Providing child safety equipment to prevent injuries: randomised contr
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《英国医生杂志》
1 Faculty of Medicine and Health Sciences, School of Nursing, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2HA, 2 Division of Primary Care, University of Nottingham, Nottingham NG7 2RD, 3 Rushcliffe Primary Care Trust, Nottingham NG2 6BT, 4 Nottingham Health Informatics Service, Nottingham City Primary Care Trust, Nottingham NG1 6GN
Correspondence to: M Watson michael.watson@nottingham.ac.uk
Abstract
Unintentional injury is the leading cause of death in children in the United Kingdom.1 Moreover, it is a major cause of ill health and disability. Most unintentional injuries to children under 5 take place in the home, and children at socioeconomic disadvantage are at greater risk of injury.2
Primary healthcare teams have an important contribution to make to the prevention of unintentional injuries in children,3-5 including home safety counselling and participation in safety equipment schemes. However, there is little evidence in the United Kingdom that they can be effective in reducing unintentional injuries.
Systematic reviews have found that home safety counselling or education, with or without the provision of safety equipment, can increase the use of some items of safety equipment and improve safety behaviours in the short term, but the effect on unintentional injury is less clear.6-9 Many of the trials included in these reviews were conducted in the United States, which limits generalisability to UK settings. In addition, the reviews have highlighted the lack of high quality randomised controlled trials, specifically trials with adequate allocation concealment, blinded outcome assessment, adequate power, and a sufficient follow up period.
The high cost of safety equipment and the difficulty of installing some devices have been identified as barriers to families' implementing advice on home safety.8 No trials to date have examined the effect of providing as well as fitting equipment free of charge.
We report the main results of a randomised controlled trial assessing the effectiveness of an intervention in increasing safety practices and reducing unintentional injuries in families with children aged under 5 years, living in deprived areas.
Methods
We recruited 3428 families (3995 children) between January and May 2000, with 1711 families in the intervention arm and 1717 families in the control arm. The follow up period started on 1 June 2000 and ended on 31 May 2002. The figure shows the flow of participants through the trial. The treatment arms were well balanced at baseline (table 1).
Flow of participants through the trial
Table 1 Characteristics and safety practices of study families at baseline. Values are numbers (%) unless otherwise indicated
A total of 1163 (68%) families in the intervention arm received the safety consultation, and 619 families (36%) had free equipment fitted, and 26 (1.5%) bought equipment at low cost. Table 2 shows results for injury outcomes. The attendance rate for injury in primary care was higher (by 37%) for children in the intervention than in the control arm (P = 0.003). The treatment arms did not differ significantly for the other injury outcomes. We found no evidence that the effect of the intervention varied by family income or child age for any of the primary outcome measures (P > 0.1 for all interaction terms). A compliance analysis found similar results to the primary analysis, with a higher injury attendance rate in primary care in children in the intervention arm who received the safety consultation than in children in the control arm (incidence rate ratio 1.50, 95% confidence interval 1.21 to 1.88) but no difference in rates of attendance in secondary care or admission to hospital.
Table 2 Injury outcomes for injuries at the level of the family or child, at 24 months' follow up, by treatment arm
Table 3 shows that at one year, families in the intervention arm were significantly more likely to be safe in terms of stairs (P = 0.0004), smoke alarms (P = 0.0002), windows (P = 0.03), and storage of cleaning products (P = 0.006) and sharp objects (P = 0.005) in the kitchen than families in the control arm. At two years, families in the intervention arm were significantly more likely to be safe in terms of smoke alarms (P = 0.002), storage of medicines (P = 0.05), and cleaning products (P = 0.008) in the kitchen than families in the control arm. Absolute differences in the percentages of families with safety practices were, however, small—none exceeded 10%.
Table 3 Prevalence of safety practices at 12 and 24 months' follow up, by treatment arm. Values are numbers (percentages) of families unless otherwise indicated
Among families responding to the 12 month questionnaire, 89% (286/322) of those receiving equipment agreed or strongly agreed that they were satisfied with the safety equipment, and 70% (411/589) of families who received the consultation agreed or strongly agreed that they were satisfied with the health visitor's advice. Ninety five per cent (53/56) of responding health visitors agreed or strongly agreed that the safety consultation should be used in routine practice.
Discussion
British Medical Association. Injury prevention. London: BMA, 2001.
Department of Health. Preventing accidental injury-priorities for action. a report from the accidental injury task force to the chief medical officer. London: Department of Health, 2002.
