Caregiver Supervision and Child-Injury Risk: I. Issues in Defining and Measuring Supervision; II. Findings and Directions for Future Research

Primary caregiver employment status is associated with traumatic brain injury in children in the USA

BACKGROUND

Traumatic brain injury (TBI) is a common injury in children. Previous literature has demonstrated that TBI may be associated with supervision level. We hypothesised that primary caregiver employment would be associated with child TBI.

METHODS

A retrospective cross-sectional study was performed for children aged 0-17 using the National Survey of Children's Health (NSCH) 2018-2019. The NSCH contains survey data on children's health completed by adult caregivers from randomly selected households across the USA. We compared current TBI prevalence between children from households of different employment statuses. Current TBI was defined by survey responses indicating a healthcare provider diagnosed TBI or concussion for the child and the condition was present at the time of survey completion. Household employment status was categorised as two caregivers employed, two caregivers unemployed, one of two caregivers unemployed, single caregiver employed and single caregiver unemployed. Multivariable logistic regression was performed, controlling for sociodemographic factors.

RESULTS

Of 56 865 children, median age was 10 years (IQR: 5-14), and 0.6% (n=332) had a current TBI. Children with TBI were older than children without TBI (median 12 years vs 10 years, p<0.001). On multivariable regression, children with at least one caregiver unemployed had increased odds of current TBI compared with children with both caregivers employed.

CONCLUSIONS

Children with at least one caregiver unemployed had increased TBI odds compared with children with both caregivers employed. These findings highlight a population of families that may benefit from injury prevention education and intervention.

Caregiver accounts of unintentional childhood injury events in rural Uganda

OBJECTIVE

Complex environmental, social, and individual factors contribute to unintentional childhood injury events. Understanding context-specific antecedents and caregiver attributions of childhood injury events can inform the development of locally-targeted interventions to reduce injury risk in rural Uganda.

METHODS

Fifty-six Ugandan caregivers were recruited through primary schools and completed qualitative interviews regarding 86 unintentional childhood injury events. Descriptive statistics summarized injury characteristics, child location and activity, and supervision at time of injury. Qualitative analyses informed by grounded theory identified caregiver attributions of injury causes and caregiver actions to reduce injury risk.

RESULTS

Cuts, falls, and burns were the most common injuries reported. At the time of injury, the most common child activities were farming and playing and the most common child locations were the farm and kitchen. Most children were unsupervised. In cases where supervision was provided, the supervisor was typically distracted. Caregivers most often attributed injuries to child risk-taking but also identified social, environmental, and chance factors. Caregivers most often made efforts to reduce injury risk by teaching children safety rules, but also reported efforts to improve supervision, remove hazards, and implement environmental safeguards.

CONCLUSION

Unintentional childhood injuries have a significant impact on injured children and their families, and caregivers are motivated to reduce child injury risk. Caregivers frequently perceive child decision-making a primary factor in injury events and respond by teaching children safety rules. Rural communities in Uganda and elsewhere may face unique hazards associated with agricultural labor, contributing to a high risk of cuts. Interventions to support caregiver efforts to reduce child injury risk are warranted.

An Examination of Child Pedestrian Rule Compliance at Crosswalks around Parks in Montreal, Canada

This study aims to examine child pedestrian safety around parks by considering four rule-compliance measures: temporal, spatial, velocity and visual search compliance. In this regard, street crossing observations of 731 children were recorded at 17 crosswalks around four parks in Montreal, Canada. Information on child behaviors, road features, and pedestrian-vehicle interactions were gathered in three separate forms. Chi-square tests were used to highlight the individual, situational, behavioral and road environmental characteristics that are associated with pedestrian rule compliance. About half of our sampled children started crossing at the same time as the adults who accompanied them, but more rule violations were observed when the adult initiated the crossing. The child's gender did not have a significant impact on rule compliance. Several variables were positively associated with rule compliance: stopping at the curb before crossing, close parental supervision, and pedestrian countdown signals. Pedestrian-car interaction had a mixed impact on rule compliance. Overall, rule compliance among children was high for each of our indicators, but about two-thirds failed to comply with all four indicators. A few measures, such as longer crossing signals and pedestrian countdown displays at traffic lights, may help to increase rule compliance and, ultimately, provide safer access to parks.

Unintentional injuries and potential determinants of falls in young children: Results from the Piccolipiù Italian birth cohort

OBJECTIVES

Unintentional injuries such as falls, are particularly frequent in early childhood. To date, epidemiological studies in this field have been carried out using routine data sources or registries and many studies were observational studies with a cross-sectional design. The aims of the study are to describe unintentional injuries in the first two years of life in the Piccolipiù birth cohort, and to investigate the association between mother and children characteristics and the First Event of Raised surface Fall (FERF).

METHODS

This longitudinal observational study included 3038 children from an Italian birth cohort. Data on socio-demographic factors, socio-economic indicators, maternal health and lifestyle characteristics and child's sleeping behavior, obtained from questionnaires completed at birth, 12 and 24 months of age, were considered in the analyses as potential risk factors of FERF. Time of occurrence of FERF was analyzed using the Kaplan-Meier method. The multivariable analysis for time to event was carried out using a Cox proportional hazards model.

RESULTS

Falls from raised surfaces are the leading cause of unintentional injuries in the cohort with 610 (21.1%) and 577 (20.0%) cases among children during the first and second year of life, respectively. An increased risk of FERF was associated with several risk factors: maternal psychological distress (HR 1.41, 95%CI 1.10-1.81), maternal alcohol intake (HR 1.26, 95%CI 1.10-1.45), and child's sleeping problems (HR 1.28, 95%CI 1.09-1.51). Children with older aged mothers (HR 0.98, 95%CI 0.96-0.99) and living in northern Italy (HR 0.64, 95%CI 0.55-0.75) had a lower risk of FERF.

CONCLUSION

The results of the study suggest that a higher risk of FERF is associated with socio-demographic factors, maternal characteristics and child sleeping behavior that could hinder parent empowerment.

