Parenting interventions for the prevention of unintentional injuries in childhood

For the current issue of the Journal, we asked Dr. Carolyn Emery to comment on and put into context the recent Cochrane Review on parenting interventions for preventing unintentional injuries in childhood. 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. We included randomized controlled trials (RCTs), non-RCTs and controlled before-and-after studies, which evaluated parenting interventions administered to parents of children 18 years of age and younger and reported outcome data on injuries to children (unintentional or unspecified intent) and possession and use of safety equipment or safety practices (including the Home Observation for Measurement of the Environment [HOME] scale, which contains 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. Studies were selected, data were extracted and quality was appraised independently by two authors. Pooled relative risks (RRs) were estimated using random-effects models. Twenty-two studies were included in the review: 16 RCTs, 2 non-RCTs, 1 partially randomized trial that contained 2 randomized intervention arms and 1 nonrandomized control arm, 2 controlled before-and-after studies and 1 quasi-RCT. Seventeen studies provided interventions comprising parenting education and other support services, 15 of which were home visiting programmes and 2 of which were paediatric practice-based interventions. Two provided solely educational interventions. Nineteen studies recruited families who were from socioeconomically disadvantaged populations who 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% confidence interval [CI] 0.73 to 0.94). Sensitivity analyses were undertaken that included only RCTs at low risk for various sources of bias. Findings were found to be robust in studies at low risk for detection bias (related to blinded outcome assessment) or attrition bias (related to follow-up of less than 80% of participants in each study 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 fewer statistically significant home hazards or a greater number of safety practices in intervention families. Often 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, when Grading of Recommendations Assessment, Development, and Evaluation guidelines (GRADE) were used, the quality of the evidence was rated as moderate. Parenting interventions, most commonly provided within the home using multifaceted interventions, are effective in reducing child injury. Fairly consistent evidence suggests that they also improve home safety. This 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, to identify the features of parenting interventions that are necessary or sufficient to reduce injury, and to assess the generalizability of these findings to different population groups. The full text of the Cochrane Review is available in The Cochrane Library: Kendrick D, Mulvaney CA, Ye L, Stevens T, Mytton JA, Stewart-Brown S. Parenting interventions for the prevention of unintentional injuries in childhood. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD006020. DOI: 10.1002/14651858.CD006020.pub3. Unintentional injury accounts for the greatest public health burden in developed countries in children and adolescents based on mortality and morbidity rates. Evidence shows that Canada is no exception. Based on the 2013 UNICEF report, Canada ranks 27 of 29 in child health and safety across all Organization for Economic Co-operation and Development countries, and some of this poor record is related to unintentional injury risk (1). This is a very poor ranking given that (1) there is evidence much can be done to prevent unintentional childhood injuries and (2) unintentional injuries are predictable and preventable and one of the most consistent risk factors for paediatric unintentional injury is low socioeconomic status (2). Prioritization of the development, implementation and evaluation of injury prevention strategies aimed at reducing the public health burden of paediatric unintentional injury is critical in addressing this epidemic worldwide and in Canada. The responsibility and greatest potential to reduce this burden lies in the joint responsibilities of ‘the village that raises our children’. (3) The combined efforts of governments, communities, clinicians, teachers, community leaders, parents and youth in addressing this epidemic is essential. Evidence-informed community-level policy change (e.g., seatbelt law, bicycle helmet law, safe playgrounds, pedestrian routes), industry standards (e.g., smoke and carbon monoxide detectors, child-proof devices, safe age-appropriate toys), combined with family/parent-targeted interventions aimed at behaviour change to promote childhood safety (e.g., smoke detectors, child-proof home environment) will have the greatest effect in reducing the public health burden of unintentional injury in children. This Cochrane Review targets parental responsibility only in evaluating the effectiveness of parenting programs in preventing unintentional injuries in childhood, and secondarily, on increasing possession and use of home safety equipment and improving parental safety practices. In total, an impressive 16 of 22 (73%) studies included in this Cochrane Review were RCTs and 15 of 22 (68%) targeted families that were socioeconomically disadvantaged (e.g., at risk of neglect, teenage mothers, learning disabilities) where the risk of unintentional injury in childhood is the greatest. The studies included are primarily conducted in the USA (59%), with other studies from Australia, Canada, England, Ireland and New Zealand. As such, the generalizability to Canadian communities, particularly those that are socioeconomically disadvantaged, is high. However, the generalizability to middle- and low-income countries remains poor. The majority of studies evaluated multifaceted home-visit programs aimed at improving a range of child and often maternal health outcomes, including providing greater access to health care delivery. Injury definitions were heterogeneous and injury outcomes were primarily based on self-report data in the absence of denominator exposure data. However, consistency in findings across multiple injury types (e.g., burns, scratches, other) was also demonstrated using sensitivity analyses. Based on study quality assessment of