143

ORIGINAL ARTICLE

Group interventions for the prevention of injuries in young

children: a systematic review
B Bruce, P McGrath
...............................................................................................................................
Injury Prevention 2005;11:143–147. doi: 10.1136/ip.2004.007971

Objective: This systematic review examined group based injury prevention interventions that targeted
young children to determine the effectiveness of such strategies in enhancing children’s safety behaviors.
Methods: A comprehensive (manual and electronic) search of the literature was performed using the
following study selection criteria: (1) intervention engaged children under the age of 6 years; (2) included
a control group; (3) used a group intervention approach; (4) study written in English language; (5)
addressed unintentional injuries; and (6) outcomes included injuries, knowledge, or safety behaviors. Data
abstraction was performed independently by two researchers using a standardized approach.
Results: Nine studies met the criteria that included safety interventions of road crossing (4), car restraint
See end of article for (2), spinal cord safety (1), poison safety (1), and 911/stranger danger/street crossing (1). The types of
authors’ affiliations interventions included videos, interactive activities, cartoons, stories, puppets, singing, coloring, games,
.......................
simulation games, demonstrations, modeling/role playing, and rehearsal practice using seat belts,
Correspondence to: models, and real street crossing. The intensity and duration of interventions varied substantially and only
Ms B Bruce, IWK Health two studies randomly assigned participants. The review revealed a positive effect (knowledge, behaviour,
Centre, 5850 University
Avenue, PO Box 9700, and/or attitude) for five of the studies, three had mixed effect, and one reported no effect.
Halifax, Nova Scotia, Conclusions: Although no clear conclusions can be drawn from the limited number of studies of diverse
Canada, B3K 6R8; beth. design and rigor, researchers should attempt to minimize shortcomings occurring in community based
bruce@iwk.nshealth.ca
research. Engaging community partners including teachers and parents who influence relationships and
Accepted 22 January 2005 outcomes could provide opportunity for more rigorous, comprehensive, and integrated approach to
....................... longitudinal research that could identify key factors of successful strategies.

C
hildhood injury remains among the leading causes for
childhood morbidity and mortality.1 2 Such injuries
result in significant human and societal costs, with
both short and long term consequences ranging from
interruptions in school/sports activities to significant cogni-
tive and behavior disorders, depression, and deterioration of
family functioning, physical morbidity, and sometimes
death.3–7 However, researchers have long advocated that as
much as 90% of injuries could be prevented through
coordinated and effective education, engineering, legislation,
and enforcement strategies.7 8
provided interventions in a systematic manner to a group of
children, primarily in classroom or day care settings.
Interventions could include a broad range of strategies such
as skills training, interactive games, activities, modeling and
rehearsal, written material, and videos, but not a community
component. Interventions that focused on children but may
have also incorporated parents as secondary targets were
included. Individual interventions were not included as they
are typically delivered under different circumstances, usually
in a healthcare setting where parents are the primary target
population (for reviews see DiGuiseppi & Roberts).2

GROUP INTERVENTIONS AMONG YOUNG METHODS

CHILDREN
There has continued to be much debate about the effect of
injury prevention strategies targeted directly towards chil-
dren, in particular, preschool age children. Some argue that
children in this age group do not possess the cognitive ability
and attention to permit the integration of injury prevention
messages into their repertoire of skills.11 However, other
researchers advocate that taking advantage of early inter-
vention may provide a foundation for long term application
of safety behavior in preventing injuries.12–14
Systematic reviews have made it possible to formally and
comprehensively assess the quality of studies and draw
significant conclusions that permit further advances in the
area of inquiry. Systematic reviews not only provide
comprehensive and objective evidence to guide practice,
often resolving controversies, but they can also direct future
research efforts.9 10 The intent of this systematic review is to
explore group based injury prevention interventions that
targeted young children (under age 6 years) to determine the
effectiveness of such strategies in enhancing children’s safety
behaviors. Group level interventions refer to strategies that
Inclusion criteria
Studies were included in the systematic review if they met
the following criteria: (1) the intervention engaged children
under the age of 6 years; (2) included a control group; (3)
used a group intervention approach; (4) were written in
English; (5) addressed unintentional injuries, and (6)
outcome measures included injuries, knowledge, or safety
behaviors. The decision to include all experimental studies
whether randomized or not was due to the nature of group
level interventions that most often occur in natural settings
where it is often difficult to systematically assign participants
randomly. Only studies with control groups were included in
an effort to minimize bias. Only published English studies
were included due to the limitations of the researcher to
access translation services. No studies of intentional injuries
(violence, bullying, and abuse) were included as strategies
are often unique to this safety issue and may not be
appropriate for unintentional injuries. Knowledge, safety
Abbreviations: CINAHL, Cumulative Index to Nursing and Allied Health
Literature.

