Follow-up household assessment for child unintentional injuries two years after the intervention: A community-based study from Karachi, Pakistan

BACKGROUND

Unintentional childhood injuries are a growing public health concern, and the home is the most common location for non-fatal injuries in children less than 5 years of age. This study describes the long-term effects of two injury prevention educational interventions for caregivers-an educational pamphlet and an in-home tutorial guide-by comparing the change in the prevalence of home injury hazards before and after the interventions.

METHODS

This was a pre- (June and July 2010) and post-study with short-term follow-up (November-December 2010) and long-term follow-up (November 2012- January 2013). Neighborhood one included households that received only educational pamphlets after completing a baseline assessment; neighborhood two included households that received an in-home tutorial guide after completing the baseline assessment and receiving the educational pamphlet. The main outcome of this study was the reduction in home injury hazards for children under 5 years of age.

RESULTS

A total of 312 households participated in the long-term phase to compare the effect of the interventions. Between the short-term to long-term follow-up, injury hazards significantly reduced in neighborhood two compared to neighborhood one. These included fall hazards (walker use) (IRR 0.24 [95% CI 0.08-0.71]), drowning hazards (open bucket of water in the courtyard and uncovered water pool) (IRR 0.45 [95% CI 0.85-0.98] and IRR 0.46 [95% CI 0.76-0.94]), burn hazards (iron, water heater within reach of child) (IRR 0.56 [95% CI 0.33-0.78] and IRR 0.58 [95% CI 0.32-0.91]), poisoning hazards (shampoo/soap and medicine within reach of child) (IRR 0.53 [95% CI 0.44-0.77] and IRR 0.7 [95% CI 0.44-0.98]) and breakable objects within reach of child (IRR 0.62 [95% CI: 0.39-0.99]).

CONCLUSION

An injury prevention tutorial to caretakers of children supplemented with pamphlets could significantly decrease the incidence of falls, drowning, burns, poisoning, and cut injury hazards for children under 5 years of age in their homes in a low-resource setting. This intervention has the potential to be integrated in existing public health programs, such as Lady Health Visitors (LHVs), to disseminate injury prevention information in routine home health visits.

Preventing Unintentional Injuries in School-Aged Children: A Systematic Review

BACKGROUND AND OBJECTIVES

Unintentional injuries constitute the leading causes of death and long-term disabilities among children aged 5 to 15 years. We aimed to systematically review published literature on interventions designed to prevent unintentional injuries among school-aged children.

METHODS

We searched MEDLINE, PubMed, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO and screened the reference lists of included studies and relevant reviews. We included randomized controlled trials, controlled before-and-after studies, and interrupted time series studies. The focus of included studies was on primary prevention measures. Two reviewers collected data on type of study design, setting, population, intervention, types of injuries, outcomes assessed, and statistical results.

RESULTS

Of 30 179 identified studies, 117 were included in this review. Most of these studies were conducted in high-income countries and addressed traffic-related injuries. Evidence from included studies reveals that multicomponent educational interventions may be effective in improving safety knowledge, attitudes, and behaviors in school-aged children mainly when coupled with other approaches. Laws/legislation were shown to be effective in increasing cycle helmet use and reducing traffic-related injury rates. Findings reveal the relevance of infrastructure modification in reducing falls and improving pedestrian safety among children.

CONCLUSIONS

Additional studies are needed to evaluate the impact of unintentional injury prevention interventions on injury, hospitalizations, and mortality rates and the impact of laws and legislation and infrastructure modification on preventing unintentional injuries among school-aged children.

Keeping our children safe: piloting a hospital-based home-visitation program in Israel

Background

Unintentional childhood injuries are a leading cause of morbidity and mortality worldwide. Attempts to prevent child home injuries have rarely been implemented in hospital settings which present an important opportunity for intervention. The SHABI (‘Keeping our Children Safe; SHomrim Al BetIchut Yeladenu’) program recruits at-risk families presenting with child injury to the Emergency Department. Medical/nursing students conduct two home visits and provide safety equipment and guidance. The objective of this study was to investigate the impact of SHABI on participating families’ home-safety.

