Preventing Unintentional Injuries in School-Aged Children: A Systematic Review

We searched the MEDLINE, PubMed, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO databases up to December 2020 without restrictions for language or date. The database search strategies are presented in the Supplemental Information. Additionally, we screened the reference lists of included studies and relevant reviews.

We included studies involving school-aged children (aged 5–15 years) and parents and caregivers of school-age children. Studies with overlapping age groups (eg, 0–8 or 10–19 years) and lacking data on school-aged children were excluded. We focused on interventions or programs aimed at preventing all types of injuries among school-aged children, including drowning, burns, falls, poisoning, and road injuries (ie, vehicle, pedestrian, bicycle). Single- or multicomponent interventions involving any of the eligible injury interventions were included. We included studies that addressed primary measures that prevent injuries and excluded secondary and tertiary prevention measures that aimed to reduce the injury impact.²⁹  We included studies conducted in home, school, and community settings as well as in indoor and outdoor settings. We excluded interventions aimed at preventing injuries in hospital settings (eg, falls in hospitals settings) and studies related to sports injuries. We included randomized controlled trials (RCTs), controlled before- and-after studies (CBAs), and interrupted time series (ITS) studies and excluded abstracts, meeting proceedings, editorials, and commentaries. We included outcomes such as behavior change, observed safety practices and skills, and safety knowledge in addition to injury and mortality rates. Comparison and control groups were considered as no intervention, other interventions, or the same interventions delivered at a different level of intensity. We used standardized and pilot-tested forms and conducted calibration exercises to ensure the validity of the selection and data abstraction processes.

Teams of 2 reviewers (L.B.K., M.J., A.H., R.F., and N.H.) screened titles and abstracts of identified citations in duplicate and independently for potential eligibility. We retrieved the full text for citations judged as potentially eligible by at least 1 of the 2 reviewers.

Full-text screening was conducted in duplicate and independently by the same reviewers. The teams resolved disagreement by discussion or with the help of a third reviewer. We used standardized and pilot-tested screening forms.

The reviewer teams abstracted data from eligible studies into a standardized and pilot-tested abstraction form developed for this purpose. We collected data on study authors, title, year, type of study design, country and its income level according to The World Bank list of July 2019, population (eg, age range, sample size), characteristics of the intervention (eg, setting, type of intervention), type of injury or injuries, outcomes assessed, key findings, and statistical results. We conducted calibration exercises to ensure the validity of the data abstraction process.

One reviewer assessed the risk of bias in each study, and 1 reviewer validated results. We used the Cochrane risk-of-bias tool to assess the risk of bias in randomized trials and the Cochrane Effective Practice and Organization of Care risk-of-bias criteria for CBAs and ITS studies. We conducted calibration exercises to ensure the validity of the risk- of-bias assessment.

We calculated the agreement between reviewers for the assessment of study eligibility at the full-text screening stage using Fleiss’ κ statistics. We used the following values to judge the degree of agreement: 0.21 to 0.40 for fair agreement, 0.41 to 0.60 for moderate agreement, 0.61 to 0.80 for substantial agreement, and 0.81 to 1.00 for almost perfect agreement.³⁰ 

For the quantitative analysis, we planned to conduct a meta-analysis. However, we were not able to pool the data into a meta-analysis because of the differences and heterogeneity in the types of interventions, the types of outcomes, and the measurement methods across studies. Therefore, we report the results narratively. We also tabulated study characteristics, interventions, outcome measures, and key results for all primary studies to aid the narrative synthesis.

We summarize the selection process in Fig 1. Of 30 179 citations identified from electronic databases and 201 studies retrieved from screening the references of relevant systematic reviews, we included 117 articles.^31–147  During the full-text screening, we excluded 543 articles for the following reasons: not the population of interest (n = 362), not the study design of interest (n = 160), not the intervention of interest (n = 19), and missing full text (n = 2). Supplemental Information lists the excluded studies with reasons for exclusion. The level of agreement between the 2 reviewers during the full-text screening phase was substantial (κ = 0.777; 95% confidence interval, 0.717–0.837).

