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Parenting interventions for the prevention of unintentional injuries in childhood

  1. Denise Kendrick1,*,
  2. Caroline A Mulvaney1,
  3. Lily Ye1,
  4. Tony Stevens1,
  5. Julie A Mytton2,
  6. Sarah Stewart-Brown3

Editorial Group: Cochrane Injuries Group

Published Online: 28 MAR 2013

Assessed as up-to-date: 31 JAN 2011

DOI: 10.1002/14651858.CD006020.pub3


How to Cite

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.

Author Information

  1. 1

    University of Nottingham, Division of Primary Care, Nottingham, UK

  2. 2

    University of the West of England at Bristol, Centre for Child and Adolescent Health, Bristol, UK

  3. 3

    Warwick Medical School, Health Sciences Research Unit, Coventry, UK

*Denise Kendrick, Division of Primary Care, University of Nottingham, Floor 13, Tower Building, University Park, Nottingham, NG7 2RD, UK. denise.kendrick@nottingham.ac.uk.

Publication History

  1. Publication Status: New search for studies and content updated (conclusions changed)
  2. Published Online: 28 MAR 2013

SEARCH

 

Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 
Summary of findings for the main comparison. Parenting interventions compared to usual care for the prevention of unintentional injuries in childhood

Parenting interventions compared to usual care for the prevention of unintentional injuries in childhood

Patient or population: parents of children 18 years of age and younger
Settings:
Intervention: parenting interventions
Comparison: usual care

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Usual careParenting interventions

Medically attended or self-reported injuries - RCTs onlyLow1 RR 0.83
(0.73 to 0.94)
5074
(10 studies)
⊕⊕⊕⊝
Moderate2

69 per 100057 per 1000
(50 to 65)

High1

237 per 1000197 per 1000
(173 to 223)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio.

GRADE Working Group grades of evidence:
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Two RCTs recruited families considered at low risk of unintentional injury (low birth weight and premature infants (IHDP) and families with newborns up to 4 weeks of age (Minkowitz(a)). The remaining eight RCTs recruited families considered at high risk of unintentional injury (defined as having at least one risk factor for unintentional injury).
2 Half or more of the RCTs were susceptible to bias in terms of allocation concealment and/or outcome assessment.

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Description of the condition

In industrialised countries, injuries are the leading cause of death in childhood, accounting for 40% of all child deaths between the ages of 1 and 14 years (UNICEF 2001). In the UK, more than 160 children die from an injury (ONS 2009) each year. In addition, more than 100,000 hospital admissions (The NHS Information Centre 2007) and more than two million attendances at accident and emergency departments resulting from child injuries occur each year (DTI 2003). A steep social class gradient in child injury mortality (Roberts 1997; Edwards 2006) and morbidity (Hippisley-Cox 2002) has been noted, along with evidence that the gradient in injury mortality may be widening (Roberts 1996).

 

Description of the intervention

Parenting programmes are aimed at strengthening the quality of the parent-child relationship by improving parenting practices; aspects of parental functioning such as mental health, attributions, and cognitions; the child's emotional and behavioural adjustment; and family functioning more generally. These programmes can be provided in a variety of settings such as at home, in clinics, and in other community venues. Several recent systematic reviews have shown that they are effective in helping with behaviour problems in infants and toddlers (Barlow 2002) and in 3- to 10-year-old children (Barlow 2000), and in improving maternal psychosocial health in the short term, including reducing scores measuring anxiety and depression and enhancing self esteem (Barlow 2003) and self confidence. Evidence also shows that they are effective in improving outcomes for both teenage mothers and their children (Coren 2002).

 

How the intervention might work

Parenting programmes may reduce child injury rates through several mechanisms. First, evidence shows that maternal psychological well-being is associated with childhood unintentional injury. Higher unintentional injury rates have been found amongst children whose mothers are defined as having a psychiatric disorder (Brown 1978) or suffering from depression (Beautrais 1981; Harris 1994; O'Connor 2000) or anxiety (Bradbury 1999); as having experienced a greater number of life events, such as separation from their partner, recent bereavement, or moving the household (Beautrais 1982; O'Connor 2000); or as having higher levels of stress (Harris 1994). A large US cohort study found that depressed mothers were significantly less likely to engage in safety practices such as use of a child car seat or electric socket covers, and were less likely to keep an emetic agent for the treatment of poisoning in the home (McLennan 2000). It is therefore possible that parenting programmes may help reduce childhood unintentional injuries by improving maternal psychological health. Second, child behavioural problems, including aggressive or overactive behaviour and attention-deficit hyperactivity disorder (ADHD) (Miller 2004; Rowe 2004; Lam 2005), are associated with increased unintentional injury rates (Bijur 1986; Bijur 1988a; Bijur 1988b; Bussing 1996), and parenting programmes, by reducing child behavioural problems, may help to reduce such injuries. Third, injuries can occur when parents are unable to predict the child’s ability to perform tasks such as climbing or opening locks, or when parents expect children to understand and remember instructions aimed at keeping them safe from injury (Smithson 2011). Parenting programmes teach parents realistic expectations that are appropriate for a child’s age and developmental stage, thus potentially reducing the risk of injury (Sanders 2002; Hunt 2003). Data from a systematic review of home visiting programmes provide some evidence to support these suggested mechanisms; home visiting programmes were found to be effective in improving parenting, maternal psychosocial health, and child behavioural problems, and in reducing childhood unintentional injuries (Elkan 2000; Kendrick 2000). More recent work suggests that positive parenting (e.g. frequent praise, playing with children) is associated with a protective effect on injury rates (Schwebel 2004; Soubhi 2004). It is therefore possible that parenting programmes may help prevent childhood unintentional injury by developing particular styles of parenting. We are therefore interested in assessing the effectiveness of parenting programmes in preventing childhood injury.

 

Why it is important to do this review

We were unable to find any systematic reviews examining the effect of parenting programmes on the prevention of childhood unintentional injury for the original review; thus this review was undertaken. A recent search failed to find any recent reviews published since our original Cochrane review.

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

The primary objective of the review is to evaluate the effectiveness of parenting programmes in preventing unintentional injury in childhood.

The secondary objective of the review is to evaluate the effectiveness of parenting programmes in increasing possession and use of home safety equipment and in improving parental safety practices.

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included individually and cluster randomised controlled trials, non-randomised controlled trials, and controlled before and after studies.

 

Types of participants

We included studies in which the intervention was provided for parents of children 18 years of age and younger.

 

Types of interventions

Studies evaluating the effectiveness of individual and group-based parenting interventions were eligible for inclusion irrespective of the theoretical basis underpinning the programme. Parenting programmes are defined as interventions with a specified protocol, manual, or curriculum aimed at changing knowledge, attitudes, or skills covering a range of topics relevant to parenting. The control group in studies should not be provided with a parenting intervention.

 

Types of outcome measures

Studies were eligible for inclusion if they reported the primary outcome of:

  • Self-reported or medically attended unintentional injury or injury of unspecified intent.

or secondary outcomes of:

  • Possession and use of home safety equipment.
  • Safety practices (e.g. storage of hazardous objects and substances, safe use of baby walkers, avoidance of unsafe hot water temperature) and composite measures of safety practices, including the Home Observation for Measurement of the Environment (HOME) Inventory. The Infant-Toddler HOME Inventory, designed for use with children from birth to 3 years of age, consists of six subscales: emotional and verbal responsivity of the primary caregiver (items 1 to 11); avoidance of restriction and punishment (items 12 to 19); organisation of the physical and temporal environment (items 20 to 25), including "the child’s play environment appears safe and free of hazards"; provision of appropriate play materials (items 26 to 34); parental involvement with the child (items 35 to 40); and opportunities for variety in daily stimulation (items 40 to 45) (Caldwell 2003; Totsika 2004). A higher score indicates a more appropriate home environment for child development.

Intentional injury outcomes were excluded as these are the focus of another Cochrane review (Barlow 2006). Parent training interventions for children with ADHD, which are the subject of a protocol for a Cochrane review (Zwi 2011), were included because injury is not an outcome listed in the protocol.

 

Search methods for identification of studies

The search strategy was selected to identify randomised and non-randomised studies using terms to identify parenting programmes, injuries, safety equipment, and safety practices.

 

Electronic searches

We searched the following databases, with no language restrictions, from the date of inception to January 2011 (from 2005 to 2011 for the update):

  • Cochrane Central Register of Controlled Trials (CENTRAL), Issue 1, 2011.
  • Cochrane Database of Systematic Reviews (CDSR).
  • MEDLINE (Ovid SP), 1950 to January 2011.
  • EMBASE (Ovid SP), 1980 to January 2011.
  • BIOSIS Previews (was Biological Abstract), 1969 to January 2011.
  • PsycINFO (Ovid), 1806 to January.
  • Sociological Abstracts (was Sociofile) (CSA), 1952 to January 2011.
  • CINAHL (EBSCO), 1982 to January 2011.
  • ProQuest Dissertations and Theses (was Dissertation Abstracts), 1743 to January 2011.
  • ERIC, 1966 to January 2011.
  • Database of Abstracts of Reviews of Effectiveness, 1994 to January 2011.
  • ASSIA, 1987 to January 2011.
  • ISI Web of Science: Social Sciences Citation Index (SSCI), 1970 to January 2011.
  • ISI Web of Science: Conference Proceedings Citation Index-Social Science & Humanities (CPCI-SSH), 1990 to January 2011.
  • SIGLE (ceased March 2005).
  • ZETOC, 1993 to January 2011.