Methods

The pilot was conducted between May 2019 and March 2020 in northern Israel, an area with high child injury rates. Eligibility included families with preschool children who incurred a home injury. Home-safety was assessed by observation through the ‘Beterem’ checklist. Parents' views, knowledge, awareness of dangers and report of home injuries were assessed at the start of each visit.

Results

352 of 773 eligible families agreed to be contacted. 135 participated, 98 completed both home visits. Significant improvement in home-safety items was observed 4 months after the first visit (14 [IQR12-16]) vs. (17 [IQR15-19]; p < 0.001), accompanied by an overall increase in home safety (Mean ± SD 71.9% ± 9.5% vs. 87.1% ± 8.6%; p < 0.001). 64% reported greater awareness of dangers, 60% affirmed home was safer, and 70% valued the equipment. No difference was found in the prevalence of injuries (14 of 98 families prior and 8 after the visit; p = 0.17). Home visitors reported benefiting from the experience of working with disadvantaged families.

Conclusion

The program, which included recruitment in a hospital emergency setting and use of healthcare students as home visitors, was successfully implemented and accompanied by significant improvement in home safety with a non-significant trend of child injury decrease.

Impact of the national home safety equipment scheme 'Safe At Home' on hospital admissions for unintentional injury in children under 5: a controlled interrupted time series analysis

BACKGROUND

Unintentional home injuries are a leading cause of preventable death in young children. Safety education and equipment provision improve home safety practices, but their impact on injuries is less clear. Between 2009 and 2011, a national home safety equipment scheme was implemented in England (Safe At Home), targeting high-injury-rate areas and socioeconomically disadvantaged families with children under 5. This provided a 'natural experiment' for evaluating the scheme's impact on hospital admissions for unintentional injuries.

METHODS

Controlled interrupted time series analysis of unintentional injury hospital admission rates in small areas (Lower Layer Super Output Areas (LSOAs)) in England where the scheme was implemented (intervention areas, n=9466) and matched with LSOAs in England and Wales where it was not implemented (control areas, n=9466), with subgroup analyses by density of equipment provision.

RESULTS

57 656 homes receiving safety equipment were included in the analysis. In the 2 years after the scheme ended, monthly admission rates declined in intervention areas (-0.33% (-0.47% to -0.18%)) but did not decline in control areas (0.04% (-0.11%-0.19%), p value for difference in trend=0.001). Greater reductions in admission rates were seen as equipment provision density increased. Effects were not maintained beyond 2 years after the scheme ended.

CONCLUSIONS

A national home safety equipment scheme was associated with a reduction in injury-related hospital admissions in children under 5 in the 2 years after the scheme ended. Providing a higher number of items of safety equipment appears to be more effective in reducing injury rates than providing fewer items.

Understanding pathways to social inequalities in childhood unintentional injuries: findings from the UK millennium cohort study

BACKGROUND

Childhood unintentional injuries (UI) are common but continue to happen more often to children living in less advantaged socioeconomic circumstances (SEC). Our aim was to explore how early life factors mediate the association between SEC and UIs, using the UK Millennium Cohort Study.

METHODS

We calculated risk ratios (RR) and 95% confidence intervals (95%CI) for parental report of UI occurring between age 3 and 5 years, using Poisson regression according to family income as a measure of SEC. We explored potentially mediating pathways by controlling associations between SEC and UI for groups of early life risks in three domains: factors that may influence environmental safety, supervision and the MCS child's abilities and behaviours.

RESULTS

Twenty eight percent of children had a UI from 3 to 5 years old. Children from the lowest income quintile were more likely to be injured compared to those from the highest (RR 1.20 95%CI 1.05, 1.37). Sequentially controlling for early life factors that may influence environmental safety (RR 1.19 95%CI 1.02, 1.38), then supervision (RR 1.18, 95%CI 1.02, 1.36), and finally adding child's behaviour and abilities (RR 1.15, 95%CI 1.00, 1.34) into the model reduced the RR by 5, 10 and 25% respectively.

CONCLUSIONS

Addressing factors that may influence environmental safety and supervision, and the child's abilities and behaviours only partly explains the increased UI risk between the highest and lowest income quintiles. Further research is required to explore factors mediating associations between SEC and specific mechanisms and types of injuries.

