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Johns Hopkins International Injury Research Unit, Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
This study provides insights on the long-term effect of the two educational interventions for prevention of household injuries in children under five years.
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The interventions included educational pamphlet and in-home tutorial guide about injury prevention in children under five years.
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Injury hazards reduced in the long-term follow up for households that received in-home tutorial guide.
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The reduction in the injury types included falls, drowning, burn and poisoning.
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Injury prevention information for children under five years can be integrated to existing public healthcare system.
Abstract
Background
Unintentional childhood injuries are a growing public health concern, and the home is the most common location for non-fatal injuries in children less than 5 years of age. This study describes the long-term effects of two injury prevention educational interventions for caregivers—an educational pamphlet and an in-home tutorial guide—by comparing the change in the prevalence of home injury hazards before and after the interventions.
Methods
This was a pre- (June and July 2010) and post-study with short-term follow-up (November-December 2010) and long-term follow-up (November 2012- January 2013). Neighborhood one included households that received only educational pamphlets after completing a baseline assessment; neighborhood two included households that received an in-home tutorial guide after completing the baseline assessment and receiving the educational pamphlet. The main outcome of this study was the reduction in home injury hazards for children under 5 years of age.
Results
A total of 312 households participated in the long-term phase to compare the effect of the interventions. Between the short-term to long-term follow-up, injury hazards significantly reduced in neighborhood two compared to neighborhood one. These included fall hazards (walker use) (IRR 0.24 [95% CI 0.08-0.71]), drowning hazards (open bucket of water in the courtyard and uncovered water pool) (IRR 0.45 [95% CI 0.85-0.98] and IRR 0.46 [95% CI 0.76-0.94]), burn hazards (iron, water heater within reach of child) (IRR 0.56 [95% CI 0.33-0.78] and IRR 0.58 [95% CI 0.32-0.91]), poisoning hazards (shampoo/soap and medicine within reach of child) (IRR 0.53 [95% CI 0.44-0.77] and IRR 0.7 [95% CI 0.44-0.98]) and breakable objects within reach of child (IRR 0.62 [95% CI: 0.39-0.99]).
Conclusion
An injury prevention tutorial to caretakers of children supplemented with pamphlets could significantly decrease the incidence of falls, drowning, burns, poisoning, and cut injury hazards for children under 5 years of age in their homes in a low-resource setting. This intervention has the potential to be integrated in existing public health programs, such as Lady Health Visitors (LHVs), to disseminate injury prevention information in routine home health visits.
]. Most home injury prevention programs have been implemented in high-income countries (HICs), and there are limited studies in LMICs, specifically Pakistan [
]. Previous systematic review literature overwhelmingly suggests that multiple interventions were more effective than single intervention (What makes community based injury prevention work? In search of evidence of effectiveness). Educating caregivers for injury prevention was unique for the study setting where injuries were perceived as unavoidable event due to God-will. Understanding the uptake of single intervention is a simplistic approach for the community where education particularly delivering injury education may be the first time.
Home visitation has shown some promising effects for improving parents’ safety practices and knowledge related to home safety for children [
]. Home visitation programs are usually carried out by skilled and professional visitors (e.g., nurses) who inspect homes and educate parents regarding potential hazards that increase the likelihood of childhood injuries. In Pakistan, a randomized trial was conducted in which injury reduction counseling was provided during a home visit following a child being discharged from an emergency department. This study showed a significant reduction in the presence of both fall and choking hazards over the course of six months among children aged three years and younger [
]. Among interventions for children's safety at home, communicating information about home injury hazards to the parents of children can minimize the likelihood of childhood injuries at home [
Enough information exists on the risk factors of childhood injuries and practical measures that can be taken at home to minimize the conditions that contribute to injury, yet parents and caregivers, particularly in LMICs, fail to benefit optimally from such useful information [
Perception and awareness of unintentional childhood injuries among primary caregivers of children in Vellore, South India: a community-based cross-sectional study using photo-elicitation method.
Accidental Poisoning in Young Children: an Emergency Medicine Perspective for Pakistan and Other Low-and Middle-Income Countries and a Call for Action.
]. LMICs have limited predesigned pamphlets or information sheets to educate parents about potential home hazards that contribute to increasing the incidence of injuries among children.
In Pakistan, injury is one of the leading causes of death among children aged 1 to 5 years [
]. A study conducted in Pakistan showed the potential utility of using home visit tutorials in reducing home hazards for falls, poisoning, and choking [
]. However, there is a paucity of evidence on the long-term effect of such home-based injury education interventions in LMICs, such as Pakistan. This study explored the long-term effects of a pilot study by comparing the difference in the prevalence of home injury risks after the dissemination of injury prevention education tools, including an educational pamphlet and a tutorial.