Of the included 117 studies, the majority were RCTs (53.8%) and CBAs (42.7%), whereas 4 were ITS studies (3.4%). The majority of the studies were conducted in high-income countries (86.3%), specifically the United States (40.1%), Canada (15.3%), and the United Kingdom (11.1%). The types of injuries mostly examined were road injuries (75.2%), followed by burns (18.8%), falls (18.8%), poisoning (8.5%), and drowning (5.9%). In the majority of the studies, researchers evaluated the effectiveness of educational interventions (91.4%), whereas few assessed policies, laws and legislation, and infrastructure and engineering interventions. Knowledge, attitudes, and behaviors were the main outcomes assessed (91.4%), whereas 12.1% of the included studies were assessments of the effectiveness of interventions on injury rates. The characteristics of included studies are summarized in Table 1.

In Figs 2, 3, and 4, we provide a summary of the risk-of-bias assessment of RCTs, CBAs, and ITS, respectively. The detailed risk-of-bias assessment for each included study is provided in Supplemental Information. Overall, the quality of the evidence from the included RCTs was considered moderate, given that most of the studies scored as low risk in the domains related to attrition (incomplete outcome data), detection (blinding of outcome assessment), and reporting bias. Half of the studies scored as unclear risk in the domains related to selection bias and performance bias. Overall, the quality of the evidence from the included CBAs was considered moderate. The majority of the studies scored as low risk for baseline outcome measurements and baseline characteristics, whereas half of the studies scored as unclear risk for selective outcome reporting, incomplete outcome data, and protection against contamination. For the included ITS studies, the overall quality of the evidence was judged as high. All studies scored as low risk for the shape of intervention effect and the likelihood of the intervention to affect data collection, and most studies scored as low risk for independency of intervention of other changes and blinding of outcome assessment. Half of the studies scored as low risk for incomplete outcome data, and half scored as high risk on selective outcome reporting.

We organized the study findings according to the type of injury and its associated interventions adopted. We present the details of interventions, outcomes, and key results of included studies in Supplemental Information.

Road safety studies (n = 88) claimed the largest share of the injury intervention programs and incorporated multiple approaches aimed at improving vehicle, bicycle, and pedestrian safety (Supplemental Information).

In 4 studies, researchers proved effectiveness in reducing traffic-related injury rates^40,108  and increasing bicycle helmet use^53,65  among school-aged children, with more compliance in younger children (ie, elementary).⁵³  Enforcement of an ordinance mandating bicycle helmet use coupled with helmet giveaway and education was found to be highly effective in increasing helmet use among children aged 5 to 12 years.⁶⁵ 

Two studies revealed that the combination of infrastructure and instructions had positive results in improving pedestrian safety among children.^31,45  Children in combined interventions displayed improved safety behavior compared with those in education-only groups.⁴⁵  Pedestrian safety intervention programs at a school consisting of education and infrastructure changes, including crossing guards and physical barriers, were effective in reducing hazardous events.³¹ 

Cycling training programs and courses at school in 3 studies were found to be effective in teaching children simple behavioral strategies, such as signaling, visual search behavior, and slowing down while approaching an intersection,¹³⁶  and in improving children’s cycling skills.⁵⁷  One study assessing a cycling safety skills course (Kids CAN-BIKE) revealed no impact on improving safe cycling behaviors, knowledge, or attitudes among 4th-grade children.⁹² 