Effects of a Safety-Awareness-Promoting Program Targeting Mothers of Children Aged 0-6 Years to Prevent Pediatric Injuries in the Home Environment: Implications for Nurses

Pediatric injuries pose a significant problem, both in Turkey and worldwide, because they lead to death or disability in a number of children each year. This quasi-experimental study aimed to identify the effects of the training provided to mothers with children aged 0-6 years about the hazards that lead to pediatric injuries. The population of the research comprised mothers with children aged 0-6 years, living in the city center. Considering the educational and socioeconomic levels of the individuals registered in the family health centers (FHC), the FHCs were divided into 3 groups of high, moderate, and low socioeconomic level. Subsequently, 1 FHC was selected from each level using simple random sampling. The study was conducted with 300 volunteer mothers registered in these FHCs. The tools used for data collection included the "0-6-year-old Children's Mothers' Identification Scale of Safety Precautions for the Prevention of Pediatric Injuries," the "Risk Assessment Form for Pediatric Injuries" (RAF), and a 33-item questionnaire. After the training on the prevention of pediatric injuries, the mothers' scores on the identification of safety precautions for pediatric injuries increased significantly (p = 000). In addition, there was a significant difference between the pre- and posttest scores of the mothers (p < .05) on all dimensions of the RAF (choking, burns, poisoning, sharp object injuries, and falling; all p values <.05). Thus, the training provided to mothers to prevent pediatric injuries was effective in improving the awareness of the mothers.

Interventions to reduce accidents in childhood: a systematic review

OBJECTIVE

To review the literature on interventions planned to prevent the incidence of injuries in childhood.

SOURCE OF DATA

The PubMed, Web of Science, and Bireme databases were searched by two independent reviewers, employing the single terms accidents, accident, injuries, injury, clinical trial, intervention, educational intervention, and multiple interventions, and their combinations, present in the article title or abstract, with no limits except period of publication (2006-2016) and studies in human subjects.

SYNTHESIS OF DATA

Initially, 11,097 titles were located. Fifteen articles were selected for the review. Eleven were randomized trials (four carried out at the children's households, five in pediatric healthcare services, and two at schools), and four were non-randomized trials carried out at the children's households. Four of the randomized trials were analyzed by intention-to-treat and a protective effect of the intervention was observed: decrease in the number of risk factors, decrease in the number of medical consultations due to injuries, decrease in the prevalence of risk behaviors, and increase of the parents' knowledge regarding injury prevention in childhood.

CONCLUSION

Traumatic injuries in childhood are amenable to primary prevention through strategies that consider the child's age and level of development, as well as structural aspects of the environment.

Palestinian Nurses' and Doctors' Perceptions and Practices Regarding the Prevention of Injuries to Children in the Home: An Explorative Qualitative Study

Unintentional injuries are a growing global public health problem that causes mortality, morbidity, and disability among children. These injuries are common among under-fives and form a significant burden on healthcare systems, particularly in low- and middle-income countries. Nurses and doctors have a major role to play in the prevention of home injuries, as expressed in many international reports. In Palestine, there is a paucity of research in this area. Therefore, this study aims to explore nurses' and doctors' perceptions and practices regarding the prevention of home injuries among children aged under-five years. A qualitative approach was followed, whereby semi-structured interviews were undertaken with 24 nurses and doctors who worked with children in a primary health care setting. The derived data were analyzed using thematic analysis. This study found that most of the nurses and doctors who were interviewed reported positive attitudes toward working on this topic; the majority of them attempted to work on injury prevention. Nevertheless, they needed further support to fulfil this potential role, as they faced many barriers in their daily practice in this area. Policy makers could potentially take advantage of this attitude and support them by providing training, resources, and time for them to implement this role.

Keeping Children Safe: a multicentre programme of research to increase the evidence base for preventing unintentional injuries in the home in the under-fives

Background

Unintentional injuries among 0- to 4-year-olds are a major public health problem incurring substantial NHS, individual and societal costs. However, evidence on the effectiveness and cost-effectiveness of preventative interventions is lacking.

Aim

To increase the evidence base for thermal injury, falls and poisoning prevention for the under-fives.