Methods
Study design
This was a pre- and post-intervention study with baseline assessment (June-July 2010), short-term follow-up (November-December 2010), and long-term follow-up (November 2012-January 2013).
Participants and study setting
Respondents were caregivers of children under 5 years of age. The study setting included two neighborhoods within a low-income government housing community in Karachi, Pakistan. Details of selected neighborhoods are described elsewhere [
]. Eligibility criteria for enrollment in the study included: the presence of at least one child between the ages of 12 and 59 months, a caregiver who was able to read in Urdu, and a current plan to live in the same household for at least another three months. Households were assessed based on the eligibility criteria before enrollment. If a household had more than one child between 12 and 59 months of age, the caregiver was asked to select one as the index child to assess for the presence of home injury hazards [
An observational checklist was administered to identify the hazards by areas of the home. The checklist areas included the kitchen, bath area, living/sleeping area, courtyard/rooftop, and the outdoors immediately surrounding the home [
]. Both the pamphlet and the tutorial contained the information on injury hazards for children under 5 years of age that were commonly found in the homes of the study population along with the description of some strategies on reducing or eliminating those hazards. There was team of three female research assistants (RAs) who were trained to administer the pamphlet and guide the tutorial. The senior research assistant supervised the team. Caregiver in each household was approached by female research assistant. The purpose of the study was explained to caregiver of each household and written informed consent was taken who agreed to participate in the study. The study investigators used to assess the implementation of intervention by regular field visits initially until they were satisfied after which they did random field visits.
The pamphlet was designed in a format not requiring the presence of a health practitioner for understanding or use. It is colorful, attractive and easy to read with context relevant pictorial and is in local language. It focused on highlighting common injury hazards at homes, categorized by household area (living room, kitchen, etc.) as well as by mechanism of injuries when the hazards are not specific to area (such as poisoning and burns) with the goal of promoting hazard reduction with relevant suggestions. The RA encouraged the caregiver to read it and share it with caregivers in the home. The time to read pamphlet was around 10 minutes.
In contrast, the tutorial was an interactive tool that allowed a trained data collector to provide home injury hazard information and prevention ideas with the child's caregiver. The tutorial guide has two components; injury hazard identification and safety tips for those hazards. The RA trained in delivering this tutorial, worked with the child caregiver in each room in the home to identify specific examples of safety or hazards by asking specific questions such as “Where are the matches, lighters and household cleaners? “Can your child reach them?”. After which the RA discussed with the participants inexpensive and potentially simple ways in which identified risks could be altered. The tutorial took approximately 30 minutes per home.
One of the two neighborhoods was conveniently received an educational pamphlet and the other received the tutorial. We conducted a baseline assessment of households’ injury hazards and then implemented the intervention. After six months, we conducted short-term follow-up to assess the reduction in hazards. The original plan was to conclude the study after the short-term follow-up phase, therefore educational pamphlets were distributed to the tutorial neighborhood at the conclusion of the study for a handy reference.
However, the research team was able to secure additional funds and decided to conduct a long-term assessment of the intervention. After two years, we went back to the neighborhoods for long-term follow up of hazards in neighborhood that received only an educational pamphlet and in neighborhood that received both a tutorial and a pamphlet.
Outcome
The main outcome of this study was the reduction in home injury hazards for children under 5 years of age. We used 24 unintentional home-based injury hazards and classified them into six types of injury: falls, burns, poisoning, drowning, cut injuries, and choking.
Sample size
The sample size was explained in detail in our previous publication from our study [
The sample size was 247 in the pamphlet group and 256 households in the tutorial group at the time of intervention implementation. In the short-term follow-up, the number of households in the pamphlet group was 218 and in the tutorial group was 217. In the long-term follow-up, the number of households was 145 in the pamphlet only group and 167 in the tutorial and pamphlet group (Fig. 1).
Approval for this study was obtained from the Ethical Review Committee of the Aga Khan University (Pakistan) and the Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health (USA).
Statistical analysis
All data were entered and analyzed using SPSS (Statistical Package for the Social Sciences) version-19 [
The covariates included in the study were child's age and gender, relationship of the respondent with the child, respondent's age, and respondent's education level. Sociodemographic variables were compared between pamphlet-only versus tutorial and pamphlet groups. Frequency and percentages were reported for the presence of injury related hazards at three phases of follow-up.
The percentage of injury hazards was represented by bar charts by aggregating types of injuries into six groups in three phases: falls, burns, poisonings, drownings, lacerations, and chokings.