In 24 studies, researchers evaluated the effectiveness of interventions aimed at promoting bicycle helmet use. Eleven studies included educational interventions coupled with the distribution of discounted or free helmets. The educational interventions included single or multiple components, such as classroom-based teaching, counseling, posters, messages from a former Olympic cyclist, exhibitions, skits, stories, and parent information nights. Seven studies revealed a positive impact on helmet ownership⁸²  and use,^{37,55,82,83,89,100,138}  with 1 revealing no difference in helmet use when cost sharing was required.⁸³  Three studies yielded mixed results on helmet use, with findings from 2 revealing a positive impact on helmet ownership and no impact on helmet use^110,133  and 1 revealing a positive impact in high-income schools and no impact in low-income schools.¹¹¹  One study revealed no impact on either.¹¹³  In 6 studies, researchers evaluated the effectiveness of interventions developed on the basis of the PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation) framework, examining factors surrounding an intervention, including predisposing (ie, high helmet cost), enabling (ie, education and free/discounted helmets), and reinforcing (ie, parental education, rewards for helmet use).⁷⁴  These studies all yielded favorable outcomes, indicating increased bicycle helmet use^59,72,73  and decreased bicycle-related head injuries regardless of income,⁶⁰  sex, or age⁶¹  in addition to an improvement in knowledge.⁷⁴  Multicomponent educational interventions revealed favorable outcomes in knowledge and safety behaviors^79,116  and proper helmet use,³⁸  a decline in bicycle injury rates,⁷⁹  and increased helmet ownership and use.^68,86,99,116  Finally, 1 study evaluating a low-cost eHealth software program teaching about bicycle safety and helmet wearing revealed a positive impact on safety knowledge and behaviors.⁹⁵ 

Thirty-one educational interventions adopted various approaches to promote child pedestrian safety, including the PRECEDE framework,^51,127  tabletop and roadside training,^32,129,130  virtual reality road safety training,^{35,94, 101,120–123,131,132}  interactive computer-based video games,^33,56  educational videos,^112,126  active learning intervention programs,^{76,105,143,144}  school-based educational interventions^{36,91,135,145}  and training,⁵²  and the Think First Head and Spinal Cord Injury Prevention Program.^{58,67,139,141}  These approaches revealed improvement in children’s safety knowledge and behavior when crossing the road. Additional educational interventions in 24 studies targeted various aspects of road safety,^{34,39,43,46–49,63,64,66,81,87, 88,90,97,98,107,109,114,117,137,146}  including programs focused on the etiology of spinal cord injury,¹¹⁷  bicycle safety,¹¹⁴  alcohol use,³⁹  helmet and seat belt use,^48,62,98,117  and booster seat use.⁴²  The overwhelming majority of these educational interventions revealed improvement in children and parents’ safety knowledge and practices. Of note, the integration of an injury prevention specialist in an interactive setting substantially enhanced the effectiveness of the interventions compared with computerized tools.⁶⁶ 

In 22 studies, researchers reported on the effectiveness of fall prevention interventions in reducing fall-related injuries and enhancing knowledge, attitudes, and behaviors (Supplemental Information). Eighteen studies were evaluations of educational interventions,^{46,66,67,81,88,90, 102–104,106,109,115,117,118,137,139,141,146}  3 were of physical education and training,^50,54,70  and 1 was of infrastructural changes.⁷⁷  Educational interventions encompassed the Think First for Kids program, the Risk Watch program, and interactive educational sessions using cartoons, puzzles, and multicomponent approaches, such as lectures, lessons, presentations, videos, and posters. These interventions revealed positive results in terms of improving fall safety knowledge, attitudes, and risk-taking behaviors (eg, increased use of protective gear). One study revealed that coupling education about hazards in schools with close follow-up with an engineer and assistance in funding can be effective in reducing fall hazards.¹¹⁸  Researchers who explored the effectiveness of physical education and training showed favorable results in improving balance and motor control ability,⁷⁰  diminishing children’s harmful responses to falls⁵⁴  and reducing fracture incident rates⁵⁰  more specifically with an increased number of years of physical education.⁵⁰  Researchers of 1 study investigated playground infrastructure modifications (eg, changing the surface from wood fiber to granite sand) and showed a positive correlation with decreased arm fractures among children.⁷⁷ 