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144 Bruce, McGrath

Table 1 Study demographics

Author (year), country Study population Interventions Outcome measures
19
Chang (1995), US Preschool age Car restraint Pre and post % car restraint behavior
14 schools 2 week intensive classroom activities Random knowledge interview (25% experimental
Intervention (402) Children—film, flannel board, singing group)
Control (427) Parents—workshop, home activities, written 2–3 weeks post intervention
information
18
Renaud (1989), Canada 5 year olds Pedestrian skills 1. Attitude—perception of risk
4 schools 3 hour sessions 2. Behavior—pictures and questions
Intervention (102) 1. Attitude simulation-role play 3. Behavior observations
Control (34) 2. Behavior simulation—model training 10 days post intervention
3. Attitude-behavior simulation—role play,
modeling, training
12
Bowman (1987), Australia Preschool age Car restraint Restraint observation
30 schools 2 week intervention 1 week post intervention
Intervention (231) Education—cartoons, songs, seat belt practice
Control (221)
Rothengatter (1984), Preschool age Street crossing skills Traffic knowledge
20
Netherlands All schools in community 3 week intervention Street crossing behavior
Intervention (parent trainers) 4615 minute session 1 week post intervention
(21) Model, practice, reinforcement
(Assistant trainers) (28)
Control (73)
Luria (2000), US17 5 year olds Stranger danger, calling 911 (North American Knowledge test
10 schools emergency number), street crossing 6 month post intervention
Intervention (90) One hour session
Control (91) Lecture, practice, games, songs, coloring
Richards (1991), US13 Preschool age Spinal cord injuries Knowledge test
3 schools Several sessions over 3 months Self reported seat belt use
Intervention (72) Rehearsal, practice, interaction, reinforcement 1 week post intervention
Control (36)
15
Thomson (1992), UK 5 year olds Street crossing Behavior observation
Random selection 6630 minutes over 3 weeks 1 week post intervention
Intervention (20) Model practice 2 months post intervention
Control (10) Road side training
Liller (1998), US14 5–6 year olds Poison safety Knowledge interview
6 schools 40 minute session 1–2 weeks post intervention
Intervention (84) Interactive—songs, puppets, stories
Control (71) Parents—home activities, written information
Thomson (1998), UK16 5 year olds Street crossing Behavior observation
3 schools 6630 minute sessions 1 week post intervention
Intervention (30) 3 weeks 40 days post intervention
Controls (30) Road side training
Model practice

behaviours, and injury events were included although Data extraction

knowledge and safety behaviors are known to be the
outcomes predominantly measured in these types of studies.9
Identification of studies
The search strategy used an electronic search of several
databases including The Cochrane Library, CINAHL
(Cumulative Index to Nursing and Allied Health
Literature), PUBMED, Cambridge Scientific Abstracts,
Dissertation Abstracts, and PsycINFO for the years 1980–
2002 in an effort to enhance comparability between study
designs. Search strategy included terms ‘‘child’’, ‘‘risk
taking’’, ‘‘education’’, ‘‘evaluation’’, ‘‘prevention and con-
trol’’, ‘‘safety’’, and ‘‘injury prevention’’. In addition, biblio-
graphies of published studies and reviews were searched
for relevant studies that met the inclusion criteria. A review
of additional websites included; http://depts.washington.
edu/hiprc/childinjury, http://www.safetylit.org, www.the-
communityguide.org, and http://www.cdc.gov/ncipc/injweb/
websites.htm. Abstracts from the 6th World Conferences on
Injury Prevention and Control were also reviewed. Authors of
relevant studies and reviews were contacted as well as
recognized experts in the field of childhood injury prevention
research. After screening titles and abstracts, 307 studies
were identified as potentially eligible for inclusion.
Potentially appropriate articles were further reviewed to
determine if they met the inclusion criteria, yielding nine
studies for full review.
Two researchers independently extracted the data after full
articles were screened for inclusion. Data detailing study
design, participants, and types of injury and interventions
were documented (see table 1). Any disagreements were
resolved by consensus. Quality assessments were not
conducted due to the diverse study designs and the lack of
randomized control groups. Descriptive analysis was chosen
rather than meta-analysis as the data findings and statistical
analysis reported for outcome measures varied considerably,
making the combining of results inappropriate. Primary
outcome measures were compared for differences between
pre and post intervention between the control and interven-
tion groups. Variability in study findings was examined with
respect to study design and intervention characteristics.
RESULTS
The areas of safety interventions included four road cross-
ing,15 16 18 20 two car restraint,12 19 one spinal cord safety,13 one
poison safety,14 and one combination of 911 (North American
emergency number)/stranger danger/street crossing.17 The
types of interventions included videos, interactive activities,
cartoons, stories, puppets, singing, coloring, games, simula-
tion games, demonstrations, modeling/role playing and
rehearsal practice using seat belts, and model and real street
crossing. The parent directed activities included workshops,
home activities, and written information. In addition to the
variety of interventions delivered, the duration of delivery