Watson M. Alliances against accidents. Pract Nurs 1994;5(13): 20.
Kendrick D. Role of the primary health care team in preventing accidents to children. Br J Gen Pract 1994;44: 372-5.
Carter YH, Morgan PS, Lancashire RJ. General practitioners' attitudes to child injury prevention in the UK: a national postal questionnaire. Injury Prev 1995;1: 164-8.
Towner E, Dowswell T, Mackereth C, Jarvis S. What works in preventing unintentional injuries in children and young adolescents? An updated systematic review. London: Health Development Agency, 2001.
Lyons R, Sander L, Weightman A, Patterson J, Jones SL, Rolfe B, et al. Modification of the home environment for the reduction of injuries. Cochrane Database Syst Rev 2003;4: CD003600.
DiGuiseppi C, Roberts IG. Individual-level injury prevention strategies in the clinical setting. Future Child 2000;10: 53-82.
DiGuiseppi C, Higgins JP. Systematic review of controlled trials of interventions to promote smoke alarms. Arch Dis Child 2000;82: 341-8.
Townsend P, Phillimore P, Beattie A. Health and deprivation: inequality and the north. London: Croom Helm, 1988.
Kendrick D, Watson M, Dewey M, Woods AJ. Does sending a home safety questionnaire increase recruitment to an injury prevention trial? A randomised controlled trial. 55: 845-846. J Epidemiol Community Health 2001;55: 845-6.
Clamp M, Kendrick D. A randomised controlled trial of general practitioner safety advice for families with children under 5 years. BMJ 1998;316: 1576-9.
Mullen PD, Green LW, Persinger GS. Clinical trials of patient education for chronic conditions: A comparative meta-analysis of intervention types. Prev Med 1985;14: 753-81.
Mullen PD, Simons-Morton DG, Ramirez G, Frankowski RF, Green LW, Mains DA. A meta-analysis of trials evaluating patient education and counseling for three groups of preventive health behaviors. Patient Educ Counsel 1997;32: 157-73.
Watson M, Woods A, Kendrick D. Injury prevention: working together on an RCT. Community Pract 2002;75: 172-5.
Association for the Advancement of Automotive Medicine. The abbreviated injury scale: 1990 revision. Illinois: Association for the Advancement of Automotive Medicine, 1990.
Alwash R, McCarthy M. Measuring severity of injuries to children from home accidents. Arch Dis Child 1988;63: 635-8.
Watson M, Kendrick D, Coupland D. Validation of a home safety questionnaire used in a randomised controlled trial. Injury Prev 2003;9: 180-3.
Lovato L, Hill K, Hertert S, Hunninghake D, Probstfield J. Recruitment for controlled clinical trials: Literature summary and annotated bibliography. Control Clin Trials 1997;18: 328-52.
Watson M, Kendrick D, Woods A, Dewey M. Measuring contamination in an injury prevention randomised controlled trial. Injury Control Safety Promotion (in press).
King WJ, Klassen TP, LeBlanc J, Bernard-Bonnin AC, Robitaille Y, Pham B, et al. The effectiveness of a home visit to prevent childhood injury. Pediatrics 2001;108: 382-8.
Kendrick D, Marsh P, Fielding K, Miller P. Preventing injuries in children: cluster randomised controlled trial in primary care. BMJ 1999;318: 980-3.
Woolf AD, Saperstein A, Forjuoh S. Poisoning prevention knowledge and practices of parents after a childhood poisoning incident. Pediatrics 1992;90: 867-70.
DiGuiseppi C, Roberts I, Speirs N. Smoke alarm installation and function in inner London council housing. Arch Dis Child 1999;81: 400-3.
Elkington J, Blogg S, Kelly J, Carey V. Head injuries in infants: a closer look at baby-walkers, stairs and nursery furniture. NSW Public Health Bull 1999;10: 82-83.
Petridou E, Trichopoulos D, Mera E, Papadatos Y, Papazoglou K, Marantos A, et al. Risk factors for childhood burn injuries: a case-control study from Greece. Burns 1998;24: 123-8.
Azizi BH, Zulkifli HI, Kassim MS. Circumstances surrounding accidental poisoning in children. Med J Malaysia 1994;49: 132-7.
Mallonee S. Evaluating injury prevention programs: the Oklahoma City smoke alarm project. Future Child 2000;10: 164-74.
van Rijn OJ, Meertens RM, Kok G, Bouter LM. Determinants of behavioural risk factors for burn injuries. Burns 1991;17: 364-70.