We also searched a range of websites, including:

  • Injury Prevention Research Center at the Centers for Disease Control and Prevention (USA) (http://www.cdc.gov/injury/ - searched December 2010).
  • National Institute for Health and Clinical Excellence (NICE) (http://www.nice.org.uk/ - searched December 2010).
  • Public Health website (UK) (http://www.dh.gov.uk/en/index.htm - searched December 2010).
  • Children's Safety Network (USA) (http://www.childrenssafetynetwork.org/ - searched December 2010).
  • International Society for Child and Adolescent Injury Prevention (International) (http://iscaip.net/iscaip/ - searched December 2010).
  • Child Accident Prevention Trust (UK) (http://www.capt.org.uk/ - searched December 2010).
  • Injury Control Resource Information Network (USA) (http://www.injurycontrol.com/icrin/research.htm - searched December 2010).
  • National Injury Surveillance Unit (Australia) (http://www.nisu.flinders.edu.au/ - searched December 2010).
  • Injury Prevention Web and SafetyLit (USA) (http://www.safetylit.org/ - searched December 2010).
  • Barnado's Policy and Research Unit (UK) (http://www.barnardos.org.uk/what_we_do/policy_research_unit.htm - searched December 2010).
  • NCH (UK) (http://www.actionforchildren.org.uk/ - searched December 2010).
  • National Children's Bureau (UK) (http://www.ncb.org.uk/ - searched December 2010).
  • Children in Wales (UK) (http://www.childreninwales.org.uk/index.html - searched December 2010).
  • Homestart (UK) (http://www.home-start.org.uk/homepage - searched December 2010).

 

Searching other resources

We handsearched abstracts from the 1st to 10th World Conferences on Injury Prevention and Control and the table of contents for the journal Injury Prevention, from the first publication to January 2011. We also handsearched reference lists of articles identified through database searches and bibliographies of systematic and non-systematic reviews. Injuries, safety equipment, or safety practices may have been secondary outcome measures in clinical studies; therefore, we attempted to contact authors of studies excluded because of the outcomes they reported to ascertain if they had measured, but not reported, outcomes relevant for our review.

To identify unpublished studies, we searched the following sources:

  • The Cochrane Library.
  • Current Controlled Trials.
  • National Research Register (NRR) (up to September 2007, the date of its closure).
  • UK Clinical Research Network Study Portfolio.

No restrictions by language or publication status were applied.

 

Data collection and analysis

 

Selection of studies

A two-stage screening process was undertaken. Two review authors independently scanned titles and abstracts of articles to identify articles that could be retrieved in full. In cases of disagreement between review authors, the decision was made by a third review author. The full article was retrieved for those articles retained at this stage. Two review authors independently assessed selected articles using a standard form listing inclusion criteria, with disagreements dealt with by referral to a third review author.

 

Data extraction and management

Data extraction was undertaken independently by pairs of review authors (DK, CM, TS, LY) using a pre-tested data extraction form. For each study, we extracted data on the following: age of participants; country where study was set; whether participants were considered at risk of non-accidental injury; type of intervention (e.g. group-based, individual); aim of intervention in terms of changing parenting knowledge, parenting attitudes, or parenting skills, and in preventing non-accidental injury, improving child behaviour, and improving maternal psychosocial health; who delivered the intervention and where; the numbers of contacts and sessions; and the length of each contact/session and over what time it occurred. Data on the study population were extracted, such as living in a deprived area, age of the mother, years/level of maternal education, single parenthood, and ethnic group. We also extracted data on study design, the numbers of participants recruited for intervention and control groups, the number of intervention group parents who did not receive the intervention, and the number who completed the study.

In terms of primary outcomes (medically attended injuries) and secondary outcomes (possessions and use of safety equipment) of interest, we extracted data on the numbers of participants in the intervention and control groups and the numbers with the outcome of interest. For the primary outcome, these data were extracted at child, family, or cluster level, as appropriate to the study design. Where data were presented as the mean number of injuries over a period of time (m), we estimated the probability of a participant's not having an injury by assuming that the occurrence of injuries followed a Poisson distribution using e-m, and from this estimated the numbers of children who did and did not experience at least one injury.

For the secondary outcome of HOME score, we extracted the mean score and the standard deviation (SD) for the intervention and control groups. For cluster randomised controlled trials, we extracted the intraclass correlation coefficients (ICCs) for the primary and secondary outcome measures, if reported. We also extracted data on study outcomes, and we extracted data on the period over which outcomes were measured.

If key data were not available in the published reports, we contacted study authors to obtain missing information.

 

Assessment of risk of bias in included studies

Critical appraisal of included studies was undertaken independently by two review authors, who covered the following sources of bias for randomised controlled trials (RCTs):

  • Random sequence generation (selection bias).
  • Allocation concealment (selection bias).
  • Blinding (performance bias and detection bias).
  • Blinding of participants and personnel (performance bias).
  • Blinding of outcome assessment (detection bias).
  • Incomplete outcome data (attrition bias).
  • Selective reporting (reporting bias).
  • Other bias.

The following sources of bias were assessed for non-randomised studies:

  • Participant selection (selection bias).
  • Blinding (performance bias and detection bias).
  • Blinding of participants and personnel (performance bias).
  • Blinding of outcome assessment (detection bias).
  • Incomplete outcome data (attrition bias).
  • Selective reporting (reporting bias).
  • Risk of bias due to confounding: Was the distribution of confounders assessed between treatment arms? If so, do treatment arms appear similar in terms of confounders?
  • Other bias.

Review authors gave a brief description of possible sources of each type of bias and rated the risk of bias as high, low, unclear, or unknown. Disagreement between review authors was dealt with by referral to a third review author.

 

Measures of treatment effect

Pooled relative risks and 95% confidence intervals have been used for binary outcome measures and mean differences, and 95% confidence intervals for continuous outcome measures.

 

Unit of analysis issues

We adjusted the reported treatment effect in cluster allocated studies reporting binary outcomes as numerators and denominators, unadjusted for clustering, using the ICC of the study if available, otherwise using the ICC of similar cluster randomised studies. We adjusted numerators and denominators by using the design effect, which was calculated from the ICC and the average cluster size.

 

Dealing with missing data

We assessed missing data and dropouts for each included study and reported the number of participants included in the final analysis as a proportion of all participants in each study. Reasons for missing data are provided in the narrative summary, where available, and we assessed the extent to which the results of the review could be altered by the missing data. The extent to which studies conformed to an intention-to-treat analysis and the effects of this on the results were also assessed.

 

Assessment of heterogeneity

Statistical tests of homogeneity were undertaken using Chi2 tests (with significance defined as a P value < 0.1) and the I2 statistic. The I2 statistic describes the percentage of total variation across studies caused by heterogeneity rather than by chance. A value of 0% indicates no observed heterogeneity, and larger values show increasing heterogeneity; substantial heterogeneity is considered to exist when I2 > 50% (Higgins 2005). Pooled relative risks (RRs) and 95% confidence intervals (CIs) have been estimated for the binary outcome of occurrence of at least one self-reported or medically attended injury, with random-effects models used to allow for heterogeneity.

 

Assessment of reporting biases

Publication bias was assessed for the primary analysis with the use of a funnel plot and Egger's test (using Stata, version 11).

 

Data synthesis

Pooled RRs and 95% CIs were estimated for occurrence of at least one self-reported or medically attended injury using data from included RCTs. Pooled mean differences and 95% CIs were estimated for HOME scale scores using data from included RCTs. Random-effects models were used to allow for and to quantify the degree of statistical heterogeneity present between individual studies. When clinically homogenous studies were insufficient to be combined in a meta-analysis, or when findings were derived from non-RCTs, the results were combined in a narrative review. We produced a "summary of findings table" for the primary outcome of injuries and assessed the evidence using Grading of Recommendations Assessment, Development, and Evaluation guidelines (GRADE).

 

Subgroup analysis and investigation of heterogeneity

No subgroup analyses have been undertaken.

 

Sensitivity analysis

Sensitivity analyses have been undertaken that included only RCTs considered to be at low risk of selection bias in terms of adequate allocation concealment, detection bias in terms of blinded outcome assessment, and attrition bias as the result of follow-up of less than 80% of participants in each arm. Sensitivity analyses have also been undertaken by excluding one study when there was some uncertainty as to the extent to which the intervention was based on a protocol, manual, or curriculum (Fergusson 2005); and by including longer term (seven years), but less complete, follow-up data from one study (Johnson 2000) whose short-term follow-up data (Johnson 1993) were included in the main analysis. Finally, one study reported a range of injury types (bruises, burns, scratches, and unspecified injury, separately), and the most commonly reported outcome (bruises) was chosen for inclusion in the main analysis; sensitivity analyses were undertaken for the other outcomes (Armstrong 2000).

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Description of studies

Twenty-two studies from 30 articles were included in the review and are described in the table 'Characteristics of included studies' (Characteristics of included studies;  Table 1). The process of study selection is documented in Figure 1 (Figure 1). Several authors report results from the same study at different follow-up time points in separate papers: two papers presented results from one RCT at child's first birthday (Johnson 1993) and at 7-year follow-up (Johnson 2000); two articles presented results from one RCT at 12 (Barlow 2007) and 36 months (Barlow 2008) postnatally; two papers presented results from one RCT at two years (Olds 1986) and at 25- to 50-month follow-up (Olds 1994); two papers presented results from one RCT at four months (Armstrong 2000) and at 18 months (Fraser 2000) postnatally; two papers presented results from a non-RCT at one week and three months postpartum (Johnston 2004) and at 30 months postpartum (Johnston 2006; and two papers presented results from one RCT at two years (Duggan 1999) and three years (Duggan 2004) postrecruitment. Similarly, several authors report results from the same study in more than one paper: Results from one RCT collected at the time of the child's second birthday are presented in two papers (Caldera 2007)(Duggan 2007); results from one RCT collected at 1, 12, and 24 months postpartum are presented in two papers (Kemp 2008; Kemp 2011); and results from one RCT collected annually on the child's birthday for five years are presented in two papers (St Pierre 1999) (Goodson 2000). One paper presents the results from both an RCT (Minkovitz 2003 (a)) and a CBA (Minkovitz 2003 (b)).

 FigureFigure 1. Quorum flow chart detailing process of study selection for all studies included in the review.

