Does home visiting prevent childhood injury? A systematic review of randomised controlled trials

The effectiveness of interventions to prevent and reduce child maltreatment in high-income countries: An umbrella review

BACKGROUND

In recent decades, many interventions targeting the occurrence (primary prevention) or the recurrence (secondary prevention) of child abuse and neglect have been tested. Findings have been synthesized in several meta-analyses and systematic reviews. However, the range of interventions addressed in these studies is very broad, and an integrative assessment of this large spectrum is lacking.

OBJECTIVE

Focusing on high-income countries, we ask (i) what is known about the effectiveness of interventions to prevent or reduce child abuse and neglect and (ii) how robust this evidence is.

METHODS

A systematic review of systematic reviews, called an umbrella review, was conducted. Ten databases on OvidSP and Web of Science were searched up until April 2023. Narrative synthesis was used to document the publications' findings.

RESULTS

44 publications were included in the umbrella review. We did not find that any type of intervention had a clear, consistent, and robust track record of preventing or reducing the occurrence of child abuse and neglect. Rather, publications examining the effectiveness of interventions in all areas frequently reported non-existent, small or inconsistent effects. However, positive effects for particular interventions in specific settings did emerge. Research methodologies showed several and often severe problems.

CONCLUSIONS

We suggest several measures to improve the quality of research and call on practitioners to be persistent in developing more effective interventions.

Education on Preventing Early Childhood Injuries Using a Video Game: The VirtualSafeHome Platform

Poisonings and household injuries are frequent events among toddlers. We developed VirtualSafeHome (VSH)-a novel self-contained, Internet-based home-safety learning tool-to improve awareness of household hazards. Study aims were to investigate VSH usage characteristics. A prototype, screen-based VSH kitchen was built in Unity and delivered through the web using 3DVista and Wix. Players spot and click 21 embedded hazards. A unique feature is the ability to capture the "child's perspective" in identifying hazards. We recruited a convenience sample of adults in 2021-2022. Outcomes included number of hazards discovered, session duration, and pretest/posttest knowledge scores. Twenty-four adults identified a median 15.5 hazards; median playing time was 1022 seconds. Players reported satisfaction with ease of navigation and game features. Mean pretest/posttest knowledge scores rose from 2.0 to 2.79 (P < .035). A web-enabled video game can provide easily accessed, enjoyable training on home safety.

Implementation fidelity of the 'Stay One Step Ahead' home safety intervention: a mixed-methods analysis

OBJECTIVE

To assess implementation fidelity of the Stay One Step Ahead (SOSA), a complex intervention which was delivered by health visiting teams, children's centres, and family mentors and was aimed at preventing unintentional home injuries in children under 5 in disadvantaged communities.

STUDY DESIGN

A mixed-methods evaluation of the implementation fidelity of the SOSA intervention.

METHODS

A conceptual framework for implementation fidelity was used to triangulate data from questionnaires and semistructured interviews with parents and practitioners, observations of parent and practitioner contacts, and meeting documents. Quantitative data were analysed using logistic regression and descriptive statistics. Thematic analysis was used for qualitative data.

RESULTS

Parents in intervention wards were more likely to receive home safety advice from a practitioner than those living in matched control wards. Monthly safety messages and family mentor home safety activities were delivered with greater fidelity than other intervention components. Content most frequently adapted included the home safety checklist used by health visiting teams, and safety weeks delivered at children's centres.

CONCLUSION

Consistent with similarly complex interventions, SOSA was delivered with variable fidelity in a challenging environment. The findings add to the body of evidence on implementation fidelity of home injury prevention programmes, providing important information for future intervention development and delivery.

Prevalence of unintentional injury among left-behind children in mainland China: Evidence from epidemiological surveys

BACKGROUND

Left-behind children have become a particular concern in mainland China, and unintentional injury among these children has attracted increasing attention. This review aims to present the prevalence of unintentional injury among left-behind children and subgroups in mainland China.

METHODS

A systematic literature search was conducted using four Chinese and two English databases. The included publications were cross-sectional studies in mainland China, of which the population was recruited according to inclusion and exclusion criteria. Information was collected using self-administered questionnaires. The risk of bias was estimated using the Strengthening the Reporting of Observational Studies in Epidemiology, and pooled prevalence was estimated through the DerSimonian-Laird proportion method.

RESULTS

This review included 34 cross-sectional studies consisting 58,348 left-behind children in mainland China. Results showed that the pooled prevalence of unintentional injury was 38.24% (95% confidence interval (CI): 28.40-48.08) among left-behind children. The prevalence was higher among left-behind children (38.76%) than among non-left-behind children (27.94%), with an odds ratio of 1.65 (95% CI: 1.47-1.85). Furthermore, the prevalence of injury was higher among boys (39.12%) than among girls (28.61%), with an odds ratio of 1.58 (95% CI: 1.41-1.77). Falls had the highest prevalence of 20.79% among the types of unintentional injury. Furthermore, home was the occurrence location with the highest prevalence (16.20%). No significant difference in injury prevalence was observed among left-behind children without accompanying parents and those with single parent accompanying them.

CONCLUSIONS

This review showed a relatively high injury prevalence among left-behind children in mainland China. Boys had a higher prevalence than girls. Falls had the highest prevalence, and home was the most common occurrence location.

Prevention of Concussion

Concussion is a common pediatric problem, and the best point of intervention would be to prevent a concussion from occurring. Unfortunately, information in this area has inconsistent support for the various methods that have been attempted. In infants, concussions are typically related to safety hazards in the environment and attempts to make the environment safer have resulted in decreased injuries over time. Toddlers also face environmental hazards that are slightly different in light of their increased mobility. School-aged children and adolescents primarily sustain concussions in the course of participation in organized contact sports. Although much research has been devoted to protective equipment, there is not a clearly effective piece of equipment that prevents concussions. Some effect has been demonstrated with changes in rules and policy that limit or eliminate certain kinds of dangerous contact. Research is still being performed to adequately evaluate methods that are already being used, as well as to find new methods in the future that may help protect today's children from concussions.

Preventing child maltreatment: Examination of an established statewide home-visiting program

Although home visiting has been used in many populations in prevention efforts, the impact of scaled-up home-visiting programs on abuse and neglect remains unclear. The objective of this study was to assess the impact of voluntary participation in an established statewide home-visiting program for socially high-risk families on child maltreatment as identified by Child Protective Services (CPS). Propensity score matching was used to compare socially high-risk families with a child born between January 1, 2008 and December 31, 2011 who participated in Connecticut's home-visiting program for first-time mothers and a comparison cohort of families who were eligible for the home-visiting program but did not participate. The main outcomes were child maltreatment investigations, substantiations, and out-of-home placements by CPS between January 1, 2008 and December 31, 2013. In the unmatched sample, families who participated in home-visiting had significantly higher median risk scores (P < .001). After matching families on measured confounders, the percentages of families with CPS investigations (21.1% vs. 20.9%, P = .86) were similar between the two groups. However, there was a 22% decreased likelihood of CPS substantiations (hazard ratio [HR] 0.78, 95% confidence interval [CI] 0.64-0.95) for families receiving home visiting. First substantiations also occurred later in the child's life among home-visited families. There was a trend toward decreased out-of-home placement (HR 0.73, 95% CI 0.53-1.02, P = .06). These results from a scaled-up statewide program highlight the potential of home visiting as an important approach to preventing child abuse and neglect.