Authors of 22 studies evaluated the effectiveness of educational interventions and programs, including videos, instructions, lectures, and interactive sessions, embedded in curricula to improve knowledge, attitudes, and behaviors about burn injuries among school-aged children (Supplemental Information). The majority of education interventions were delivered at school with 1 intervention complemented by in-home visits and installation of smoke detectors,⁷⁸  2 interventions delivered at home,^98,134  and 1 intervention delivered at a research laboratory.⁴¹  Seventeen studies had favorable results in terms of improving burn safety knowledge, behaviors, and skills,^{41,44,46,63,71,75,78,80,81,88,90,96, 124,134,140,142,146}  whereas 5 revealed no impact.^{34,66,69,98,119}  Of note, 2 studies revealed the positive effect of a multicomponent education intervention on decreasing the frequency of burn injuries in the intervention group.^88,146 

In 10 studies, researchers investigated the impact of educational interventions on improving safety knowledge, attitudes, and behaviors about poisoning among school-aged children^{46,63,66,81,84,85,88,90,109,146}  (Supplemental Information). The majority of the interventions were administered in a school setting, with 1 study administered at a pediatric clinic.⁶⁶  Educational programs such as the Injury Minimization Program and Risk Watch revealed little improvement in children’s poisoning prevention knowledge.^63,81  Nonetheless, multicomponent educational interventions that included letters, handbooks, posters, lectures, educational videos, manuals, and parents-child discussions were found to significantly increase knowledge about safety, improve injury risk behavior,^{46,84,109,146}  and decrease poisoning frequency in intervention groups.^88,90  A multisensory interactive teaching approach was adopted in 1 study to educate children about chemical hazards; it proved effective in improving long-term knowledge retention compared with a traditional teacher-centered educational approach.⁸⁵  Receipt of safe behavior instructions through a computerized kiosk in a pediatric emergency department revealed limited improvement in parental safe practices compared with information delivered by an injury prevention specialist.⁶⁶ 

Among the 7 studies of educational drowning interventions for school-aged children (Supplemental Information), researchers of 5 evaluated the usefulness of adopting multicomponent education programs (ie, videos, presentations, lectures, brochures, booklet, leaflets, information cards, promotional materials),^{46,63,88,93,128,147}  whereas those of 1 assessed a testimonial-based video intervention.¹²⁵  Five of these studies were administered in a school setting,^{46,63, 88,125,128}  whereas 1 study was administered at the swimming pool.⁹³  All 7 studies consistently showed positive results in terms of improving children’s behaviors and safety knowledge^{46,63,88,125,128}  and parental knowledge¹⁴⁷  and supervision of children at public swimming pools.⁹³  One study found positive results in terms of decreasing minor and serious unintentional drowning.⁸⁸  Of note, the reported positive results significantly differed across various age groups, with a major improvement observed in younger compared with older age groups (eg, 6–10 vs 11–14 and 5–7 vs 8–12 years).^93,128 

In this systematic review, we identified 117 studies that evaluated injury interventions and their effectiveness in preventing unintentional injuries among school-aged children. Despite the high prevalence of injuries in children of LMICs, we confirm that there are a limited number of intervention studies in these countries, as corroborated by findings from other reviews that noted similar evidence.^13,26,148  One plausible explanation is the inadequate safety measures adopted and the neglected efforts taken by these countries to prevent injuries in school-aged children.

This review reveals that the majority of the injury intervention studies reported in the literature evaluated traffic-related injuries compared with other types of injuries such as poisoning and drowning, which claim a large share of the school-aged children injury burden. The focus of most reported studies was on educational interventions and their effectiveness in preventing unintentional injuries, whereas that of a smaller number of studies was on other types of interventions, such as laws and legislation and engineering and infrastructure. Of note, researchers mainly reported the impact of interventions on knowledge, attitudes, and behaviors with limited evidence on effectiveness in reducing injury, hospitalization, or mortality rates, which can be explained by the educational nature of most of the interventions investigated. Another explanation of the dearth of studies assessing the aforementioned outcomes could be the challenges in conducting and designing such studies in terms of the intensive resources and large sample sizes required.