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Group interventions for the prevention of injuries in young children
Table 2 Study descriptions
Author (year), country
19
Chang (1995), US
Renaud (1989), Canada18
Bowman (1987), Australia12
Rothengatter (1984),
Netherlands20
Luria (2000), US17
Richards (1991), US13
Thomson (1992), UK15
Liller (1998), US14
16
Thomson (1998), UK
*p,0.05.
varied substantially from a minimum of one 40 minute
session to two weeks’ intensive classroom instruction of
unspecified session duration.
The participants ranged in age from 3–6 years of age. Eight
studies engaged preschool students (3–5 years old) and one
study14 was conducted with kindergarten children (5–6 years
145
Intervention group Control group Weaknesses Strengths
Behavior Behavior 1. Blind observation not reported 1. Matched for baseline seat belt use,
Pre: 21.9% Pre: 22.1% 2. No randomization schools size, education philosophy
Post: 44.3% Post: 23.8% 3. No report intensity/dose 2. Minimum essential program
p,0.001 p = NS 4. Random knowledge pre and post—? activities
Knowledge Knowledge not Same children 3. Control group received intervention
Seat belt (4/4), p,0.02 tested post testing
Car seat (1/4), p,0.001
Practice (2/4), p,0.001
Three intervention groups 1. Attitude and behavior tested 1. Children randomly assigned
(attitude, behavior, attitude/ immediately following session 2. Trained observer
behavior) v control 2. Blind observation not reported 3. Measure validated
Attitude mean difference 3. Post test only 4. Control for gender and school in
1. 0.60* analysis
2. 0.72*
3. 0.52*
Behavior mean difference
1. 0.33
2. 20.57
3. 0.94*
Observation mean difference
1. 0.83
2. 2.48
3. 2.22
Pre: 60.6% Pre: 59.9% 1. Intensity/dose not reported 1. Schools randomized
Post: 75.0% Post: 60.3% 2. Pre/post observation? Same children 2. Trained observer
p,0.009 p = 0.93 3. Interrater reliability
4. Matched for baseline
5. Intervention materials provided
Knowledge (parent trainer) Knowledge 27.33– 1. Intensity/dose not reported 1. Program pilot tested
26.80–28.71 29.32 2. No randomization 2. Trained interventionist
(Assistant trainer) 27.65– 3. Observation tool not reported 3. Minimum dose
31.82 4. Blind observation not reported 4. Control group received intervention
5. No group statistical test differences post testing
reported
Crossing street m = 1.90, Crossing street 1. Community instructors—training not 1. Schools randomized
p = 0.29 m = 1.40, p = 0.29 reported
Calling 911 m = 4.15, Calling 911 2. Blind observation not reported
p = 0.41 m = 3.66, p = 0.41 3. Newly developed instrument—not
Stranger danger m = 1.33, Stranger danger tested
p = 0.57 m = 1.65, p = 0.57 4. Intensity/dose not reported
Knowledge m = 2.58, Knowledge 1. Blind observation not reported 1. Program pilot tested
p,0.05 m = 1.28, p,0.05 2. Intensity not reported 2. Instrument tested
Seat belt use 60–75%, NS Seat belt use 60– 3. Self report by preschoolers 3. Teachers trained
75%, NS
Demonstration Demonstration 1. Children randomly selected but no 1. Trained interventionist
Pre: 14% Pre: 4% report of random assignment 2. Observation assessment—interrater
Post: 37% Post: 12% reliability
t = 2.41, p,0.05 Post 2: 12% 3. Randomly selected
Post 2: 37% Road behavior 4. Control for gender
t = 2.83, p,0.05 Pre: 4% 5. Consistent intervention—dose
Road behavior Post: 12% monitored
Pre: 10% Post 2: 12%
Post: 35%
t = 2.17, p,0.05
Post 2: 34%
t = 2.36, p,0.05
Knowledge OR 2.2–144.5, 1. Post test only 1. Teachers prepared
p,0.05 2. School sited selected by School Board 2. Instrument pilot tested
3. No randomization
4. Blind observation not reported
Road skill Road skill 1. Matched sample for gender, school
Pre: 15% Pre: 16% 2. Trained parent volunteers
Post: 43% Post: 13% 3. Intervention previously tested
t = 24.95, 4. Interrater reliability established
p = 0.001 5. Blind observation reported
Post 2 Post 2 6. Consistency of dose monitored
Pre: 15% Pre: 16%
Post: 35% Post: 16%
t = 24.11, p = 0.001
old). All studies had a control group. The majority of school
sites were chosen based on the cooperation of the school
board/community resource agencies or the school/teacher
willingness to follow protocol and the suitability of school
environments for intervention. Some study sites were
selected for their location, in high risk neighbourhoods or
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146
in different socioeconomic communities. The number of
children participating in each study was broad, ranging from
