowledge of most important risk factors in traffic. The students
were asked to identify the three most important factors associated with
traffic injuries (drunk driving, speeding, and inattention) out of a list of
nine possible risk factors. The mean number of correct answers was used
as outcome measure.
2.3.1.2. Age group most at risk. The students were asked to identify the
A.B. Bojesen and S.B. Rayce
age group most often affected by severe traffic injuries, including fa­
talities, (15 to 24-year-olds) out of a list of six other age intervals. We
used a binary indicator of correct answer as the outcome measure.
2.3.1.3. Seat belt use. Danish law requires that all passengers use a seat
belt. The students were asked how often they used a seat belt when in a
car. The response categories were assigned a numerical value and were:
‘never’ = 1, ‘rarely’ = 2, ‘almost always’ = 3, ‘always’ = 4. In the effect
analysis, seatbelt use is treated as a numerical outcome.
2.3.1.4. Cycling behavior. Cycling behavior was measured by a four-
item index comprising four ordinal items on different aspects of
cycling habits or behaviors: helmet use, texting, talking on the phone
and listening to music while cycling. Of these behaviors, texting and
talking on the phone, while cycling, are prohibited by law. Helmet use is
strongly recommended but not mandatory. The four items were 1) ‘How
often do you wear a bike helmet?’, 2) ‘How often do you text while
cycling?’, 3) ‘How often do you listen to music while cycling?’ and 4)
“How often do you talk on the phone while cycling?” The response
categories were: 1) ‘Never’, 2) ‘Rarely’, 3) “Sometimes’ and 4) ‘Always’
with the last three items reverse-scored so that higher values reflect safe
cycling behaviors and low values unsafe bicycling behaviors. The
average score of answered items was used as outcome measure, thereby
treating cycling behavior as a numerical outcome. This approach facil­
itates interpretation compared to rank-based approaches while correc­
tion of standard errors using robust estimators relaxes assumptions of
normality and homoscedasticity. Students with more than two items
missing were excluded from the analysis (n = 11). Initial factor analysis
using a weighted least squares factor model for ordinal data supported a
one-factor model. Cronbach’s Alpha was 0.68 (95 % CI: 0.66− 0.70). For
the subgroup analysis, a dichotomized variable on risky cycling
behavior was used: students scoring 3 (corresponding to ‘Sometimes’ for
wearing a bike helmet and ‘rarely’ for the reverse-scored items on
cycling behavior) or less at baseline vs. students with a score above 3.
2.3.2. Covariates
Seven covariates that may affect behavior in traffic: age, gender,
grade, family type and parental educational attainment, drunkenness
and experience with cannabis were recorded at baseline. These mea­
sures were also included in the inverse probability weighting and in the
adjusted models. All observed factors are included and reported in order
to assess any imbalances at baseline and to minimize the impact of any
potential biases driven by observed measures.
Family type was measured based on the item ‘Who do you live with?’
Response categories included: ‘With my mother and father’, ‘With my
mother or my father’, ‘Alternately at my mother’s and my father’s’,
‘Mostly at my foster parents or other family’ or ‘Others’. The responses
were divided into three categories: 1) Parents living together, 2) Parents
living apart (‘With my mother or my father’ and ‘Alternately at my
mother’s and my father’s’) and 3) Foster parents or Others.
Parental educational attainment was reported by the students for both
parents and subsequently combined into a joint measure reflecting the
highest educational level of the parents. The response categories were:
1) primary and lower secondary school, 2) upper secondary school, 3)
vocational training, 4) short-cycle higher education (academy profes­
sion programs at the Academies of Professional Higher Education lasting
2− 2½ years), 5) medium-cycle higher education (professional bachelor
programs at the University Colleges, e.g. nurse or pedagogue lasting 3–4
years), 6) long-cycle higher education (bachelor, master and PhD de­
grees obtained at the universities), and ‘don’t know’. A dichotomous
variable was used in the subgroup analyses: 1) Upper secondary school