Helicopter parenting during emerging adulthood: Consequences for career identity and adaptability

This study explores the relationship between parental over involvement and the career development of emerging adults. Specifically, it investigates how emerging adults’ career meta competencies of vocational identity formation and career adaptability relate to perceived helicopter parenting. Participants included 491 emerging adults studying in a Canadian University (74.1% female, average age = 20.4 years old). We begin by reviewing the commonalities between helicopter parenting and other parenting constructs and styles. Next, using structural equation modeling, we explore the relationships between perceived helicopter parenting and the components of vocational identity (exploration: in depth exploration, in breadth; commitment: career commitment, identification with commitment; and reconsideration: career self doubt, career flexibility) and career adaptability, as well as the relationships between identity components and career adaptability. Third, we explore the association between perceived helicopter parenting and identity status progress (i.e., achievement, foreclosure, moratorium, undifferentiated, and searching moratorium). Results indicate that individuals reporting higher levels of perceived helicopter parenting experience significantly lower levels of career adaptability and in-depth exploration. Furthermore, these individuals report higher levels of career self doubt and are more likely to be in the vocational identity status of searching moratorium. Limitations and future research directions are discussed.

Effect of parental supervision of infants at age 4 to 6 months on injuries at age 4 to 12 months

This study analyzed the effect of parental supervision of infants at age 4 to 6 months on injuries at age 4 to 12 months. Among all Korean children born during 2008-2009, 464,326 (50.6%) infant had parents who responded to a questionnaire that surveyed their safety and supervision when infant were 4 to 6 months-old. Based on questionnaire score, infant were divided into "safe" or "unsafe" group. 1:1 propensity score matching was used to balance the groups, and injury diagnosis and treatments were analyzed. After matching, we examined the records of 405,862 infant. The unsafe group had significantly increased risk ratios (RRs) for injury of head/neck (RR: 1.06), trunk/abdominopelvic region (RR: 1.12), upper extremities (RR: 1.04), and from burn and frostbite (RR: 1.10). The risks of a wound and fracture and foreign body injury were significantly greater in infant whose parents sometimes left them alone (RR: 1.15 and 1.06, respectively), and whose parents did not always keep their eyes on them (RR: 1.04 and 1.13, respectively). Infant whose parents had a hot drink when carrying them had an increased risk of burn injuries (RR: 1.21). Injuries were less common in infant whose parents provided more supervision.

Sex Differences in the Relation Between Supervision and Injury Risk Across Motor Development Stages: Transitioning From Infancy Into Toddlerhood

Rationale

Addressing a notable gap in research on injuries during infancy, this longitudinal study examined sex differences in the relationship between parents’ typical levels of supervision and infants’ injuries across motor development stages.

Method

Parents were recruited and completed biweekly phone calls about their infant’s motor skills. Once the infant was able to sit up independently, then a home visit was scheduled. Applying a participant-event monitoring method, parents were taught to complete diary forms (injury, supervision), which they started doing once the child could move from their seated location on the floor in some way (e.g., roll, crawl). Recordings continued until a month after the child could walk independently. Data (injury, supervision) were averaged within each motor development stage (low, high), and associations across stages were examined.

Results

Model testing indicated that supervision level moderated the relation between injury rate across motor development stages, but the strength of this association varied by sex of the child. More intense supervision predicted lower injury rates for girls more so than for boys.

Conclusions

Although the emergence of motor milestones has been associated with increased risk of injury during infancy, the current findings indicate that greater supervision can reduce this risk. However, supervision alone is not as effective to moderate injury risk for boys as it is for girls. Thus, for boys, additional strategies (e.g., hazard removal) may also be warranted to maximize reduction in their risk of injury as they acquire increasing motor skills.

The spectrum and burden of in-patient paediatric musculoskeletal diseases in Northern Tanzania

BACKGROUND

Musculoskeletal diseases (MSD) are a major contributor to the global burden of disease and disability, and disproportionally affect low- and middle-income countries; however, there is a dearth of epidemiological data. Affected children often face increased morbidity, social isolation and economic hardship.

AIM

To assess the spectrum and burden of paediatric MSD in children aged 5-18 years admitted to a major referral hospital in Tanzania.

METHODS

This was a retrospective cohort study of children aged 5-18 years admitted to Kilimanjaro Christian Medical Centre (KCMC) whose initial diagnosis was recognised as a musculoskeletal condition by the International Classification of Diseases-10 between 1 January and 31 December 2017.

RESULTS

During 2017, 163 cases of confirmed paediatric MSD were admitted to KCMC, representing 21.2% of all admissions of children aged 5-18 years (n = 769). Bone disease was the most common diagnosis. They comprised 106 (65.0%) traumatic fractures, 31 (19.0%) osteo-articular infections, 9 (5.5%) malunions and 3 (1.8%) pathological fractures. Congenital defects and rheumatic disease were relatively uncommon, accounting for only 6 (3.7%) and 4 (2.5%) MSD admissions, respectively.

CONCLUSION

The majority of cases of MSD were related to fractures, followed by osteo-articular infections, while recognised cases of rheumatic disease were rare. The study, although small, identified the sizeable burden and spectrum of paediatric MSD admitted to a hospital in Tanzania over a 12-month period and highlights the need for larger studies to inform the optimal allocation of health resources.

ABBREVIATION

CI: confidence interval; HIC: high-income countries; HIV: human immunodeficiency virus; ICD-10: International Classification of Diseases 10; IQR: interquartile range; JIA: juvenile idiopathic arthritis; KCMC: Kilimanjaro Christian Medical Centre; LMIC: low- and middle-income countries; MSD: musculoskeletal diseases: NAI: non-accidental injury; NIHR: National Institute for Health Research; PAFLAR: Paediatric Society of the African League Against Rheumatism; RTA: road traffic accidents; SCD: sickle cell disease; SLE: systemic lupus erythematosus; SSA: sub-Saharan Africa.

Child-Pedestrian Traffic Safety at Crosswalks—Literature Review

Child pedestrians make up 30% of the total number of children injured in road traffic in the EU. They are a particularly vulnerable subgroup because they exhibit specific traffic behavior related to cognitive and physical development, sociodemographic characteristics, and environmental conditions. This paper provides an overview of research of parameters that affect the safety of children in the conflict zones of the intersection—crosswalks. The overview was undertaken targeting available research mostly conducted in the last 10 years all over the world, related to the identification of parameters that affect the safety of child-pedestrians, and models developed for the prediction of pedestrian and child-pedestrian behavior. Research conducted on various urban networks provides insight into locally and more widely applicable impact parameters connected to child characteristics and infrastructural and traffic elements, but also distractors (e.g., electronic devices) as new phenomena influencing children’s road safety. A review of pedestrian behavior-prediction models suggests that models are being developed for the general population, and models for children’s behavior, with specific parameters, are missing. For further research, more detailed analysis of the impact of distractors and of COVID–19 pandemic non-mobility, as well as an analysis of possible infrastructural solutions to increase children’s road traffic safety, is suggested.