Pilot Study of a Novel Partnership for Installing Smoke Alarms

Objectives To demonstrate the feasibility of partnering fire department personnel and home visiting nurses to increase the number of low-income homes protected by smoke alarms. Methods During a regularly scheduled home visit, nurses at the Nurse-Family Partnership of Maricopa County (NFP) informed their clients about an opportunity to have smoke alarms installed in their homes for free. For interested families, nurses sent a referral to the Phoenix Fire Department (PFD), scheduled an appointment, and accompanied the PFD volunteers during the installation. During the appointment, PFD personnel installed alarms and provided safety education. Clients completed a follow-up survey 1-3 months after the installation visit. In-depth interviews were completed with key informants from NFP and PFD to solicit feedback on the program. Results Fifty-two smoke alarm installation visits were completed. Before the fire department arrived, 55% of homes had no working smoke alarm. Almost all (94%) homes received at least one new smoke alarm, and every home had at least one working smoke alarm at the end of the fire department visit. At follow-up, all homes maintained at least one working smoke alarm. Members from both organizations were enthusiastic about, and supportive of the project. NFP nurses appreciated the skill and knowledge of the firefighters; PFD representatives noted that the nurses' relationships with clients made it easier for them to gain access to families who are often described as "hard-to-reach". Conclusions Partnering home visiting nurses and fire departments can be successful to increase the number of vulnerable homes with smoke alarms.

Surveillance Bias in Child Maltreatment: A Tempest in a Teapot

Background: Children are believed to be more likely to be reported for maltreatment while they are working with mental health or social service professionals. This "surveillance bias" has been claimed to inflate reporting by fifty percent or more, and has been used to explain why interventions such as home visiting fail to reduce official maltreatment reporting rates. Methods: We use national child abuse reporting data (n = 825,763), supplemented by more detailed regional data from a multi-agency administrative data study (n = 7185). We determine the percentage of all re-reports made uniquely by mental health and social service providers within and across generations, the report sources which could be subject to surveillance bias. Results: At three years after the initial Child protective services (CPS) report, the total percentage of national reports uniquely made by mental health or social service providers is less than 10%, making it impossible that surveillance bias could massively inflate CPS reporting in this sample. Analysis of national data find evidence of a very small (+4.54%) initial surveillance bias "bump" among served cases which decays to +1.84% within three years. Our analysis of regional data showed similar or weaker effects. Conclusions: Surveillance bias effects appear to exist, but are very small.

Home safety education and provision of safety equipment for injury prevention (Review)

BACKGROUND

In industrialised countries injuries (including burns, poisoning or drowning) are the leading cause of childhood death and steep social gradients exist in child injury mortality and morbidity. The majority of injuries in pre-school children occur at home but there is little meta-analytic evidence that child home safety interventions reduce injury rates or improve a range of safety practices, and little evidence on their effect by social group.

OBJECTIVES

We evaluated the effectiveness of home safety education, with or without the provision of low cost, discounted or free equipment (hereafter referred to as home safety interventions), in reducing child injury rates or increasing home safety practices and whether the effect varied by social group.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2009, Issue 2) in The Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Social Sciences Citation Index (SSCI), ISI Web of Science: Conference Proceedings Citation Index- Science (CPCI-S), CINAHL (EBSCO) and DARE (2009, Issue 2) in The Cochrane Library. We also searched websites and conference proceedings and searched the bibliographies of relevant studies and previously published reviews. We contacted authors of included studies as well as relevant organisations. The most recent search for trials was May 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs), non-randomised controlled trials and controlled before and after (CBA) studies where home safety education with or without the provision of safety equipment was provided to those aged 19 years and under, and which reported injury, safety practices or possession of safety equipment.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. We attempted to obtain individual participant level data (IPD) for all included studies and summary data and IPD were simultaneously combined in meta-regressions by social and demographic variables. Pooled incidence rate ratios (IRR) were calculated for injuries which occurred during the studies, and pooled odds ratios were calculated for the uptake of safety equipment or safety practices, with 95% confidence intervals.

MAIN RESULTS

Ninety-eight studies, involving 2,605,044 people, are included in this review. Fifty-four studies involving 812,705 people were comparable enough to be included in at least one meta-analysis. Thirty-five (65%) studies were RCTs. Nineteen (35%) of the studies included in the meta-analysis provided IPD. There was a lack of evidence that home safety interventions reduced rates of thermal injuries or poisoning. There was some evidence that interventions may reduce injury rates after adjusting CBA studies for baseline injury rates (IRR 0.89, 95% CI 0.78 to 1.01). Greater reductions in injury rates were found for interventions delivered in the home (IRR 0.75, 95% CI 0.62 to 0.91), and for those interventions not providing safety equipment (IRR 0.78, 95% CI 0.66 to 0.92). Home safety interventions were effective in increasing the proportion of families with safe hot tap water temperatures (OR 1.41, 95% CI 1.07 to 1.86), functional smoke alarms (OR 1.81, 95% CI 1.30 to 2.52), a fire escape plan (OR 2.01, 95% CI 1.45 to 2.77), storing medicines (OR 1.53, 95% CI 1.27 to 1.84) and cleaning products (OR 1.55, 95% CI 1.22 to 1.96) out of reach, having syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.44) or poison control centre numbers accessible (OR 3.30, 95% CI 1.70 to 6.39), having fitted stair gates (OR 1.61, 95% CI 1.19 to 2.17), and having socket covers on unused sockets (OR 2.69, 95% CI 1.46 to 4.96). Interventions providing free, low cost or discounted safety equipment appeared to be more effective in improving some safety practices than those interventions not doing so. There was no consistent evidence that interventions were less effective in families whose children were at greater risk of injury.

AUTHORS' CONCLUSIONS

Home safety interventions most commonly provided as one-to-one, face-to-face education, especially with the provision of safety equipment, are effective in increasing a range of safety practices. There is some evidence that such interventions may reduce injury rates, particularly where interventions are provided at home. Conflicting findings regarding interventions providing safety equipment on safety practices and injury outcomes are likely to be explained by two large studies; one clinic-based study provided equipment but did not reduce injury rates and one school-based study did not provide equipment but did demonstrate a significant reduction in injury rates. There was no consistent evidence that home safety education, with or without the provision of safety equipment, was less effective in those participants at greater risk of injury. Further studies are still required to confirm these findings with respect to injury rates.

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.

Home injury risks to young children in Karachi, Pakistan: a pilot study

OBJECTIVE

To pilot an in-home unintentional injury hazard assessment tool and to quantify potential injury risks for young children in a low-income urban setting.

METHODS

Two low-income neighbourhoods in Karachi, Pakistan, were mapped, and families with at least one child between the ages of 12 and 59 months were identified. Using existing available home injury risk information, an in-home injury risk assessment tool was drafted and tailored to the local setting. Home injury assessments were done in June-July 2010 after obtaining informed consent.

RESULTS

Approximately 75.4% of mothers were educated through at least grade 12. The main risks identified were stoves within the reach of the child (n=279, 55.5%), presence of open buckets in the bathroom (n=240, 47.7%) within the reach of the child, and pedestal fans accessible to the child (n=242, 48.1%). In terms of safety equipment, a first-aid box with any basic item was present in 70% of households, but only 4.8% of households had a fire extinguisher in the kitchen.

CONCLUSIONS

This was the first time that an in-home, all-unintentional injury risk assessment tool was tailored and applied in the context of a low-income community in Pakistan. There was a significant burden of hazards present in the homes in these communities, representing an important opportunity for injury prevention. This pilot may have future relevance to other LMICs where child injury prevention is a critical need.

Parenting interventions for the prevention of unintentional injuries in childhood

BACKGROUND

Parent education and training programmes can improve maternal psychosocial health, child behavioural problems and parenting practices. This review assesses the effects of parenting interventions for reducing child injury.

OBJECTIVES

To assess the effects of parenting interventions for preventing unintentional injury in children aged under 18 years and for increasing possession and use of safety equipment and safety practices by parents.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, BIOSIS Preview, PsycINFO, Sociological Abstracts, Social Science Citation Index, CINAHL, ProQuest Dissertations and Theses, ERIC, DARE, ASSIA, Web of Science, SIGLE and ZETOC. We also handsearched abstracts from the World Conferences on Injury Prevention & Control and the journal Injury Prevention. The searches were conducted in January 2011.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (non-RCTs) and controlled before and after studies (CBAs), which evaluated parenting interventions administered to parents of children aged 18 years and under, and reported outcome data on injuries for children (unintentional or unspecified intent), possession and use of safety equipment or safety practices (including the Home Observation for Measurement of the Environment (HOME) scale which contained an assessment of home safety) by parents. Parenting interventions were defined as those with a specified protocol, manual or curriculum aimed at changing knowledge, attitudes or skills covering a range of parenting topics.