 

Types of studies

Sixteen (73%) included studies were RCTs (Gutelius 1977; Olds 1986; IHDP 1990; Feldman 1992; Johnson 1993; Kitzman 1997; Duggan 1999; St Pierre 1999; Armstrong 2000; Koniak-Griffin 2003; Llewellyn 2003; Minkovitz 2003 (a); Fergusson 2005; Barlow 2007; Caldera 2007; Kemp 2011), two (9%) were non-RCTs (Johnston 2004; Culp 2007), one (5%) was a partially randomised study with two randomised intervention arms and one non-randomised control arm (Larson 1980), two (9%) were CBA studies (Emond 2002; Minkovitz 2003 (b)), and one (5%) was a quasi-RCT (Hardy 1989). Four studies used clustered allocation (Emond 2002; Minkovitz 2003 (b); Johnston 2004; Culp 2007). Thirteen studies (59%) were from the United States, three from Australia (14%), two (9%) each from Canada and England, and one (5%) each from Ireland and New Zealand.

 

Types of participants

Fifteen of the studies recruited socio-economically disadvantaged participants (Gutelius 1977; Larson 1980; Olds 1986; Hardy 1989; Johnson 1993; Kitzman 1997; Duggan 1999; St Pierre 1999; Armstrong 2000; Emond 2002; Koniak-Griffin 2003; Fergusson 2005; Barlow 2007; Caldera 2007; Kemp 2011); five of these studies specifically recruited participants considered to be at risk of child abuse or neglect (Olds 1986; Duggan 1999; Armstrong 2000; Barlow 2007; Caldera 2007), and two specifically recruited young mothers (15 to 19 years of age) (Gutelius 1977; Koniak-Griffin 2003). Two studies recruited participants with a learning disability (Feldman 1992; Llewellyn 2003), one study recruited mothers who were considered at risk of poor coping as a parent (Kemp 2011), one study recruited mothers of low birth weight premature infants (IHDP 1990), two studies recruited first-time mothers ( Johnson 1993; Culp 2007), and three studies recruited consecutive newborns from a range of paediatric practices (Minkovitz 2003 (a); Minkovitz 2003 (b); Johnston 2004).

 

Types of interventions

Seventeen studies evaluated multi-faceted home visiting programmes aimed at improving a range of child and often maternal health outcomes (Gutelius 1977; Larson 1980; Olds 1986; Hardy 1989; IHDP 1990; Johnson 1993; Kitzman 1997; Duggan 1999; St Pierre 1999; Armstrong 2000; Emond 2002; Koniak-Griffin 2003; Fergusson 2005; Barlow 2007; Caldera 2007; Culp 2007; Kemp 2011). Three studies evaluated paediatric practice-based multi-faceted interventions, aimed at improving a range of child health outcomes, all of which included some home visits (Minkovitz 2003 (a); Minkovitz 2003 (b); Johnston 2004), but these were not the main method of delivery of the intervention. Two studies provided solely educational interventions in the home (Feldman 1992; Llewellyn 2003). The 20 studies evaluating multi-faceted interventions provided both parenting education and a range of other support services, including 12 that helped the family with solving a variety of problems (Kitzman 1997; Larson 1980; IHDP 1990; Johnson 1993; St Pierre 1999; Emond 2002; Minkovitz 2003 (a); Minkovitz 2003 (b); Johnston 2004; Fergusson 2005; Barlow 2007; Kemp 2011) and 12 that facilitated access to child healthcare (Gutelius 1977; Larson 1980; Olds 1986; IHDP 1990; Kitzman 1997; Duggan 1999; Minkovitz 2003 (a); Minkovitz 2003 (b); Johnston 2004; Caldera 2007) or other community services (Olds 1986; Hardy 1989; Duggan 1999; Armstrong 2000).

All studies provided the intervention to individual parents. In addition, four studies provided opportunities for peer support from other parents (St Pierre 1999; Minkovitz 2003 (a); Minkovitz 2003 (b); Kemp 2011) and one for enhanced informal support from family and friends (Olds 1986); and five studies provided parenting education to groups of parents (Gutelius 1977; IHDP 1990; St Pierre 1999; Koniak-Griffin 2003; Johnston 2004), which, as a consequence, also provided opportunities for peer support. One of the two studies that provided solely educational interventions (Llewellyn 2003) included a control group that received home visits in which the visitor discussed parents' experiences of raising their children but without the educational intervention, thus allowing the effect of the home visit as opposed to that of the education to be assessed (Llewellyn 2003).

 

Types of outcome measures

Sixteen studies reported medically attended or self-reported injury (Gutelius 1977; Larson 1980; Olds 1986; Hardy 1989; IHDP 1990; Johnson 1993; Kitzman 1997; Duggan 1999; Armstrong 2000; Emond 2002; Koniak-Griffin 2003; Minkovitz 2003 (a); Minkovitz 2003 (b); Fergusson 2005; Caldera 2007; Culp 2007). Of these, one did not provide numerators and denominators (Emond 2002). Data from one study (IHDP 1990) for use in the meta-analysis were taken from data reported in a systematic review (Roberts 1996b). Data from another study (Culp 2007) were calculated from unpublished data. Kitzman (Kitzman 1997) reported the incidence of five types of hospital encounters for injuries and ingestions, including the number of outpatient visits and the number of hospitalizations; data on the total number of healthcare encounters for injuries and ingestions were used in the meta-analysis for this review.

One study presented maternal reports of medically attended injuries in the first and second years of life (Duggan 1999), and a separate article from the same study reported hospitalisations in the first three years of life (Duggan 2004), which are not mutually exclusive outcomes. Data from the first two years of life were included in the meta-analysis as the number of events for this outcome was higher.

Seven studies reported a range of safety outcomes, including use of socket covers (Emond 2002; Minkovitz 2003 (a); Minkovitz 2003 (b); Johnston 2006) and stair gates (Emond 2002; Johnston 2006), lowering of hot water heater temperature (Minkovitz 2003 (a); Minkovitz 2003 (b); Culp 2007), use of cabinet locks and knowing the number to call if a child ingests harmful substances (Minkovitz 2003 (a); Minkovitz 2003 (b); Johnston 2006), accessibility of poisons (Olds 1986), presence of stickers on poisonous substances (Minkovitz 2003 (a); Minkovitz 2003 (b)), having a functional smoke alarm (Minkovitz 2003 (a); Minkovitz 2003 (b)), and adhering to sleep safety practices (Feldman 1992; Johnston 2004). Two studies reported a range of home hazards using different tools (Olds 1986; Llewellyn 2003), and one study reported use of a home safety index at 3 and 30 months (Johnston 2004; Johnston 2006), based on the presence of a functioning smoke alarm, regular and correct use of a car seat, absence or safe storage of firearms in the house, and, for the 3-month data collection period only, following safe sleep practices (Johnston 2004).

Ten studies (Larson 1980; Olds 1986; Kitzman 1997; Duggan 1999; St Pierre 1999; Armstrong 2000; Koniak-Griffin 2003; Barlow 2007; Caldera 2007; Kemp 2011) measured the quality of the home environment using the HOME Inventory, one subscale of which measures organisation of the environment in relation to child development and safety. Of the ten studies, a total of eight reported total HOME scores, three reported "organisation of the home environment" subscale scores, and two reported scores for subscales that were irrelevant to the outcomes of this review ( Table 2). The HOME score was most commonly measured at 12 months. One study measured the quality of the home environment by using the Massachusetts Home Safety Questionnaire (Culp 2007).

 

Risk of bias in included studies

Studies were assessed for quality using the criteria described in the table 'Characteristics of included studies' (Characteristics of included studies). In terms of selection bias, 10 (63%) of the 16 RCTs had low risk as the result of adequate random sequence generation and seven (44%) because of adequate allocation concealment (Figure 2; Figure 3). Although 15 (94%) of the 16 RCTs were judged to be at high risk of performance bias, only five (31%) were judged to be at high risk of detection bias. Six (38%) of the 16 RCTs had a high risk of attrition bias, and five (31%) were judged as being at high risk of selective reporting bias.

 FigureFigure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
 FigureFigure 3. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all 22 included studies.

 

Effects of interventions

See:  Summary of findings for the main comparison Parenting interventions compared to usual care for the prevention of unintentional injuries in childhood

 

Medically attended or self-reported injury: RCTs

Eleven RCTs reported medically attended or self-reported injury. One did not provide outcome by treatment group (Koniak-Griffin 2003); thus results from ten RCTs were used in a meta-analysis. Findings from this ( Analysis 1.1) show that the intervention arm families had a statistically significantly lower risk of injury than control arm families (RR 0.83, 95% CI 0.73 to 0.94; Chi2 = 9.23, 9 degrees of freedom (df), P = 0.42; I2 = 2%). There did not appear to be any evidence of publication bias amongst the ten RCTs in the primary analysis (Egger's test regression coefficient = -0.65 (standard error (SE) 0.49), P = 0.22) (Figure 4). The study reported by Duggan (Duggan 2004), which measured maternal reports of medically attended injuries and medical records of hospitalisations for trauma, found 1.5% of the 342 children in the intervention group hospitalised for trauma in the first three years of life compared with 1.7% of the 231 children in the control group (statistical significance not reported). One article described two studies that evaluated the same paediatric clinic-based multi-faceted intervention (Minkovitz 2003 (a);Minkovitz 2003 (b)) using an RCT and a CBA. The randomised sites showed no statistically significant difference in emergency department (ED) use for injuries (odds ratio (OR) 0.94, 95% CI 0.65 to 1.34, P = 0.09). Although the Koniak-Griffin study (Koniak-Griffin 2003) reported numbers of visits to the ED by treatment group, the authors state that most of these visits were needed for illness, and that although only eight children were treated for injuries and accidents, this was not reported by treatment group.