Child Farm-Related Injury in Australia: A Review of the Literature

Children on farms have been identified as a population vulnerable to injury. This review seeks to identify child farm-related injury rates in Australia and to determine the key hazards and contributing risk factors. This critical review utilised the PRISMA guidelines for database searching. Research from the year 2000 onward was included as well as earlier seminal texts. Reference lists were searched, and the relevant research material was explored. Our primary focus was on Australian peer-reviewed literature with international and grey literature examples included. Evidence suggests that there is limited Australian research focusing on child farm-related injuries. Child representation in farm-related injuries in Australia has remained consistent over time, and the key hazards causing these injuries have remained the same for over 20 years. The factors contributing to child rates of farm injury described in the literature include child development and exposure to dangerous environments, the risk-taking culture, multi-generational farming families, lack of supervision, child labour and lack of regulation, limited targeted farm safety programs, underuse of safe play areas, financial priorities and poor understanding and operationalisation of the hierarchy of control. It is well known that children experience injury on farms, and the key hazards that cause this have been clearly identified. However, the level of exposure to hazards and the typical attitudes, behaviours and actions of children and their parents around the farm that contribute to chid injury remain unexplored.

Day care as a strategy for drowning prevention in children under 6 years of age in low- and middle-income countries

BACKGROUND

Drowning is responsible for an estimated 320,000 deaths a year, and over 90% of drowning mortality occurs in low- to middle-income countries (LMICs), with peak drowning rates among children aged 1 to 4 years. In this age group, mortality due to drowning is particularly common in rural settings and about 75% of drowning accidents happen in natural bodies of water close to the home. Providing adequate child supervision can protect children from drowning, and organized formal day care programs could offer a way to achieve this.

OBJECTIVES

Primary objective • To assess the effects of day care programs for children under 6 years of age on drowning-related mortality or morbidity, or on total drowning accidents (fatal and non-fatal), in LMICs, compared to no day care programs or other drowning prevention interventions Secondary objectives • To assess the effects of day care programs in LMICs for children under 6 years of age on unsafe water exposure • To assess safety within these programs (e.g. transmission of infection within day care, physical or sexual abuse of children within day care) • To assess the incidence of unintentional injury within these programs • To describe the cost-effectiveness of such programs, in relation to averted drowning-related mortality or morbidity SEARCH METHODS: On November 23, 2019, and for an update on August 18, 2020, we searched MEDLINE (PubMed), Embase, CENTRAL, ERIC, and CINAHL, as well as two trial registries. On December 16, 2019, and for an update on February 9, 2021, we searched 12 other resources, including websites of organizations that develop programs targeted to children.

SELECTION CRITERIA

We included randomized, quasi-randomized, and non-randomized controlled studies (with explicitly listed specific study design features) that implemented formal day care programs as a single program or combined with additional out-of-day care components (such as educational activities aimed at preventing injury or drowning or early childhood development activities) for children of preschool age (below 6 years of age) in LMICs for comparison with no such programs or with other drowning prevention interventions. Studies had to report at least one outcome related to drowning or injury prevention for the children enrolled.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection and data extraction, as well as risk of bias and GRADE assessment.

MAIN RESULTS

Two non-randomized observational studies, conducted in rural Bangladesh, involving a total of 252,631 participants, met the inclusion criteria for this review. One of these studies compared a formal day care program combined with parent education, playpens provided to parents, and community-based activities as additional out-of-day care components versus no such program. Overall we assessed this study to be at moderate risk of bias (moderate risk of bias due to confounding, low risk of bias for other domains). This study showed that implementation of a formal day care program combined with parent education, provision of playpens to parents, and community-based activities, in a rural area with a high drowning incidence, likely reduces the risk of death from drowning over the study period of 4 years and 8 months compared to no day care program (hazard ratio 0.18, 95% confidence interval [CI] 0.06 to 0.58; 1 study, 136,577 participants; moderate-certainty evidence). Drowning morbidity (non-fatal drowning resulting in complications), total drowning (fatal and non-fatal), unsafe water exposure, and program safety (e.g. transmission of infection within day care, physical or sexual abuse of children within day care) were not reported, nor was the incidence of other unintentional injuries. Cost-effectiveness was reported as 812 USD (95% CI 589 to 1777) per disability-adjusted life-year averted as a consequence of drowning (moderate-certainty evidence). The second study compared day care programs with or without playpens provided to parents as an additional component versus only playpens provided to parents as an alternative drowning prevention intervention. Overall we assessed the study to be at critical risk of bias because we judged bias due to confounding to be at critical risk. As the certainty of evidence was very low, we are uncertain about the effects on drowning mortality rate of implementing a day care program compared to providing playpens (rate ratio 0.25, 95% CI 0.15 to 0.41; 1 study; 76,575 participants; very low-certainty evidence). Likewise, we are uncertain about the effects of a day care program with playpens provided as an additional component versus playpens provided alone (rate ratio 0.06, 95% CI 0.02 to 0.12; 1 study, 45,460 participants; very low-certainty evidence). The other outcomes of interest - drowning morbidity, total drowning, unsafe water exposure, program safety, incidence of other unintentional injuries, and cost-effectiveness - were not reported.

AUTHORS' CONCLUSIONS

This review provides evidence suggesting that a day care program with additional out-of-day care components such as community-based education, parent education, and playpens provided to parents likely reduces the drowning mortality risk in regions with a high burden of drowning compared to no intervention.

Perception and awareness of unintentional childhood injuries among primary caregivers of children in Vellore, South India: a community-based cross-sectional study using photo-elicitation method

OBJECTIVE

We studied the primary caregivers' perception, and further, their awareness of unintentional childhood injuries in south India.

METHODS

A cross-sectional study was conducted in the rural block of Kaniyambadi, Vellore, among 300 primary caregivers of children aged between 0 and 14 years. A semi-structured interview was conducted with the primary caregivers using a photo-elicitation method, with a visual depiction of ten injury risky scenarios for a child. Scoring was done to assess the perception of environmental hazards in these scenarios, and further, knowledge on the prevention of these injuries. An independent 't' test was done to elicit differences in mean scores and a multivariate regression analysis was applied to ascertain factors independently associated with the scores.