or shorter and 2) above secondary school. Students who did not know
any of their parents’ educational level were coded as missing.
Drunkenness was measured by the item: ‘At which age did you get
drunk for the first time?’ with the following response categories: ‘I have
4
Accident Analysis and Prevention 147 (2020) 105773
never been drunk’,’ 18 years or older’,’ 17 years’, (…), ‘13 years’, ‘12
years or younger’ and ‘Don’t know’. We dichotomized the response
categories into whether the student had ever been drunk or not. ‘Don’t’
know’ was coded as missing.
Experience with cannabis-based drugs was measured by the item:
‘Have you ever smoked hash, marihuana or skunk?’ The response cat­
egories were ‘No’ and ‘Yes’.
2.4. Statistical analysis
Categorical variables were described using two-way frequency tables
and corresponding percentages. Inferential comparisons were based on
chi-square test. Numerical variables were described using means and
standard deviations. Mann-Whitney-Wilcoxon test for ordinal data was
used for comparison between groups at baseline.
Inverse probability weights were used to control for the impact of the
selection and dropout processes, which filters out some students from
the initial sample of 3,536 respondents. The inverse probability weight
assigns a higher weight to students who are less likely to respond to the
follow-up questionnaire. The probability was calculated using all
available baseline data in cross-validated boosted forest model (The
random Forest package in R; ten cross validations). The random forest is
an ensemble of decision trees that, combined, estimate the probability of
having answered the follow-up questionnaire. Decision trees are tree
models with branches defined by variable value cut-offs or categories
(Liaw and Wiener, 2002). The inverse of the estimated probability (1-pˆ)
is then used as a probability weight in a robust linear regression model to
take account of any selection bias by giving more weight to observations
of student less likely to respond to the questionnaire. This procedure
eliminates the impact of the selection bias caused by observed factors.
Table S1 in the supplementary materials compares the group with
follow-up responses to the group without follow-up responses.
The main effects were tested using linear regression with robust
standard errors taking into account the clustering of students in schools
(White, 1982). Logit regression was used for one outcome: identification
of risk age groups. Observations were weighted using the inverse of the
probability of answering the follow-up questionnaire and adjusted for all
baseline covariates and the baseline measure of the outcome evaluated.
This ensures that any observed imbalances at baseline are not trans­
ferred to the effect estimates in model 3. Raw estimates, weighted es­
timates, and adjusted estimates are reported.
All analyses were conducted using R 3.6.1. Randomization was
carried out in SAS.
3. Results
3.1. Sample characteristics and differences at baseline
Students with a matched response at follow-up differed significantly
in some ways from students with no match (Supplementary table S1);
they were slightly younger (p = 0.005) and a higher proportion lived
together with both parents (p = 0.001). A slightly higher proportion had
parents with a medium-cycle education (p = 0.032) and a lower pro­
portion has ever been drunk (p = 0.019). Significant differences in
outcome measures were found for knowledge on age group most at risk
(p = 0.016) and overall cycling behavior (p = 0.002) with students with
a response at follow-up having slightly more favorable outcomes
compared to students with no match at follow-up.
Table 1 shows the baseline characteristics of the analysis sample. The
sample was well-balanced in gender (51.4 % females). The majority of
students were 14–15 years old (84.7 %) attending the 8th or 9th grade
(98.1 %). Students living with both parents made up 72.6 % of the
sample. While 26.9 % answered that they did not know their parents
education, 40.7 % of the students had a parental educational back­
ground of medium- to long-cycle higher education and 11.2 % a back­
ground of upper secondary school or shorter. 27.3 % had been drunk at
A.B. Bojesen and S.B. Rayce Accident Analysis and Prevention 147 (2020) 105773