 FigureFigure 4. Funnel plot of comparison: 1 Intervention versus Control (n/N in clustered studies adjusted for clustering), outcome: 1.1 Medically attended or self-reported injuries - RCTs only.

&&One study (Johnson 2000) reported medically attended injury at 7-year follow-up from the Community Mothers trial (Johnson 1993). Investigators reported that 10 of 38 children in the intervention group and 17 of 38 children in the control group had had an accident that required a visit to the hospital (RR 0.59, 95% CI 0.31 to 1.11, P = 0.09). Unfortunately, two thirds of participants had been lost to follow-up by seven years, but a sensitivity analysis was undertaken that included the longer term but not the shorter term results, as these were encompassed in the longer term results. The findings were robust to the use of the longer term results (RR 0.83, 95% CI 0.74 to 0.94, P = 0.52).

Sensitivity analyses were undertaken first by using each of the injury outcomes reported in a previous trial (Armstrong 2000). The findings were robust to the varying definitions of injury (burns RR 0.85, 95% CI 0.75 to 0.96; scratches RR 0.85, 95% CI 0.75 to 0.96; unspecified injury RR 0.84, 95% CI 0.74 to 0.95). Findings were also robust (RR 0.85, 95% CI 0.75 to 0.97) to excluding one study in which the extent to which the intervention was based on a protocol, manual, or curriculum was unclear (Fergusson 2005).

Finally, sensitivity analyses were undertaken for the primary analysis, including only RCTs at low risk of various sources of bias. The findings were robust to including only those studies at low risk of detection bias in terms of blinded outcome assessment (RR 0.83, 95% CI 0.71 to 0.97) (Kitzman 1997; Duggan 1999; Armstrong 2000; Caldera 2007) and at low risk of attrition bias in terms of follow-up of less than 80% of participants in each arm (RR 0.80, 95% CI 0.70 to 0.93) (Gutelius 1977; IHDP 1990; Johnson 1993; Kitzman 1997; Duggan 1999; Armstrong 2000; Fergusson 2005; Caldera 2007). When analyses were restricted to studies at low risk of selection bias in terms of inadequate allocation concealment (RR 0.83, 95% CI 0.67 to 1.04) (Johnson 1993; Kitzman 1997; Duggan 1999; Armstrong 2000; Minkovitz 2003 (a)), the relative risk was similar but the 95% CIs were wider and the effect size was no longer statistically significant, possibly as a result of the small number of studies included in this subgroup analysis. Overall, when GRADE was used, the quality of the evidence was rated as moderate ( Summary of findings for the main comparison).

 

Medically attended or self-reported injury: non-RCTs

Six non-RCTs reported medically attended or self-reported injury. Two of the non-RCTS used clustered allocation (Minkovitz 2003 (b); Culp 2007) and reported numerators and denominators for ED use for injury-related causes, allowing us to adjust for clustering by using an ICC of 0.017 (Kendrick 1999), and these were rounded to the nearest integer. Two studies that evaluated the same paediatric clinic-based multi-faceted intervention (Minkovitz 2003 (a); Minkovitz 2003 (b)) by using an RCT and a CBA, found a statistically significant reduction in ED use for injuries only in the CBA study sites (OR 0.67, 95% CI 0.49 to 0.90, P = 0.02). After adjustments were made for clustering, it was noted that 32 visits to the ED for injury related for 368 children in the intervention arm, and 40 were reported for 342 children in the control arm (Minkovitz 2003 (b)). One study (Larson 1980) found that 64 children in the intervention arm suffered 42 accidents compared with 32 accidents suffered by 41 children in the control arm-a statistically significant difference (P < 0.1). A second study also found statistically significantly fewer intervention arm mothers than mothers in the control arm reporting injuries to their children in the preceding 12 months after adjustments were made for confounding factors and for clustering (OR 0.54, 95% CI 0.33 to 0.88, P = 0.022) (Emond 2002). In contrast, another study (Hardy 1989) reported 8 (6%) observations of sustained closed head trauma for 131 children in the intervention arm and 15 (11%) for 132 children in the control arm. This difference was not statistically significant. Similarly, the Culp study (Culp 2007) did not find a statistically significant difference between intervention and control arms. After adjustment for clustering, 7 visits were made to the ED for the care of 103 children in the intervention arm, and 11 visits were made for 86 children in the control arm (statistical significance not reported).

 

Home safety outcomes

Studies reported home safety practices and hazards using a variety of methods and scales.

 

Home Observation for Measurement of the Environment (HOME) scores

Ten studies reported total HOME or subscale scores ( Table 2). One study (Duggan 1999) reported only results from subscales that were irrelevant to this review. Authors most often reported HOME scores at 12 months (six of ten studies) but frequently reported insufficient detail for the study data to be included in a meta-analysis. Data on total HOME scores at 12 months from three RCTs (Armstrong 2000; Koniak-Griffin 2003; Barlow 2007) were included in a meta-analysis. Data from one RCT (Koniak-Griffin 2003) were received in a personal communication. Results from the meta-analysis show no statistically significant difference in total HOME scores between intervention and control arm families (mean difference 0.57, 95% CI -0.59 to 1.72, Chi2 = 0.41, 2 df, P = 0.82; I2 = 0%) (a higher HOME score represents a more enriched home environment for the child). Another trial (Armstrong 2000) also reported organisation of the home environment subscale scores and found a statistically significant difference favouring the intervention arm (mean score intervention arm 5.70 (SD 0.77) vs mean score control arm 5.11 (SD 1.16), P < 0.05). An additional trial (Barlow 2008) reported that no statistically significant differences were found between home visiting and control groups on the HOME Inventory scale at 36 months postnatally (mean score intervention arm = 24.76 (no SD reported), mean score control arm = 23.45 (no SD reported), P = 0.98).

Of the six studies not included in the meta-analysis that reported total HOME scores or organisation of the environment subscale scores, two found statistically significant differences favouring intervention arm families (Larson 1980; Kitzman 1997). Another group (Kitzman 1997) found a statistically significant effect of the intervention on the overall HOME score at 24 months (total HOME score intervention arm 32.3 vs control arm 30.9 (SDs not reported), mean difference -1.3, 95% CI -2.2 to -0.4, P = 0.003). An additional trial (Larson 1980) found that mothers in intervention group A (antenatal and postnatal programme) had statistically significantly higher overall HOME scores compared with those in group B (postnatal programme only) or in the control arm at three of the four assessment points (mean group A at six weeks, six months, 12 months, and 18 months: 29.3, 35.2, 40.1, and 41.2; vs mean group B: 25.8, 33.7, 37.8, and 38.6; vs mean control arm: 26.7; 33.2; 37.8; and 39.0 (no SD reported); P values < 0.001; < 0.005; < 0.017; and < 0.041).

Four studies found no statistically significant difference between treatment arms, although one study found statistically significant differences only amongst distressed mothers (Kemp 2011). Another group (Caldera 2007) found no statistically significant difference in total HOME scores at 24-month follow-up (mean score intervention arm 36.7 vs 35.9 control arm (SD not reported), P = 0.10). Fewer intervention families than control families had extremely poor total HOME scores (i.e. less than or equal to 33) (20% vs 31%, P < 0.001). Group scores did not differ statistically significantly on any HOME subscale. One trial (Kemp 2011) reported organisation of the home environment subscale scores and found no statistically significant difference between groups (mean score intervention arm 4.92 (SE 0.08), mean score control arm 4.84 (SE 0.08), mean difference 0.09, 95% CI -0.13 to 0.30, P = 0.43). This group (Kemp 2011) also reported scores for mothers with more than one risk factor (mean score intervention arm 4.96 (SE 0.10), mean score control arm 4.68 (SE 0.11), mean difference 0.27 (95% CI -0.03 to 0.57), P = 0.07) and for distressed mothers (mean score intervention arm 5.00 (SE = 0.10), mean score control arm 4.60 (SE=0.10), mean difference 0.40 (95% CI 0.11 to 0.69), P = 0.01). It is not clear whether reported results were measured at 12 or 24 months. Another study (Olds 1994) reported no statistically significant differences in total HOME scores at both 34 (mean score intervention arm 39.08, mean score control arm 39.03, mean difference -0.05, 95% CI -1.92 to 1.84) and 46 months (mean score intervention arm 39.66, mean score control arm 39.67 (no SD reported), mean difference 0.01, 95% CI -1.66 to 1.67). One trial (St Pierre 1999) presented total HOME scores measured at four years and found no statistically significant difference between groups (mean score intervention arm 32.55 (SD 9.46), mean score control arm 33.03 (SD 9.45), P value reported only as "non-significant").

 

Safety practices

Seven studies reported specific safety practices or use of items of safety equipment; 5 studies found effects favouring intervention arm families.

One study (Olds 1994) found no effect of the intervention on the extent to which mothers reported that they kept poisonous substances out of reach of their children or used child restraints in cars. Another study (Feldman 1992) measured sleep safety but reported findings only for all child care skills combined. The intervention arm had a statistically significant higher score for all child care skills at follow-up than was reported for the control arm (intervention arm mean 88.1% skills correct (no SD reported) vs control arm mean 60.6% skills correct (no SD reported), P < 0.001). Other investigators (Emond 2002) reported that statistically significantly more mothers in the intervention arm used electric socket covers (OR adjusted for confounders and clustering 1.92, 95% CI 1.16 to 3.17, P = 0.019) and safety gates (data not reported) than control arm mothers.

One study (Johnston 2004) found no statistically significant difference in the use of safe-sleep practices at 3 months postpartum between treatment groups (intervention arm 80.1% vs control arm 80.3%, adjusted RR 1.02, 95% CI 0.98 to 1.05). Another study (Johnston 2006), reporting on the same participants as were described in an earlier study (Johnston 2004) at 30 months postpartum, found that intervention arm families were statistically significantly more likely to use stair gates than were control arm families (I 33.2% vs C 30.2%, RR 1.19, 95% CI 1.15 to 1.23, P < 0.05) and to have the local poison control centre number accessible (I 95.8% vs C 90.4%, RR 1.08, 95% CI 1.03 to 1.12, P < 0.05) but were statistically significantly less likely to use safety latches on cabinets (I 66.8% vs C 77.9%, RR 0.88, 95% CI 0.83 to 0.93, P < 0.05). No statistically significant difference between groups was noted for use of covers on electric outlets (I 92.9% vs C 92.3%, RR 1.00, 95% CI 0.98 to 1.03).