RESULTS

Primary caregivers had adequate perception regarding risks posed to children in scenarios such as climbing trees (96.2%), playing near construction sites (96%), firecrackers (96.4%) and crossing unmanned roads with no traffic signals (94%). Knowledge of prevention was poor however, in the following scenarios: a woman riding a bicycle without safety features, with child pillion sitting behind bare foot and legs hanging by one side (72.6%); a child playing near a construction site (85.9%); and a child playing with plastic bags (88.3%). Overall, educational status of the primary caregiver and socioeconomic status were associated with poorer perception of risks and knowledge about unintentional childhood injuries and their prevention.

CONCLUSIONS

Pragmatic community-based childhood interventions incorporated into existing programs, with a special focus on road traffic injuries, burns and suffocation need to be implemented in high-risk settings of rural populations in South India.

Childhood vulnerability to drowning in the Western Cape, South Africa: Risk differences across age and sex

INTRODUCTION

Drowning is amongst the leading causes of death of children and young people worldwide, with high concentrations in Southeast Asia and Sub-Saharan Africa. In the Western Cape province in South Africa, drowning mortality rates for children were reported at 3.8 per 100,000 population. Internationally, evidence suggests that unimpeded access to water bodies and containers and lapses in supervision together with the child's limited developmental capacities, place children at greater risk of drowning. This study examined the risk for fatal drowning by age cohort and sex in child and adolescent (0-19 years old) in the Western Cape.

METHOD

Demographic and descriptive data for child drowning fatalities from 2010 to 2016 were obtained from the Western Cape Forensic Pathology Service. Descriptive variables included location of drowning incident by body of water, time of day, day of week and season. Data were analysed by age cohorts aligned to child psychosocial developmental stages. Descriptive statistics reported fatality frequencies by age cohort and sex, and logistic regression was conducted to detect differences in drowning risk across these categories.

RESULTS

A total of 538 childhood drowning fatalities were analysed, with the highest proportion occurring in children aged 13-19 years (29.6%) and the majority occurring in males (75.8%). Sex, location of drowning incident and season were significant predictors of drowning across the age cohorts. Relative to females, males between ages 0-1 and 2-3 years were less likely to drown when compared with older children.

CONCLUSION

This study confirms existing evidence that children younger than five are most at risk of drowning. In contrast to international and local research findings that have indicated a similar or higher risk for drowning amongst boys compared with girls aged 3 years and younger, this study identified that males were less likely to drown between the ages of 0 and 3 years compared with girls.

Causes of distraction leading to supervision lapses in cases of fatal drowning of children 0-4 years in Australia: A 15-year review

AIM

Supervision is a strategy for preventing drowning among children. However, supervision lapses continue to be a contributory factor in child drowning. This study aims to identify, describe and analyse the causes of distraction leading to lapses in supervision in child drowning.

METHODS

A total population survey of all fatal unintentional drownings among children aged 0-4 years between 1 July 2002 and 30 June 2017 was undertaken using data from the Australian National Coronial Information System. Among closed coronial cases, causes of distraction leading to lapses in supervision were collected as free text from closed case documentation and subsequently thematically grouped into categories. Univariate and χ² analysis was undertaken (P < 0.01).

RESULTS

A total of 447 children drowned during the study period (62.0% male; 66.9% aged 1-2 years; 53.3% swimming pools; 79.4% falls into water). Of the 426 (95.3%) closed cases, common supervision lapses were due to indoor household duties (27.6%), outdoor household duties (12.6%) and talking/socialising (11.9%).

CONCLUSIONS

This study has identified common scenarios for distractions leading to supervision lapses including the link between indoor household duties and bathtub drowning deaths and talking/socialising for deaths in swimming pools and at rivers. Challenges include medical issues impacting sole carers. The 7% of cases where a supervision lapse occurred due to miscommunication are opportunities to further reinforce the need for a designated supervisor, particularly with two or more adults present. Study findings on distraction causes, and strategies to minimise them, should be incorporated into national public awareness campaigns aimed at parents and care givers of this at-risk group.

Incidence, Risk and Protective Factors for Unintentional, Nonfatal, Fall-Related Injuries at Home: A Community-Based Household Survey from Ujjain, India

Background

Childhood injury is an increasing public health burden and considered a major cause of childhood morbidity and mortality worldwide. In this study, we identified the distribution and risk factors for fall-related child injuries at home in Ujjain, India.

Methods

A community-based, cross-sectional study was conducted in 2017 in Ujjain, India, which included 6308 children up to 18 years of age living in 2518 households. Data were collected using a pretested, semi-structured, proforma from the parents of the included children.

Results

The overall incidence of home injury was 7.78% (95% confidence interval [CI]: 7.12–8.84) in the last 1 year, ie, 2015–16. The incidence was significantly higher at 5–10 years of age (odds ratio [OR]: 2.91, 95% CI: 1.75–4.85; P < 0.001), followed by 1–5 years (OR: 2.66, 95% CI: 1.59–4.45; P < 0.001). The incidence of injuries was higher in boys than in girls (adjusted odds ratio [aOR]: 1.73, 95% CI: 1.43–2.10; P < 0.001). Other risk factors associated with unintentional fall injuries at home were residence (rural vs urban; aOR: 1.25, 95% CI: 1.03–1.51; P = 0.018), number of family members (≤4 vs 5–10 and ≤4 vs >10; aOR: 0.69, 95% CI: 0.56–0.86; P < 0.001 and aOR: 0.67, CI: 0.48–0.94; P < 0.023, respectively), cooking area (combined vs separate; aOR: 0.82, 95% CI: 0.68–1.00; P = 0.057), and whether mother is alive vs not alive (aOR: 2.09, 95% CI: 1.10–3.94; P = 0.023).

Conclusion

The incidence of fall injuries among children at home in Ujjain, India, was similar to other resource constraint settings. The incidence was higher in rural areas, in the age group of 5–10 years, and in families in which the mother was not alive. By contrast, large and combined families had a lower incidence of falls.

Development and validation of a health educational booklet

Purpose

This study aimed to develop and validate a health education booklet (Be SAFE booklet) as a guide to improving knowledge, attitude, and practice toward drowning prevention and water safety among parents of primary school children in a local community in Selangor.

Design/methodology/approach

This methodological study was conducted in two phases: the development of the content, and validation of the educational material. Booklet development involved content survey and design development. These steps consisted of a content analysis method, information from current literature, document analysis from the stakeholder, and input from parents or guardians and children. The validation by nine panel experts and 15 parents/guardians involved both review, content validity, and face validity.