DATA COLLECTION AND ANALYSIS

Studies were selected, data were extracted and quality appraised independently by two authors. Pooled relative risks (RR) were estimated using random effect models.

MAIN RESULTS

Twenty two studies were included in the review: 16 RCTs, two non-RCTs, one partially randomised trial which contained two randomised intervention arms and one non-randomised control arm, two CBA studies and one quasi randomised controlled trial. Seventeen studies provided interventions comprising parenting education and other support services; 15 of which were home visiting programmes and two of which were paediatric practice-based interventions. Two provided solely educational interventions. Nineteen studies recruited families who were from socio-economically disadvantaged populations, were at risk of adverse child outcomes or people who may benefit from extra support, such as single mothers, teenage mothers, first time mothers and mothers with learning difficulties. Ten RCTs involving 5074 participants were included in the meta-analysis, which indicated that intervention families had a statistically significant lower risk of injury than control families (RR 0.83, 95% CI 0.73 to 0.94). Sensitivity analyses undertaken including only RCTs at low risk of various sources of bias found the findings to be robust to including only those studies at low risk of detection bias in terms of blinded outcome assessment and attrition bias in terms of follow up of fewer than 80% of participants in each arm. When analyses were restricted to studies at low risk of selection bias in terms of inadequate allocation concealment the effect size was no longer statistically significant. Several studies found statistically significant fewer home hazards or a greater number of safety practices in intervention families. Of ten studies reporting scores on the HOME scale, data from three RCTs were included in a meta-analysis which found no evidence of a difference in quality of the home environment between treatment arms (mean difference 0.57, 95% CI -0.59 to 1.72). Most of the studies reporting home safety practices, home hazards or composite home safety scores found statistically significant effects favouring intervention arm families. Overall, using GRADE, the quality of the evidence was rated as moderate.

AUTHORS' CONCLUSIONS

Parenting interventions, most commonly provided within the home using multi-faceted interventions are effective in reducing child injury. There is fairly consistent evidence that they also improve home safety. The evidence relates mainly to interventions provided to families from disadvantaged populations, who are at risk of adverse child health outcomes or whose families may benefit from extra support. Further research is required to explore mechanisms by which these interventions may reduce injury, the features of parenting interventions that are necessary or sufficient to reduce injury and the generalisability to different population groups.

Role of a poison center in reducing unintentional childhood ingestion by targeting pre-event risk factors

OBJECTIVES

Unintentional poisoning is a frequent presentation in the pediatric emergency care settings. We sought to determine the current incidence of unintentional poison ingestions in children who present to the emergency care in the city of Al Ain in United Arab Emirates, to create a profile of the products ingested, and to compare our data with a previous study conducted before the inception of a poison and drug information center.

METHODS

We reviewed all cases of unintentional poisoning in children 10 years or younger, who presented at 2 tertiary level emergency care centers during January-December 2010. Two hundred cases met our inclusion criteria. Data on demographics, type and amount of noxious substance ingested, time of presentation, and outcomes were collected. Annual incidence was estimated, and data were compared with the previous study.

RESULTS

The annual incidence of unintentional poisoning in the UAE is 2.35 per 1000 children 10 years or younger. The incidence is decreasing, especially for household chemical ingestions. The incidence is twice as high among native Emirati children compared with expatriate children. There was an increase in cosmetics- and synthetic hormone-related poisonings, as well as in the involvement of younger infants.

CONCLUSIONS

The incidence of unintentional pediatric poisoning in the UAE is decreasing particularly in household chemical ingestions. Targeted health promotion campaigns by the poison center may have led to this drop. The sociological, environmental, and cultural factors that might be contributing to the greater use of emergency care in native children should be investigated.

The First-aid Advice and Safety Training (FAST) parents programme for the prevention of unintentional injuries in preschool children: a protocol

BACKGROUND

Unintentional injury is the leading cause of preventable death in children in the UK, and 0-4-year-olds frequently attend emergency departments following injuries in the home. Parenting programmes designed to support parents, promote behaviour change and enhance parent-child relationships have been shown to improve health outcomes in children. It is not known whether group-based parenting programmes have the potential to prevent unintentional injuries in preschool children.

METHODS

A study to develop a group-based parenting programme to prevent unintentional home injuries in preschool children, and assess the feasibility of evaluation through a cluster-randomised controlled trial. The intervention, designed for parents of children who have sustained a medically attended injury, will be developed with two voluntary sector organisations. The feasibility study will assess ability to recruit parents, deliver the programme and follow-up participants. Participants will complete questionnaires at baseline, 3 months and 6 months, and report injuries in their preschool children using a tool designed and validated for this study. Qualitative methods will assess user and deliverer perceptions of the programme.

DISCUSSION

This study will develop the first group-based parenting programme to prevent injuries in preschool children, and design tools for parent-reported injury outcomes. A key challenge will be to recruit parents to participate in a manner that is non-stigmatising, and does not result in feelings of guilt or belief that they are perceived to be a bad parent. The findings will be used to prepare a trial to assess the effectiveness and cost-effectiveness of the intervention.

Home safety education and provision of safety equipment for injury prevention

BACKGROUND

In industrialised countries injuries (including burns, poisoning or drowning) are the leading cause of childhood death and steep social gradients exist in child injury mortality and morbidity. The majority of injuries in pre-school children occur at home but there is little meta-analytic evidence that child home safety interventions reduce injury rates or improve a range of safety practices, and little evidence on their effect by social group.

OBJECTIVES

We evaluated the effectiveness of home safety education, with or without the provision of low cost, discounted or free equipment (hereafter referred to as home safety interventions), in reducing child injury rates or increasing home safety practices and whether the effect varied by social group.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2009, Issue 2) in The Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Social Sciences Citation Index (SSCI), ISI Web of Science: Conference Proceedings Citation Index- Science (CPCI-S), CINAHL (EBSCO) and DARE (2009, Issue 2) in The Cochrane Library. We also searched websites and conference proceedings and searched the bibliographies of relevant studies and previously published reviews. We contacted authors of included studies as well as relevant organisations. The most recent search for trials was May 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs), non-randomised controlled trials and controlled before and after (CBA) studies where home safety education with or without the provision of safety equipment was provided to those aged 19 years and under, and which reported injury, safety practices or possession of safety equipment.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. We attempted to obtain individual participant level data (IPD) for all included studies and summary data and IPD were simultaneously combined in meta-regressions by social and demographic variables. Pooled incidence rate ratios (IRR) were calculated for injuries which occurred during the studies, and pooled odds ratios were calculated for the uptake of safety equipment or safety practices, with 95% confidence intervals.

MAIN RESULTS

Ninety-eight studies, involving 2,605,044 people, are included in this review. Fifty-four studies involving 812,705 people were comparable enough to be included in at least one meta-analysis. Thirty-five (65%) studies were RCTs. Nineteen (35%) of the studies included in the meta-analysis provided IPD.There was a lack of evidence that home safety interventions reduced rates of thermal injuries or poisoning. There was some evidence that interventions may reduce injury rates after adjusting CBA studies for baseline injury rates (IRR 0.89, 95% CI 0.78 to 1.01). Greater reductions in injury rates were found for interventions delivered in the home (IRR 0.75, 95% CI 0.62 to 0.91), and for those interventions not providing safety equipment (IRR 0.78, 95% CI 0.66 to 0.92).Home safety interventions were effective in increasing the proportion of families with safe hot tap water temperatures (OR 1.41, 95% CI 1.07 to 1.86), functional smoke alarms (OR 1.81, 95% CI 1.30 to 2.52), a fire escape plan (OR 2.01, 95% CI 1.45 to 2.77), storing medicines (OR 1.53, 95% CI 1.27 to 1.84) and cleaning products (OR 1.55, 95% CI 1.22 to 1.96) out of reach, having syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.44) or poison control centre numbers accessible (OR 3.30, 95% CI 1.70 to 6.39), having fitted stair gates (OR 1.61, 95% CI 1.19 to 2.17), and having socket covers on unused sockets (OR 2.69, 95% CI 1.46 to 4.96).Interventions providing free, low cost or discounted safety equipment appeared to be more effective in improving some safety practices than those interventions not doing so. There was no consistent evidence that interventions were less effective in families whose children were at greater risk of injury.