One group (Minkovitz 2003 (a)), reporting results from an RCT, found no statistically significant difference in the proportion of families who lowered the temperature on water heaters (intervention arm 64.4% vs control arm 60.4%, P = 0.11) or who used safety latches on cabinets (intervention arm 63.3% vs control arm 61.8%, P = 0.34). However, a statistically significant difference was noted in the proportion of families who used covers on electric sockets (intervention arm 91.9% vs control arm 88.8%, P = 0.04). Results from the CBA (Minkovitz 2003 (b)) found no statistically significant difference in the proportion of families who lowered the temperature on water heaters (intervention arm 56.8% vs control arm 56.3%, P = 0.82), used covers on electric sockets (intervention arm 90.5% vs control arm 89.5%, P = 0.46), or used safety latches on cabinets (intervention arm 63.5% vs control arm 62.5%, P = 0.62). Another group (Culp 2007) reported that intervention arm families were more likely to have hot water adjusted to a safe temperature and electric cords beyond a child's reach (figures and P values not reported).

 

Home hazards

Two studies reported measures of home hazards.

The first (Olds 1994) reported statistically significantly fewer observed hazards in the home at both 34 months (mean intervention arm 0.22 vs control arm 0.38 (no SD reported), P = 0.04) and 46 months (mean intervention arm 0.21 vs control arm 0.46 (no SD reported), P = 0.003) amongst intervention arm families than control arm families.

The other study (Llewellyn 2003) compared the Home Learning Programme with home visits without parental education, with lesson only booklets without any face-face education and with usual care. They found that parents in the Home Learning Programme group identified statistically significant more dangers within the home (mean 76.25 (SD 10.64)) than those who had received home visits without parental education (mean 54.82 (SD 15.78)) or those who had received only usual care (two groups: mean first control group 55.70 (SD 8.06), mean second control group 57.33 (SD 19.22), P < 0.001); suggesting that the beneficial effects were attributable to the parenting intervention rather than the home visit, but care must be taken in interpreting this finding as it relates only to one study. Parents in the Home Learning Programme group also identified statistically significantly more dangers within the home (mean 76.27 (SD 13.67)) than those in the lesson booklet only group (mean 62.0 (SD 12.53), P < 0.001), suggesting a greater effect of face-to-face education written information. The Home Learning Programme group also identified a statistically significantly greater number of precautions to reduce the risk of injury (mean 78.85 (SD 17.24)) than those who had received home visits without parental education (mean 48.91 (SD 15.36)), or those who had received usual care (two groups, mean first control group 47.10 (SD 13.76), mean second control group 45.33 (SD 13.87), P < 0.001), again suggesting a beneficial effect of parental education above that achieved from the home visit. Parents in the Home Learning Programme group identified statistically significantly more precautions to reduce the risk of injury (mean 85.27 (SD 21.12)) than those in the lesson booklet only group (mean 54.29 (SD 17.06), P < 0.001), again suggesting greater effects of face-to-face education than written information. Finally, parents in the Home Learning Programme group implemented a statistically significantly greater number of precautions to reduce the risk of injury (mean 88.09 (SD 34.92)) than those in the lesson booklet only group (mean 57.50 (SD 11.48), P < 0.001), again suggesting that face-to-face educational visits had a greater effect than written information.

 

Composite home safety measures

One study (Johnston 2004) reported a composite home safety measure, the Home Safety Index, which was developed for the study and comprised the sum of binary responses to six items (maximum possible score 7) on car seat use, safe storage of firearms, functioning smoke detectors, scald prevention activities, and safe infant sleep practices. At 3 months postpartum, intervention arm families had a statistically significantly higher mean score (reflecting safer practices) than control arm families (intervention arm mean 6.28 (SD 0.89) vs control arm mean 6.10 (SD 1.11), difference between the means 0.10, 95% CI 0.02 to 0.17). This difference was due mainly to differences in gun storage practices.

Another group (Johnston 2006), reporting on the same families discussed in the earlier trial (Johnston 2004) but at 30 months postpartum, used the same tool minus the sleep safety practices. Intervention arm families were statistically significantly more likely to report safe practices for all items than were control arm families (intervention arm 86.2% vs control arm 72.1%, RR 1.19, 95% CI 1.09 to 1.28, P < 0.05).

A later trial (Culp 2007) assessed home safety using the Massachusetts Home Safety Questionnaire. This scale assessed both safety practices and use of safety equipment. At 12 months, families in the intervention group had statistically significantly safer homes (mean (M) 38.1, SD 2.4) than did control group families (M 36.9, SD 2.6, t(261) 3.9, P = 0.0001).

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Principal findings

We have found that parenting interventions, most commonly provided on a one-to-one basis in the home as part of multi-faceted interventions to improve a range of child (and often maternal health) outcomes during the first two years of a child's life, are effective in reducing self-reported or medically attended injury amongst young children. This finding was consistent across studies with little evidence of statistical heterogeneity between effect sizes. This finding was also robust to most aspects of study quality and study design. All but one of the studies contributing to this analysis evaluated multi-faceted home visiting programmes. However, one study, in which the intervention was provided primarily in paediatric primary care, found a similar effect size to that from the home visiting programmes, but this was confined to a non-randomised part of the study. Only two studies reported effects of parenting interventions comprising solely educational interventions, neither of which measured injury outcomes or was included in the meta-analyses.

In terms of home safety, parenting interventions appeared to have a greater effect on home safety practices and reduction of hazards than on HOME scores. Meta-analysis of HOME scores found no statistically significant difference between treatment arms. Only three studies were included in this meta-analysis. Three studies not included in the meta-analysis found statistically significant differences in total HOME scores or organisation of the environment subscale scores. Three studies reporting home safety using alternative composite scores found that intervention arm families had statistically significantly safer homes. Five of the seven studies assessing home safety practices and use of safety equipment found statistically significant effects favouring intervention arm families. The two studies reporting home hazards found fewer hazards in the homes of intervention arm families. Therefore, fairly consistent evidence indicates that parenting interventions can have a positive effect on both home safety and childhood injury rates. Only one study used a control group that received home visits but without also providing a parenting intervention (Llewellyn 2003), thus allowing the effect of the intervention to be assessed above any effect of the home visit per se. Findings in this report suggested that the beneficial effects were attributable to the parenting intervention rather than to the home visit, but care must be taken in interpreting this finding because it relates to only one study.

 

Strengths and weaknesses of this systematic review

Our search strategy included searching a large number of bibliographic databases and grey literature and handsearching some conference abstracts and journals. However, our search terms included injury and home safety outcome terms, and these may have been secondary outcomes in some studies; therefore, this may have led to some studies being missed in our searches. However, we attempted to contact the authors of all studies excluded on the basis of outcomes to ascertain whether they had measured any outcomes relevant to our review. Of the seven papers excluded on the basis of lack of relevant outcomes, the authors of two confirmed that they did not assess unintentional injury, two authors were untraceable, and three did not respond. No evidence of publication bias was found, although the number of studies included in this assessment was fairly small (10), hence the funnel plot and Egger's test should be interpreted with caution. The analysis adjusted for cluster allocated studies, and sensitivity analyses were undertaken to test assumptions regarding the potential for bias; uncertainty as to the extent to which the intervention was based on a protocol, manual, or curriculum; and follow-up period and injury type. Findings were robust to these assumptions.

The parenting interventions included in our review were complex interventions, and only a minority of studies were explicit about the theoretical basis of the intervention or hypothesised about why it may have resulted in a reduction in childhood injuries (Olds 1986; Kitzman 1997; Minkovitz 2003 (a); Minkovitz 2003 (b); Johnston 2004). Meta-analyses for home safety outcomes other than HOME scores were not possible because of the variety of tools and subscales used. The meta-analysis of HOME scores did not find a statistically significant difference between treatment arms but included only three studies, and hence will have had limited power. In addition, the meta-analysis was restricted to the total HOME score containing six domains, only one of which measured home safety.

The generalisability of these findings is limited by the study populations, which mainly consisted of families considered to be 'at risk' of adverse child health outcomes. In addition, all included studies came from high-income countries, so the findings may not be generalisable to low- or middle0income countries. All studies provided the intervention to individual parents, and whilst several also included some parents groups, none of the studies delivered the intervention primarily to groups of parents, hence findings may not be generalisable to group-based parenting interventions. Similarly, most studies provided the intervention mainly within the home, so the findings may not be generalisable to parenting interventions provided outside the home.

 

Strengths and weaknesses of included studies

All reviews are dependent on the quality of reporting in the included studies and the availability and willingness of study authors to respond to requests for information. It did not come as a surprise that the more recently published studies, especially RCTs, tended to be reported more comprehensively. Most studies described the content of the intervention in sufficient detail and described and reported injury outcomes, enabling data to be extracted for meta-analysis. Three cluster allocated studies reported findings adjusted for clustering (Emond 2002; Minkovitz 2003 (b); Johnston 2004). Most studies used parental reports of injuries, which may be subject to biased reporting, particularly because blinding participants to treatment arm allocation is not possible with interventions such as these. However, there did not appear to be a consistent relationship between self-reported injury or that verified by medical records and effect size. Safety outcomes were reported less consistently, with a minority of studies reporting whether a statistically significant difference was found, but not reporting effect sizes for some safety outcomes (Olds 1986; Feldman 1992; Emond 2002; Culp 2007). Some studies reported overall Home Observation for Measurement of the Environment scores but not the subscale most relevant to child safety (Larson 1980; Olds 1986; Kitzman 1997; St Pierre 1999; Armstrong 2000; Koniak-Griffin 2003; Barlow 2007; Caldera 2007), or an overall score for the Massachusetts Home Safety Questionnaire but not subscale scores for safety practices and use of safety equipment (Culp 2007), or scores for all child care skills combined but not separate sleep safety scores (Feldman 1992). It is possible that improvements in the safety subscales were not reflected in improvements in overall scores (Armstrong 2000). The quality of studies was variable, with half or more of the RCTs included in the meta-analysis being susceptible to bias in terms of allocation concealment and/or outcome assessment. However, despite this, sensitivity analyses demonstrated little impact on the results of excluding studies without blinded outcome assessment. Excluding studies without adequate allocation concealment resulted in a similar effect size, but the effect was no longer statistically significant, possibly because of lack of power. Only two studies included in the meta-analysis reported high attrition rates.

