Effects of improved access to safety counseling, products, and home visits on parents' safety practices: results of a randomized trial

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

Background

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

Methods

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

Results

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

Conclusion

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

Enhancing parental knowledge of childhood and adolescence safety: An interventional educational campaign

BACKGROUND

Safeguarding children and adolescents from unintentional injuries is a significant concern for parents and caregivers. With them staying more at home during the coronavirus disease 2019 pandemic, more educational tools and valid educational programs are warranted to improve parental knowledge and awareness about childhood and adolescences' safety. This study aims to explore the effectiveness of childhood and adolescence safety campaigns on parents' knowledge and attitude toward preventable injuries.

METHODS

This was a pre-post experimental study, in which the predesigned assessments were used as an evaluation tool before and after attending a childhood and adolescence safety campaign. The pre-post assessment question included questions to evaluate the socio-demographic status, followed by knowledge questions in line with the current childhood and adolescence safety campaign. The outcomes of interest were assessed before and after attending the campaign's stations.

RESULTS

Three hundred eight parents volunteered to participate in this study. Their knowledge score improved from 36.2 [standard deviation (SD) 17.7] to 79.3 (SD 15.6) after attending the Campaign (t value = 34.6, P < .001). Both, perceptions on the preventability of accidents and the parents' perceived usefulness of educational campaigns showed improvements, with (t value = 6.3, P < .001) and (t value = 3.097, P < .001), respectively.

CONCLUSION

The educational childhood and adolescence safety campaign for caregivers in Saudi Arabia resulted in a significant increase in the overall knowledge and attitudes toward childhood and adolescence's safety. As children and adolescents are currently staying at home more, additional educational tools and programs are warranted to promote safe practices among parents and caregivers.

Better safe than sorry: Evaluating the implementation process of a home-visitation intervention aimed at preventing unintentional childhood injuries in the hospital setting

Background

Child home injuries prevention interventions have rarely been implemented in hospitals. The SHABI program ("Keeping our Children Safe"; in Hebrew: "SHomrim Al BetIchut Yeladenu") recruits at-risk families arriving with child injury to the Emergency Department. Medical/nursing students conduct two home visits four months apart, providing safety equipment and guidance. One hundred thirty-five families had a first visit and 98 completed the second. Fifty percentage of families were ultra-Orthodox Jews, 11% Arab, and 28% had ≥3 preschool children. We investigated SHABI's implementation using the Consolidated Framework for Implementation Research (CFIR).

Methods

Between May 2018 and March 2021 SHABI was implemented in the Emergency Department of a hospital in Israel's northern periphery, an area with high child injury rates. The Implementation process was examined through Emergency Department medical records and tracking registries, hospital management, nurses', and home visitors' meetings notes (n = 9), and a research diary. Hospital's inner setting and SHABI's characteristics were evaluated through interviews with hospital management, nurses, and home visitors 8 months after baseline (n = 18). Home visitors' characteristics were evaluated through interviews, post-visit questionnaire on challenges encountered (n = 233), families' perceptions of SHABI and home visitors' skills through telephone interviews (n = 212); and home visitors awareness of dangers at home (n = 8) baseline and 8 months later. Qualitative data were analyzed through explanatory content analysis according to CFIR constructs. Quantitative data were analyzed using X2 and Wilcoxon test for dependent subgroups.

Results

Despite alignment between SHABI and the hospital's mission, structural hospital-community disconnect prevented implementation as planned, requiring adaptation and collaboration with the medical school to overcome this barrier. Recruitment was included in the initial patient triage process but was only partially successful. Medical/nursing students were recruited as home visitors, and following training proved competent. Children were a distraction during the visits, but home visitors developed strategies to overcome this.

Conclusions

Injury prevention programs in hospitals have significant benefits. Identifying implementation barriers and facilitators allowed implementers to make adaptations and cope with the innovative implementation setting. Models of cooperation between hospital, community and other clinical settings should be further examined.

Infant Injury Prevention Education for Pregnant Women Attending Antenatal Class: A Quasi-Experimental Study

It is important to educate caregivers in order to prevent infant injuries. However, there have been few studies on the effects of education on pregnant women. This study aimed to evaluate the effects of injury prevention group education on this group. Study participants were recruited from a group of pregnant mothers attending an antenatal class in Tokyo. Participants were assigned to either the intervention or control group based on the month in which they attended the existing antenatal class. Both groups received a leaflet on injury prevention, but only the intervention group received an additional short one-shot lecture. The implementation of each of the nine safety practices was assessed during home visits after childbirth. Of the 131 study participants (56 in the control group and 75 in the intervention group), 106 (80.9%) received home visits after birth. Mothers in the intervention group implemented three practices significantly more than those in the control group: Keep soft objects away from the baby's head (38.3% vs. 13.0%), Do not place your baby on a high surface (74.6% vs. 52.2%), and Use the baby carrier correctly (93.3% vs. 76.1%). In the future, we plan to follow up the participants to evaluate the program's long-term effects, and to continue to improve the program.

Poisoning exposure from non-pharmaceutical products in residents of structured living facilities

OBJECTIVE

The objectives of this study were to describe poisonings occurring in older or disabled patients residing in structured living facilities, identify risk factors, and propose preventive measures.

METHOD

This was a prospective and observational study, covering all cases of poisoning occurring in structured living facilities in the Brittany region of France. All calls were received at the Grand Ouest Poison Control Centre (PCC) of Angers and were recorded from 1 February 2019 to 31 January 2020. The clinical severity of the poisonings was assessed using the Poisoning Severity Score (PSS). Clinical severity was compared by univariate and multivariate analyses using the following dependent variables: PSS score < 2 and PSS ≥ 2.

RESULTS

This study included 158 residents with a median age of 83 years (5-116 years old). The average number of residents supervised by a member of the supervisory staff was 11 (+/-10.7). The substance ingested was a personal hygiene product or a cleaning product in 48% and 25% of cases, respectively. The most frequently ingested product was a bar of soap (n = 20). All moderate to severe cases (4.6%, n = 8 including one death) occurred in residents with dementia living in nursing homes for elderly patients, and 9% of residents required hospital treatment. In more than 50% of cases (n = 83), the product was provided by the facility and in 23% (n = 40), it was brought in by the family. Ingestion of a bar of soap or a product brought in by the family was significantly associated with higher poisoning severity (PSS ≥ 2). After adjustment for age, sex and the number of residents per supervisor, the severity of poisoning was significantly greater after ingestion of a bar of soap (OR = 12.33, CI95 [2.12, 71.63], p = 0.005).

CONCLUSION

Older adults residing in medical facilities who have a history of dementia and/or cognitive impairment are more at risk of non-medicinal product poisoning. Clinical severity and the hospitalisation rate were greater when bar soap was ingested.