AUTHORS' CONCLUSIONS

Home safety interventions most commonly provided as one-to-one, face-to-face education, especially with the provision of safety equipment, are effective in increasing a range of safety practices. There is some evidence that such interventions may reduce injury rates, particularly where interventions are provided at home. Conflicting findings regarding interventions providing safety equipment on safety practices and injury outcomes are likely to be explained by two large studies; one clinic-based study provided equipment but did not reduce injury rates and one school-based study did not provide equipment but did demonstrate a significant reduction in injury rates. There was no consistent evidence that home safety education, with or without the provision of safety equipment, was less effective in those participants at greater risk of injury. Further studies are still required to confirm these findings with respect to injury rates.

Theory! The missing link in understanding the performance of neonate/infant home-visiting programs to prevent child maltreatment: a systematic review

CONTEXT

Home-visiting programs have been offered for more than sixty years to at-risk families of newborns and infants. But despite decades of experience with program delivery, more than sixty published controlled trials, and more than thirty published literature reviews, there is still uncertainty surrounding the performance of these programs. Our particular interest was the performance of home visiting in reducing child maltreatment.

METHODS

We developed a program logic framework to assist in understanding the neonate/infant home-visiting literature, identified through a systematic literature review. We tested whether success could be explained by the logic model using descriptive synthesis and statistical analysis.

FINDINGS

Having a stated objective of reducing child maltreatment-a theory or mechanism of change underpinning the home-visiting program consistent with the target population and their needs and program components that can deliver against the nominated theory of change-considerably increased the chance of success. We found that only seven of fifty-three programs demonstrated such consistency, all of which had a statistically significant positive outcome, whereas of the fifteen that had no match, none was successful. Programs with a partial match had an intermediate success rate. The relationship between program success and full, partial or no match was statistically significant.

CONCLUSIONS

Employing a theory-driven approach provides a new way of understanding the disparate performance of neonate/infant home-visiting programs. Employing a similar theory-driven approach could also prove useful in the review of other programs that embody a diverse set of characteristics and may apply to diverse populations and settings. A program logic framework provides a rigorous approach to deriving policy-relevant meaning from effectiveness evidence of complex programs. For neonate/infant home-visiting programs, it means that in developing these programs, attention to consistency of objectives, theory of change, target population, and program components is critical.

Childhood unintentional injuries: need for a community-based home injury risk assessments in pakistan

Background. A substantial proportion of the annual 875,000 childhood unintentional injury deaths occur in the home. Very few printed tools are available in South Asia for disseminating home injury prevention information. Methods. Three tools were planned: an injury hazard assessment tool appropriate for a developing country setting, an educational pamphlet highlighting strategies for reducing home injury hazards, and an in-home safety tutorial program to be delivered by a trained community health worker. Results. The three tools were successfully developed. Two intervention neighborhoods in Karachi, Pakistan, were mapped. The tools were pretested in this local setting and are now ready for pilot testing in an intervention study. Conclusion. Planning for an innovative, community-based pilot study takes considerable time and effort in a low-income setting like Pakistan. The primary outcome of the pre-testing phase of the study was the development of three important tools geared for low-income housing communities in Pakistan.

Home visits during pregnancy and after birth for women with an alcohol or drug problem

BACKGROUND

One potential method of improving outcome for pregnant or postpartum women with a drug or alcohol problem is with home visits.

OBJECTIVES

To determine the effects of home visits during pregnancy and/or after birth for women with a drug or alcohol problem.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011), CENTRAL (The Cochrane Library 2011, Issue 4 of 4), MEDLINE (1966 to 30 November 2011), EMBASE (1980 to 30 November 2011), CINAHL (1982 to 30 November 2011) and PsycINFO (1974 to 30 November 2011) supplemented by searches of citations from previous reviews and trials and contact with experts.

SELECTION CRITERIA

Studies using random or quasi-random allocation of pregnant or postpartum women with a drug or alcohol problem to home visits. Trials enrolling high-risk women of whom more than 50% were reported to use drugs or alcohol were also eligible.

DATA COLLECTION AND ANALYSIS

Review authors performed assessments of trials independently. We performed statistical analyses using fixed-effect and random-effects models where appropriate.

MAIN RESULTS

Seven studies (reporting 803 mother-infant pairs) compared home visits mostly after birth with no home visits. Visitors included community health nurses, paediatric nurses, trained counsellors, paraprofessional advocates, midwives and lay African-American women. Several studies had significant methodological limitations. There was no significant difference in continued illicit drug use (three studies, 384 women; risk ratio (RR) 1.05, 95% confidence interval (CI) 0.89 to 1.24), continued alcohol use (three studies, 379 women; RR 1.18, 95% CI 0.96 to 1.46), failure to enrol in a drug treatment program (two studies, 211 women; RR 0.45, 95% CI 0.10 to 1.94), not breastfeeding at six months (two studies, 260 infants; RR 0.95, 95% CI 0.83 to 1.10), incomplete six-month infant vaccination schedule (two studies, 260 infants; RR 1.09, 95% CI 0.91 to 1.32), the Bayley Mental Development Index (three studies, 199 infants; mean difference 2.89, 95% CI -1.17 to 6.95) or Psychomotor Index (MD 3.14, 95% CI -0.03 to 6.32), child behavioural problems (RR 0.46, 95% CI 0.21 to 1.01), infants not in care of biological mother (two studies, 254 infants; RR 0.83, 95% CI 0.50 to 1.39), non-accidental injury and non-voluntary foster care (two studies, 254 infants; RR 0.16, 95% CI 0.02 to 1.23) or infant death (three studies, 288 infants; RR 0.70, 95% CI 0.12 to 4.16). Individual studies reported a significant reduction in involvement with child protective services (RR 0.38, 95% CI 0.20 to 0.74) and failure to use postpartum contraception (RR 0.41, 95% CI 0.20 to 0.82).

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend the routine use of home visits for pregnant or postpartum women with a drug or alcohol problem. Further large, high-quality trials are needed.

Mothers' AdvocateS In the Community (MOSAIC)--non-professional mentor support to reduce intimate partner violence and depression in mothers: a cluster randomised trial in primary care

BACKGROUND

Effective interventions to increase safety and wellbeing of mothers experiencing intimate partner violence (IPV) are scarce. As much attention is focussed on professional intervention, this study aimed to determine the effectiveness of non-professional mentor support in reducing IPV and depression among pregnant and recent mothers experiencing, or at risk of IPV.

METHODS

MOSAIC was a cluster randomised trial in 106 primary care (maternal and child health nurse and general practitioner) clinics in Melbourne, Australia. 63/106 clinics referred 215 eligible culturally and linguistically diverse women between January 2006 and December 2007. 167 in the intervention (I) arm, and 91 in the comparison (C) arm. 174 (80.9%) were recruited. 133 (76.4%) women (90 I and 43 C) completed follow-up at 12 months.

INTERVENTION

12 months of weekly home visiting from trained and supervised local mothers, (English & Vietnamese speaking) offering non-professional befriending, advocacy, parenting support and referrals.

MAIN OUTCOME MEASURES

Primary outcomes; IPV (Composite Abuse Scale CAS) and depression (Edinburgh Postnatal Depression Scale EPDS); secondary measures included wellbeing (SF-36), parenting stress (PSI-SF) and social support (MOS-SF) at baseline and follow-up.

ANALYSIS

Intention-to-treat using multivariable logistic regression and propensity scoring.