 

Findings in relation to previous research

Although no existing systematic reviews have examined the effects of parenting interventions on child injury, our findings are consistent with those of two previous meta-analyses examining the effects of home visiting programmes on child injury (Roberts 1997; Elkan 2000).

 

Potential explanations for the findings

The authors of included studies suggest that a reduction in injuries may have occurred via a range of mechanisms, including increasing the ability of parents to manage minor injuries without medical help (Kitzman 1997), improving the quality of child care provided (Olds 1986; Kitzman 1997), and providing parental 'guidance' (Olds 1986) on home safety (Olds 1986; Culp 2007) and on the greater belief that children must be protected to "succeed in school, work, and mainstream society" (Olds 1986). Our review suggests that parenting interventions are likely to improve home safety, but other plausible explanations can be offered for why parenting interventions may reduce childhood injuries. All studies included in the primary meta-analysis were aimed at improving a range of child (and often maternal) health outcomes. Six of these studies reported statistically significant improvements in child behaviour (Gutelius 1977; Olds 1986; IHDP 1990; Fergusson 2005; Johnston 2006; Caldera 2007); three reported statistically significant less punitive discipline practices amongst intervention group parents (Kitzman 1997; Duggan 1999; Fergusson 2005); five reported statistically significantly increased or improved mother-child interaction (Gutelius 1977; Olds 1986; Johnson 1993; Armstrong 2000; Johnston 2004); and two reported statistically significant improvements in maternal psychological well-being (Johnson 1993; Johnston 2004). It is therefore possible that the reduction in childhood injuries may result from improvements in child behaviour, more effective supervision or discipline practices, or greater or more positive interactions between mother and child, all of which may be associated with improved maternal psychological well-being. A recent large systematic review of home safety education and the provision of safety equipment found strong evidence that these increased home safety practices and behaviours, along with some evidence that they reduced childhood injury (Kendrick 2012). None of the studies included in our review specifically provided or fitted home safety equipment, and it is plausible that combining parenting interventions with the provision and fitting of safety equipment may further enhance their effect on childhood injury. Understanding how parenting interventions work and which components of often complex interventions are necessary or sufficient to reduce childhood injury is important for designing effective and efficient services for children and parents.

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 

Implications for practice

Parenting interventions, most commonly provided within the home as part of a multi-faceted intervention to improve a range of child (and often maternal health) outcomes, are effective in reducing self-reported or medically attended unintentional injury. Fairly consistent evidence also suggests that they improve home safety. This evidence relates mainly to interventions provided to families 'at risk' of adverse child health outcomes, including those 'at risk' of child abuse and neglect. Health and social care providers should make home visiting programmes available to such families as part of their injury prevention and wider child and maternal health strategies. Such provision is also likely to have a range of other beneficial effects for maternal and child health.

 
Implications for research

A series of research questions remain to be answered: whether parenting interventions delivered outside the home have positive effects on childhood injury; whether parenting educational interventions, as opposed to multi-faceted interventions, delivered within or outside the home and aimed at improving a range of parenting practices are effective in reducing childhood injury; whether group-based parenting interventions are effective in reducing childhood injury; whether providing home safety education and safety equipment further increases the effectiveness of parenting interventions in reducing child injury; and finally, whether parenting interventions are effective in reducing child injury when delivered to families not considered to be 'at risk' of adverse child health outcomes.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

We would like to thank A. Culp for providing us with unpublished data and J. Barlow for providing us with a copy of an unpublished report.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
Download statistical data

 
Comparison 1. Intervention versus Control (n/N in clustered studies adjusted for clustering)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Medically attended or self-reported injuries - RCTs only105074Risk Ratio (M-H, Random, 95% CI)0.83 [0.73, 0.94]

 
Comparison 2. Total HOME scores

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Total HOME scores3368Mean Difference (IV, Random, 95% CI)0.57 [-0.59, 1.72]

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Appendix 1. Search strategy

Cochrane Injuries Group Specialised Register (searched 24 Jan 2011): 57 records (limit: 2005 to 2011)

1.      (child* or infan* or toddl* or pre-school* or preschool* or "pre school" or young* or adolesc* or pediat* or paediat* or minor* or boy* or girl* or teen* or adolesc* or baby or babies)

2.      ((accident* AND  prevent*) or safety or (safe* AND  device*) or (safe* AND  equipment*) or (infan* AND  equipment*) or (protective AND  device*) or injur* or wound* or accident* or fracture* or poison* or suffocat* or asphyx* or drown* or burn* or scald* or lacer* or contus* or (smok* AND  inhal*))

3.      (parent* AND  program*) or (parent* AND  train*) or (parent* AND  educat*) or (parent* AND  promot*) or (parent* AND  skill*) or (parent* AND  intervent*) or (parent* AND  group*) or (parent* AND  support*) or ("parent-child relations" or "parent-child interaction" or  "object attachment")

4.      1 and 2 and 3

Cochrane Central Register of Controlled Trials 2011, issue 1 (The Cochrane Library): 101 records

#1        ((parent* near3 program*) or (parent* near3 train*) or (parent* near3 educat*) or (parent* near3 promot*) or (parent* near3 skill*) or (parent* near3 intervent*) or (parent* near3 group) or (parent* near3 support) or (parent-child relations or parent-child interaction or object attachment)):ti, ab

#2        ((accident* near3 prevent*) or safety or (safe* near3 device*) or (safe* near3 equipment*) or (infan* near3 equipment*) or (protective near3 device*) or injur* or wound* or accident* or fracture* or poison* or suffocat* or asphyx* or drown* or burn* or scald* or lacer* or contus* or (smok* near3 inhal*)):ti, ab

#3        (child* or infan* or toddl* or pre-school* or preschool* or pre school* or young* or adolesc* or pediat* or paediat* or minor* or boy* or girl* or teen* or adolesc* or baby or babies):ti, ab

#4        (#1 AND #2 AND #3)

MEDLINE (Ovid SP) 1950 to 2011 week 2 (limit: 2005 to 2011): 274 records

1. (infan$ or child$ or teen$ or adolesc$ or minor$ or toddl$ or bab$).mp. 

2. ((parent$ adj3 program$) or (parent$ adj3 train$) or (parent$ adj3 educat$) or (parent$ adj3 promot$) or (parent$ adj3 skill$) or (parent$ adj3 intervent$) or (parent$ adj3 group) or (parent$ adj3 support) or (parent-child relations or parent-child interaction or object attachment)).mp.

3. ((accident$ adj3 prevent$) or safety or (safe$ adj3 device$) or (safe$ adj3 equipment$) or (infan$ adj3 equipment$) or (protective adj3 device$) or injur$ or wound$ or accident$ or fracture$ or poison$ or suffocat$ or asphyx$ or drown$ or burn$ or scald$ or lacer$ or contus$ or (smok$ adj3 inhal$)).mp.  

4. (randomised controlled trial or randomized controlled trial or random allocation or double blind method or clinical trial or control group or evaluat$ or intervent$ or comparative study).mp.

5. 1 and 2 and 3 and 4

EMBASE (Ovid SP) 1980 to 2011 week 2 (limit:2005 to 2011): 406 records

1.      ((parent* adj3 program*) or (parent* adj3 train*) or (parent* adj3 educat*) or (parent* adj3 promot*) or (parent* adj3 skill*) or (parent* adj3 intervent*) or (parent* adj3 group) or (parent* adj3 support) or (parent-child relations or parent-child interaction or object attachment)).mp.

2.      ((accident* adj3 prevent*) or safety or (safe* adj3 device*) or (safe* adj3 equipment*) or (infan* adj3 equipment*) or (protective adj3 device*) or injur* or wound* or accident* or fracture* or poison* or suffocat* or asphyx* or drown* or burn* or scald* or lacer* or contus* or (smok* adj3 inhal*)).mp.

3.      (randomised controlled trial or randomized controlled trial or random allocation or double blind method or clinical trial or control group or evaluat* or intervent* or comparative study).mp.

4.      (child* or infan* or toddl* or pre-school* or preschool* or pre?school* or young* or adolesc* or pediat* or paediat* or minor* or boy* or girl* or teen* or adolesc* or baby or babies).mp.