Design and implementation of a multifaceted injury prevention intervention in Bedouin children in southern Israel

BACKGROUND

Child injury is prevalent in the Bedouin community of southern Israel, with higher injury rates compared with the general population. Bedouin children aged 0-4 were twice as likely as children from other population groups to suffer any injury, and for example, incidence of burns in Bedouin children was 0.91/1000 children, compared with 0.46/1000 in Jewish children.

METHODS

A multifaceted injury prevention intervention was developed based on best practice methods, culturally adapted and implemented in nine Bedouin towns in collaboration with local authorities. Intervention elements included a youth leadership scheme, workshops for mothers in maternal child health centres, home safety visits, a preschool intervention and a media campaign. Outcome assessment of change following home visits was conducted. Process evaluation included a survey of mothers and focus groups with youth participants.

RESULTS

High participation was demonstrated indicating acceptability of the programme. Assessment of home visits showed an improvement in the level of household safety between first and second visits, as measured by a checklist. Youth participants expressed satisfaction in the programme, which gave them confidence and practical tools.

CONCLUSION

A multifaceted intervention programme was conducted in the Bedouin community in southern Israel and found to be acceptable, with high participation levels. Collaboration between national and local authorities improved implementation, and multiple programmes in different settings enabled broad exposure to the programme.

A RCT Testing If a Storybook Can Teach Children About Home Safety

OBJECTIVE

Unintentional injuries are the leading cause of death for children under 19 years of age. For preschoolers, many injuries occur in the home. Addressing this issue, this study assessed if a storybook about home safety could be effective to increase preschoolers' safety knowledge and reduce their injury-risk behaviors.

METHODS

Applying a randomized controlled trial design, normally developing English speaking preschool children (3.5-5.5 years) in Southwestern Ontario Canada were randomly assigned to the control condition (a storybook about healthy eating, N = 30) or the intervention condition (a storybook about home hazards, N = 29). They read the assigned storybook with their mother for 4 weeks; time spent reading was tracked, and fidelity checks based on home visits were implemented.

RESULTS

Comparing postintervention knowledge, understanding score, and risk behaviors across groups revealed that children who received the intervention were able to identify more hazards, provide more comprehensive safety explanations, and demonstrate fewer risky behaviors compared with children in the control group (ηp2 = 0.13, 0.19, and 0.51, respectively), who showed no significant changes over time in safety knowledge, understanding, or risk behaviors. Compliance with reading the safety book and fidelity in how they did so were very good.

CONCLUSIONS

A storybook can be an effective resource for educating young children about home safety and reducing their hazard-directed risk behaviors.

Age in months and birth order in infant nonfatal injuries: A retrospective cohort study

Objective

To examine the age in months at which infants visited outpatient clinics or emergency rooms for the first time for nonfatal injuries and to identify risk factors for the occurrence of these injuries.

Study design

Retrospective cohort study.

Methods

We used a health insurance claims database in Japan. Infants born between April 2012 and December 2014 were identified and followed until 12 months of age. We identified their first visit to outpatient clinics or emergency rooms because of nonfatal injuries (wounds/fractures, foreign bodies, and burns). Cox regression analysis was used to examine the association of nonfatal injuries with infants’ sex, birth order, and parental age.

Results

We identified 46,431 eligible infants. Of these, 7606 (16.4%) were brought to an outpatient clinic or emergency room for nonfatal injuries within 12 months of birth. Of the 7,606, 21.7% were aged ≤4 months and 44.7% ​≤ ​7 months. First-born infants were more likely to have wounds/fractures and burns.

Conclusion

One-fifth of first nonfatal infant injuries occurred within 4 months of age. Healthcare providers should provide early education about injury prevention, especially to caregivers of first-born infants.

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Nonfatal injuries within first year of birth occurred in 16% of infants.

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22% of first injuries occurred within 4 months of birth.

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First-born infants were more likely to have wounds/fractures and burns.

Effect of lock boxes and education on safe storage of medications

BACKGROUND

Safe medication storage is a proven barrier to ingestions in the pediatric population, but caregivers are often unaware of the importance of safe storage practices or do not have a safe place to store medications. Caregivers may also not be fully aware that the patterns of opioid use and misuse have recently reached crisis levels. The objectives of this study were to define medication storage practices and knowledge of the opioid crisis of participants and to assess the effectiveness of an emergency department intervention on safe medication storage.

METHODS

This was a prospective interventional study of caregivers in an urban pediatric emergency department (ED) on safe medication storage and the opioid crisis. Questions assessed the caregivers' current perceptions and practices related to medication storage and disposal, and opioid crisis awareness. The intervention included verbal instruction about recommended safe storage methods and the opioid crisis, provision of a medication safety handout, and distribution of a medication lock box. A follow-up phone survey conducted 2 weeks later asked participants about use of and satisfaction with the lock box. Frequencies of safe storage behaviors were calculated, and the chi-square statistic was used to compare storage behavior after the intervention.

RESULTS

Fifty caregivers of 112 children were enrolled. Only 4% reported they currently stored medications in a locked or latched place. Thirty-eight percent reported their main barrier to storing medications safely was that they did not have a locked or latched storage location. Fifty percent were unaware of the opioid crisis. Ninety-two percent reported they would use a lock box if given one. Twenty-eight participants (56%) responded to the follow-up phone call survey 2 weeks later. At follow up 90% (25/28) reported they placed their medications within the provided lock box (p < 0.00001). Ninety-two percent reported being "very satisfied" with the lock box and how it works.

CONCLUSIONS

Despite widespread reporting on this issue, many caregivers remain unaware of safe medication storage practices and the opioid crisis. Providing medication lock boxes removes a commonly reported barrier to safely storing medications and improved reported practices.

Evaluation of a mobile safety center's impact on pediatric home safety knowledge and device use

Background

A Mobile Safety Center (MSC) is designed to remove financial accessibility barriers to home safety by providing education and safety devices within local communities. The objective of this study was to evaluate the impact of an MSC on pediatric home safety knowledge and device use.

Methods

We conducted a prospective home safety interventional study. Parents and grandparents with children at home were recruited at community events attended by the MSC. Participants completed a pre-test survey assessing demographics and current home safety knowledge, practices, and device use. Participants then attended the MSC’s short home safety educational program. Afterwards, participants completed a knowledge reassessment post-test and were offered free safety devices: a smoke detector, a gun lock, and a childproofing kit comprising outlet covers, doorknob covers, and cabinet latches. We administered two follow-up surveys four weeks and six months after visiting the MSC. Descriptive statistics, Friedman tests, Wilcoxon Sum-Rank tests, and Pearson Chi-Square were used to assess respondent demographic characteristics and changes in home safety knowledge, practices, and device use.