The Generalized Estimating Equation (GEE) for binary outcome with logit link function was used to identify factors related with different types of injury hazards. Exchangeable correlation coefficient structure was used to account for clustering in the data due to three different phases. The model was also adjusted for socio-demographic variables of respondent and child because of their potential role as confounders. Crude and adjusted incidence rate ratios (IRRs) and corresponding 95% confidence intervals (CIs) were reported for each type of injury-related hazard from short-term to long-term follow-up.
Results
The results include145 households in neighborhood with only pamphlet and 167 households in neighborhood with tutorial and pamphlet group.
Overall, the two groups had a comparable demographic, except for education level of respondents (Table 1). Respondents in pamphlet group had a higher education level (78.6% of respondents had 9 years of education or more) than in tutorial and pamphlet group (63.5% of respondents had 9 years of education or more). The mean age of respondents in intervention group one was 30.8 years old, comparable with 31.4 years in intervention group two. Most of the respondents in both groups were mothers (82.8% in pamphlet and 77.8% in tutorial and pamphlet group). In terms of child characteristics, in both groups, slightly more than half were males (55.7% each). The mean age of the index child in intervention group one was 55.47 months (SD=16.4) and was 49.59 months (SD=14.99) in intervention group two.
Table 1Baseline sociodemographic characteristics of the study participants by groups.
Hazards were high during the baseline phase and decreased in the short-term follow-up period; however, some injury-related hazards increased during the long-term follow-up phase, including falls among the pamphlet-only group and burns and poisonings among both intervention groups. There was a decreasing trend of injury hazards for drowning, cut injuries (lacerations), and choking for both interventions over all three phases (Fig. 1).
Choking had the lowest and burning had the highest proportions of injury hazard in both groups. The proportion of injury hazard of falls, drowning, cut injuries and chokings were higher in intervention group one when compared with intervention group two. On the other hand, injury hazards of burns and poisoning were higher in intervention group two (Table 2).
Table 2Percentage distribution of presence of different injury hazards by intervention status in the long-term follow-up assessment phase.
Types of Injury Hazards
Intervention group 1 [n=145]
Intervention group 2 [n=167]
n [%]
n [%]
Falls
45%
44%
Walker present/used
17 [11.7]
19 [11.4]
Accessible rooftop without railing
59 [40.7]
65 [38.9]
Drowning
24%
13%
Open bucket of water inside the house
7 [4.8]
4 [2.4]
Open buckets of water present in the courtyard
7 [4.8]
4 [2.4]
Uncovered vat/pool of water
30 [20.7]
19 [11.4]
Burns
92.4%
98.6%
Stove within reach of the child
133 [91.7]
138 [82.6]
Matches within reach
101 [69.7]
112 [67.1]
Open fire within reach
84 [57.9]
99 [59.3]
Iron within reach of the child
64 [44.1]
75 [44.9]
Overloaded Outlets
11 [7.6]
22 [13.2]
Frayed/loose cords within reach of child
14[9.7%]
24[14.4%]
Water heater within reach of child
16[11%]
11[6.6%]
Poisoning
72%
89%
Non labeled of fluids containers
73 [50.3]
98 [58.7]
Cleaning supplies within reach
6 [4.1]
6 [3.6]
Shampoos/soap within reach
73 [50.3]
67 [40.1]
Medicines within reach of the child
37 [25.5]
34 [20.4]
Cut injuries
79%
77%
Breakable objects within reach of the child
38 [26.2]
26 [15.6]
Knives within reach
89 [61.4]
98 [58.7]
Fan/sharp object within reach
30 [20.7]
44 [26.3]
Are any structures with sharp/hard protruding components
23 [15.9]
46 [27.5]
Bed/furniture or wall have any sharp corners within reach of the child
50 [34.5]
59 [35.3]
Television or any item placed on a trolley with wheels without locks
18 [12.4]
23 [13.8]
Chokings
6%
5%
Any small choking hazards within reach of the child
9 [6.2]
7 [4.2]
Any of the child's toys too small (choking hazard), pointed, or sharp
We assessed 24 minor and six major injury-related hazards by intervention status, taking the pamphlet group as reference both with (adjusted) and without (crude) socio-demographic variables from short-term to long-term follow-up. At the multivariable level (adjusted), the injury hazards which performed significantly better for the tutorial group were walker present/used (IRRa=0.24; 95% CI: 0.08, 0.71) with 76% reduction at long-term follow-up; open buckets of water present in the courtyard (IRRa=0.45; 95% CI: 0.85, 0.98) with 55% reduction at long-term follow-up; uncovered vat/pool of water (IRRa=0.46; 95% CI: 0.76, 0.94) with 54% reduction at long-term follow-up; iron within reach of child (IRRa=0.56; 95% CI: 0.33, 0.78) with 44% reduction at long-term follow-up; water heater within reach of child (IRRa=0.58; 95% CI: 0.32, 0.91) with 42% reduction at long-term follow-up; shampoos/soap within reach of child (IRRa=0.53; 95% CI: 0.44, 0.77) with 47% reduction at long-term follow-up; medicine within reach of child (IRRa=0.70; 95% CI: 0.44, 0.98) with 30% reduction at long-term follow-up; and breakable objects within reach of child (IRRa=0.62; 95% CI: 0.39, 0.99) with 38% reduction at long-term follow-up. On the other hand, the injury hazards which performed significantly better for the pamphlet group were burns (IRRa=1.61; 95% CI: 1.14, 2.30) with 161% increase for the tutorial group at long-term follow-up and non-labelled chemical fluid containers (IRRa=1.75; 95% CI: 1.24, 2.46) with 175% increase for the tutorial group at long-term follow-up. No significant reductions or increases were observed in the remaining injury hazards (Table 3).