Methods

Six work streams comprising five multicentre case–control studies assessing risk and protective factors, a study measuring quality of life and injury costs, national surveys of children’s centres, interviews with children’s centre staff and parents, a systematic review of barriers to, and facilitators of, prevention and systematic overviews, meta-analyses and decision analyses of home safety interventions. Evidence from these studies informed the design of an injury prevention briefing (IPB) for children’s centres for preventing fire-related injuries and implementation support (training and facilitation). This was evaluated by a three-arm cluster randomised controlled trial comparing IPB and support (IPB+), IPB only (no support) and usual care. The primary outcome was parent-reported possession of a fire escape plan. Evidence from all work streams subsequently informed the design of an IPB for preventing thermal injuries, falls and poisoning.

Results

Modifiable risk factors for falls, poisoning and scalds were found. Most injured children and their families incurred small to moderate health-care and non-health-care costs, with a few incurring more substantial costs. Meta-analyses and decision analyses found that home safety interventions increased the use of smoke alarms and stair gates, promoted safe hot tap water temperatures, fire escape planning and storage of medicines and household products, and reduced baby walker use. Generally, more intensive interventions were the most effective, but these were not always the most cost-effective interventions. Children’s centre and parental barriers to, and facilitators of, injury prevention were identified. Children’s centres were interested in preventing injuries, and believed that they could prevent them, but few had an evidence-based strategic approach and they needed support to develop this. The IPB was implemented by children’s centres in both intervention arms, with greater implementation in the IPB+ arm. Compared with usual care, more IPB+ arm families received advice on key safety messages, and more families in each intervention arm attended fire safety sessions. The intervention did not increase the prevalence of fire escape plans [adjusted odds ratio (AOR) IPB only vs. usual care 0.93, 95% confidence interval (CI) 0.58 to 1.49; AOR IPB+ vs. usual care 1.41, 95% CI 0.91 to 2.20] but did increase the proportion of families reporting more fire escape behaviours (AOR IPB only vs. usual care 2.56, 95% CI 1.38 to 4.76; AOR IPB+ vs. usual care 1.78, 95% CI 1.01 to 3.15). IPB-only families were less likely to report match play by children (AOR 0.27, 95% CI 0.08 to 0.94) and reported more bedtime fire safety routines (AOR for a 1-unit increase in the number of routines 1.59, 95% CI 1.09 to 2.31) than usual-care families. The IPB-only intervention was less costly and marginally more effective than usual care. The IPB+ intervention was more costly and marginally more effective than usual care.

Limitations

Our case–control studies demonstrate associations between modifiable risk factors and injuries but not causality. Some injury cost estimates are imprecise because of small numbers. Systematic reviews and meta-analyses were limited by the quality of the included studies, the small numbers of studies reporting outcomes and significant heterogeneity, partly explained by differences in interventions. Network meta-analysis (NMA) categorised interventions more finely, but some variation remained. Decision analyses are likely to underestimate cost-effectiveness for a number of reasons. IPB implementation varied between children’s centres. Greater implementation may have resulted in changes in more fire safety behaviours.

Conclusions

Our studies provide new evidence about the effectiveness of, as well as economic evaluation of, home safety interventions. Evidence-based resources for preventing thermal injuries, falls and scalds were developed. Providing such resources to children’s centres increases their injury prevention activity and some parental safety behaviours.

Future work

Further randomised controlled trials, meta-analyses and NMAs are needed to evaluate the effectiveness and cost-effectiveness of home safety interventions. Further work is required to measure NHS, family and societal costs and utility decrements for childhood home injuries and to evaluate complex multicomponent interventions such as home safety schemes using a single analytical model.

Trial registration

Current Controlled Trials ISRCTN65067450 and ClinicalTrials.gov NCT01452191.

Funding

The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 14. See the NIHR Journals Library website for further project information.

Home safe home: Evaluation of a childhood home safety program

BACKGROUND

The London Health Sciences Centre Home Safety Program (HSP) provides safety devices, education, a safety video, and home safety checklist to all first-time parents for the reduction of childhood home injuries. The objective of this study was to evaluate the HSP for the prevention of home injuries in children up to 2 years of age.

METHODS

A program evaluation was performed with follow-up survey, along with an interrupted time series analysis of emergency department (ED) visits for home injuries 5 years before (2007-2013) and 2 years after (2013-2015) implementation. Spatial analysis of ED visits was undertaken to assess differences in home injury rates by dissemination areas controlling differences in socioeconomic status (i.e., income, education, and lone-parent status) at the neighborhood level.