Results

We recruited 50 participants, of whom 29 (58%) completed follow-up 1, 30 (60%) completed follow-up 2, and 26 (52%) completed both. Participants who completed both follow-ups increased total correct answers to safety knowledge questions between the pre-test and post-test (p = 0.005), pre-test and follow-up 1 (p = 0.003), and pre-test and follow-up 2 (p = 0.012) with no significant changes between the post-test, follow-up 1, and follow-up 2. Of the respondents who reported accepting safety products, outlet covers were used most frequently, followed by the smoke detector, doorknob covers, cabinet latches, and the gun lock.

Conclusions

The MSC may be an effective means of increasing home safety among families with children, as participation in the MSC’s home safety educational program significantly increased home safety knowledge and spurred home safety device use. Implementation of MSCs could potentially reduce childhood injury rates within communities through promotion of home safety.

Cultural adaptation for country diversity: A systematic review of injury prevention interventions caused by domestic accidents in children under five years old

Background: Children under five years old are the most vulnerable in home-injuries. More than half of the accident happens at home. Intervention programs are effective ways to reduce the risk of injuries. The use of cultural strategies has been recommended for effective interventions. The aim of this study was to evaluate cultural adaptability in interventional studies which were performed to prevent injuries caused by domestic accidents in children under five years old in all countries.

Methods: This systematic review has been conducted from June to July 2016. Iran Medex, Magiran, SID from Persian databases and Scopus, Web of Science, Science direct, Pub Med, Biomed central from English databases were employed. Available cultural adaptation guidelines were used to compare the cultural adaptation strategies. A search of studies had been conducted from the creation of databases until July 2016.

Results: Overall, 15 studies were entered into the analyses. The interventional approach in 11 studies was an educational approach. Consequently, 8 studies from 11 reported that they had significantly achieved all expected outcomes. Three studies had used behavioral change models or theories to achieve the desired changes. Seven studies had considered socio-cultural strategy in their interventions, and six studies had reported achieving outcomes. Only seven studies acquired a minimum score of cultural adaptation.

Conclusion: In this systematic review, an educational intervention was effective in preventing child injuries. If cultural strategies are taken into consideration in interventions, they will have a change in behavior in this regard. Also, theoretical frameworks and models can be effective.

Sex and age differences in hospitalized pediatric traumatic brain injury

BACKGROUND

The aim of this study was to investigate the epidemiological characteristics of pediatric traumatic brain injury (TBI) requiring hospitalization in Chinese children ≤17 years of age according to sex and age group.

METHODS

This study retrospectively analyzed pediatric TBI inpatient data obtained via electronic health records from one children's hospital in China. Patients aged ≤17 years admitted to the hospital due to TBI between 1 January 2013 and 31 December 2015 were identified using International Classification of Diseases (ICD) -9 and ICD-10 codes. The demographic, injury, and hospitalization characteristics were analyzed by sex and age groups.

RESULTS

The subject consisted of 1,087 pediatric TBI patients admitted to the hospital (61.5% boys). The highest proportion of hospitalization was observed in the 1-3 years age group. For both boys and girls, the most common diagnosis was "traumatic epidural hematoma" and the leading mechanism of TBI was "fall". The median length of hospital stay was 8.5 days and the median hospitalization cost was 7,977.4 Chinese yuan (approximately $US 1,140).

CONCLUSIONS

Boys and children aged 1-3 years incurred more pediatric TBI requiring hospitalization than their counterparts. Prevention of falls, the most common injury mechanism in both boys and girls, is an important strategy to reduce pediatric TBI and related hospitalizations.

Child Housing Assessment for a Safe Environment (CHASE): a new tool for injury prevention inside the home

OBJECTIVE

To develop a tool to assess the safety of the home environment that could produce valid measures of a child's risk of suffering an injury.

METHODS

Tool development: A four-step process was used to develop the CHASE (Child Housing Assessment for a Safe Environment) tool, including (1) a literature scan, (2) reviewing of existing housing inspection tools, (3) key informants interviews, and (4) reviewing the National Electronic Injury Surveillance System to determine the leading housing elements associated with paediatric injury. Retrospective case-control study to validate the CHASE tool: Recruitment included case (injured) and control (sick but not injured) children and their families from a large, urban paediatric emergency department in Baltimore, Maryland in 2012. Trained inspectors applied both the well-known Home Quality Standard (HQS) and the CHASE tool to each enrollee's home, and we compared scores on individual and summary items between cases and controls.

RESULTS

Twenty-five items organised around 12 subdomains were included on the CHASE tool. 71 matched pairs were enrolled and included in the analytic sample. Comparisons between cases and controls revealed statistically significant differences in scores on individual items of the CHASE tool as well as on the overall score, with the cases systematically having worse scores. No differences were found between groups on the HQS measures.

CONCLUSION

Programmes conducting housing inspections in the homes of children should consider including the CHASE tool as part of their inspection measures. Future study of the CHASE inspection tool in a prospective trial would help assess its efficacy in preventing injuries and reducing medical costs.

Wombs and Whippersnappers: Reflections on Health Education Research and Opportunities for the Future

My talk will describe two public health problems facing women and children that were the focus of the work my colleagues and I did over my years as a health behavior change researcher. I start by addressing why a focus on women and children is important from a public health perspective and then provide two mini case studies: (1) identifying needs and interventions for women living with HIV and intimate partner violence and (2) disseminating proven interventions to reduce unintentional injuries in children. The conclusions present thoughts on the contributions of health education to these public health concerns and opportunities for the future.

Trends in trauma-related mortality among adolescents: A 6 year snapshot from a teaching hospital's post mortem data

INTRODUCTION

The aim is to explore the trends in trauma mortality in children aged 0-18 years can help to co-ordinate resources toward research and programs to reduce the burden.

METHODS

This is a retrospective study carried out on adolescents ≤18 years of age autopsied according to the attorney request at Forensic Medicine & Toxicology department of King George's Medical University, Lucknow, India in the period from January 1st, 2009 to December 31st, 2014.

RESULTS

There were 9160 deaths from all causes in children ≤18 years old, 7747 of which were due to trauma related causes, with a female predominance of 1.3:1. The age distribution revealed that 65.8% of deaths occurred in the 10-18 age group. Road traffic accidents (RTA) was the most prevalent cause (3635 deaths - 46.92%), followed by asphyxia (1128 deaths - 14.56%) and sexual assault (649 deaths - 8.37%). Asphyxia/suffocation was the major cause of injury with 31.96% of deaths within group <1 year; asphyxia (28.66%) and transport-related injuries (32.27%) were more predominant in the 1-4 age group; transport-related deaths were frequent in the 5-9 age group (45.14%), 10-14 age group (55.68%) and in the group 15-18 age group (51.69%). Regarding times of death, 61% occurred at the scene, 5.6% during pre-hospital care, 26.2% occurred at the hospital within the first 24 h after admission, and the remaining 7.6% of deaths occurred after 24 h after admission to the hospital. When we analyzed the deaths according to the intent, homicides occurred in 16% of cases. Unintentional injuries occurred in 69% of deaths and self-inflicted injuries were identified in 15% cases.