30 to 829 children. Several studies either matched for gender
and socioeconomic status or controlled for these potential
confounding factors in the analysis phase. The interventions
occurred in classroom groups in all nine studies with teachers
delivering the intervention in four studies,12–14 19 trained
parent/volunteer in three,16 17 20 the researcher in one,15 and
unknown in one study.18 Most studies provided interventions
to the entire class with only two studies using small groups of
five15 and three.16 Table 1 includes descriptions of each study’s
population, intervention, and outcome measures.
Four studies reported random selection, two by school12 17
and two by student.15 18 Measurement data were collected by
teachers for the most part, and in two studies by the
researchers themselves.15 16 Only one study reported blinded
observations.16 Outcome measurement occurred anywhere
from immediately following the intervention to six months
after intervention. Overall, the review revealed a positive
effect for five of the studies;12 14–16 19 three had mixed
effects13 18 20 and one reported no effect.17 Of those studies
demonstrating an effect, differences in behaviour,12 15 16 19
attitude,18 and knowledge14 18 20 were reported. No studies
measured changes in injuries.
Table 2 includes descriptions of the intervention and
control groups and the strengths and weaknesses of each
study.
Potential bias
Many of the schools were chosen based on convenience and
willingness of the school to permit research activities to take
place, whereas other schools were chosen for their represen-
tativeness of different geographic areas and socioeconomic
demography. Although attempts to select schools represen-
tative of the population are useful, the convenience sampling
was one of practicality and consideration must be given to
the potential for bias when convenience samples are used.
Cluster randomization is often considered to be the gold
standard in these types of studies but can be difficult to
achieve and complex to implement in community settings.21
Only two of the studies used cluster randomization.12 17
Although most studies indicated that considerable effort
had been made to ensure the individual responsible for the
delivery of the intervention was well prepared before
initiation of the intervention, some studies were vague about
preparation17 18 and monitoring for consistency of program
delivery. In fact, most studies reported that the delivery
varied depending on the individual. Despite the reported
attempt to establish a minimum expectation, investigators
did not report on the comprehensiveness of delivery beyond
the minimum nor did they monitor for fidelity of interven-
tion that ranged from one 40 minute session to two weeks of
intense learning opportunities. Furthermore, some studies
actively engaged parents whereas others did not report on the
level of parental involvement. In other respects, the follow up
measurement varied considerably from immediately follow-
ing the intervention to six months after intervention. Clearly
the intensity and duration of intervention follow up and
preparation of the interventionist may influence the outcome
assessment.21 Outcomes were usually measured using obser-
vation techniques or knowledge tests based on the interven-
tion content. Most assessments were primarily developed for
the specific study and were not rigorously tested. Although
observation is a useful strategy, it was not clear in the
majority of the studies whether the observers were blind to
the group assignment of the children. Lack of blinding could
bias reporting. More generally, potential for publication bias
must be considered given that only studies published in
English since 1980 were included in this review.
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Bruce, McGrath
DISCUSSION
This review suggests that group interventions could enhance
children’s safety behaviors during early childhood. The
studies were all conducted with children aged 3–6 years
from a diversity of neighbourhoods and socioeconomic
backgrounds. Although the diversity of samples makes
comparison of studies difficult it strengthens the external
validity of the consistent effect of the interventions in
different populations. In addition, regardless of the safety
issue addressed, positive results were demonstrated providing
evidence that children may respond to such strategies. The
rigor of the study designs were similar in that they all
included a control group and all but two conducted baseline