On the basis of the findings of this review, we suggest that multicomponent educational interventions, including school-based curricula such as the Injury Minimization Program for Schools, Risk Watch, and Think First, can be effective in improving safety knowledge, attitudes, and behaviors among school-aged children. However, evidence from the included studies reveals that complementing educational interventions with other approaches can substantially increase knowledge retention, foster behavioral changes, and result in more effective interventions. For instance, distributing free helmets along with educational interventions leads to an increase in bicycle helmet use among children, mainly as a result of overcoming the financial barrier associated with helmet use among low-income families. Multiple factors should be considered when designing educational interventions. For instance, parents’ involvement in educational interventions is equally important and shown to improve safety knowledge and behaviors among children. Similar evidence has been noted by authors of another review,¹³  confirming that interventions targeting parents are effective in reducing child injuries. As opposed to passive teaching, active and engaged learning are additional contributing factors to the success of injury interventions. Interactive sessions and simulation exercises lead to increases in the effectiveness of education interventions targeting school-aged children. Simulation exercises alone through trainings on tabletops or in virtual environments revealed promising results in improving road crossing behavior in school-aged children. Although we found in this review breadth of evidence on the effectiveness of educational intervention on safety knowledge and behaviors, there is limited evidence on the impact of these educational interventions on injury rates.²⁶ 

Laws and legislation were found to be major contributors to effective road safety interventions, particularly in increasing bicycle helmet use and reducing traffic-related injury rates among school-aged children. These findings are consistent with Cochrane reviews revealing that mandatory bicycle helmet legislation is effective in increasing helmet use and in reducing head injuries.^149,150  Our review reveals the scarcity of studies evaluating policies, laws, and legislation aimed at preventing other types of unintentional injuries. Of note, our findings underscore the age variation in safety regulation compliance, as younger children were more likely to abide by regulations, suggesting the need to couple laws and legislation with enforcement when dealing with older children.

In a limited number of the included studies, researchers evaluated the effectiveness of infrastructural interventions coupled with instructions and education in reducing injury risks and improving safe behaviors among children. These findings reveal the relevance of infrastructure modification and built-in safety and their effects on reducing falls and in improving pedestrian safety among school-aged children.

In this review, we have identified a major knowledge gap in the impact of unintentional injury prevention interventions on child injury morbidity and mortality rates. We used rigorous methods to highlight a gap in evaluating the effect of policies, laws, and legislation on preventing unintentional injuries among school-aged children; this is also applicable when it comes to interventions assessing infrastructure and engineering changes. We encourage global researchers to focus their future investigations on addressing these knowledge gaps, mainly the effectiveness of different interventions in averting injury morbidity and mortality.

With this review, we provide a powerful tool to inform policymakers and other stakeholders, interested in designing and delivering interventions to reduce risks of unintentional injuries in their communities. Funders are called on to invest in research on the effectiveness of unintentional injury prevention interventions in LMICs given the high burden of unintentional injuries in these countries and the limited contextualized evidence.

This systematic review has 3 main strengths. First, to our knowledge, it is the first to examine a wide range of interventions to prevent unintentional injuries in school-aged children. Second, we used standard, explicit, and rigorous methods in conducting this review¹⁵¹  and followed standard methods for reporting.¹⁵²  Third, we conducted a comprehensive search on multiple databases and the references of all relevant articles. We have also included RCTs, CBAs, and ITS studies, which can provide high-quality evidence. One of the limitations of this review is the lack of feasibility to perform a meta-analysis and data pooling because of the variety of interventions, outcomes assessed, and measurement methods. Moreover, the majority of included studies are conducted in high-income countries, which makes it challenging to generalize the review findings to LMICs.

CBA

controlled before-and-after study

ITS

interrupted time series

LMIC

low- and middle-income country

RCT

randomized controlled trial