Findings

The booklet was developed by emphasizing on four main aspects related to drowning prevention and water safety; namely, supervision, alertness, first aid, and education. The assessment rated by the content validity index (CVI), resulted in an I-CVI ranging from 0.78 to 1 and S-CVI of 0.94; the face validity achieved a level of agreement with an average of 94 percent. The results indicated that the Be SAFE booklet was validated and could be considered useful in helping to promote drowning prevention and water safety among primary school pupils' parents.

Originality/value

This article contributed ideas for the concept and aspect of health messages to be incorporated into health education materials for drowning prevention and water safety.

Safety of School Playgrounds: Field Analysis From a Randomized Sample

Research supports recess, however, playground injuries are prevalent with more than 200,000 cases per year requiring medical attention. School playgrounds are among the leading location for injury. The purpose was to identify the safety and risk factors of playground environments and impact attenuation characteristics of surfacing materials. Results demonstrated 46% playground spaces protected students from traffic. Results found 75% of playgrounds were exposed to full sun, and unitary surface materials were up to 49°F warmer than the air temperature. There was an increase in the probability of risk whether equipment height was over 9 ft for loose fill surfacing materials or over 6 ft for unitary surfaces. Loose strings or ropes looped over equipment were found on 23% of playgrounds. This study provides discussion and data pertaining to numerous aspects of playground safety. Strategies for school nurses are shared to shape policies and education for playground safety practices.

Parental supervision and discomfort with children walking to school in low-income communities in Cape Town, South Africa

OBJECTIVE

The risk of pedestrian injury is compounded for children living in low-income communities due to factors such as poor road and pedestrian infrastructure, reliance on walking as a means of transport, and compromised supervision. Parents play an important role in child pedestrian safety. The primary objective of this study was to examine the effects of child pedestrian variables on parental discomfort with regard to letting their child walk to and from school and on the frequency of adult supervision.

METHODS

A cross-sectional study was conducted using a convenience sample from 3 schools participating in a pedestrian safety school initiative. The schools are situated in low-income, high-risk communities in the City of Cape Town. A parent survey form was translated into isiXhosa and sent home with learners to those parents who had consented to participate. The response rate was 70.4%, and only parents of children who walk to and from school were included in the final sample (n = 359). Child pedestrian variables include the time taken to walk to school, parental rating of the child's ability to safely cross the road, and the frequency of adult supervision.

RESULTS

More than half of parents reported that their child walked to and from school without adult supervision. About 56% of children took less than 20 min to walk to school. Most parents (61%) were uncomfortable with their child walking to school, although the majority of parents (55.7%) rated their child's ability to cross the road safely as better or significantly better than average (compared to peers). The parents did not perceive any differences in pedestrian risk factors between boys and girls or between younger (6-9 years) and older (10-15 years) children. The time spent by a child walking to school and parents' perceptions of their child's road-crossing ability were found to be significant predictors of parental discomfort (in letting their child walk). Younger children and children who spent less time walking were more likely to be supervised by an adult.

CONCLUSIONS

Many South African schoolchildren have to navigate the roads without adult supervision from a young age. Caregivers, especially in low-income settings, often have limited options with regard to getting their child to school safely. Regardless of the child's age and gender, the time that they spend on the roads is an important factor for parents in terms of pedestrian safety.

Social Cognition, Child Neglect, and Child Injury Risk: The Contribution of Maternal Social Information Processing to Maladaptive Injury Prevention Beliefs Within a High-Risk Sample

Objective

Inadequate supervision has been linked to children's injuries. Parental injury prevention beliefs may play a role in supervision, yet little theory has examined the origins of such beliefs. This study examined whether mothers who perpetrated child neglect, who as a group provide inadequate supervision, have more maladaptive beliefs. Then, it tested a social information processing (SIP) model for explaining these beliefs.

Methods

SIP and injury prevention beliefs were assessed in disadvantaged mothers of preschoolers (N  =  145), half with child neglect histories.

Results

The neglect group exhibited significantly more maladaptive injury prevention beliefs than comparisons. As predicted, SIP was linked to beliefs that may increase injury risk, even after accounting for relevant sociodemographic variables.

Conclusions

Findings support the link of beliefs to injury risk and suggest that specific cognitive problems may underlie these beliefs. Future work should further validate this model, which may inform enhancements to prevention efforts.

Examination of a pilot intervention program to change parent supervision behaviour at Australian public swimming pools

ISSUE ADDRESSED

Drowning is one of the leading causes of unintentional death in children worldwide. There is limited evidence about the effectiveness of programs targeting child drowning prevention at public swimming pools. We examined the effectiveness of a public education program (Keep Watch @ Public Pools) for improving child supervision levels by parents at public swimming pools.

METHODS

The program was evaluated via an observational study of parent supervision behaviour with children aged 0-14 years. Measures included domains of attention, proximity and preparedness. A rating scale from 0 = least effective to 4 = most effective was used, based upon the supervision domains. Seven public swimming pools in Melbourne, Victoria, Australia were randomised to either intervention or control pool. The intervention occurred over six weeks, and observations were taken over a one-week period both pre- and postintervention. Observations of a total of 10 186 children and 6930 parents/carers were recorded and analysed.

RESULTS

A significant improvement in attention, proximity and preparedness was observed in parents of children aged 6-10 years at intervention pools. However, similar results were not observed in parents of children aged 0-5 years and 11-14 years.

CONCLUSIONS

Supervision behaviour of parents can be modified, and the implications of these results for the community through to practice and policy are discussed. SO WHAT?: Targeted public education programs provide an effective way of improving parental supervision of children at public swimming pools. Such education programs should be widely implemented throughout public swimming pools, as one part of a comprehensive approach to drowning prevention.

Supervising for Home Safety Program: A Randomized Controlled Trial (RCT) Testing Community-Based Group Delivery

Objective

The individually delivered Supervising for Home Safety (SHS) program improves caregivers' injury-related beliefs and supervision practices. The current randomized controlled trial used a group delivery in a community setting and assessed program impact, feasibility, and acceptance.

Methods

Caregivers of 2-5-year-olds were randomized to receive either the SHS or an attention-matched control program.

Results

In the SHS group only, there were increases from baseline to postintervention in the following: beliefs about children's vulnerability to injury, caregiver preventability of injuries, and self-efficacy to do so; readiness for change in supervision; and watchful supervision. Face-to-face recruitment by staff at community organizations proved most successful. Caregivers' satisfaction ratings were high, as was caregiver engagement (95% completed at least seven of the nine sessions).

Conclusion

The SHS program can be delivered to groups of caregivers in community settings, is positively received by caregivers, and produces desirable changes that can be expected to improve caregivers' home safety practices.