Hedlund J. Risky business: safety regulations, risk compensation, and individual behavior. Injury Prev 2000;6: 82-9.(Michael Watson, lecturer in public healt)
Correspondence to: M Watson michael.watson@nottingham.ac.uk
Abstract
Unintentional injury is the leading cause of death in children in the United Kingdom.1 Moreover, it is a major cause of ill health and disability. Most unintentional injuries to children under 5 take place in the home, and children at socioeconomic disadvantage are at greater risk of injury.2
Primary healthcare teams have an important contribution to make to the prevention of unintentional injuries in children,3-5 including home safety counselling and participation in safety equipment schemes. However, there is little evidence in the United Kingdom that they can be effective in reducing unintentional injuries.
Systematic reviews have found that home safety counselling or education, with or without the provision of safety equipment, can increase the use of some items of safety equipment and improve safety behaviours in the short term, but the effect on unintentional injury is less clear.6-9 Many of the trials included in these reviews were conducted in the United States, which limits generalisability to UK settings. In addition, the reviews have highlighted the lack of high quality randomised controlled trials, specifically trials with adequate allocation concealment, blinded outcome assessment, adequate power, and a sufficient follow up period.
The high cost of safety equipment and the difficulty of installing some devices have been identified as barriers to families' implementing advice on home safety.8 No trials to date have examined the effect of providing as well as fitting equipment free of charge.
We report the main results of a randomised controlled trial assessing the effectiveness of an intervention in increasing safety practices and reducing unintentional injuries in families with children aged under 5 years, living in deprived areas.
Methods
We recruited 3428 families (3995 children) between January and May 2000, with 1711 families in the intervention arm and 1717 families in the control arm. The follow up period started on 1 June 2000 and ended on 31 May 2002. The figure shows the flow of participants through the trial. The treatment arms were well balanced at baseline (table 1).
Flow of participants through the trial
Table 1 Characteristics and safety practices of study families at baseline. Values are numbers (%) unless otherwise indicated
A total of 1163 (68%) families in the intervention arm received the safety consultation, and 619 families (36%) had free equipment fitted, and 26 (1.5%) bought equipment at low cost. Table 2 shows results for injury outcomes. The attendance rate for injury in primary care was higher (by 37%) for children in the intervention than in the control arm (P = 0.003). The treatment arms did not differ significantly for the other injury outcomes. We found no evidence that the effect of the intervention varied by family income or child age for any of the primary outcome measures (P > 0.1 for all interaction terms). A compliance analysis found similar results to the primary analysis, with a higher injury attendance rate in primary care in children in the intervention arm who received the safety consultation than in children in the control arm (incidence rate ratio 1.50, 95% confidence interval 1.21 to 1.88) but no difference in rates of attendance in secondary care or admission to hospital.
Table 2 Injury outcomes for injuries at the level of the family or child, at 24 months' follow up, by treatment arm
Table 3 shows that at one year, families in the intervention arm were significantly more likely to be safe in terms of stairs (P = 0.0004), smoke alarms (P = 0.0002), windows (P = 0.03), and storage of cleaning products (P = 0.006) and sharp objects (P = 0.005) in the kitchen than families in the control arm. At two years, families in the intervention arm were significantly more likely to be safe in terms of smoke alarms (P = 0.002), storage of medicines (P = 0.05), and cleaning products (P = 0.008) in the kitchen than families in the control arm. Absolute differences in the percentages of families with safety practices were, however, small—none exceeded 10%.
Table 3 Prevalence of safety practices at 12 and 24 months' follow up, by treatment arm. Values are numbers (percentages) of families unless otherwise indicated
Among families responding to the 12 month questionnaire, 89% (286/322) of those receiving equipment agreed or strongly agreed that they were satisfied with the safety equipment, and 70% (411/589) of families who received the consultation agreed or strongly agreed that they were satisfied with the health visitor's advice. Ninety five per cent (53/56) of responding health visitors agreed or strongly agreed that the safety consultation should be used in routine practice.
Discussion
British Medical Association. Injury prevention. London: BMA, 2001.
Department of Health. Preventing accidental injury-priorities for action. a report from the accidental injury task force to the chief medical officer. London: Department of Health, 2002.
Watson M. Alliances against accidents. Pract Nurs 1994;5(13): 20.
Kendrick D. Role of the primary health care team in preventing accidents to children. Br J Gen Pract 1994;44: 372-5.