RESULTS

A total of 3,458 first-time parents participated in the HSP (a 74% compliance rate). Of these, 20% (n = 696) of parents responded to our questionnaire, with 94% reporting the program to be useful (median, 6; interquartile range, 2 on a 7-point Likert scale) and 81% learning new strategies for preventing home injuries. The median age of the respondent's babies were 12 months (interquartile range, 1). The home safety check list was used by 87% of respondents to identify hazards in their home, with 95% taking action to minimize the risk. The time series analysis demonstrated a significant decline in ED visits for home injuries in toddlers younger than2 years of age after HSP implementation. The declines in ED visits for home injuries remained significant over and above each socioeconomic status covariate.

CONCLUSION

Removing hazards, supervision, and installing safety devices are key facilitators in the reduction of home injuries. Parents found the HSP useful to identify hazards, learn new strategies, build confidence, and provide safety products. Initial finding suggests that the program is effective in reducing home injuries in children up to 2 years of age.

LEVEL OF EVIDENCE

Therapeutic/care management study, level V.

Baby gate-related injuries among children in the United States, 1990-2010

OBJECTIVE

Baby gates are one of the most widely used home safety products to protect children from home hazards. The objective was to describe the epidemiology of baby gate and barrier-associated injuries among children. It was hypothesized that injuries experienced by children ages ≤2 years and those >2 years were significantly different as a result of differences in gate interactions.

METHODS

A retrospective analysis was conducted by using nationally representative data from the National Electronic Injury Surveillance System. A total of 1188 actual cases were reviewed and national estimates generated.

RESULTS

An estimated 37,673 children were treated in emergency departments for injuries associated with gates, yielding an average of 1794 cases annually. The incidence of gate-related injuries increased significantly from 3.9 per 100,000 children in 1990 to 12.5 per 100,000 children in 2010 (P < .001). Patients were primarily boys (61.0%) and were <2 years of age (60.4%). Patients <2 years of age were most often injured by falls down stairs (odds ratio 6.72; 95% confidence interval 6.32-7.16) after the collapse of the gate. Patients aged 2 to 6 were most often injured by contact with the gate (odds ratio 2.03; 95% confidence interval 1.95-2.12), resulting in open wounds (55.4%) and soft-tissue injuries (24.2%).

CONCLUSIONS

Given the clear dichotomy between injury characteristics of patients aged <2 years and patients aged 2 to 6 years of age, as well as the prevalence of preventable injuries, greater efforts are needed to promote proper usage, ensure safety in product design, and increase awareness of age-related recommendations for use of gates.

Surf, sand, scrapes and stings: First aid incidents involving children at New Zealand beaches, 2007–2012

Aims: In spite of the popularity of beaches for family recreation, little is known about childhood injuries sustained at beaches. It is the purpose of this study to analyse data from incidents necessitating first aid treatment from reports compiled by surf lifeguards on New Zealand beaches.Method: A retrospective analysis of first aid incidents involving children (<16 years) was conducted using data obtained from Surf Life Saving New Zealand incident report forms during five summer seasons from 2007 to 2012. In addition to demographic data, the incident reports included such detail as the type of injury, the activity and location prior to injury, the injury outcome, and the first aid equipment used.Results: Children (n = 4407) accounted for one-half (52%) of all injuries; of these, 55% were male, and incidence peaked in the 11- to 15-year age group (24%). Most incidents (90%) required minor treatment, with lacerations (44%) the most common injury. Marine stings accounted for one-quarter (24%) of injuries and were most frequent among younger children (<10 years). Injuries to the extremities were frequently noted in the incident reports, the feet (33%) and hands (8%) being common sites.Conclusions: Although most (90%) injury incidents were minor in nature, their frequency (880 cases per season) suggests that greater emphasis on prevention rather than cure would be efficacious. Ways of promoting child beach safety via greater care giver awareness, the use of protective clothing and footwear, and child safety promotion via health professionals and safety organisations are discussed.