RESULTS

There was evidence of a true difference in mean abuse scores at follow-up in the intervention compared with the comparison arm (15.9 vs 21.8, AdjDiff -8.67, CI -16.2 to -1.15). There was weak evidence for other outcomes, but a trend was evident favouring the intervention: proportions of women with CAS scores ≥ 7, 51/88 (58.4%) vs 27/42 (64.3%) AdjOR 0.47, CI 0.21 to 1.05); depression (EPDS score ≥ 13) (19/85, 22% (I) vs 14/43, 33% (C); AdjOR 0.42, CI 0.17 to 1.06); physical wellbeing mean scores (PCS-SF36: AdjDiff 2.79; CI -0.40 to 5.99); mental wellbeing mean scores (MCS-SF36: AdjDiff 2.26; CI -1.48 to 6.00). There was no observed effect on parenting stress. 82% of women mentored would recommend mentors to friends in similar situations.

CONCLUSION

Non-professional mentor mother support appears promising for improving safety and enhancing physical and mental wellbeing among mothers experiencing intimate partner violence referred from primary care.

TRIAL REGISTRATION

ACTRN12607000010493http://www.anzctr.org.au.

Determination of Infant-Safe Homes in a Community Injury Prevention Program

BACKGROUND

The home is the most common site of childhood injury. To address this problem, Orange County Emergency Management developed the novel "Welcome to the World" program to provide paramedic-delivered home safety inspections and interventions to improve early childhood safety.

OBJECTIVES

To determine the prevalence of infant-safe homes and to examine differences in home infant safety based on the number of children in the home.

METHODS

Paramedics visited households with newborns or expectant mothers for a home visit at their request. Each visit included a home safety inspection, correction of certain safety practices, one-on-one teaching of injury prevention topics, and distribution of educational materials and safety devices. A retrospective analysis of data recorded during these visits included criteria used in defining an infant-safe home, including 1) presence of a functioning smoke detector, 2) bathwater temperature measured < 120 degrees F, 3) correct crib slat spacing, and 4) presence of a car seat.

RESULTS

Paramedics conducted 110 home visits, of which 57% were first-time parents. Only 33% (n = 10) of multiple-child homes and 38% (n = 14) of one-child homes were defined as infant safe by meeting all four criteria.

CONCLUSIONS

An alarmingly low number of homes were infant safe (n = 24) and the number of children in the home did not seem to affect home safety. Further research is needed to determine the efficacy of the "Welcome to the World" program.

Interventions to prevent child maltreatment and associated impairment

Although a broad range of programmes for prevention of child maltreatment exist, the effectiveness of most of the programmes is unknown. Two specific home-visiting programmes-the Nurse-Family Partnership (best evidence) and Early Start-have been shown to prevent child maltreatment and associated outcomes such as injuries. One population-level parenting programme has shown benefits, but requires further assessment and replication. Additional in-hospital and clinic strategies show promise in preventing physical abuse and neglect. However, whether school-based educational programmes prevent child sexual abuse is unknown, and there are currently no known approaches to prevent emotional abuse or exposure to intimate-partner violence. A specific parent-training programme has shown benefits in preventing recurrence of physical abuse; no intervention has yet been shown to be effective in preventing recurrence of neglect. A few interventions for neglected children and mother-child therapy for families with intimate-partner violence show promise in improving behavioural outcomes. Cognitive-behavioural therapy for sexually abused children with symptoms of post-traumatic stress shows the best evidence for reduction in mental-health conditions. For maltreated children, foster care placement can lead to benefits compared with young people who remain at home or those who reunify from foster care; enhanced foster care shows benefits for children. Future research should ensure that interventions are assessed in controlled trials, using actual outcomes of maltreatment and associated health measures.

The impact of a home visitation programme on household hazards associated with unintentional childhood injuries: a randomised controlled trial

BACKGROUND

The continued high mortality and morbidity rates for unintentional childhood injuries remain a public health concern. This article reports on the influence of a home visitation programme (HVP) on household hazards associated with unintentional childhood injuries in a South African low-income setting.

METHODS

A randomised controlled trial (n=211 households) was conducted in a South African informal settlement. Community members were recruited and trained as paraprofessional visitors. Four intervention visits were conducted over 3 months, focusing on child development, and the prevention of burn, poison, and fall injuries. The HVP, a multi-component intervention, included educational inputs, provision of safety devices, and an implicit enforcement strategy. The intervention effect (IE) was measured with a standardised risk assessment index that compared post-intervention scores for intervention and control households.

RESULTS

A significant reduction was observed in the hazards associated with electrical and paraffin appliances, as well as in hazards related to poisoning. Non-significant changes were observed for burn safety household practices and fall injury hazards.

CONCLUSIONS

This study confirmed that a multi-component HVP effectively reduced household hazards associated with electrical and paraffin appliances and poisoning among children in a low-income South African setting.

An examination of interventions to reduce respiratory health and injury hazards in homes of low-income families

We evaluated whether combining asthma trigger reduction with housing structural repairs, device disbursement and education in low-income households with children would improve self-reported respiratory health and reduce housing-related respiratory health and injury hazards (convenience sample of n=67 homes with 63 asthmatic and 121 non-asthmatic children). At baseline, a visual assessment of the home environment and a structured occupant interview were used to examine 29 potential injury hazards and 7 potential respiratory health hazards. A home-specific intervention was designed to provide the children's parents or caretakers with the knowledge, skills, motivation, supplies, equipment, and minimum housing conditions necessary for a healthy and safe home. The enrolled households were primarily Hispanic and owned their homes. On average, 8 injury hazards were observed in the homes at baseline. Four months following intervention, the average declined to 2.2 hazards per home (p<0.001), with 97% of the parents reporting that their homes were safer following the interventions. An average of 3.3 respiratory health hazards were observed in the homes at baseline. Four months following intervention, the average declined to 0.9 hazards per home (p<0.001), with 96% of parents reporting that the respiratory health of their asthmatic children improved. A tailored healthy homes improvement package significantly improves self-reported respiratory health and safety, reduces respiratory health and injury hazards, and can be implemented in concert with a mobile clinical setting.

Preventing childhood falls at home: meta-analysis and meta-regression

BACKGROUND

Childhood falls are an important global public health problem, but evidence on their prevention has not been quantitatively synthesized. Despite social inequalities in childhood injury rates, there is a lack of evidence examining the effect of fall-prevention practices by social group.

METHODS

A systematic review of literature was conducted up to June 2004 and meta-analysis using individual patient data to evaluate the effect of home-safety interventions on fall-prevention practices and fall-injury rates. Meta-regression examined the effect of interventions by child age, gender, and social variables. Included were 21 studies, 13 of which contributed to meta-analyses.

RESULTS

Home-safety interventions increased stair-gate use (OR=1.26; 95% CI=1.05, 1.51), and there was some evidence of reduced baby-walker use (OR=0.66; 95% CI=0.43, 1.00), but little evidence of increased possession of window locks, screens, or windows with limited opening (OR=1.16, 95% CI=0.84, 1.59) or of nonslip bath mats or decals (OR=1.15; 95% CI=0.51, 2.62). Two studies reported nonsignificant effects on falls (baby-walker-related falls on flat ground [OR=1.35; 95% CI=0.64, 2.83] or down steps or stairs [OR=0.70; 95% CI=0.14, 3.49]) and medically attended falls (OR=0.78; 95% CI=0.61, 1.00).

CONCLUSIONS

Home-safety education and the provision of safety equipment improved some fall-prevention practices, but the impact on fall-injury rates is unclear. There was some evidence that the effect of home-safety interventions varied by social group.

Parenting interventions and the prevention of unintentional injuries in childhood: systematic review and meta-analysis

OBJECTIVES

To evaluate the effectiveness of parenting interventions in preventing unintentional injury and increasing parental safety practices.

DATA SOURCES

A range of medical and social science electronic databases were searched. Abstracts from the first to seventh World conferences on injury prevention and control and the journal Injury Prevention were hand searched.

REVIEW METHODS

Randomized controlled trials (RCTs), non-randomized controlled trials (non-RCTs) and controlled before and after studies, providing parenting interventions to parents of children aged 0-18 years and reporting injuries, safety equipment or safety practices were included. Studies were selected, data extracted and quality appraised independently by two reviewers. Pooled relative risks were estimated using random effect models.