Table 3Crude and adjusted incidence risk ratio (95% CI) of presence of injury hazards by intervention status from short-term to long-term follow-up phase.
This study provides insight into changes in injury hazards within the home environment of children under the age of 5 years after having received community-based educational interventions on injury prevention in Karachi, Pakistan. At the long-term follow-up, the injury hazards for falls, burns, drowning and poisoning reduced in the households that received both the in-home tutorial and the educational pamphlet.
It is possible that the combination of in-home tutorials and education pamphlets helped to increase the spread of injury prevention information to a wider range of audiences among family and community members. The respondents may have shared the educational pamphlet and content of the in-home tutorial with other members of the family, which may have resulted in a combined effort to reduce injury hazards for children. Moreover, one-on-one in-home tutorial discussions may have stimulated greater interest in the respondents to act on the injury prevention information. Other studies have also suggested that disseminating injury prevention using more than one approach and involving a wide range of community members is more effective than relying on one method or only educating parents [
Approaches used by parents to keep their children safe at home: a qualitative study to explore the perspectives of parents with children aged under five years.
]. These studies have suggested that injury prevention information should reach all stakeholders, including schools, child healthcare providers, city authorities, community mobilizers, the environment, building regularity agencies, media, legal and child rights activists, along with parents and caregivers [
Effect of community-based intervention on knowledge, attitude, and self-efficacy toward home injuries among Egyptian rural mothers having preschool children.
Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing: a randomized controlled trial.
Preventing unintentional injuries to children in the home: a systematic review of the effectiveness of programmes supplying and/or installing home safety equipment.
]. They provide a wide range of services to both urban and rural populations, including basic nursing care, maternal and child health services, and community worker training [
]. These LHVs can serve as a sustainable model for reducing home injuries by providing a comprehensive home injury education along with an information package.
Child injury prevention requires global attention, but the majority of interventions have been implemented and studied in HICs [
Sethi D, Mitis F, Racioppi F. Preventing injuries in Europe: from international collaboration to local implementation: WHO Regional Office Europe; 2010.
]. Furthermore, studies from HICs have shown that educational interventions are more effective in preventing injuries when they are combined with legislative changes and regulatory and enforcement strategies [
]. However, the effectiveness of educational interventions in injury reduction is debated among injury scholars, policymakers, and regulatory agencies [
Environmental change interventions to prevent unintentional home injuries among children in low-and middle-income countries: A systematic review and meta-analysis.
]. For example, the educational program may not have been adapted to the target group; the content of the message was too broad without a specific action plan for injury prevention; and the duration of the educational campaign was too short [
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.
]. Educational content in injury prevention should be small, specific, and concrete, and it should be appropriate to the immediate needs of the learner with a combination of reinforcement strategies [
]. A successful example is the “Play It Safe” campaign conducted in England through mass media (BBC) in combination with home visits with specific injury prevention advice [
]. Injury educational campaigns are more effective when combined with other strategies, such as providing a resource for home modifications, environmental change-facilitation, and improving the overall living condition of the community [
]. Education is also a major part of a widely used framework for injury prevention known as the 5 E's: engineering, education, encouragement, enforcement, and evaluation [
]. However, the largest number of research projects done regarding injury prevention in LMICs have focused on educational interventions as opposed to other prevention strategies, such as law enforcement, environmental modifications, and advocacy [
]. Multiple interventions, such as environmental changes, safety devices, and supportive home visits, can contribute to a culture of home safety for children [
]. Such interventions are critical since parents in LMICs may not have access to contextually relevant injury prevention information. They also lack access to pediatricians or injury prevention programs required to offer injury prevention education and awareness, as is happening in HICs [
]. In LMICs, injury prevention education and advocacy cannot only rely on medical care providers; therefore, it is important to engage multiple stakeholders, such as schools, community health visitors, and local partners, and to mobilize and train them for child injury prevention programs.