CONCLUSIONS

Findings show that there was a predominance of deaths in children and adolescents males, between 15 and 18 years old, mainly from road traffic accidents. This study highlights the burden of trauma caused mortalities in children, which requires instant action.

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

Background

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

Aim

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

Methods

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Trial registration

Current Controlled Trials ISRCTN65067450 and ClinicalTrials.gov NCT01452191.

Funding

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

A randomised safety promotion intervention trial among low-income families with toddlers

BACKGROUND

Toddler-aged children are vulnerable to unintentional injuries, especially those in low-income families.

OBJECTIVE

To examine the effectiveness of an intervention grounded in social cognitive theory (SCT) on the reduction of home safety problems among low-income families with toddlers.

METHODS

277 low-income mother-toddler dyads were randomised into a safety promotion intervention (n=91) or an attention-control group (n=186). Mothers in the safety promotion intervention group received an eight-session, group-delivered safety intervention targeting fire prevention, fall prevention, poison control and car seat use, through health education, goal-setting and social support. Data collectors observed participants' homes and completed a nine-item checklist of home safety problems at study enrolment (baseline), 6 and 12 months after baseline. A total score was summed, with high scores indicating more problems. Linear mixed models compared the changes over time in home safety problems between intervention and control groups.

RESULTS

The intent-to-treat analysis indicated that the safety promotion intervention group significantly reduced safety problems to a greater degree than the attention-control group at the 12-month follow-up (between-group difference in change over time β=-0.54, 95% CI -0.05 to -1.03, p=0.035), with no significant differences at the 6-month follow-up.

CONCLUSIONS

A safety promotion intervention built on principles of SCT has the potential to promote toddlers' home safety environment. Future studies should examine additional strategies to determine whether better penetration/compliance can produce more clinically important improvement in home safety practices.

TRIAL REGISTRATION NUMBER

NCT02615158; post-results.

Prevention of and Interventions for Dating and Sexual Violence in Adolescence

Dating violence (also known as adolescent relationship abuse) and sexual violence are prevalent from the middle school years throughout adolescence, peak in young adulthood, and are associated with multiple poor physical and mental health consequences. By offering universal education and brief anticipatory guidance with all adolescent patients about healthy and unhealthy relationships and sexual consent, health care providers can help promote healthy adolescent sexual relationships, ensure youth know about available resources and supports for relationship abuse and sexual violence (including how to help a friend), and facilitate connections to victim service advocates, both for prevention and intervention.

Safe Storage of Opioid Pain Relievers Among Adults Living in Households With Children

OBJECTIVES

To describe safe storage practices and beliefs among adults who have used a prescription opioid pain reliever (OPR) in the past year; to compare practices and beliefs among those living with younger (<7 years) versus older children (7-17 years).

METHODS

A survey was administered to a nationally representative sample of adults reporting OPR use in the previous 12 months and who had children <18 years old living with them. We used Health Belief Model-derived items to measure beliefs. Safe storage was defined as locked or latched for younger children and as locked for older children. Regression models examined the association between beliefs and safe storage practices.

RESULTS

Among 681 adults who completed our survey and reported having children in their home, safe storage was reported by 32.6% (95% confidence interval [CI], 21.4-43.8) of those with only young children, 11.7% (95% CI, 7.2-16.2) among those with only older children, and 29.0% (95% CI, 18.3-39.8) among those with children in both age groups. Among those asked to answer survey questions thinking about only their oldest child, the odds of reporting safe storage decreased by half as perceived barriers increased (0.505; 95% CI, 0.369-0.692), increased twofold as efficacy increased (2.112; 95% CI, 1.390-3.210), and increased (1.728; 95% CI, 1.374-2.174) as worry increased.

CONCLUSIONS

OPRs are stored unsafely in many households with children. Educational messages should address perceived barriers related to safe storage while emphasizing how it may reduce OPR access among children.

Racial and Ethnic Differences in Injury Prevention Behaviors Among Caregivers of Infants

INTRODUCTION

African American and Latino children experience higher rates of traumatic injury and mortality, but the extent to which parents of different races and ethnicities disparately enact injury prevention behaviors has not been fully characterized. The objective of this study is to evaluate the association between caregiver race/ethnicity and adherence to injury prevention recommendations.

METHODS

This was a cross-sectional analysis of caregiver-reported baseline data from the Greenlight study, a cluster-randomized pediatric obesity prevention trial. Data were collected between 2010 and 2012 in four academic pediatric practices and analyzed in 2015. Non-adherence to injury prevention recommendations was based on five domains: car seat safety, sleeping safety, fire safety, hot water safety, and fall prevention.

RESULTS

Among 864 caregiver-infant pairs (17.7% white, non-Hispanic; 49.9% Hispanic; 27.7% black, non-Hispanic; 4.7 % other, non-Hispanic), mean number of non-adherent injury prevention behaviors was 1.8 (SD=0.9). In adjusted regression, Hispanic caregivers had higher odds of non-adherence to car seat safety (AOR=2.1, 95% CI=1.2, 3.8), and lower odds of non-adherence with fall prevention (AOR=0.4, 95% CI=0.3, 0.7) compared with whites. Black, non-Hispanic caregivers had higher odds of non-adherence to car seat safety (AOR=2.4, 95% CI=1.3, 4.4) and sleeping safety (AOR=2.1, 95% CI=1.3, 3.2), but lower odds of fall prevention non-adherence (AOR=0.5, 95% CI=0.3, 0.8) compared with whites.

CONCLUSIONS

A high prevalence of non-adherence to recommended injury prevention behaviors is common across racial/ethnic categories for caregivers of infants among a diverse sample of families from low-SES backgrounds.