Table 1
Background characteristics and outcome measures at baseline. Percentages and means (SD).
Analysis sample
Students with matched baseline and follow-up responses

Control LIVE Total

(n = 480) (n = 527) (n = 1007)

n % n % P n %

Baseline characteristics
Gender Male 233 48.5 256 48.6 489 48.6
Female 247 51.5 271 51.4 0.991 518 51.4
Age 12− 13 years 64 13.3 61 11.6 125 12.4
14− 15 years 399 83.1 454 86.1 853 84.7
16− 18 years 17 3.5 12 2.3 0.318 29 2.9
Grade 7th 8 1.7 3 0.6 11 1.1
8th 315 65.6 319 60.5 634 63.0
9th 148 30.8 205 38.9 353 35.1
10th 9 1.9 0 0.0 0.000 9 0.9
Family type Parents living together 332 69.2 399 75.7 731 72.6
Parents living apart 136 28.3 118 22.4 254 25.2
Foster parents or other 12 2.5 10 1.9 0.067 22 2.2
Parental education Do not know 119 24.8 152 28.8 271 26.9
Primary and lower secondary school 14 2.9 13 2.5 27 2.7
Upper secondary school 37 7.7 49 9.3 86 8.5
Vocational training 71 14.8 86 16.3 157 15.6
Short-cycle higher education 28 5.8 28 5.3 56 5.6
Medium-cycle higher education 130 27.1 131 24.9 261 25.9
Long-cycle higher education 81 16.9 68 12.9 0.410 149 14.8
Been drunk No 326 67.9 378 71.7 704 69.9
Yes 137 28.5 138 26.2 275 27.3
Missing/Don’t know 17 3.5 11 2.1 0.230 28 2.8
Tried cannabis No 462 96.2 518 98.3 980 97.3
Yes 17 3.5 8 1.5 25 2.5
Missing 1 0.2 1 0.2 0.119 2 0.2
Outcome measures at baseline
Risk age group identified No 116 24.2 113 21.4 229 22.7
Yes 364 75.8 414 78.6 0.303 778 77.3
Mean SD Mean SD P Mean SD
Risk factors identified 1.87 0.74 1.87 0.76 0.812 1.87 0.75
Seat belt use 3.89 0.34 3.90 0.35 0.431 3.89 0.34
Cycling behavior 3.17 0.63 3.13 0.66 0.363 3.15 0.64
Single items for Cycling behavior
Helmet use 2.57 1.23 2.59 1.25 0.795 2.58 1.24
Texting 3.42 0.70 3.35 0.71 0.071 3.38 0.71
Music 3.18 0.93 3.13 0.90 0.245 3.15 0.91
Phone 3.52 0.61 3.46 0.64 0.110 3.49 0.63

least one time. Significant baseline imbalances at a 5% level of signifi­
cance were found for school grade, only. Compared to the control group,
a higher proportion of the students in the intervention group attended
the 7th or 8th grade.
The lower section of Table 1 shows the baseline measurement of the
outcome variables. The age group experiencing the highest number of
injuries and fatalities in traffic was correctly pointed out by 77.3 % of
the students. The mean number of correctly identified risk factors in
traffic was 1.87 (SD = 0.75) with only 20.4 % of the students being able
to identify the three most important risk factors in traffic (results not
shown). The average score on seat belt use was 3.89 (SD = 0.34)
(possible scoring range: 1–4, with a high score being better (see Section
2.3.1 for response categories)) and 90.6 % of the students answered that
they always use a seat belt while being in a car (results not shown). The
average scores on the cycling behavior scale items were 3.15 (SD = 0.64)
(possible scoring range: 1–4, with a high score being better). For the
single items on cycling behavior, 30.8 % of the students reported always
wearing a helmet. Approximately half of the students (51.0 %) never
texted, 40.6 % never listened to music and 54.5 % never used their
mobile phones when cycling (results not shown). No significant baseline
imbalances were found for any of the outcome measures.
3.2. Main effects of the LIVE intervention
Table 2 shows the main effects of the study. The LIVE intervention
had a significant and positive effect on the students’ abilities to identify
the three most important risk factors in traffic (β = 0.18, 95 % CI:
0.08− 0.28). The impact of selection bias due to the variables observed at
baseline was negligible, since the effect estimate was robust in the
weighted regression and after adjusting for background variables and
knowledge on risk factors at baseline. Unobserved variables might still
introduce a bias. With a combined standard deviation of 0.76 on this
outcome, this corresponds to a standardized mean difference (SMD:
Cohen’s d) of 0.21. No significant effects were found on knowledge of
age group most at risk, seat belt use, or overall cycling behavior. The
exploratory analysis on the single items on cycling behavior showed a
small but significant increase in helmet use in the intervention group (β
= 0.10, 95 % CI: 0.08− 0.28); SMD = 0.10).
3.3. Subgroup analyses
Table 3 shows the results of the subgroup analyses. Besides testing
the main effects of the intervention, we conducted subgroup analyses to
test whether effects on the two behavioral outcome measures: seat belt
use and overall cycling behavior were modified by gender, parental
education or overall cycling behavior at baseline. While gender did not
modify the effect on seatbelt use, a significant subgroup effect was found
in relation to cycling behavior in the unadjusted analysis for females.
After weighting and adjustment for baseline measures, this effect
became insignificant. When introduced as an interaction term, there