RESULTS

Fifteen studies (11 RCTs) were included, 11 of which were home visiting programmes and two of which were paediatric practice-based interventions. Thirteen studies recruited families at risk of adverse child health outcomes. Intervention arm families had a significantly lower risk of injury (RR 0.82, 95% CI 0.71-0.95), as measured by self-report of medically or non-medically attended injury. Several studies found fewer home hazards, a home environment more conducive to child safety, or a greater number of safety practices in intervention arm families.

CONCLUSIONS

Parenting interventions, most commonly provided within the home, using multi-faceted interventions appear to be effective in reducing unintentional child injury. Further research is required to explore the mechanisms by which parenting interventions reduce injury, the features of interventions that are necessary to reduce injury, and their generalizability to different population groups.

The evidenced-based care behind the early management of head injured children

Trauma remains the highest cause of death in children over the age of 1. Head injury accounts for the highest mortality. There is much information on the treatment of head injuries and indications for CT scanning. This review aims to summarise the key differences between paediatric and adult victims of trauma and outline the key steps in management of head injured children, from prevention through to who should have a CT scan and initial management in the emergency department (ED) if transfer is required to a PICU or neurosurgical unit. Information is also provided on recommendations for follow up of children who do not require PICU or neurosurgical care.

WITHDRAWN: Home-based support for disadvantaged adult mothers

BACKGROUND

Babies born to socio-economically disadvantaged mothers are at higher risk of a range of problems in infancy. Home visiting programs are thought to improve outcomes, both for mothers and children, largely through advice and support.

OBJECTIVES

To assess the effectiveness of home visiting programmes for women who have recently given birth and who are socially or economically disadvantaged.

SEARCH STRATEGY

We searched the following electronic databases: The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 3, 2006); MEDLINE (1966 to March 2006); EMBASE (1980 to 2006 week 12); CINAHL (1982 to March week 4 2006); PsycINFO (1872 to March week 4 2006); ASSIA (1987 to March 2006); LILACS (1982 to March 2006); and Sociological Abstracts(1963 to March 2006). We searched grey literature using ZETOC (1993 to March 2006); Dissertation Abstracts International (late 1960s to 2006); and SIGLE (1980 to March 2006). We also undertook communication with published authors about ongoing or unpublished research.

SELECTION CRITERIA

Included studies were randomised controlled trials investigating the efficacy of home visiting directed at disadvantaged adult mothers.

DATA COLLECTION AND ANALYSIS

Two reviewers (EC and JP or CB) independently assessed titles and abstracts identified in the search for eligibility. Data were extracted and entered into RevMan (EC, JP and CB), synthesised and presented in both written and graphical form (forest plots). Outcomes included in this review were established at the protocol stage by an international steering group. The review does not report on all outcomes reported in included studies.

MAIN RESULTS

We included 11 studies with 4751 participants in this review. Data show no statistically significant differences for those receiving home visiting, either for maternal outcomes (maternal depression, anxiety, the stress associated with parenting, parenting skills, child abuse risk or potential or breastfeeding) or child outcomes (preventive health care visits, psychosocial health, language development, behaviour problems or accidental injuries. Evidence about uptake of immunisations is mixed, and the data on child maltreatment difficult to interpret.

AUTHORS' CONCLUSIONS

This review suggests that for disadvantaged adult women and their children, there is currently no evidence to support the adoption of home visiting as a means of improving maternal psychosocial health, parenting or outcomes for children. For reasons discussed in the review, this does not amount to a conclusion that home visiting programmes are ineffective, but indicates a need to think carefully about the problems that home visiting might influence, and improvements in the conduct of outcome studies in this area.

WITHDRAWN: Home-based support for disadvantaged teenage mothers

BACKGROUND

Babies born to socio-economically disadvantaged mothers are at higher risk of injury, abuse or neglect and health problems than babies born to more affluent mothers; disadvantaged teenage mothers are at particular risk of adverse outcomes. Home-visiting programs are thought to improve outcomes for both mothers and children, largely through advice and support.

OBJECTIVES

To assess the effectiveness of home-visiting programmes for women who have recently given birth and who are socially or economically disadvantaged.

SEARCH STRATEGY

The following electronic databases were searched: CENTRAL (2006, Issue 3); MEDLINE (1966 to March 2006); EMBASE (1980 to week 12 2006); CINAHL (1982 to March week 4 2006); PsycINFO (1872 to March week 4 2006); ASSIA (1987 to March 2006); LILACS (1982 to March 2006); and Sociological Abstracts (1963 to March 2006). Grey literature was also be searched using ZETOC (1993 to March 2006); Dissertation Abstracts International (late 1960s to 2006); and SIGLE (1980 to March 2006). Communication with published authors about ongoing or unpublished research was also undertaken.

SELECTION CRITERIA

Included studies were randomised controlled trials investigating the efficacy of home visiting directed at teenage mothers.

DATA COLLECTION AND ANALYSIS

Titles and abstracts identified in the search were independently assessed for eligibility by two review authors (EC and JP or CB). Data were extracted and entered into RevMan (EC, JP and CB), synthesised and presented in both written and graphical form (forest plots). Outcomes included in this review were established at the protocol stage by an international steering group. The review did not report on all outcomes reported in included studies.

MAIN RESULTS

Five studies with 1838 participants were included in this review. Data from single studies provided support for the effectiveness of home visiting on some outcomes, but the evidence overall provided only limited support for the effectiveness of home visiting as a means of improving the range of maternal and child outcomes considered in this review.

AUTHORS' CONCLUSIONS

This review suggests there is only limited evidence that home-visiting programmes of the kind described in this review can impact positively on the quality of parenting of teenage mothers or on child development outcomes for their offspring. For reasons discussed in the review, this does not amount to a conclusion that home-visiting programmes are ineffective but indicates a need to think carefully about the problems that home visiting might influence and about improvements in the conduct and reporting of outcome studies in this area.

Welcome to the world: findings from an emergency medical services pediatric injury prevention program

BACKGROUND

Unintentional injuries are the most common cause of morbidity and mortality in young children, and most injuries occur in the home.

OBJECTIVES

To report findings from a primary prevention program that trained paramedics to conduct home safety surveys, provide family safety education, and identify common pediatric injury risks in the home.

METHODS

We retrospectively reviewed standardized records from each survey, abstracting information on family demographics, safety devices and practices, and provision of educational materials and safety equipment. We descriptively analyzed and reported statistics as means and percent frequencies.

RESULTS

Two-hundred sixty-two families participated and had children averaging 21 months of age. Ninety-eight percent (250/255) had a smoke detector, and 65% (140/215) had a fire extinguisher, with 77% (192/250) and 76% (107/140) of these respective devices functional. Twenty-seven percent (55/202) had a fire evacuation plan, and 33% (18/55) reported ever practicing their plan. For bathwater sites, 56% had temperatures measured less than 120 degrees F. Eighty-five percent (218/257) had medications, and 53% (134/249) had household chemicals out of reach of children, but most reported storage in an unlocked location. Eighty-five percent (42/49) reported storing guns unloaded, and 45% (22/49) stored all guns in locked locations. Paramedics distributed 63 smoke detectors, 46 fire extinguisher vouchers, 234 first-aid kits, and 225 educational packets.

CONCLUSIONS

Participating families had high rates of fire/burn hazards and unsafe storage practices. Paramedics can recognize common hazards in the home, can provide education and mitigation to reduce risks of pediatric injury, and can distribute home safety devices in a community injury prevention program.

Home safety in inner cities: prevalence and feasibility of home safety-product use in inner-city housing

OBJECTIVES

Residential injuries cause significant morbidity and mortality in infants and young children. The American Academy of Pediatrics recommends initiating injury-prevention counseling during health supervision visits in the first 6 months of life. The objectives of this study were to describe and compare self-reported and observed home safety practices in urban, low-income families who were expecting or had a child <12 months old and to assess the feasibility of using safety products depending on the design and repair of urban homes.

PARTICIPANTS AND METHODS

Women who were pregnant or had an infant <12 months old and who were enrolled in East Baltimore's Healthy Start home-visiting program were eligible for the study. For this pilot project, we used a prospective predesign/postdesign. Maternal self-report and investigator home observations documented the use of working smoke alarms on each level of the home, stair gates or doors blocking the top and bottom of all staircases, adult medication storage in locked cabinets, and the environmental feasibility of safety-product use.