Carter YH, Morgan PS, Lancashire RJ. General practitioners' attitudes to child injury prevention in the UK: a national postal questionnaire. Injury Prev 1995;1: 164-8.
Towner E, Dowswell T, Mackereth C, Jarvis S. What works in preventing unintentional injuries in children and young adolescents? An updated systematic review. London: Health Development Agency, 2001.
Lyons R, Sander L, Weightman A, Patterson J, Jones SL, Rolfe B, et al. Modification of the home environment for the reduction of injuries. Cochrane Database Syst Rev 2003;4: CD003600.
DiGuiseppi C, Roberts IG. Individual-level injury prevention strategies in the clinical setting. Future Child 2000;10: 53-82.
DiGuiseppi C, Higgins JP. Systematic review of controlled trials of interventions to promote smoke alarms. Arch Dis Child 2000;82: 341-8.
Townsend P, Phillimore P, Beattie A. Health and deprivation: inequality and the north. London: Croom Helm, 1988.
Kendrick D, Watson M, Dewey M, Woods AJ. Does sending a home safety questionnaire increase recruitment to an injury prevention trial? A randomised controlled trial. 55: 845-846. J Epidemiol Community Health 2001;55: 845-6.
Clamp M, Kendrick D. A randomised controlled trial of general practitioner safety advice for families with children under 5 years. BMJ 1998;316: 1576-9.
Mullen PD, Green LW, Persinger GS. Clinical trials of patient education for chronic conditions: A comparative meta-analysis of intervention types. Prev Med 1985;14: 753-81.
Mullen PD, Simons-Morton DG, Ramirez G, Frankowski RF, Green LW, Mains DA. A meta-analysis of trials evaluating patient education and counseling for three groups of preventive health behaviors. Patient Educ Counsel 1997;32: 157-73.
Watson M, Woods A, Kendrick D. Injury prevention: working together on an RCT. Community Pract 2002;75: 172-5.
Association for the Advancement of Automotive Medicine. The abbreviated injury scale: 1990 revision. Illinois: Association for the Advancement of Automotive Medicine, 1990.
Alwash R, McCarthy M. Measuring severity of injuries to children from home accidents. Arch Dis Child 1988;63: 635-8.
Watson M, Kendrick D, Coupland D. Validation of a home safety questionnaire used in a randomised controlled trial. Injury Prev 2003;9: 180-3.
Lovato L, Hill K, Hertert S, Hunninghake D, Probstfield J. Recruitment for controlled clinical trials: Literature summary and annotated bibliography. Control Clin Trials 1997;18: 328-52.
Watson M, Kendrick D, Woods A, Dewey M. Measuring contamination in an injury prevention randomised controlled trial. Injury Control Safety Promotion (in press).
King WJ, Klassen TP, LeBlanc J, Bernard-Bonnin AC, Robitaille Y, Pham B, et al. The effectiveness of a home visit to prevent childhood injury. Pediatrics 2001;108: 382-8.
Kendrick D, Marsh P, Fielding K, Miller P. Preventing injuries in children: cluster randomised controlled trial in primary care. BMJ 1999;318: 980-3.
Woolf AD, Saperstein A, Forjuoh S. Poisoning prevention knowledge and practices of parents after a childhood poisoning incident. Pediatrics 1992;90: 867-70.
DiGuiseppi C, Roberts I, Speirs N. Smoke alarm installation and function in inner London council housing. Arch Dis Child 1999;81: 400-3.
Elkington J, Blogg S, Kelly J, Carey V. Head injuries in infants: a closer look at baby-walkers, stairs and nursery furniture. NSW Public Health Bull 1999;10: 82-83.
Petridou E, Trichopoulos D, Mera E, Papadatos Y, Papazoglou K, Marantos A, et al. Risk factors for childhood burn injuries: a case-control study from Greece. Burns 1998;24: 123-8.
Azizi BH, Zulkifli HI, Kassim MS. Circumstances surrounding accidental poisoning in children. Med J Malaysia 1994;49: 132-7.
Mallonee S. Evaluating injury prevention programs: the Oklahoma City smoke alarm project. Future Child 2000;10: 164-74.
van Rijn OJ, Meertens RM, Kok G, Bouter LM. Determinants of behavioural risk factors for burn injuries. Burns 1991;17: 364-70.
Hedlund J. Risky business: safety regulations, risk compensation, and individual behavior. Injury Prev 2000;6: 82-9.(Michael Watson, lecturer in public healt)