Evaluation of the Safety Detective Program: A Classroom-Based Intervention to Increase Kindergarten Children's Understanding of Home Safety Hazards and Injury-Risk Behaviors to Avoid

Home injuries are a leading cause of mortality and morbidity for young children. Most programs that aim to improve their knowledge of home safety have been narrowly focused on one injury type and/or required specialized personnel for delivery. The purpose of the current study was to evaluate the effectiveness of a new Safety Detective Program that was designed to teach young children (4-6 years) about several types of home safety hazards and unsafe behaviors, with the program delivered in a classroom setting by non-experts based on manualized training. The current study used a randomized group, pre-post design to evaluate the effectiveness of the program to increase children's knowledge and understanding of home safety hazards and injury-risk behaviors to avoid. Children participated in six structured sessions, covering burns, falls, drowning, and poisoning. Each session involved play-based activities (storybook, song, and game or craft) to teach main messages about hazards and injury-risk behaviors, a take home activity, and a parent information sheet about the injury type covered that day. An individually administered photo-sort task with follow-up interview was used to measure intervention and control group participants' knowledge and understanding of injury-risk behaviors before and after program delivery. Children in the intervention, but not the control, group exhibited significant gains in their knowledge and understanding of home safety hazards and injury-risk behaviors to avoid, establishing the effectiveness of the program. This evaluation indicates that the Safety Detective Program can be delivered in classrooms without requiring specialized personnel or extensive training and with positive changes obtained. The program holds much promise as a means of improving kindergarten children's understanding of a broad range of home hazards and injury-risk behaviors that are relevant to their safety.

Evaluation Activities to Strengthen an Injury Prevention Resource Center for Urban Families

The Johns Hopkins Children’s Safety Center (CSC) is a unique health care provider and patient education resource that elevates the attention injury prevention receives in a medical setting and reduces barriers to injury prevention experienced by low-income, urban families, the Center’s priority population. This article describes the CSC’s development, implementation, and selected elements of its evaluation. Because evaluation has played an important role in the CSC from its inception through its implementation and sustainability, three evaluation activities are described: process evaluation to monitor activity, impact evaluation to understand its effects on parents’ safety behaviors, and qualitative interviews with CSC visitors and non-visitors to enhance services. Implications of each evaluation activity are described and recommendations are made for strengthening the CSC.

Does Health Literacy Level Influence the Effectiveness of a Kiosk-Based Intervention Delivered in the Pediatric Emergency Department?

OBJECTIVE

This study assesses parents' literacy skills and evaluates how literacy levels influenced the effectiveness of a health communication intervention designed to improve safety knowledge in low-income, urban families.

METHODS

A total of n = 450 parents of children aged 4 to 66 months completed the Rapid Estimate of Adult Literacy in Medicine (REALM) and participated in a randomized trial of an injury prevention intervention delivered via computer kiosk in a pediatric emergency department. A safety knowledge test was administered by telephone 2 to 4 weeks later.

RESULTS

More than one-third of parents were assessed by the REALM to have marginal (30%) or inadequate (8%) reading levels; the remaining 62% of parents had adequate reading levels. REALM scores were independently associated with knowledge gains for poison storage and smoke alarms.

CONCLUSIONS

Participants reading level had an independent and significant effect on safety knowledge outcomes. Literacy level should be considered in all patient education efforts.

Toward a centralized database for child safety centers: Results of a feasibility pilot study

BACKGROUND

Safety centers (SCs) are hospital-affiliated outlets that provide families with safety products and personalized education about preventing injuries. Roughly 40 SCs are in operation across the United States, but no single model for staffing, supplying, or sustaining them has emerged. The project aimed to determine the feasibility of a centralized database for SC evaluation as the first step toward growing this proven intervention.

METHODS

An Expert Advisory Committee was convened to determine data collection elements and procedures. Representatives from nine hospital-based SCs collected data about car seat and bike helmet sales and education provided between August 1, 2013, to December 31, 2013.

RESULTS

A total of 645 study-related safety products were distributed at cost (72%), below cost (10%), or for free (19%). Education was provided for 96% of all products distributed, including receipt of print materials (81%) and product demonstrations (83%). Visitors to SCs were usually referred by a hospital provider (34%), followed by word of mouth (24%) and walk-in (22%). Seven of nine SCs were able to contribute data. Stability of SCs and capacity of staff emerged as facilitators of centralized data collection feasibility.

CONCLUSION

We demonstrate that centralized data collection is feasible and that information to compare centers can be obtained. However, for more meaningful comparisons to emerge and to enable all SCs the ability to participate, support is needed institutionally for staff to be able to capture data and nationally to grow and sustain a database that represents the broader diversity of topics and services offered.

Cluster randomized controlled trial protocol: addressing reproductive coercion in health settings (ARCHES)

Background

Women ages 16–29 utilizing family planning clinics for medical services experience higher rates of intimate partner violence (IPV) and reproductive coercion (RC) than their same-age peers, increasing risk for unintended pregnancy and related poor reproductive health outcomes. Brief interventions integrated into routine family planning care have shown promise in reducing risk for RC, but longer-term intervention effects on partner violence victimization, RC, and unintended pregnancy have not been examined.

Methods/Design

The ‘Addressing Reproductive Coercion in Health Settings (ARCHES)’ Intervention Study is a cluster randomized controlled trial evaluating the effectiveness of a brief, clinician-delivered universal education and counseling intervention to reduce IPV, RC and unintended pregnancy compared to standard-of-care in family planning clinic settings. The ARCHES intervention was refined based on formative research. Twenty five family planning clinics were randomized (in 17 clusters) to either a three hour training for all family planning clinic staff on how to deliver the ARCHES intervention or to a standard-of-care control condition. All women ages 16–29 seeking care in these family planning clinics were eligible to participate. Consenting clients use laptop computers to answer survey questions immediately prior to their clinic visit, a brief exit survey immediately after the clinic visit, a first follow up survey 12–20 weeks after the baseline visit (T2), and a final survey 12 months after the baseline (T3). Medical record chart review provides additional data about IPV and RC assessment and disclosure, sexual and reproductive health diagnoses, and health care utilization. Of 4009 women approached and determined to be eligible based on age (16–29 years old), 3687 (92 % participation) completed the baseline survey and were included in the sample.

Discussion

The ARCHES Intervention Study is a community-partnered study designed to provide arigorous assessment of the short (3-4 months) and long-term (12 months) effects of a brief, clinician-delivered universal education and counseling intervention to reduce IPC, RC and unintended pregnancy in family planning clinic settings. The trial features a cluster randomized controlled trial design, a comprehensive data collection schedule and a large sample size with excellent retention.

Trial Registration

ClinicialTrials.gov NCT01459458. Registered 10 October 2011.

Preventing childhood scalds within the home: Overview of systematic reviews and a systematic review of primary studies

OBJECTIVE

To synthesise and evaluate the evidence of the effectiveness of interventions to prevent scalds in children.

METHODS

An overview of systematic reviews (SR) and a SR of primary studies were performed evaluating interventions to prevent scalds in children. A comprehensive literature search was conducted covering various resources up to October 2012. Experimental and controlled observational studies reporting scald injuries, safety practices and safety equipment use were included.