RESULTS

Home safety practices were higher by maternal self-report than by investigator observation. Fifty-five percent of families who reported a working smoke alarm on every level of the home had nonworking or absent smoke alarms noted during investigator observation. Of assessed staircases, 67% could not accommodate a wall-mounted gate at the top of the stairs, and 38% could not accommodate a pressure-mounted gate at the bottom of the stairs. Although most families reported locked storage of medications, 77% had unlocked medication storage documented during home observation.

CONCLUSIONS

In this sample of urban families, implementation of American Academy of Pediatrics-recommended safety practices is low. The structural design of urban homes may be a significant barrier to home safety-product use. The American Academy of Pediatrics Injury Prevention Program sheets, manufacturers of safety products, and legislators need to address injury-prevention issues unique to urban, low-income families.

Home-based support for disadvantaged adult mothers

BACKGROUND

Babies born to socio-economically disadvantaged mothers are at higher risk of a range of problems in infancy. Home visiting programs are thought to improve outcomes, both for mothers and children, largely through advice and support.

OBJECTIVES

To assess the effectiveness of home visiting programmes for women who have recently given birth and who are socially or economically disadvantaged.

SEARCH STRATEGY

We searched the following electronic databases: The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 3, 2006); MEDLINE (1966 to March 2006); EMBASE (1980 to 2006 week 12); CINAHL (1982 to March week 4 2006); PsycINFO (1872 to March week 4 2006); ASSIA (1987 to March 2006); LILACS (1982 to March 2006); and Sociological Abstracts(1963 to March 2006). We searched grey literature using ZETOC (1993 to March 2006); Dissertation Abstracts International (late 1960s to 2006); and SIGLE (1980 to March 2006). We also undertook communication with published authors about ongoing or unpublished research.

SELECTION CRITERIA

Included studies were randomised controlled trials investigating the efficacy of home visiting directed at disadvantaged adult mothers.

DATA COLLECTION AND ANALYSIS

Two reviewers (EC and JP or CB) independently assessed titles and abstracts identified in the search for eligibility. Data were extracted and entered into RevMan (EC, JP and CB), synthesised and presented in both written and graphical form (forest plots). Outcomes included in this review were established at the protocol stage by an international steering group. The review does not report on all outcomes reported in included studies.

MAIN RESULTS

We included 11 studies with 4751 participants in this review. Data show no statistically significant differences for those receiving home visiting, either for maternal outcomes (maternal depression, anxiety, the stress associated with parenting, parenting skills, child abuse risk or potential or breastfeeding) or child outcomes (preventive health care visits, psychosocial health, language development, behaviour problems or accidental injuries. Evidence about uptake of immunisations is mixed, and the data on child maltreatment difficult to interpret.

AUTHORS' CONCLUSIONS

This review suggests that for disadvantaged adult women and their children, there is currently no evidence to support the adoption of home visiting as a means of improving maternal psychosocial health, parenting or outcomes for children. For reasons discussed in the review, this does not amount to a conclusion that home visiting programmes are ineffective, but indicates a need to think carefully about the problems that home visiting might influence, and improvements in the conduct of outcome studies in this area.

Home-based support for disadvantaged teenage mothers

BACKGROUND

Babies born to socio-economically disadvantaged mothers are at higher risk of injury, abuse or neglect and health problems than babies born to more affluent mothers; disadvantaged teenage mothers are at particular risk of adverse outcomes. Home-visiting programs are thought to improve outcomes for both mothers and children, largely through advice and support.

OBJECTIVES

To assess the effectiveness of home-visiting programmes for women who have recently given birth and who are socially or economically disadvantaged.

SEARCH STRATEGY

The following electronic databases were searched: CENTRAL (2006, Issue 3); MEDLINE (1966 to March 2006); EMBASE (1980 to week 12 2006); CINAHL (1982 to March week 4 2006); PsycINFO (1872 to March week 4 2006); ASSIA (1987 to March 2006); LILACS (1982 to March 2006); and Sociological Abstracts (1963 to March 2006). Grey literature was also be searched using ZETOC (1993 to March 2006); Dissertation Abstracts International (late 1960s to 2006); and SIGLE (1980 to March 2006). Communication with published authors about ongoing or unpublished research was also undertaken.

SELECTION CRITERIA

Included studies were randomised controlled trials investigating the efficacy of home visiting directed at teenage mothers.

DATA COLLECTION AND ANALYSIS

Titles and abstracts identified in the search were independently assessed for eligibility by two review authors (EC and JP or CB). Data were extracted and entered into RevMan (EC, JP and CB), synthesised and presented in both written and graphical form (forest plots). Outcomes included in this review were established at the protocol stage by an international steering group. The review did not report on all outcomes reported in included studies.

MAIN RESULTS

Five studies with 1838 participants were included in this review. Data from single studies provided support for the effectiveness of home visiting on some outcomes, but the evidence overall provided only limited support for the effectiveness of home visiting as a means of improving the range of maternal and child outcomes considered in this review.

AUTHORS' CONCLUSIONS

This review suggests there is only limited evidence that home-visiting programmes of the kind described in this review can impact positively on the quality of parenting of teenage mothers or on child development outcomes for their offspring. For reasons discussed in the review, this does not amount to a conclusion that home-visiting programmes are ineffective but indicates a need to think carefully about the problems that home visiting might influence and about improvements in the conduct and reporting of outcome studies in this area.

Disparities in child abuse mortality are not explained by injury severity

BACKGROUND

Unadjusted abuse-related mortality has been demonstrated to be nearly 4-fold higher for African American (AA) children. Little is known about the etiology of this disparity. This study examines the importance of injury severity and initial presentation in explaining the observed disparity.

METHOD

Our trauma database was reviewed to identify all abused patients admitted over a 10-year period. Outcomes among white and AA children were compared with specific attention to injury severity scores and initial presentation. Logistic regression and Cox proportional hazard analyses were performed to evaluate the impact of race on outcome.

RESULTS

There were 443 abused children identified. Thirty-eight percent of the group was AA. The overall mortality was 7.7%; however, the AA mortality was significantly higher than white children (14.8% vs 3.3%; P < .05). After controlling for injury severity and physiology at presentation, the odds ratio of mortality for an AA child was 9.14 (95% confidence interval, 1.97-42.43). Survival analysis confirmed the disparity after revealing a hazard ratio of dying for AA children of 6.51 (95% confidence interval, 2.74-15.47) compared with white children.

CONCLUSION

Despite attempts to control for the clinical presentation and injury severity of abused children, significant differences in mortality persist between AA and white children.

Home safety education and provision of safety equipment for injury prevention

BACKGROUND

In industrialised countries injuries are the leading cause of childhood death and steep social gradients exist in child injury mortality and morbidity. The majority of injuries in pre-school children occur at home, but there is little meta-analytic evidence that child home safety interventions improve a range of safety practices or reduce injury rates and little evidence on their effect by social group.

OBJECTIVES

We evaluated the effectiveness of home safety education, with or without the provision of low cost, discounted or free equipment in increasing home safety practices or reducing child injury rates and whether the effect varied by social group.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, DARE, ASSIA, Psychinfo and Web of Science, plus a range of relevant web sites, conference proceedings and bibliographies. We contacted authors of included studies and surveyed a range of organisations.

SELECTION CRITERIA

Randomised controlled trials (RCTs), non-randomised controlled trials and controlled before and after studies where home safety education with or without the provision of safety equipment was provided to those aged 19 years and under, which reported safety practices, possession of safety equipment or injury.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. We attempted to obtain individual participant level data (IPD) for all included studies and summary data and IPD were simultaneoulsy combined in meta-regressions by social and demographic variables.