5
A.B. Bojesen and S.B. Rayce Accident Analysis and Prevention 147 (2020) 105773

Table 2
Mean scores by intervention group at follow up. Raw, weighted, and adjusted main effect estimates (β) (95 % CI) of the LIVE intervention on knowledge, seatbelt use,
and cycling behavior.
Control LIVE Model (1) Model (2) Model (3)
a b
(n = 480) (n = 527) Unadjusted Weighted and adj. Weighted and fully adj.

Outcomes Mean SD Mean SD β 95 % CI β 95 % CI β 95 % CI

Risk factors identified 2.03 0.75 1.87 0.79 0.16 (0.05¡0.26) 0.16 (0.05¡0.26) 0.18 (0.08¡0.28)
Risk age group identifiedc 0.86 0.35 0.83 0.38 0.23 (− 0.12 to 0.58) 0.25 (− 0.10 to 0.61) 0.23 (− 0.13 to 0.60)
Seatbelt use 3.89 0.37 3.88 0.41 0.01 (− 0.04 to 0.06) 0.01 (− 0.04 to 0.06) 0.00 (− 0.03 to 0.08)
Cycling behavior 3.09 0.65 3.10 0.65 − 0.01 (− 0.09 to 0.08) − 0.01 (− 0.10 to 0.08) 0.02 (− 0.03 to 0.08)
Exploratory analyses of single items on cycling behavior
Helmet use 2.63 1.26 2.51 1.21 0.13 (− 0.04 to 0.29) 0.13 (− 0.03 to 0.30) 0.10 (0.02–0.18)
Texting 3.31 0.75 3.38 0.71 − 0.07 (− 0.17 to 0.03) − 0.08 (− 0.18 to 0.02) − 0.04 (− 0.12 to 0.04)
Music 3.07 0.90 3.08 0.96 − 0.02 (− 0.14 to 0.11) − 0.01 (− 0.14 to 0.11) 0.02 (− 0.07 to 0.11)
Phone 3.35 0.73 3.41 0.70 − 0.06 (− 0.16 to 0.03) − 0.06 (− 0.16 to 0.03) − 0.03 (− 0.12 to 0.05)

Note: Model (1) provides raw estimates without any weighting or adjustment. a Model (2) adds an inverse probability weight based on baseline characteristics. b Model
(3) weighted and adjusted for age, gender, grade, family type, drunkenness, and cannabis experience, parental education as well the baseline measure of the outcome
evaluated. Estimation is done by linear regression with robust standard errors. cThe estimate for risk age group is based on logit regression. Significant results marked
with bold.

Table 3
Subgroup analyses. Mean scores by intervention group at follow up. Raw, weighted, and adjusted effect estimates (β) (95 % CI) stratified by gender, parental education,
and risky cycling behavior at baseline.
Control LIVE Model (1) Model (2) Model (3)