RCTs, the greatest risk of bias was performance bias (94% of RCTs) with potential for systematic differences in the attention given to families in the intervention group due to lack of blinding of the researcher and study participants with ‘usual care’ in the control group. As such, the specific child safety intervention components may not explain any differences found between study groups. In addition, attrition bias associated with drop-out was also of concern in 38% of the RCTs. The authors did, however, perform sensitivity analyses including only RCTs at low risk of various primary sources of bias. The primary findings were significant and consistent with a 17% protective effect demonstrated in the overall meta-analysis, when including only four studies at low risk of detection bias (blinded outcome assessment) and eight studies at low risk of attrition bias (>80% follow-up in each study group). Sensitivity analyses in which only five studies with adequate allocation concealment were included resulted in a similar point estimate; however, the difference in outcomes was no longer statistically significant. The RE-AIM framework should be considered as a tool developed and widely used for evaluating the effectiveness of implemented programs aimed at behaviour change in a health promotion context (4). In a sport injury prevention context specifically, Finch et al. further elucidate the application of RE-AIM in evaluating the public health impact of interventions with a focus on understanding the implementation context (5). RE-AIM includes evaluating implementation through five key components including Reach (the proportion of the target population that participated in the intervention), Effectiveness (the success rate if implemented as intended), Adoption (the proportion of people, settings, practices and plans that adopt the intervention), Implementation (the extent to which the intervention is implemented as intended in the real world) and Maintenance (the extent to which the intervention is sustained over time). The RE-AIM framework would be useful in evaluating the public health impact of parent targeted interventions focused on reducing the risk of paediatric unintentional injury as it provides cues on how to think about the full complexities of the implementation context, including facilitators and barriers. Consideration of RE-AIM should be fundamental in evaluating implementation in injury prevention in youth sport and recreation and would be of considerable value to consider in the context of paediatric unintentional injury prevention (6). Home-based individually targeted parenting education interventions focused on safety, as part of a multifaceted child health home visiting program, appear to be effective in reducing self-reported or medically attended injury among young children and improving home safety. The only study evaluating an intervention provided primarily in a primary care setting was evaluated in a nonrandomized study with inherent biases, demonstrating, however, a similar protective effect. In Canada, early childhood health care is primarily delivered through primary care settings, including community health centres. Many families are connected to early intervention community services through their family physician, children’s school and child care providers in the community. In this Cochrane Review, safety-focused interventions were a component of a multifaceted health intervention. As such, it remains unclear if parenting safety education interventions are independently effective in reducing childhood injury. Perhaps group-based parenting interventions delivered in a community setting may be more cost-effective, but the effectiveness of such a group delivery remains unknown. As only families ‘at risk’ of adverse child health outcomes were targeted in this review, the effectiveness of such programs across all populations also requires further inquiry. Based on meta-analyses, the overall protective effect of a home-based safety intervention is estimated to be a reduction in injury risk of 17%, with uncertainly based on 95% CI suggesting a risk reduction as small as 6% and as great as 27% (based on a reported RR of 0.83 [95% CI 0.73 to 0.94]). Based on original data provided in Analysis 1.1, the absolute risk reduction translates to an estimated number-needed-to-treat of more than 20 family home visits to avoid one unintentional childhood injury. From an economic evaluation perspective, it may be that individual family home visits may not be the most cost-effective approach to maximizing reach and effectiveness of childhood safety interventions. Further consideration and evaluation of group-based community and primary care interventions is recommended. In addition, in acute care settings (e.g., emergency departments, trauma centres), injury prevention counselling may be an important educational tool once the family has been affected by injury. Parenting education interventions focused on safety are important to inform a reduction in unintentional injury among young children and improving home safety. Topics such as child-proofing the home, helmet use and regular smoke and carbon monoxide detector checks are reasonable to discuss annually with young families in primary care. The implementation context for such interventions (e.g., home, community clinic, primary care) requires further evaluation. This Cochrane Review focuses on individually targeted home-based parenting interventions in reducing the risk of unintentional injuries in childhood and secondarily on increasing possession and use of home safety equipment and improving parental safety practices. This is one approach to reducing unintentional childhood injury risk, targeting parental responsibility in the ‘village’ that raises our children (3). Evidence-informed community-level policy and industry standards, combined with family/parent-targeted interventions aimed at behaviour change to promote childhood safety, may have the greatest protective effect in reducing the public health burden of unintentional injury in children. Methodologically rigorous evaluation of multilevel approaches to childhood safety is recommended to inform the greatest public health impact in reducing the significant burden of unintentional injuries in childhood.

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