RESULTS

Fourteen systematic reviews and 39 primary studies were included. There is little evidence that interventions are effective in reducing the incidence of scalds in children. More evidence was found that inventions are effective in promoting safe hot tap water temperature, especially when home safety education, home safety checks and discounted or free safety equipment including thermometers and thermostatic mixing valves were provided. No consistent evidence was found for the effectiveness of interventions on the safe handling of hot food or drinks nor improving kitchen safety practices.

CONCLUSION

Education, home safety checks along with thermometers or thermostatic mixing valves should be promoted to reduce tap water scalds. Further research is needed to evaluate the effectiveness of interventions on scald injuries and to disentangle the effects of multifaceted interventions on scald injuries and safety practices.

Network meta-analysis to evaluate the effectiveness of interventions to prevent falls in children under age 5 years

BACKGROUND

This study aimed to simultaneously evaluate the effectiveness of a range of interventions to increase the possession of safety equipment or behaviours to prevent falls in children under 5 years of age in the home.

METHODS

A recently published systematic review identified studies to be included in a network meta-analysis; an extension of pairwise meta-analysis that enables comparison of all evaluated interventions simultaneously, including comparisons not directly compared in individual studies.

RESULTS

29 primary studies were identified, of which 16 were included in at least 1 of 4 network meta-analyses. For increasing possession of a fitted stair gate, the most intensive intervention (including education, low cost/free home safety equipment, home safety inspection and fitting) was the most likely to be the most effective, with an OR versus usual care of 7.80 (95% CrI 3.08 to 21.3). For reducing possession or use of a baby walker: education only was most likely to be most effective, with an OR versus usual care of 0.48 (95% CrI 0.31 to 0.84). Little difference was found between interventions for possession of window locks (most intensive intervention versus usual care OR=1.56 (95% CrI 0.02 to 89.8)) and for not leaving a child alone on a high surface (education vs usual care OR=0.89 (95% CrI 0.10 to 9.67)). There was insufficient evidence for network meta-analysis for possession and use of bath mats.

CONCLUSIONS

These results will inform healthcare providers of the most effective components of interventions and can be used in cost-effectiveness analyses.

Prevention of injury and violence in the USA

In the first three decades of life, more individuals in the USA die from injuries and violence than from any other cause. Millions more people survive and are left with physical, emotional, and financial problems. Injuries and violence are not accidents; they are preventable. Prevention has a strong scientific foundation, yet efforts are not fully implemented or integrated into clinical and community settings. In this Series paper, we review the burden of injuries and violence in the USA, note effective interventions, and discuss methods to bring interventions into practice. Alliances between the public health community and medical care organisations, health-care providers, states, and communities can reduce injuries and violence. We encourage partnerships between medical and public health communities to consistently frame injuries and violence as preventable, identify evidence-based interventions, provide scientific information to decision makers, and strengthen the capacity of an integrated health system to prevent injuries and violence.

Health literacy and injury prevention behaviors among caregivers of infants

BACKGROUND

Unintentional injury is a leading cause of infant mortality.

PURPOSE

To examine the role of caregiver health literacy in infant injury prevention behaviors.

METHODS

A cross-sectional analysis of data collected in 2010-2012 from a randomized trial at four pediatric clinics was performed in 2012-2013. Caregiver health literacy was assessed with the Short Test of Functional Health Literacy in Adults. Caregiver-reported adherence to American Academy of Pediatrics-recommended injury prevention behaviors was assessed across seven domains: (1) car seat position; (2) car seat use; (3) sleeping safety; (4) fire safety; (5) hot water safety; (6) fall prevention; and (7) firearm safety.

RESULTS

Data were analyzed from 844 English- and Spanish-speaking caregivers of 2-month-old children. Many caregivers were non-adherent with injury prevention guidelines, regardless of health literacy. Notably, 42.6% inappropriately placed their children in the prone position to sleep, and 88.6% did not have their hot water heater set <120°F. Eleven percent of caregivers were categorized as having low health literacy. Low caregiver health literacy, compared to adequate health literacy, was significantly associated with increased odds of caregiver non-adherence with recommended behaviors for car seat position (AOR=3.4, 95% CI=1.6, 7.1) and fire safety (AOR=2.0, 95% CI=1.02, 4.1) recommendations. Caregivers with low health literacy were less likely to be non-adherent to fall prevention recommendations (AOR=0.5, 95% CI=0.2, 0.9).

CONCLUSIONS

Non-adherence to injury prevention guidelines was common. Low caregiver health literacy was significantly associated with some injury prevention behaviors. Future interventions should consider the role of health literacy in promoting injury prevention.

Enhancing fire department home visiting programs: results of a community intervention trial

This study evaluates the impact of an enhanced fire department home visiting program on community participation and installation of smoke alarms, and describes the rate of fire and burn hazards observed in homes. Communities were randomly assigned to receive either a standard or enhanced home visiting program. Before implementing the program, 603 household surveys were completed to determine comparability between the communities. During a 1-year intervention period, 171 home visits took place with 8080 homes. At baseline, 60% of homes did not have working smoke alarms on every level, 44% had unsafe water temperatures, and 72% did not have carbon monoxide alarms. Residents in the enhanced community relative to those in the standard community were significantly more likely to let the fire fighters into their homes (75 vs 62%). Among entered homes, those in the enhanced community were significantly more likely to agree to have smoke alarms installed (95 vs 92%), to be left with a working smoke alarm on every level of the home (84 vs 78%), and to have more smoke alarms installed per home visited (1.89 vs 1.74). The high baseline rates of home hazards suggest that fire department home visiting programs should take an "all hazards" approach. Community health workers and community partnerships can be effective in promoting fire departments' fire and life safety goals. Public health academic centers should partner with the fire service to help generate evidence on program effectiveness that can inform decision making about resource allocation for prevention.

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.

Translating Life Course Theory to clinical practice to address health disparities

Life Course Theory (LCT) is a framework that explains health and disease across populations and over time and in a powerful way, conceptualizes health and health disparities to guide improvements. It suggests a need to change priorities and paradigms in our healthcare delivery system. In "Rethinking Maternal and Child Health: The Life Course Model as an Organizing Framework," Fine and Kotelchuck identify three areas of rethinking that have relevance to clinical care: (1) recognition of context and the "whole-person, whole-family, whole-community systems approach;" (2) longitudinal approach with "greater emphasis on early ("upstream") determinants of health"; and (3) need for integration and "developing integrated, multi-sector service systems that become lifelong "pipelines" for healthy development". This paper discusses promising clinical practice innovations in these three areas: addressing social influences on health in clinical practice, longitudinal and vertical integration of clinical services and horizontal integration with community services and resources. In addition, barriers and facilitators to implementation are reviewed.