(n = 480) (n = 527) Unadjusted Weighted and adj.a Weighted and fully adj.b

Outcomes by subgroup Mean SD Mean SD β 95 % CI β 95 % CI β 95 % CI

Seat belt use by gender

Male 3.88 0.40 3.85 0.45 0.03 (− 0.05 to 0.03 (− 0.05 to 0.01 (− 0.06 to
0.11) 0.10) 0.07)
Female 3.90 0.35 3.91 0.37 − 0.01 (− 0.07 to − 0.01 (− 0.08 to 0.00 (− 0.05 to
0.06) 0.05) 0.06)
Seat belt use by parental education:
Upper secondary school or shorter 3.92 0.33 3.77 0.68 0.14 (− 0.07 to 0.14 (− 0.07 to 0.12 (− 0.07 to
0.36) 0.36) 0.31)
Vocational training or longer 3.88 0.40 3.90 0.34 − 0.03 (− 0.09 to − 0.03 (− 0.09 to − 0.02 (− 0.07 to
0.03) 0.03) 0.03)
Cycling behavior by gender:
Male 3.12 0.64 3.02 0.67 0.10 (− 0.03 to 0.10 (− 0.03 to 0.04 (− 0.04 to
0.22) 0.23) 0.13)
Female 3.06 0.66 3.16 0.63 − 0.10 (− 0.22 to − 0.11 (− 0.23 to 0.01 − 0.06 to 0.08)
0.01) 0.01)
Cycling behavior by parental education:
Upper secondary school or shorter 3.01 0.66 3.06 0.63 − 0.04 (− 0.30 to − 0.04 (− 0.30 to − 0.04 (− 0.19 to
0.21) 0.22) 0.11)
Vocational training or longer 3.14 0.62 3.11 0.64 0.03 (− 0.08 to 0.03 (− 0.08 to 0.04 (− 0.03 to
0.13) 0.14) 0.10)
Cycling behavior by risky cycling behavior at
baseline:
Baseline score ≤3 2.73 0.52 2.74 0.55 − 0.01 (− 0.10 to 0.00 (− 0.10 to 0.02 (− 0.06 to
0.09) 0.09) 0.09)
Baseline score >3 2.64 0.50 2.63 0.54 0.01 (− 0.09 to 0.02 (− 0.09 to 0.00 (− 0.08 to
0.11) 0.12) 0.08)

Note: Model (1) provides raw estimates without any weighting or adjustment. a Model (2) adds an inverse probability weight based on baseline characteristics. b Model
(3) weighted and adjusted for age, gender, grade, family type, drunkenness, and cannabis experience, parental education as well the baseline measure of the outcome
evaluated. Estimation by linear regression with robust standard errors. Significant results marked with bold. The subgroup analysis was performed by estimating
treatment effects separately for each group. Supplementary tests of interaction terms for the subgroups showed no significant differences.

were no significant effects (results not shown). Parental educational
background did not modify the effect of the intervention on any of the
two outcomes. Neither did the effect on overall cycling behavior depend
on risky cycling behavior at baseline. All subgroup analyses are sup­
plemented with corresponding tests of interaction between treatment
and subgroup. None of these tests showed significant differences (results
not shown).
4. Discussion
This cluster-randomized controlled study evaluated the effect of a
Danish road safety educational program for lower secondary school
students. Using testimonials by road accident survivors the program
aimed to provide the students with better insight into, and under­
standing of, the consequences of traffic accidents and to motivate them
to make safer choices in traffic. The current study focused on the effect of
a) knowledge about risk factors in traffic and b) two behavioral out­
comes specifically relevant for the age group: seatbelt use and cycling
behavior. One out of three essential purposes of the program was to
increase youngsters’ knowledge of risk factors in traffic. While a small
effect was found on the students’ knowledge of the three most important
risk factors at follow-up, no effect was found on the other knowledge-
related outcome: age group most at risk. Although the finding of a
positive effect may suggest that the program has the potential to