5.      1 and 2 and 3 and 4

6.      5

7.      limit 6 to yr="2005 - 2010"

 ISI Web of Science: Social Sciences Citation Index (SSCI) 1970 to January 2011 (limit:2005 to 2011) and ISI Web of Science: Conference Proceedings Citation Index- Social Science & Humanities (CPCI-SSH) –1990 to January 2011(limit:2005 to 2011): 185 records

 1.      (child* or infan* or toddl* or pre-school* or preschool* or pre school* or young* or adolesc* or pediat* or paediat* or minor* or boy* or girl* or teen* or adolesc* or baby or babies)

2.      ((accident* SAME prevent*) or safety or (safe* SAME device*) or (safe* SAME equipment*) or (infan* SAME equipment*) or (protective SAME device*) or injur* or wound* or accident* or fracture* or poison* or suffocat* or asphyx* or drown* or burn* or scald* or lacer* or contus* or (smok* SAME inhal*))

3.      (parent* SAME program*) or (parent* SAME train*) or (parent* SAME educat*) or (parent* SAME promot*) or (parent* SAME skill*) or (parent* SAME intervent*) or (parent* SAME group) or (parent* SAME support) or (parent-child relations or parent-child interaction or object attachment)

4.      1 AND 2 AND 3

5.      (randomised OR randomized OR randomly OR random order OR random sequence OR random allocation OR randomly allocated OR at random OR randomized controlled trial) 

6.      (controlled clinical trial OR controlled trial OR clinical trial OR placebo)

7.      ((singl* OR doubl* OR trebl* OR tripl*) SAME (blind* OR mask*))

8.      5 OR 6 OR 7

9.      (human*)

10.  8 AND 9

11.  4 AND 10

 CINAHL (EBSCO) 1982 to 24 Jan 2011 (limit:2005 to 2011): 213 records

 S1   (child* or infan* or toddl* or pre-school* or preschool* or pre school* or young* or adolesc* or pediat* or paediat* or minor* or boy* or girl* or teen* or adolesc* or baby or babies) 

S2   ((accident* N3 prevent*) or safety or (safe* N3 device*) or (safe* N3 equipment*) or (infan* N3 equipment*) or (protective N3 device*) or injur* or wound* or accident* or fracture* or poison* or suffocat* or asphyx* or drown* or burn* or scald* or lacer* or contus* or (smok* N3 inhal*))

 S3   (parent* N3 program*) or (parent* N3 train*) or (parent* N3 educat*) or (parent* N3 promot*) or (parent* N3 skill*) or (parent* N3 intervent*) or (parent* N3 group) or (parent* N3 support) or (parent-child relations or parent-child interaction or object attachment)

 S4   S1 and S2 and S3

ASSIA and ERIC

(infan* or child* or teen* or adolesc* or minor* or toddl* or bab*) and ((parent* within 3 program*) or (parent* within 3 train*) or (parent* within 3 educat*) or (parent* within 3 promot*) or (parent* within 3 skill*) or (parent* within 3 intervent*) or (parent* within 3 group) or (parent* within 3 support*) or ((parent-child relations) or (parent-child interaction) or (object attachment))) and ((accident* within 3 prevent*) or safety or (safe* within 3 device*) or (safe* within 3 equipment*) or (infan* within 3 equipment*) or (protective within 3 device*) or injur* or wound* or accident* or fracture* or poison* or suffocat* or asphyx* or drown* or burn* or scald* or lacer* or contus* or (smok* within 3 inhal*)) and (((randomised controlled trial) or (randomized controlled trial) or (random allocation)) or ((double blind method) or (clinical trial) or (control group)) or (evaluat* or intervent* or (comparative study)))

ProQuest dissertation and thesis

(infan* or child* or teen* or adolesc* or minor* or toddl* or bab*) AND (parent*) AND (injur* or accident* or wound*) AND (randomi* controlled trial or random* allocation) OR (double blind method) OR (clinical trial or control group) OR (comparative stud* or evalua* or intervent*) AND PDN(>1/1/2005) AND PDN(<12/31/2011)

BIOSIS Preview

Topic=(infan* OR child* OR teen* OR adolesc* or minor* OR toddl* OR bab*) AND Topic=(parent* program* OR parent* train* OR parent* educat* OR parent* promot* OR parent* skill* OR parent* intervent* OR parent* group OR parent* support* OR (parent-child relations OR parent-child interaction OR object attachment)) AND Topic=(injur* OR accident* OR wound* OR fracture* OR safe* OR protect* OR poison* OR suffocat* OR asphyx* OR drown* OR burn* OR scald* OR lacer* OR contus*) AND Topic=((randomised controlled trial OR randomized controlled trial OR random allocation) OR (double blind method OR clinical trial OR control group) OR (evaluat* OR intervent* OR comparative study))

Databases=PREVIEWS Timespan=2005-2011

Sociological Abstracts

#1  (infan* or child* or teen* or adolesc* or minor* or toddl* or bab*) and (((((parent-child relations) or (parent-child interaction)) or ((parent-child relations) or (parent-child interaction)) or (object attachment)) and ((accident* or injur* or wound* or accident* or fracture* or poison* or suffocat* or asphyx* or drown* or burn* or scald* or lacer* or contus*) or (safe* or protective*) or (smok* within 3 inhal*)) and (((randomised controlled trial) or (randomized controlled trial) or (random allocation)) or ((double blind method) or (clinical trial) or (control group)) or (evaluat* or intervent* or (comparative study)))

Zetoc

general: child or infant or baby and parent.

general: parenting intervention and injury.

 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Last assessed as up-to-date: 31 January 2011.


DateEventDescription

29 May 2013AmendedCopy edits made.



 

History

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Protocol first published: Issue 2, 2006
Review first published: Issue 4, 2007


DateEventDescription

8 August 2012New citation required and conclusions have changedThe review has been updated with data from seven new studies. We have now included a meta-analysis of HOME scores. The results and conclusions have changed (minor).

31 January 2011New search has been performedThe search for studies was updated to January 2011. Seven new studies are included.



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

DK had the original idea for the review. DK, CM, JM, and SS-B drafted the study protocol. LY and CM undertook the searches. LY, CM, TS, and DK undertook data extraction. CM undertook the analyses. CM and DK drafted the final review.

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Internal sources

  • University of Nottingham, UK.
  • University of Warwick, UK.

 

External sources

  • Department of Health, UK.
    • This Cochrane update was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme (project number 09/02/02) and a summary will be published in Health Technology Assessment.
    • The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health.

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

1. Types of outcomes measures: We also reported scores on the HOME scale, thus section 3 of “Types of outcomes measures” now reads:

"Safety practices (e.g. storage of hazardous objects and substances, safe use of baby walkers, avoidance of unsafe hot water temperature) and composite measures of safety practices, including the Home Observation for Measurement of the Environment (HOME) Inventory. The Infant-Toddler HOME Inventory, designed for use with children from birth to 3 years of age, consists of six subscales: emotional and verbal responsivity of the primary caregiver (items 1 to 11); avoidance of restriction and punishment (items 12 to 19); organisation of the physical and temporal environment (items 20 to 25), including "the child’s play environment appears safe and free of hazards"; provision of appropriate play materials (items 26 to 34); parental involvement with the child (items 35 to 40); and opportunities for variety in daily stimulation (items 40 to 45) (Caldwell 2003; Totsika 2004). A higher score indicates a more appropriate home environment for child development."

In addition, in this update, we had sufficient data to undertake a meta-analysis of HOME scores.

2. Websites searched: We also searched “Public Health website (UK).”

3. Quality assessment: In the protocol, we stated that we would assess the quality of non-randomised studies using the tool developed by Reisch and colleagues (Reisch, 1989). However we did not use the Reisch tool, and thus this section now reads as below:

“The following sources of bias were assessed for non-randomised studies:

  • Participant selection (selection bias).
  • Blinding (performance bias and detection bias).
  • Blinding of participants and personnel (performance bias).
  • Blinding of outcome assessment (detection bias).
  • Incomplete outcome data (attrition bias).
  • Selective reporting (reporting bias).
  • Risk of bias due to confounding: Was the distribution of confounders assessed between treatment arms? If so, do treatment arms appear similar in terms of confounders?
  • Other bias.”

4. Quality assessment: In addition, we have added the following sentence to this section:

“Disagreement between review authors was dealt with by referral to a third review author.”

5. Measures of treatment effect: We stated in the protocol that we would pool results and present them as relative risks and 95% CIs for the binary outcomes. We have adjusted this sentence to read:

 “Pooled relative risks and 95% confidence intervals have been used for binary outcome measures and mean differences, and 95% confidence intervals for continuous outcome measures.”

6. Data analysis/synthesis: We stated in the protocol, “if there are sufficient studies, we will pool results and present them as relative risks and 95% CIs for the binary outcomes of possession of items of safety equipment, safety practices, and occurrence of at least one self-reported medically attended injury.” However in the review, we pooled results for self-reported medically attended injuries and HOME scores, and thus we have written the following sentence in the full review:

“Pooled relative risks and 95% CIs were estimated for occurrence of at least one self-reported or medically attended injury. Pooled mean differences and 95% CIs were estimated for HOME scale scores.”

7. Primary and secondary analyses: In the protocol, we state, “As the review includes both randomised and non-randomised studies, the primary analysis will be based on randomised studies, with a secondary analysis including both randomised and non-randomised studies.” However we have not combined RCTs and non-RCTs in a single meta-analysis.

Thus in the review under “Data synthesis,” we have written, “Pooled RRs and 95% CIs were estimated for occurrence of at least one self-reported or medically attended injury using data from included RCTs.” and “When clinically homogenous studies were insufficient to be combined in a meta-analysis, or when findings were derived from non-RCTs, the results were combined in a narrative review.” 

8. Sensitivity analyses: We stated in the protocol, “sensitivity analyses would be undertaken for individual aspects of the study quality, as discussed in the section on quality assessment.” In the final review, we give more precise detail, stating the following: “Sensitivity analyses have been undertaken that included only RCTs considered to be at low risk of selection bias in terms of adequate allocation concealment, detection bias in terms of blinded outcome assessment, and attrition bias as the result of follow-up of less than 80% of participants in each arm.”