Children and adolescents deaths from trauma-related causes in a Brazilian City

Introduction

Injury is the first cause of death worldwide in the population aged 1 to 44. In developed countries, the most common trauma-related injuries resulting in death during childhood are traffic accidents, followed by drowning.

Methods

This retrospective study based on autopsy examinations describes the epidemiology profile of deaths by trauma-related causes in individuals younger than 18 years from 2001 to 2008 in the city of Campinas. The aim is to identify epidemiology changes throughout the years in order to develop strategies of prevention.

Results

There were 2,170 deaths from all causes in children < 18 years old, 530 of which were due to trauma-related causes, with a male predominance of 3.4:1. The age distribution revealed that 76% of deaths occurred in the 10-17 age group. The most predominant trauma cause was firearm injury (47%). Other frequent causes were transport-related injuries (138 cases-26%; pedestrians were struck in 57.2% of these cases) and drowning (55 cases-10.4%). Asphyxia/suffocation was the cause of death in 72% of cases in children < 1 year old; drowning (30.8%) was predominant in the 1-4 age group; transport-related deaths were frequent in the 5-9 age group (56%) and the 10-14 age group (40.4%). Gun-related deaths were predominant (68%) in the 14-17 age group. 51% of deaths occurred at the scene.

Conclusions

There was a predominance of deaths in children and adolescents males, between 15-17 years old, mainly from gun-related homicides, and the frequency has decreased since 2004 after the disarmament statute and the combating of violence.

Impact of case exposures on physician behavior responses in childhood poisoning: quality and cost implications

OBJECTIVES

When measuring physicians' competencies, there is no consensus as to what would constitute an optimum exposure in unintentional pediatric poisoning. In the absence of universal protocols and poison centers' support, the behavior responses of the physicians can vary depending on their exposure to cases. We sought to determine if there was a correlation between the case exposure and physicians' behavior choices that could affect quality and cost of care.

METHODS

A cross-sectional study was conducted in 2010, and a self-reporting survey questionnaire was given to the physicians in the pediatric emergency departments and primary care centers in the city of Al Ain. The physicians' responses were plotted against (a) the number of cases the physicians have had managed in the preceding 12 months and (b) the number of years the physicians have had been in practice

RESULTS

One hundred seven physicians partook in the survey. We found that the physicians who had managed more than 2 cases of childhood poisoning in the preceding year chose significantly more positive behavior responses when compared with those who had managed 2 cases or less. There was no significant difference when the responses were measured against the physicians' number of years of practice.

CONCLUSIONS

Physicians' practice effectiveness may improve if they manage at least 3 cases of childhood poisoning in a year. Physicians training modules could be developed for those physicians who do not get the optimum exposure necessary in improving physicians' behaviors associated with effective quality and cost efficiency.

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.

Preventing childhood falls within the home: overview of systematic reviews and a systematic review of primary studies

In most countries falls are the most common medically attended childhood injury and the majority of injuries in pre-school children occur at home. Numerous systematic reviews have reviewed evidence of the effectiveness of falls prevention interventions, but this evidence has not been synthesised into an overview, making it difficult for policy makers and practitioners to easily access the evidence. To synthesise all available evidence, we conducted an overview of reviews of home safety interventions targeting childhood falls, extracted data from primary studies included in the reviews and supplemented this with a systematic review of primary studies published subsequent to the reviews. Bibliographic databases, websites, conference proceedings, journals and bibliographies of included studies were searched for systematic reviews of studies with experimental or controlled observational designs. Thirteen reviews were identified containing 24 primary studies. Searches for additional primary studies identified five further studies not included in reviews. Evidence of the effect of interventions on falls or fall injuries was sparse, with only one of three primary studies reporting this outcome finding a reduction in falls. Interventions were effective in promoting the use of safety gates and furniture corner covers. There was some evidence of a reduction in baby walker use. The effect on the use of window safety devices, non-slip bath mats/decals and the reduction of tripping hazards was mixed. There was limited evidence that interventions were effective in improving lighting in corridors, altering furniture layout and restricting access to roofs. Most interventions to prevent childhood falls at home have not been evaluated in terms of their effect on reducing falls. Policy makers and practitioners should promote use of safety gates and furniture covers and restriction of baby walker use. Further research evaluating the effect of interventions to reduce falls and falls-related injuries is urgently required.

Still too hot: examination of water temperature and water heater characteristics 24 years after manufacturers adopt voluntary temperature setting

Although water heater manufacturers adopted a voluntary standard in the 1980s to preset thermostats on new water heaters to 120°F, tap water scald burns cause an estimated 1500 hospital admissions and 100 deaths per year in the United States. This study reports on water temperatures in 976 urban homes and identifies water heater and household characteristics associated with having safe temperatures. The temperature of the hot water, type and size of water heater, date of manufacture, and the setting of the temperature gauge were recorded. Demographic data, including number of people living in the home and home ownership, were also recorded. Hot water temperature was unsafe in 41% of homes. Homeowners were more likely to have safer hot water temperature (<120°F) than renters (63 vs 54%; P < .01). For 11% of gas water heaters, the water temperature was >130°F, although the gauge was set at less than 75% of its maximum setting. In a multivariate logistic regression, electric water heaters were more likely to have safe hot water temperatures than gas water heaters (odds ratio R=4.99; P < .01). Water heaters with more gallons per person in the household were more likely to be at or below the recommended 120°F. Our results suggest that hot water temperatures remain dangerously high for a substantial proportion of urban homes despite the adoption of voluntary standards to preset temperature settings by manufacturers. This research highlights the need for improved prevention strategies, such as installing thermostatic mixing valves, to ensure a safer temperature.

Fire and scald burn risks in urban communities: who is at risk and what do they believe about home safety?

While largely preventable, fire and hot water-related injuries are common in the United States. Measures recommended to reduce these injuries are smoke alarms (SAs) and lowered hot water temperatures. This study aims to: (i) describe the prevalence of working SAs and safe water temperatures among low-income, urban communities and (ii) explore the relationship between these behaviors and individuals' knowledge and beliefs about them. In this cross-sectional study, the Health Belief Model was used as a guide for understanding the safety behaviors. A total of 603 households had their SAs and hot tap water temperatures tested and were surveyed about their knowledge and beliefs related to these safety behaviors. We found that 40% of households had working SAs on every level and 57% had safe hot water temperatures. Perceived severity and self-efficacy were significantly associated with SA coverage, whereas perceived susceptibility and beliefs about benefits were significantly associated with safe hot water temperatures. This study demonstrates the need to increase the number of homes with working SAs and safe hot water temperatures. Messages focused on a safe home environment could communicate the ease and harm reduction features of SAs and benefits and risk reduction features of safe hot water temperatures.