Caregiver Supervision Practices and Risk of Childhood Unintentional Injury Mortality in Bangladesh

Unintentional injury-related mortality rate, including drowning among children under five, is disproportionately higher in low- and middle-income countries. The evidence links lapse of supervision with childhood unintentional injury deaths. We determined the relationship between caregiver supervision and unintentional injury mortality among children under five in rural Bangladesh. We conducted a nested, matched, case-control study within the cohort of a large-scale drowning prevention project in Bangladesh, “SOLID—Saving of Children’s Lives from Drowning”. From the baseline survey of the project, 126 cases (children under five with unintentional injury deaths) and 378 controls (alive children under five) were selected at case-control ratio of 1:3 and individually matched on neighborhood. The association between adult caregiver supervision and fatal injuries among children under five was determined in a multivariable conditional logistic regression analysis, and reported as adjusted matched odds ratio (MOR) with 95% confidence intervals (CIs). Children under five experiencing death due to unintentional injuries, including drowning, had 3.3 times increased odds of being unsupervised as compared with alive children (MOR = 3.3, 95% CI: 1.6–7.0), while adjusting for children’s sex, age, socioeconomic index, and adult caregivers’ age, education, occupation, and marital status. These findings are concerning and call for concerted, multi-sectoral efforts to design community-level prevention strategies. Public awareness and promotion of appropriate adult supervision strategies are needed.

Child pedestrian safety knowledge, behaviour and road injury in Cape Town, South Africa

Pedestrian injuries are a leading cause of death among South African children, and young children residing in low-income communities are more at risk, due to various factors such as inadequate road infrastructure, exposure to traffic due to reliance on walking as a means of transport, and lack of supervision. This study used a cross-sectional, non-randomized self-report survey to assess pedestrian safety knowledge, road-crossing behaviour and pedestrian injuries of primary school children in selected low-income settings in Cape Town. The survey focused on three primary schools that had joined the Safe Kids Worldwide Model School Zone Project and was administered to 536 children aged 6-15 years, in their home language of isiXhosa. Descriptive and bivariate analyses as well as multivariate regression analyses were conducted to investigate potential predictor variables for pedestrian collision severity and unsafe road-crossing behaviour. Walking was the sole form of travel for 81% of the children, with a large proportion regularly walking unsupervised. Children who walk to or from school alone were younger and reported riskier road-crossing behaviour, although children who walk accompanied tended to have higher pedestrian collision severity. "Negligent Behaviour" related to road-crossing was significantly associated with higher pedestrian collision severity, with predictors of "Negligent Behaviour" including the lack of pedestrian safety knowledge and greater exposure to traffic in terms of time spent walking. More than half of the reported pedestrian collisions involved a bicycle, and older boys (10-15 years) were most at risk of experiencing a severe pedestrian injury. The findings substantiate emerging evidence that children in low-income settings are at greater risk for child pedestrian injury, and emphasise the need for evidence-based safety promotion and injury prevention interventions in these settings.

Risk factors of bicycle traffic injury among middle school students in chaoshan rural areas of china

BACKGROUND

Bicycle injuries are a leading cause of accidental death among children in the world, and bicycle-related injuries are also very common in China, thus to find out bicycle injury risk factors is imperative. This study aims to identify the cyclist-, bicycle- and road-related risk factors of bicycle injury, to develop health education programs as an intervention and to provide a scientific basis for establishing policies against bicycle injury.

METHODS

We selected two middle schools randomly among seven schools in Chaoshan rural areas,where the main means of transportation for students from home to school was bicycle. The subjects were middle school students from 7th to 9th grades from Gucuo Middle School and Hefeng Middle School. Cyclists were surveyed through questionnaires about bicycle injury in the past 12 months.

RESULTS

Multivariable logistic analysis showed that compared with a combination-type road、 motor lane and a non-intact road were both risk factors of bicycle injuries. This was followed by riding with fatigue, non-motor lane and inattentive riding.

CONCLUSION

Bicycle injuries are frequent in China. Three risk factors on bicycle traffic injury among middle school students in Chaoshan rural areas of China were identified. This study provides important data to develop intervention strategies for China and other developing countries.

The Role of Adult Perceptions and Supervision Behavior in Preventing Child Injury

Supervision is an important factor in reducing injury risk. There are multiple factors that can affect the appropriate level of supervision including risk perception, anticipation of injury, and distracted behaviors. This study examined the perceived risks of child injury among parents and child caregivers and their supervision behavior among adults in an urban playground. Participant data from 25 individuals were collected through observations and anonymous self-reported surveys. More than half of the participants indicated practice of appropriate supervisory behavior, including attentiveness to their child's behavior and proximity to their child during play. Caregivers were more likely to report more careful levels of supervision. One-fourth of participants reported a change in the supervisory behavior during periods of distraction, specifically with phone use. Of the variables tested, there was a significant association between the variable 'talking to other adults' during supervision and 'prior injury' (P value = 0.04, 95% CI 0.03-0.91). Parents were more likely to report that they would leave their child unattended if they believed that the playground was a safe environment for play. There was a difference between self-reported behaviors and actual observed behavior, which is likely due to varying perspectives regarding child safety and injury prevention. In regards to injury risk, findings highlight the important role of appropriate supervisory behaviors and risk perceptions in preventing child injuries.

Madres, padres y profesores como educadores de la resiliencia en niños colombianos

Resumen El objetivo del estudio consistió en analizar el aporte de las prácticas educativas de madres, padres y profesores en el desarrollo de la resiliencia en niños(as). Se contó con 417 niños(as), 199 profesores, 111 mamás y 80 papás de zona rural de nivel socioeconómico bajo. Fue un estudio transversal, de análisis correlacional, explicativo. Las niñas mostraron mayor nivel de generosidad, laboriosidad y resiliencia total en comparación con los niños. Las mamás tienden a practicar la aceptación y apoyo, la afirmación del poder, el retiro del afecto y el trato rudo más que los papás. Las profesoras también ejercen estás prácticas pero en menor proporción que los dos padres. La aceptación de papás y profesoras, el monitoreo de los dos padres y la afirmación del poder de las profesoras, son variables que pesan de manera significativa en la explicación de resiliencia en los niños(as). Es importante diseñar estrategias de intervención conjuntas en el contexto familiar y escolar desde edades tempranas, con el fin de desarrollar procesos de resiliencia en niños, teniendo en cuenta el papel protagónico de los padres y los profesores en este proceso.