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
Armstrong 2000 {published data only}
Barlow 2007 {published data only}
  • Barlow J, Davis H, McIntosch E, Jarrett P, Mockford C, Stewart-Brown S. Role of home visiting in improving parenting and health in families at risk of abuse and neglect: results of a multicentre randomised controlled trial and economic evaluation. Archives of Disease in Childhood 2007;92(3):229-33.
Caldera 2007 {published data only}
  • Caldera D, Burrell L, Rodriguez K, Crowne SS, Rodhe C, Duggan A. Impact of a statewide home visiting program on parenting and on child health and development. Child Abuse & Neglect 2007;31:829-52.
Culp 2007 {unpublished data only}
Duggan 1999 {published data only}
Emond 2002 {published data only}
Feldman 1992 {published data only}
  • Feldman MA, Case L, Sparks B. Effectiveness of a child-care training program for parents at-risk for child neglect. Canadian Journal of Behavioural Science 1992;24(1):14-28.
Fergusson 2005 {published data only}
Gutelius 1977 {published data only}
  • Gutelius MF, Kirsch AD, McDonald S, Riddick Brooks M, McErlan T. Controlled study of child health supervision: behaviour results. Pediatrics 1977;60(3):294-304.
Hardy 1989 {published data only}
  • Hardy JB, Streett R. Family support and parenting education in the home: an effective extension of clinic-based preventive health care services for poor children. Journal of Pediatrics 1989;115(6):927-31.
IHDP 1990 {published data only}
  • The Infant Health & Development Program. Enhancing the outcomes of low-birth-weight, premature infants. A multisite, randomized trial. Journal of the American Medical Association 1990;263(22):3035-42.
Johnson 1993 {published data only}
Johnston 2004 {published data only}
  • Johnston B, Huebner CE, Tyll LT, Barlow WE, Thompson RS. Expanding developmental and behavioural services for newborns in primary care: effects on parental well being, practice and satisfaction. American Journal of Preventive Medicine 2004;26(4):356-66.
Kemp 2011 {published data only}
  • Kemp L, Harris E, McMahon C, Matthey S, Vimpani G, Anderson T, et al. Child and family outcomes of a long-term nurse home visitation programme: a randomised controlled trial. Archives of Diseases in Childhood 2011;96:533-540.
Kitzman 1997 {published data only}
  • Kitzman H, Olds DL, Henderson CR, Hanks C, Cole R, Tatelbaum R, et al. Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomised controlled trial. Journal of the American Medical Association 1997;278(8):644-52.
Koniak-Griffin 2003 {published data only}
  • Koniak-Griffin D, Verzemnieks IL, Anderson NLR, Brecht M-L, Lesser J, Kim S, et al. Nurse visitation for adolescent mothers. Nursing Research 2003;52(2):127-136.
Larson 1980 {published data only}
Llewellyn 2003 {published data only}
  • Llewellyn G, McConnell D, Honey A, Mayes R, Russo D. Promoting health and home safety for children of parents with intellectual disability: a randomized controlled trial. Research in Developmental Disabilities 2003;24(6):405-31.
Minkovitz 2003 (a) {published data only}
  • Minkovitz C, Hughart N, Strobino D, Scharfstein D, Grason H, Hou W, et al. A practice-based intervention to enhance quality of care in the first 3 years of life. Journal of the American Medical Association 2003;293(23):3081-91.
Minkovitz 2003 (b) {published data only}
  • Minkovitz C, Hughart N, Strobino D, Scharfstein D, Grason H, Hou W, et al. A practice-based intervention to enhance quality of care in the first 3 years of life. Journal of the American Medical Association 2003;293(23):3081-91.
Olds 1986 {published data only}
  • Olds DL, Henderson CR, Chamberlain R Jr, Tatelbaum R. Preventing child abuse and neglect: a randomized trial of nurse home visitation. Pediatrics 1986;78(1):65-78.
St Pierre 1999 {published data only}
  • St Pierre R, Layzer JI. Using home visits for multiple purposes: the Comprehensive Child Development Program. The Future of Children 1999;1:134-151.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
Akinbami 2001 {published data only}
  • Akinbami LJ, Cheng TL, Kornfeld D. A review of teen-tot programs: comprehensive clinical care for young parents and their children. Adolescence 2001;36(142):381-93.
Babul 2007 {published data only}
  • Babul S, Olsen L, Janseen P, McIntee P, Raina P. A randomized trial to access the effectiveness of an infant home safety programme. International Journal of Injury Control and Safety Promotion 2007;14(2):109-17.
Baron-Epel 2006 {published data only}
  • Baron-Epel O, Hemmo-Lotem M, Mike-Doron R, Endy-Findling L, Balin L. Injury prevention counselling of families with children hospitalized due to injuries: the "Personalized Injury Prevention" program. 8th World Conference on Injury Prevention and Safety Promotion. South Africa, 2006.
Beirens 2006 {published data only}
  • Beirens T. Effectiveness of standardized safety information provided through Dutch well-child clinics to parents of 11-18 months old toddlers. World Safety Conference. 2006.
Bond 2006 {published data only}
  • Bond LA, Burns CE. Mothers' beliefs about knowledge, child development and parenting strategies: expanding the goals of parenting programs. The Journal of Primary Prevention 2006;27(6):555-71.
Conroy 1994 {published data only}
  • Conroy M. Increasing agreement on safe parenting in two-parent families at risk for physical child abuse (Dissertation). University of San Francisco 1994.
Culp 1998 {published data only}
Cupples 2011 {published data only}
  • Cupples ME, Stewart MC, Percy A, Hepper P, Murphy C, Halliday HL. A RCT of peer-mentoring for first-time mothers in socially disadvantaged areas (the MOMENT study). Archives of Diseases in Childhood 2011;96:252-8.
Dawson 1989 {published data only}
Donnellan 1981 {published data only}
  • Donnellan GJ, et al. Prevention Service programs for infants of mentally-ill mothers: progress report. 89th Annual Meeting of the.American Psychological Association. Los Angeles, CA, August 24-28, 1981.
Ertem 2006 {published data only}
Feldman 2004 {published data only}
Fitzpatrick 1997 {published data only}
Gershater-Molko 2002 {published data only}
  • Gershater Molko RM, Lutzker JR, Wesch D. Project SafeCare: improving health, safety, and parenting skills in families reported for, and at-risk for, child maltreatment. Journal of Family Violence 2003;18(6):377-86.
Gershater-Molko 2003 {published data only}
  • Gershater-Molko RM. A comprehensive evaluation of project Safecare: health, safety, bonding and recidivism in families reported for, and at risk for, child maltreatment, and finishing treatment (Dissertation). University of Kansas 2002.
Gray 1979 {published data only}
Guyer 2000 {published data only}
  • Guyer B, Hughart N, Strobino D, Jones A, Scharfstein D. Assessing the impact of pediatric-based developmental services on infants, families and clinicians: challenges to evaluating the Healthy Steps Program. Pediatrics 2000;105(3):E33.
Hedges 2005 {published data only}
  • Hedges S, Simmes D, Martinez A, Linder C, Brown S. A home visitation program welcomes home first-time moms and their infants. Home Healthcare Nurse 2005;23(5):286-9.
Hemmo-Lotom 2006 {published data only}
  • Hemmo-Lotom, M. Parental knowledge, attitudes and practice concerning prevention of children's falls. 8th World Conference on Injury Prevention and Safety Promotion. South Africa, 2006.
Huxley 1993 {published data only}
Jackson 2009 {published data only}
  • Jackson C, Dickinson DM. Developing parenting programs to prevent child health risk behaviours: a practice model. Health Education Research 2009;24(6):1029-1042.
Johnson 2009 {published data only}
  • Johnson S, Whitelaw A, Glazebrook C, Israel C, Turner R, White IR, et al. Randomized trial of a parenting intervention for very preterm infants: outcome at 2 years. The Journal of Pediatrics 2009;155(4):488-94.
Jordaan 2006 {published data only}
  • Jordaan E. The usefulness of a new instrument, developed to measure the prevention effect of the home visitation programme, focussing on unintentional home injuries in young children in a low income South African setting. 8th World Conference on Injury Prevention and Safety Promotion, South Africa. 2006.
Jouriles 2010 {published data only}
  • Jouriles EN, McDonald R, Rosenfiled D, Norwood WD, Spiller L, Stephens N, et al. Improving parenting in families referred for child maltreatment: a randomized controlled trial examining effects of project support. Journal of Family Psychology 2010;24(3):328-38.
Kluger 2000 {published data only}
  • Kluger MP, Alexander G, Curtis PA (editors). What Works in Child Welfare. CWLA, USA, 2000.
Lealman 1983 {published data only}
McAuley 2004 {published data only}
  • McAuley C, Knapp M, Beecham J, McCurry N, Sleed M. Young families under stress. Outcomes and costs of home start support. York, Joseph Rowntree Foundation, 2004.
Odendall 2009 {published data only}
  • Odendall W. The impact of a home visitation programme on household hazards associated with unintentional childhood injuries: a randomised controlled trial. Accident Analysis and Prevention 2009;41(1):182-90.
Powell 2004 {published data only}
  • Powell C, Baker-Henningham H, Walker S, Gernay J, Grantham-McGregor S. Feasibility of integrating early stimulation into primary care for undernourished Jamaican children: cluster randomised controlled trial. British Medical Journal 2004;329(7457):89-93.
Quraishi 2005 {published data only}
  • Quraishi AY, Mickalide AD, Cody BE. Follow the leader: a national study of safety role modelling among parents and children. Washington, DC, National SAFE KIDS Campaign, April 2005.
Sharma 2006 {published data only}
  • Sharma G. Educational intervention in changing knowledge of mothers of under five children in reducing injuries among Nepalese children. 8th World Conference on Injury Prevention and Safety Promotion, South Africa. 2006.
Smith 1984 {published data only}
Subhi 2009 {published data only}
  • Subhi B. Community orientation and promotion and home injuries prevention among Arab children in Israel. BASPCAN Seventh National Congress, Swansea. 2009.
Swart 2008 {published data only}
  • Swart L, Van Niekerk A, Seedat M, Jorddann E. Paraprofessional home visitation program to prevent childhood unintentional injuries in low-income communities: a cluster randomized controlled trial. Injury Prevention 2008;14(3):164-9.
Taban 2001 {published data only}
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Trudeau 2010 {published data only}
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Tsoumakas 2009 {published data only}
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Additional references

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
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