Epidemiology of paediatric minor head injury: Comparison of injury characteristics with Indices of Multiple Deprivation

BACKGROUND

Head injury (HI) is a common presentation to Child Emergency Departments (CEDs), but the actual number of children attending with minor HI is unclear. Most research has focussed on admitted patients, often relying on hospital-coded admission data. We studied the incidence of minor HI presenting to the CED of a major teaching hospital in Coventry and Warwickshire. HI attendances were compared with population data to identify injury patterns relating to deprivation.

METHODS

All CED admissions were screened by the research team, and data on minor head injuries (GCS 13-15) collected prospectively from 1st January until 31st August 2011. Information was collected on demographics, ethnicity, cause and severity of injury, injury location (in or outside the home), other injuries and mode of arrival. Deprivation data were obtained by cross-referencing postcodes with English Indices of Multiple Deprivation (IMD 2010). For comparison, the hospital audit department provided figures for coded head injuries during the same period.

RESULTS

During the 8 month period, hand-searching identified 1747 children with minor HI, aged between 0 and 16 years. Of these 99% had minimal HI (GCS 15 or 'alert'). In the same period, hospital-coded minor HIs numbered only 1081. HIs formed 9% of all CED attendances. Thirteen children returned to the CED with worrying symptoms after discharge home. Approximately 3.4% of the local paediatric population attend the CED with HI per year (3419/100,000 population). Falls accounted for 62% of HIs overall, rising to 77% in children aged 0-5. Most in-home head injuries (81%) were the result of falls (p<0.0001). Significantly more injuries took place inside the home for 0-5 year olds (58%) than for older children (20%) (p<0.0001). Children living in the most deprived areas were more likely to attend the CED with HI (RR: 1.19; CI: 1.06-1.35, p=0.004), and arrive using emergency services (OR: 1.77; CI: 1.30-2.40, p<0.001). There were no significant differences between the deprived and non-deprived groups for location or cause of injury.

CONCLUSIONS

Young children are particularly at risk of HI and parents should be offered information on injury prevention. More children from deprived areas attended with HI and these families may benefit most from targeted interventions.

Delivery of a national home safety equipment scheme in England: a survey of local scheme leaders

Aims:

Unintentional home injuries sustained by preschool children are a major cause of morbidity in the UK. Home safety equipment schemes may reduce home injury rates. In 2009, the Royal Society for the Prevention of Accidents was appointed as central coordinator of a two-year, £18m national home safety equipment scheme in England. This paper reports the findings from a national survey of all scheme leaders responsible for local scheme delivery.

Methods:

A questionnaire mailed to all local scheme leaders sought details of how the schemes were operated locally; barriers and facilitators to scheme implementation; evaluation of the local scheme and its sustainability.

Results:

A response rate of 73% was achieved. Health visitors and family support workers played a key role in both the identification of eligible families and performing home safety checks. The majority of local scheme leaders (94.6%) reported that they thought their local scheme had been successful in including those families considered ‘harder to engage’. Many scheme leaders (72.4%) reported that they had evaluated the provision of safety equipment in their scheme and over half (56.6%) stated that they would not be able to continue the scheme once funding ceased.

Conclusions:

Local schemes need support to effectively evaluate their scheme and to seek sustainability funding to ensure the future of the scheme. There remains a lack of evidence of whether the provision of home safety equipment reduces injuries in preschool children.

Barriers to, and facilitators of, the prevention of unintentional injury in children in the home: a systematic review and synthesis of qualitative research

Background

This review considers barriers to, and facilitators of, success for interventions to reduce unintentional injury to children in the home through supply and/or installation of home safety equipment, and looks at risk assessments.

Methods

A systematic review of qualitative research. Bibliographic databases were searched for studies on interventions to reduce unintentional child injury in the home, or on related attitudes and behaviours. Studies were quality appraised, findings extracted, and a conceptual framework was developed to assess factors affecting the success of interventions.

Results

Nine peer-reviewed journal articles were included. Barriers and facilitators were highlighted at organisational, environmental and personal levels. Effective provision of safety equipment involves ongoing support with installation and maintenance. Take up and success of interventions depends on adjusting interventions according to practical limitations and parents' cultural expectations. A particular barrier was parents' inability to modify rented or shared accommodation.

Conclusions

The review highlights ways in which health inequalities affect the take up and success of home safety interventions, and how health workers can use this knowledge to facilitate future interventions.