Profile and Risk Factor Analysis of Unintentional Injuries in Children

OBJECTIVE

To study the profile and various risk factors associated with unintentional injuries in children.

METHODS

The study is a cross sectional analysis of data collected from 351 children presenting with unintentional injury to a tertiary care hospital in Navi Mumbai, India. Data were collected about variables based on Haddon Phase Factor Matrix - host, environment and agent factors. Proportions for categorical variables across various groups were compared using Chi square test or Fisher's exact test. Logistic regression model was used to evaluate the factors.

RESULTS

Falls (36 %) were the most common injuries followed by bites (23 %). Majority of children were school going children (38 %) followed by preschool children (29 %). Forty-seven percent were from lower socioeconomic class. Commonest place of injury was home (48 %) and the commonest time was evening (49 %). Though there was male predominance in injuries, the difference across gender did not vary significantly (p = 0.15). Poisonings were significantly more common in infants and toddlers and in rural population (p < 0.001); kerosene being the commonest agent. Rural population is at more risk of bites compared to urban (p < 0.001); dog bites being the commonest followed by scorpion bites. Foreign bodies were significantly more common in upper and middle socioeconomic class and bites, in lower socioeconomic class (p < 0.005). Injuries from rural area and lower socioeconomic class were more serious, requiring hospitalization; they were also more likely to present late to the hospital (p < 0.05).

CONCLUSIONS

Profile of injuries varies widely as per the variations in agent, host and environmental factors. Socio-environmental, economic conditions and infancy-toddler age groups are predisposing risk factors for bites and poisoning. Although rural areas and lower socioeconomic class population are more vulnerable to serious types of injuries, they still lack essential basic medical care.

The Association of Parental Coping and Childhood Injury

Objectives Injuries are the leading cause of pediatric morbidity and mortality in the United States. Interaction between child, parent and environmental factors may contribute to injuries. This study investigates the association between coping with parenthood and injuries in children age 0-5 years. Methods In this cross-sectional observational study, we analyzed data from the 2007 National Survey of Children's Health, a random-digit-dialing, nationally-representative telephone survey. Information was obtained from a caregiver about children 5 years of age or younger. Parental coping with the demands of parenthood was categorized into three groups-"very well", "somewhat well" and "not very well" or "not very well at all". Injury was defined as caregiver report of any injury within the previous 12 months that required medical attention. Results This study included 27,471 surveys about children 5 years of age or younger. With weighted analysis, 10.4 % of children were reported to have an injury; 31.1 % of caregivers reported coping with parenthood "somewhat well" and 1.7 % reported coping "not very well"/"not very well at all". The adjusted odds ratio of sustaining an injury was 1.26 (95 % CI 1.00, 1.59) for children of parents who reported coping somewhat well with the demands of parenthood compared to those with parents coping very well. Conclusions Parental report of coping with parenthood less than very well was associated with injury in children ages 0-5 years, further highlighting the importance of the interaction between parent factors and childhood injury.

The Transition from Crawling to Walking: Can Infants Elicit an Alteration of Their Parents' Perception?

Our study was designed to address a gap in the literature on parents' perception and motivation to protect their infants from potential risk of injury in the transition from crawling to walking. The participants were 260 Italian subjects, of whom 158 were women and 102 men, aged between 20 and 45 years. They were asked to draw two domestic objects (a kitchen table and a CD cover) to assess the possible alterations in the perception of environmental elements seen by the parents as a potentially dangerous cause of unintentional injury for their child. Analysis showed that the group of mothers with children aged 9-18 months had drawn the largest tables, while the table areas of the other two categories of women were much smaller. As for the males, the group that drew the largest tables was the one with children, but not in the age range of 9-18 months, while there was little difference between the other two groups. The final descriptive analysis concerned the average scores on the STAI-Y tests both for state and trait anxiety. In all groups a substantial parity was observed, except for the non-parent men, who had a lower level of state anxiety. Both the fathers and the mothers of children aged 9-18 months obtained lower scores, both for state and trait anxiety. Based on the findings, we demonstrate that children transitioning from crawling to walking can elicit a perceptive reactivity in their mothers, which satisfies their natural need to protect their offspring.

Approaches used by parents to keep their children safe at home: a qualitative study to explore the perspectives of parents with children aged under five years

Background

Childhood unintentional injury represents an important global health problem. Many unintentional injuries experienced by children aged under 5 years occur within the home and are preventable. The aim of this study was to explore the approaches used by parents of children under five in order to help prevent unintentional injuries in the home and the factors which influence their use. Understanding how parents approach risk-management in the home has important implications for injury practitioners.

Methods

A multi-centre qualitative study using semi-structured interviews. A thematic approach was used to analyse the data. Sixty five parents of children aged under 5 years, from four study areas were interviewed: Bristol, Newcastle, Norwich and Nottingham.

Results

Three main injury prevention strategies used by parents were: a) Environmental such as removal of hazards, and use of safety equipment; b) parental supervision; and c) teaching, for example, teaching children about safety and use of rules and routine. Strategies were often used in combination due to their individual limitations. Parental assessment of injury risk, use of strategy and perceived effectiveness were fluid processes dependent on a child’s character, developmental age and the prior experiences of both parent and child. Some parents were more proactive in their approach to home safety while others only reacted if their child demonstrated an interest in a particular object or activity perceived as being an injury risk.

Conclusion

Parents’ injury prevention practices encompass a range of strategies that are fluid in line with the child’s age and stage of development; however, parents report that they still find it challenging to decide which strategy to use and when.

Parent-Child Injury Prevention Conversations Following a Trip to the Emergency Department

OBJECTIVES

The goal of the study was to examine how parents use conversation to promote the internalization of safety values after their child has been seriously injured.

METHODS

Parent interviews detailing postinjury conversations were coded for strategies mentioned to prevent injuries in the future and information about circumstances surrounding the injury.

RESULTS

Logistic regression analyses revealed that parents were more likely to discuss why an activity was dangerous with older than younger children, and were more likely to urge daughters than sons to be more careful in the future. Injuries resulting from the presence of environmental hazards predicted parents telling children to be more careful in the future. Having others involved predicted parents urging children not to engage in the behavior again.

CONCLUSIONS

Findings suggest that parents modulated strategies according to age, gender, and injury circumstances to maximize the likelihood that children would behave differently in the future.

Risk and protective factors for falls on one level in young children: multicentre case-control study

BACKGROUND

Childhood falls are an important global public health problem, but there is lack of evidence about their prevention. Falls on one level result in considerable morbidity and they are costly to health services.