Using the pediatric emergency department to deliver tailored safety messages: results of a randomized controlled trial

OBJECTIVE

This study aimed to evaluate the impact of a computer kiosk intervention on parents' self-reported safety knowledge as well as observed child safety seat, smoke alarm use, and safe poison storage and to compare self-reported versus observed behaviors.

METHODS

A randomized controlled trial with 720 parents of young children (4 months to 5 years) was conducted in the pediatric emergency department of a level 1 pediatric trauma center. Enrolled parents received tailored safety information (intervention) or generic information (control) from a computer kiosk after completing a safety assessment. Parents were telephoned 4 to 6 months after the intervention to assess self-reported safety knowledge and behaviors; in-home observations were made 1 week after the telephone interview for a subset of 100 randomly selected participants. Positive and negative predictive values were compared between the intervention and control groups.

RESULTS

The intervention group had significantly higher smoke alarm (82% vs. 78%) and poison storage (83% vs 78%) knowledge scores. The intervention group was more likely to report correct child safety seat use (odds ratio, 1.36; 95% confidence interval, 1.05-1.77; P = 0.02). Observed safety behaviors were lower than self-reported use for both groups. No differences were found between groups for positive or negative predictive values.

CONCLUSIONS

These results add to the limited literature on the impact of computer tailoring home safety information. Knowledge gains were evident 4 months after intervention. Discrepancies between observed and self-reported behavior are concerning because the quality of a tailored intervention depends on the accuracy of participant self-reporting. Improved measures should be developed to encourage accurate reporting of safety behaviors.

Results of a randomized controlled trial assessing the efficacy of the Supervising for Home Safety program: Impact on mothers' supervision practices

Unintentional injury constitutes a major health risk for young children, with many injuries occurring in the home. Although active supervision by parents has been shown to be effective to prevent injuries, evidence indicates that parents do not consistently apply this strategy. To address this issue, a randomized controlled trial was conducted to evaluate the impact of the Supervising for Home Safety program on parent supervision practices in the home and when unobtrusively observed in a naturalistic laboratory setting. Using a participant-event monitoring procedure, parents of children aged 2 through 5 years completed supervision recording sheets weekly both before and after exposure to the intervention program; Control parents completed the same measures but received a program focusing on child nutrition and active lifestyles. Unobtrusive video recordings of parent supervision of their child in a room containing contrived hazards also were taken pre- and post-intervention. Results indicated that groups did not differ in demographic characteristics. Comparisons of post- with pre-intervention diary reported home supervision practices revealed a significant decrease in time that children were unsupervised, an increase in in-view supervision, and an increase in level of supervision when children were out of view, with all changes found only for the Intervention group. Similarly, only parents in the Intervention group showed a significant increase in attention to the child in the contrived hazards context, with these differences evident immediately after and 3 months after exposure to the intervention. These results provide the first evidence that an intervention program can positively impact caregiver supervision.

Home safety practices in an urban low-income population: level of agreement between parental self-report and observed behaviors

Home-related injuries are overrepresented in children from low-income households. The objectives of this study were to determine frequencies of home safety behaviors and the level of agreement between parental self-report and observed safety practices in low-income homes. In a prospective, interventional home injury prevention study of 49 low-income families with children <5 years old, a trained home visitor administered baseline parental home safety behavior questionnaires and assessments. There was high agreement between caregiver self-report and home visitor observation for lack of cabinet latch (99%, 95% confidence interval [CI] = 88%-99%) and stair gate use (100%, 95% CI = 88-100%). There was lower agreement for the safe storage of cleaning supplies (62%, 95% CI = 46%-75%), sharps (74%, 95% CI = 59%-85%), and medicines/vitamins (83%, 95% CI = 69%-92%) because of the overreporting of safe practices. Self-reports of some home safety behaviors are relatively accurate, but certain practices may need to be verified by direct assessment.

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.

Mixed treatment comparisons using aggregate and individual participant level data

Mixed treatment comparisons (MTC) extend the traditional pair-wise meta-analytic framework to synthesize information on more than two interventions. Although most MTCs use aggregate data (AD), a proportion of the evidence base might be available at the individual level (IPD). We develop a series of novel Bayesian statistical MTC models to allow for the simultaneous synthesis of IPD and AD, potentially incorporating study and individual level covariates. The effectiveness of different interventions to increase the provision of functioning smoke alarms in households with children was used as a motivating dataset. This included 20 studies (11 AD and 9 IPD), including 11 500 participants. Incorporating the IPD into the network allowed the inclusion of information on subject level covariates, which produced markedly more accurate treatment-covariate interaction estimates than an analysis solely on the AD from all studies. Including evidence at the IPD level in the MTC is desirable when exploring participant level covariates; even when IPD is available only for a fraction of the studies. Such modelling may not only reduce inconsistencies within networks of trials but also assist the estimation of intervention subgroup effects to guide more individualised treatment decisions.

Network meta-analysis to evaluate the effectiveness of interventions to increase the uptake of smoke alarms

This study is the first known to use network meta-analysis to simultaneously evaluate the effectiveness of interventions to increase the prevalence of functioning smoke alarms in households with children. The authors identified 24 primary studies from a systematic review of reviews and of more recently published primary studies, of which 23 (17 randomized controlled trials and 6 nonrandomized comparative studies) were included in 1 of the following 2 network meta-analyses: 1) possession of a functioning alarm: interventions that were more "intensive" (i.e., included components providing equipment (with or without fitting), home inspection, or both, in addition to education) generally were more effective. The intervention containing all of the aforementioned components was identified as being the most likely to be the most effective (probability (best) = 0.66), with an odds ratio versus usual care of 7.15 (95% credible interval: 2.40, 22.73); 2) type of battery-powered alarms: ionization alarms with lithium batteries were most likely to be the best type for increasing functioning possession (probability (best) = 0.69). Smoke alarm promotion programs should ensure they provide the combination of interventions most likely to be effective.

Disparities in the prevalence of smoke alarms in U.S. households: Conclusions drawn from published case studies

INTRODUCTION

Deaths from fires and burns are a leading cause of fatal home injury in the United States. Smoke alarms are one of the most effective interventions to prevent residential fire deaths. Nationwide, more than 95% of homes are estimated to have at least one smoke alarm. There is evidence that homes at highest risk of fire deaths lag behind national averages in smoke alarm use and maintenance.

METHOD

We compiled a comprehensive list of published studies that focus on smoke alarm prevalence in high-risk homes. Our findings show that there are substantial gaps in both smoke alarm presence and functional status between high-risk homes and national average estimates.

CONCLUSIONS

To save more lives, improved efforts are needed to reduce the disparity in smoke alarm prevalence and functional use in the United States.