MAIN RESULTS

Eighty studies were included; 37 of which were included in at least one meta-analysis. Twenty-three (62%) were RCTs and 12 (32%) included in the meta-analysis provided IPD. Home safety education was effective in increasing the proportion of families with safe hot tap water temperatures (OR 1.35, 95% CI 1.01 to 180), functional smoke alarms (OR 1.85, 95% CI 1.24 to 2.75), storing medicines (OR 1.58, 95% CI 1.18 to 2.13) and cleaning products (OR 1.63, 95% CI 1.22 to 2.17) out of reach, syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.44) and poison control centre numbers accessible (OR 3.66, 95% CI 1.84 to 7.27), fitted stair gates (1.26, 95% CI 1.05 to 1.51), socket covers on unused sockets (OR 3.73, 95% CI 1.48 to 9.39) and storing sharp objects out of reach (OR 1.52, 95% CI 1.01 to 2.29). There was a lack of evidence that interventions reduced rates of thermal injuries, poisoning or a range of injuries. There was no consistent evidence that interventions were less effective in families whose children were at greater risk of injury.

AUTHORS' CONCLUSIONS

Home safety education provided most commonly as one-to-one, face-to-face education, in a clinical setting or at home, especially with the provision of safety equipment is effective in increasing a range of safety practices. There is a lack of evidence regarding its impact on child injury rates. There was no consistent evidence that home safety education, with or without the provision of safety equipment was less effective in those at greater risk of injury.

The role of health professionals in childhood injury prevention: a systematic review of the literature

OBJECTIVE

To systematically review the literature to explore health professionals' knowledge, attitudes and practices and their role in childhood injury prevention.

METHODS

MEDLINE (1966-September Week 1 2005), EMBASE (1980-2005 Week 37), CINAHL (1982-September Week 1 2005), BRITISH NURSING INDEX (1985-September 2005) and PsychINFO (1967-August Week 5 2005) were searched using relevant 'medical subheadings' (for MEDLINE, EMBASE and CINAHL) and 'thesaurus terms' (for PsychINFO).

RESULTS

Twenty-five primary studies were retrieved, the majority of which were surveys. Health professionals' knowledge was reported to be variable, although generally they have a positive attitude towards childhood injury prevention. Even with adequate knowledge and positive attitudes there appear to be barriers in prevention practice.

CONCLUSION

There continues to be a need for high quality research specifically looking at how to change practice. Nevertheless, although training may be effective at increasing health professionals' knowledge and changing their attitudes, legislative and engineering measures may ultimately more effective at reducing the burden of childhood injuries.

PRACTICE IMPLICATIONS

Barriers to practice for health professionals need to be taken into account. No matter how knowledgeable nor how positive their attitudes to childhood injury prevention if barriers to practice are not addressed we will move no closer to reducing the burden of injuries in childhood. Those health professionals who are positive about their role may be best suited to continue to raise the issue campaigning for legislative and engineering changes which can reduce childhood injuries.

Impact of intervention surveillance bias on analyses of child welfare report outcomes

Two studies using data from child maltreatment intervention outcome evaluations were conducted examining several aspects of surveillance bias, including directly measuring rates of surveillance reporting, comparing characteristics of surveillance versus nonsurveillance reports, examining differences across service types and doses, and testing how ignoring versus removing surveillance reports in the data affects survival analysis. The net effect of surveillance bias was small in the studies examined. Home-visiting services were not biased more than center-based services, and bias was not greater among intervention compared to prevention cases. Surveillance reports were equally as severe as nonsurveillance reports, failing to support the hypothesis that surveillance serves as early detection of less severe maltreatment. However, surveillance bias was far more substantial during time periods when participants were actively engaged in services. Therefore, the net impact of surveillance could vary with service engagement rates and the relative duration of service engagement and postservice follow-up times.

Trials and tribulations of protecting children from environmental hazards

Society is increasingly aware of the profound impact that the environment has on children's health. Not surprisingly, there is increasing public scrutiny about children's exposures to environmental hazards, especially for disadvantaged children. These trends underscore the ethical imperative to develop a framework to protect children from environmental hazards. Such a framework must include regulations to test new chemicals and other potential hazards before they are marketed, a strategy to conduct research necessary to protect children from persistent hazards that are widely dispersed in their environment, stronger regulatory mechanisms to eliminate human exposures to recognized or suspected toxicants, and guidelines about the ethical conduct of research and the role of experimental trials that test the efficacy and safety of interventions to prevent or ameliorate children's exposure to persistent toxicants or hazards that are widely dispersed in their environment.

From repression to prevention against violence: a challenge posed to civil society and the health sector

This article deals with the proposal of the Pan American Health Organization for the prevention of violence, following the precepts of the "World report on violence and health" of the WHO. In this analysis the authors distinguish the approach of public safety (generally based on repression) from the way public health approaches this issue, based on the traditional concepts that constitute its patrimony: promotion of health, prevention of physical and emotional injuries, and the strengthening of citizenship. The authors show that the health sector has already embraced the issue definitively but that even so the problem is still far from occupying the outstanding place it deserves in the public health agenda, together with other health problems of the contemporaneous populations of the world and the Americas. The text concludes establishing a link between prevention of violence and the Millennium development goals, which in principle urge society for taking action towards human rights, solidarity and quality of life.

Reaching an underserved population with a randomly assigned home safety intervention

OBJECTIVE

To access an underserved, mobile segment of a monolingual Spanish speaking population and to improve maternal self efficacy for home safety behaviors using a culturally appropriate intervention.

DESIGN

A pre- and post-test experimental design tested differences in maternal childhood injury health beliefs (MCIHB) and controllable safety hazards (CHS). Participants were randomly assigned to experimental and control groups. Baseline data assessed demographic and study variables comparability. The intervention included counseling, assessment of maternal safety practices, and provision of safety items.

SETTING

A non-urban area in Texas where low income, largely migrant Hispanics represent the majority of residents.

PARTICIPANTS

Eighty two mothers of 1--4 year old children.

RESULTS

The 95% retention rate of an itinerant, hard to reach population suggests that minority participants may be receptive to culturally appropriate home visits. The intervention group demonstrated improved self efficacy for home safety behaviors (F (2, 77)=7.50, p=0.01). Mothers with stronger self efficacy and fewer perceived barriers had fewer accessible in-home hazards. Observed home hazard predictors were: (a) never being married; (b) poor home repair, (c) lower self efficacy for safety behaviors; and (d) control group status.

CONCLUSIONS

Safety items coupled with a home visit tailored to child age and maternal culture was an effective intervention in a hard to reach population. This study contributes to designing research for a monolingual population with limited local language proficiency and community residency. Injuries represent a major source of health disparities in these neglected populations.

Rationales for home safety promotion in the Iranian primary healthcare system: results from a pilot study

OBJECTIVE

To analyse the prerequisites for a nationwide primary healthcare (PHC) home safety promotion programme in Iran.

BACKGROUND

Injury is a major public health problem throughout the world, currently accounting for one-seventh of all premature deaths and disabilities. Within 20 years, it is estimated that the proportion will increase to one-fifth. The present healthcare system in Iran was started in 1979, with a major focus on easy access to services and prevention. The system is based on the 'health house', which is run by community health workers. A survey shows that 36% of injuries occur in the home environment. A pilot phase of the Home Safety Promotion Programme was initiated in 1994, and included safety checking at home for fences, kitchens, drugs and poisons, heaters, electricity, and stairs and ladders. The pilot study covered 478,551 households out of the 12 million (approximately) in Iran. Sixty-nine supervisors were involved individually, assembled into eight focus groups.

RESULTS

Household safety increased by 10-20% over the 4 years of the study. The frequency of home visits changed from annual to seasonal, since all participants agreed that there were seasonal differences in safety problems. The supervisors showed a high level of knowledge of injury as a public health problem, and also positive attitudes towards doing something about safety on the basis of a PHC scheme. The role of a surveillance system was highlighted, and it was suggested that such a system should be added to the programme.

DISCUSSION AND CONCLUSION

Based on our preliminary findings, there were reasons to obtain a policy decision concerning a national programme for safety promotion before extending the pilot scheme to the whole country. A national safety programme was decided upon following completion of the pilot study. It includes a home-related-injury surveillance system that is mandatory in rural areas and voluntary in some cities.