OBJECTIVE

To estimate ORs for falls on one level in children aged 0-4 years for a range of safety behaviours, safety equipment use and home hazards.

DESIGN, SETTING AND PARTICIPANTS

Multicentre case-control study at hospitals, minor injury units and general practices in and around four UK study centres. Participants included 582 children less than 5 years of age with a medically attended fall injury occurring at home and 2460 controls matched on age, sex, calendar time and study centre.

MAIN OUTCOME MEASURE

Fall on one level.

RESULTS

Cases' most common injuries were bangs on the head (52%), cuts or grazes not needing stitches (29%) or cuts or grazes needing stitches (17%). Comparing cases to community controls in the adjusted analyses, significant findings were observed for only two exposures. Injured children were significantly less likely to live in a household without furniture corner covers (adjusted OR (AOR) 0.72, 95% CI 0.55 to 0.95), or without rugs and carpets firmly fixed to the floor (AOR 0.76, 95% CI 0.59 to 0.98).

CONCLUSIONS

We did not find any safety practices, use of safety equipment or home hazards associated with a reduced risk of fall on one level. Our findings do not provide evidence to support changes to current injury prevention practice.

Older siblings as potential supervisors of younger siblings: sibling supervisors' recognition of injury-risk behaviours and beliefs about supervisee risk taking and potential injury outcomes

BACKGROUND

Past research has shown that increased injury risk for supervisees during sibling supervision is in part due to the supervision practices of older siblings.

METHODS

The current study used a photo sorting task to examine older siblings' recognition of injury-risk behaviours, their perceived likelihood of supervisees engaging in, or being injured while engaging in, these behaviours, and awareness of past risk-taking behaviours of supervisees. Mothers completed the same measures and an interview about sibling supervision in the home.

RESULTS

Mothers reported that sibling supervision occurred most frequently in the kitchen, living room, and children's bedrooms, for approximately 39 min/day, and that the more time the children spent together in a room, the more frequently the older sibling supervised the younger one. The most common reasons mothers gave for why sibling supervision was allowed included beliefs that the older child knows about hazards and unsafe behaviours and that the child could provide adequate supervision. Photo sort results revealed that older siblings were able to correctly identify about 98% of risk behaviours, with these scores significantly higher than what mothers expected (79%). However, compared with mothers, older siblings were less aware of risk behaviours that their younger siblings had engaged in previously. In addition, mothers rated supervisees as 'fairly likely' both to engage in risk behaviours and to experience an injury if they tried these behaviours, whereas sibling supervisors rated both supervisee risk behaviour and injury outcomes as 'not likely' to occur.

CONCLUSION

Older siblings showed good knowledge of hazards but failed to realize that younger children often engage in injury-risk behaviours. Efforts to improve the supervision practices of sibling supervisors need to include changing their perception of supervisees' injury vulnerability and potential injury severity, rather than targeting to increase knowledge of injury-risk behaviours per se.

Parental perceptions of barriers and facilitators to preventing child unintentional injuries within the home: a qualitative study

Background

Childhood unintentional injury represents an important global health problem. Most of these injuries occur at home, and many are preventable. The main aim of this study was to identify key facilitators and barriers for parents in keeping their children safe from unintentional injury within their homes. A further aim was to develop an understanding of parents’ perceptions of what might help them to implement injury prevention activities.

Methods

Semi-structured interviews were conducted with sixty-four parents with a child aged less than five years at parent’s homes. Interview data was transcribed verbatim, and thematic analysis was undertaken. This was a Multi-centre qualitative study conducted in four study centres in England (Nottingham, Bristol, Norwich and Newcastle).

Results

Barriers to injury prevention included parents’ not anticipating injury risks nor the consequences of some risk-taking behaviours, a perception that some injuries were an inevitable part of child development, interrupted supervision due to distractions, maternal fatigue and the presence of older siblings, difficulties in adapting homes, unreliability and cost of safety equipment and provision of safety information later than needed in relation to child age and development. Facilitators for injury prevention included parental supervision and teaching children about injury risks. This included parents’ allowing children to learn about injury risks through controlled risk taking, using “safety rules” and supervising children to ensure that safety rules were adhered to. Adapting the home by installing safety equipment or removing hazards were also key facilitators. Some parents felt that learning about injury events through other parents’ experiences may help parents anticipate injury risks.

Conclusions

There are a range of barriers to, and facilitators for parents undertaking injury prevention that would be addressable during the design of home safety interventions. Addressing these in future studies may increase the effectiveness of interventions.

Children's recognition of dangerous household products: child development and poisoning risk

OBJECTIVE

Preliterate children may be poisoned because they fail to distinguish safe versus hazardous household products.

METHODS

Study 1: A total of 228 children aged 18-54 months completed four tasks assessing ability to recognize product safety. Study 2: A total of 68 children aged 17-31 months chose products to drink from pairs of dangerous versus beverage bottles. Study 3: A total of 119 children aged 18-42 months sorted 12 objects into toys, things you can drink, and things that are bad/dangerous.

RESULTS

Left alone, children frequently touched dangerous household products. Children frequently misidentified poisonous products as safe. Some developmental trends emerged. The following packaging features apparently helped children recognize danger: black bottle color; opaque packaging; salient symbols like insects; lack of pointy spouts; squared, not round, bottles; and metal, not plastic, containers.

CONCLUSIONS

Developing cognition helps preliterate children distinguish safe from dangerous household products. Multiple aspects of product packaging may reduce child poisoning risk if implemented by industry or policy.

Managing children's risk of injury in the home: does parental teaching about home safety reduce young children's hazard interactions?

Past research confirms that parents extend much effort to teach their young children about safety, but little is known about this process. The present study examined mothers' use of teaching as a strategy to manage young children's risk of home injury and how this impacts children's hazard interactions. Mothers of three-year-olds completed an in-home room-by-room interview in which they identified injury hazards that concern them, reported on use of teaching to manage risk of injury from these hazards, rated children's understanding of these safety issues and compliance with behavioral guidelines regarding these safety issues, and reported on children's recent interactions with these hazards. They also completed questionnaire measures of how difficult the child is to manage and the child's typical level of risk taking. Results revealed that children's understanding of safety impacted both their compliance and hazard interactions, moderating the impact of risk taking on compliance and also the impact of children's difficult-to-manage score on hazard interactions. These findings demonstrate that teaching strategies need to effectively enhance children's understanding of the safety issue in order to reduce children's risk of hazard interactions.