6
A.B. Bojesen and S.B. Rayce
increase youngsters’ knowledge about risky situations in traffic, the
results are not convincing from a broader perspective. We did not find
any effect on behavior in terms of seatbelt use or overall cycling
behavior and this was consistent across potential modifiers of the
effectiveness of the program: gender, parental educational background,
and cycling behavior at baseline. However, a small positive effect was
found on a single cycle item: helmet use. The limited effect on the
behavioral outcomes draws attention to the fact that an increased
knowledge of risk factors did not generally seem to translate into safer
traffic behavior among the youngsters. There may be a number of rea­
sons for this.
Regarding seatbelt use, one explanation for the lack of effect may be
that seat belt use was already widespread in our study sample. At
baseline, 99 % of the students answered that they always (90.6 %) or
almost always (8.4 %) used a seat belt thereby leaving less margin for
improvement. Another study of a road safety program using testimonials
found positive effect on seatbelt use in a sample of American high school
students (King et al., 2008). In this sample, the baseline level of seatbelt
use was substantially lower compared to the level in our study sample
thus indicating that it may be possible to increase seatbelt use through
such interventions.
In a similar way, the increase in helmet use, specifically, may be due
to the relative low starting point at baseline compared to the three other
cycling behaviors comprised in the cycling behavior index. However, we
found no effect on overall cycling behavior even when examining the
effect among those with risky bicycle behavior at baseline. Our finding
of no effect on cycling behavior is in line with the findings of the Dutch
study by Feenstra et al. (2014). Positive effects were found on two beliefs
in their study, but also a negative effect regarding attitude towards vi­
olations of traffic rules at follow-up. While the negative effect found by
Feenstra et al. (2014) may be attributed to activation of fear responses
(Carey et al., 2013), the limited effect on cycling behavior may also be
attributed to the type of accident represented by the ambassadors. None
of the existing effect studies state that they use testimonials by a person
involved in an accident involving a bicycle. This was also the case for the
LIVE intervention. It is possible that youngsters who are not yet drivers
themselves will not be able to relate sufficiently to the ambassador. If so,
this may have affected their personal risk perception and feeling of
susceptibility leading to less motivation for behavior change. In a similar
way it is possible that personal characteristic of the ambassador such as
age, gender and background affect to which degree the students are able
to relate to the ambassador. Although the ambassadors in the LIVE
intervention focused on their life as a youngster when giving their
testimonial, they were substantially older (age span: 27− 50 years) than
their audience. In a survey conducted by The Danish Road Safety
Council, the council found that most of the students attached little or no
value to the age of the ambassador. However, some students did express
that the age of the ambassador affected their ability to relate to the
testimonial. Finally, it is possible that the testimonial were so over­
whelming to some students that the actual message was not recognized.
Even though the ambassadors deliberately avoided a fear approach and
a survey by the Danish Road Safety council found that the majority of
students rated the LIVE visits as either ‘good’ or ‘very good’, it can not be
ruled out that the testimonials generated a fear response among some
students.
Other reasons for increased knowledge not leading to a safer overall
cycling behavior and only to a small increase in helmet usage may relate
to the age group of the intervention. Although knowledge is a prereq­
uisite for behavior, personal beliefs such as susceptibility, attitudes,
intentions, and efficacy most likely play an essential role on whether
traffic and health-related information is translated into behavior (Alonso
et al., 2018; Lewis et al., 2007). The greatest gap between intention and
behavior seem to exist when a) individuals lack control over the
behavior in question, b) a behavior is performed in a social setting, and
c) the behavior is a habit (Webb and Sheeran, 2006). The two last
characteristics specifically relate to cycling behavior. For many
7
Accident Analysis and Prevention 147 (2020) 105773
European youngsters riding a bike is a daily activity often performed in
company of friends. Thus, wearing a helmet may make you stand out
from the peer group. In addition, cycling may be associated with habits
such as music listening. Additionally, adolescence is a period charac­
terized by a greater willingness to engage in risky behavior and less
focus on long-term consequences, especially when together with friends
(Raftery and Wundersitz, 2011; Twisk et al., 2014). Therefore, knowl­
edge on the most important risk factor in traffic may very well have been
overruled by a desire to conform to peer group norms. Provision of
effective guidance on action might strengthen the path from knowledge
and intentions to actual behavior (Peters et al., 2013). Although some
guidance on action was given during a LIVE session, this was not sys­
tematically incorporated in the LIVE intervention in 2016. Therefore,
guidance on action to some degree depended on the specific ambas­
sador. It is thus likely that the absence of systematical and practical
guidance may have impeded the effectiveness of the intervention.
The randomized and controlled study design is one of the strengths of
this study. The use of a school level cluster-randomized design mini­
mized the risk of the effect being contaminated by other classes telling