Strengths of the study
This is one of only a few studies implementing injury prevention information in an LMIC setting. Although there are well-established interventions in high-income settings, delivering them directly in low-income settings may not be appropriate. In this study, we used tailored injury prevention instructions, according to the feasibility and applicability of the injury reduction measures specific to the context of the information recipients. Furthermore, the implementation was carried out in the community setting within the homes, which gave more opportunity for interaction and involvement with the families. Previous studies have mostly occurred in clinical settings where healthcare providers are busy with medical service provisions and patients/visitors are seeking medical services for a specific health issue.
Limitations of the study
Our study had several limitations. First, this follow-up assessment was not a formal evaluation study to assess the effectiveness of the program by cluster randomization. One site was arbitrarily chosen as the intervention group (in-home tutorial) and the other as the control group (education pamphlet). This arbitrary choice may have resulted in the educational level difference between the two groups—in the educational pamphlet group, the mothers had a significantly higher educational level as compared to the in-home tutorial group. Second, in intervention group two, some households may have missed receiving the educational pamphlet. We did not record or monitor the delivery of this material because the distribution of the educational pamphlet was not an intended intervention. Third, there was a long duration gap (two years) between the short-term follow-up and the long-term follow-up assessment. This gap resulted in a high proportion of loss-to-follow-up among study participants as there was house shifting among the residents. The area was a governmental housing society, and the residents were mostly from low-middle income status living on rental agreements. Intervention group one had a 65% loss-to-follow-up, and intervention group two had 59%. Although the research team accounted for loss-to-follow-up within the sample size, we did not expect to lose such high numbers of participants. Lastly, we did not assess injury incidence in this study. Therefore, we are not sure that the intervention had any effect on the number of injury events or on behavioral modification in the recipients. (Fig. 2)
Fig. 2Aggregate percentage of injury hazards at baseline, short-term, and long-term follow-up.
In conclusion, following the implementation of two injury prevention dissemination methods—an in-home tutorial and the distribution of an educational pamphlet—we found that using both strategies together could significantly decrease the presence of home hazards for falls, drownings, burns, poisoning, and cut injuries among children under 5 years of age in a low resource setting. The injury prevention information was tailored to the context of our recipients. These teaching modalities have the potential to be integrated into existing public health interventions. However, integrating this kind of one-to-one injury prevention education can be challenging, especially in a resource-constrained setting. Program implementation must consider training educators and standardizing the delivery alongside logistical and other emerging issues. Future studies can explore effective methods of integrating injury prevention information within the existing public health service delivery system in LMICs. Specifically, a larger community trial can be conducted to compare the effectiveness of injury prevention dissemination methods and should address the limitations identified in this study.
Supplementary material
Publication of this supplement is supported by the NIH grant D43 TW 007292 through the Aga Khan University.
Declaration of Competing Interest
The authors declare that they have no competing interests
Acknowledgment
This work was supported by the World Health Organization's Division of Violence and Injury Prevention, and the Johns Hopkins Center for Global Health. Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under Award Number D43TW007292 (URK and JAR). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Fogarty International Center nor the National Institutes of Health.
Perception and awareness of unintentional childhood injuries among primary caregivers of children in Vellore, South India: a community-based cross-sectional study using photo-elicitation method.
Accidental Poisoning in Young Children: an Emergency Medicine Perspective for Pakistan and Other Low-and Middle-Income Countries and a Call for Action.
Approaches used by parents to keep their children safe at home: a qualitative study to explore the perspectives of parents with children aged under five years.
Effect of community-based intervention on knowledge, attitude, and self-efficacy toward home injuries among Egyptian rural mothers having preschool children.
Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing: a randomized controlled trial.
Preventing unintentional injuries to children in the home: a systematic review of the effectiveness of programmes supplying and/or installing home safety equipment.
Sethi D, Mitis F, Racioppi F. Preventing injuries in Europe: from international collaboration to local implementation: WHO Regional Office Europe; 2010.
Environmental change interventions to prevent unintentional home injuries among children in low-and middle-income countries: A systematic review and meta-analysis.
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.
Mean±SD
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