about the LIVE visits. Likewise, the structured format and the quality
assurance of the LIVE visits is also a strength. Before making school visits
on their own, the ambassadors go through courses and subsequently
participate in two yearly workshops. Regular monitoring is a central part
of the intervention and is performed by the Road Safety Council.
Although some difference may exist depending on the ambassador, (e.g.
in guidance on how to change behavior) the organizational backdrop
ensures a high level of fidelity in the execution of the intervention.
This study also has some limitations. Firstly, less than a third of the
students measured at baseline were linked to a response at follow-up.
This increases the risk of bias since the likelihood of a linked follow-
up response could be associated with treatment assignment. Secondly,
it was not recorded how many survey links were distributed at baseline
which hindered any quantification of response rates. The large number
of student responses at baseline nevertheless, moderates the impact of
these two limitations. These responses enabled us to estimate the
probability of not answering (or not being linked to) the follow-up
survey. By weighting the model estimation with the inverse of this
probability, the impact of any bias pertaining to factors observed at
baseline was reduced. The results suggest that the impact of any such
bias is most likely limited and that dropouts or missing links to follow-up
responses are rooted in a random process related to a cumbersome data
collection process. Only in the gender subgroup effects on bicycle
behavior did we observe inconsistent estimates depending on adjust­
ment. This suggests a gendered response pattern. Thirdly, characteristics
of the ambassador such as age, gender and accident type information
may affect to which degree the students are able to relate to the story of
the ambassadors. With perceived susceptibility being a key component
in behavior change (Ruiter et al., 2014), ambassador characteristics may
have modified the effectiveness of using testimonials. Since data did not
comprise information on ambassador characteristics, we were, however,
not able to conduct subgroup analyses. Finally, measures on perceived
susceptibility, attitudes, intentions, perceived response efficacy, or
self-efficacy were not included in the survey. Although feeling suscep­
tible to a risk is a prerequisite for behavior change, adolescents’ sus­
ceptibility to peer pressure might also inhibit the translation of personal
beliefs into behavioral outcomes, making behavior a key outcome
(Twisk et al., 2014). Information on these beliefs would have enabled us
to investigate the causal mechanism between receiving the intervention
and the two behavioral outcomes of the study. The lack of information
on personal beliefs, especially perceived susceptibility and efficacy, is
therefore a limitation of the study.
The analyses of our study do not enable us to draw conclusions on the
most effective approach for generating behavioral change among young
pre-drivers. However, in its present form the testimonials used in the
LIVE intervention do not seem to generate the desired behavioral change
among students in lower secondary school. Feenstra et al. (2010) suggest
A.B. Bojesen and S.B. Rayce
that emphasis is put on increasing responsibility, strengthening
self-efficacy and resistance to peer pressure and that fear evoking mes­
sages are avoided. In their evaluation of ‘Traffic Informers’ Feenstra
et al. (2014) furthermore, conclude that we need more information on
behaviors that increase adolescents risk in traffic and the determinants
of these behaviors in order to design effective interventions.
5. Conclusions
In conclusion, this study suggests that although classroom-based
interventions using testimonials may have the potential to improve
knowledge of risk factors in traffic, the effectiveness of the Road Safety
LIVE intervention was limited. Knowledge of risks factors in traffic is a
prerequisite for change, but does not necessarily translate into safer
cycling behavior and seatbelt use in a population of young pre-drivers.
There is still a need for more studies on road safety educational pro­
grams targeted at pre-drivers. Future studies should examine to which
degree programs can be further adapted to fit this age group. Such
studies should focus on the effect of ambassador characteristics, i.e.
whether the ambassador is representative for the age group targeted and
the story and mode of transportation (e.g. walking or cycling) of the
ambassador. Furthermore, focus should be on whether specific guidance
on action on how to make safe choices in traffic and deal with social
norms and group pressure is provided, 2) whether the intervention also
aims to increase self-efficacy and 3) on studying mechanisms of change.
Funding
This work was funded by The Danish Road Safety Council. The
Danish Road Safety Council did not have any influence on the analysis of
the data or the drafting of the manuscript.
CRediT authorship contribution statement
Anders Bo Bojesen: Conceptualization, Methodology, Formal
analysis, Data curation, Writing - original draft. Signe Boe Rayce:
Conceptualization, Methodology, Writing - original draft, Writing - re­
view & editing.
Declaration of Competing Interest
The authors report no declarations of interest.
Acknowledgements
The authors thank The Danish Road Safety Council for providing
information about the Road Safety LIVE intervention and the schools
and students for participation. We also thank Helle Hansen at VIVE, the
Danish Center for Social Science Research, for trial administration and
for information on the practical details of the randomized controlled
trial of the LIVE intervention.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.aap.2020.105773.
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