testing for comparison. The weakness of the interventions
was in the lack of control over the intensity and duration of
the intervention, and preparation of the interventionist. None
included an adequate measure of fidelity of the intervention.
It is difficult to conclusively analyze the findings without this
level of rigor that could significantly contribute to differences
in outcomes. In addition, no study attempted to measure
rates of injuries, so it remains unclear whether such
interventions have the potential to actually alter injury rates
among children. Furthermore, the potential for long term
impact, particularly in relation to injury rates cannot be
determined, as no study included a long term follow up.
Future efforts should focus on developing collaborative
research teams that include community partners such as
teachers and parents using studies of enhanced rigor. Such
initiatives could strengthen opportunities to conduct long
term studies that measure key factors linked to injuries such
as parental involvement, teacher awareness and prevention
strategies, school and community attributes, child behaviors,
peer relationships, and supervision. Such efforts may yield
more accurate evidence of associations and lead to develop-
ment and measurement of causal relationships.
The elements of the successful programs included group
sessions that incorporated multiple interactive learning
tools12 14–16 19 including group activities and rehearsal oppor-
tunities. Typically, the leaders were well trained and could be
teachers, parents, or volunteers. The optimal dose is not clear
and requires further assessment. Furthermore, it is not
obvious whether engaging parents as reinforcement has any
significant effect. Practice appears key to positive outcomes in
that children need to be exposed to opportunities to develop
problem solving skills rather than content specific knowledge
alone.15 16 20 Equally important is the interactive component
rather than the traditional didactic approach to increasing
children’s knowledge of safety behavior.13–16 18–20 A compre-
hensive approach that integrates such learning approaches
into curriculum in the early years may be worthy of further
research.
Regardless of the safety topic that was addressed, the
majority of studies demonstrated some positive effects. This
suggests that potential exists to positively influence the
development of safety behaviors among young children using
group interventions. The challenge remains as to whether
these behaviors are transferable and can be incorporated into
a child’s repertoire of decision making skills about injury
risks. This could create the potential to influence the rate of
injuries.
Future research needs to standardize intervention strate-
gies in a variety of situations to better assess the ability of
such interventions to impact on children’s safety behaviors
and ultimately on the risk of injury. Although the challenges
are numerous and often discouraging in community settings,
it remains important to establish scientific rigor through the
random allocation of children or groups of children to
treatment and control groups. Studies that incorporate
established data collection tools, blind observation, and long
Group interventions for the prevention of injuries in young children 147

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LACUNAE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
US child restraint use in 2004

I
nfants and toddlers in America continue to be restrained at high use levels when riding in
motor vehicles, while use among children aged 4–7 has declined. This result is from the
National Occupant Protection Use Survey (NOPUS), which provides the only probability
based observed data on child restraint use in the US. The NOPUS is conducted by the
National Center for Statistics and Analysis in the National Highway Traffic Safety
Administration (NHTSA). Specifically, 98% of infants and 93% of children aged 1–3
observed in passenger vehicles stopped at a stop sign or stoplight in 2004 were restrained in
some type of restraint, whether a rear or front facing safety seat, a booster seat, or a safety
belt. In contrast, only 73% of children ages 4–7 were restrained, down from 83% two years
ago. Drivers who restrain themselves continue to be more likely to restrain their child
passengers. In 2004, 86% of 0–7 year old children driven by belted drivers were restrained,
compared with 50% of children with unbelted drivers. This suggests that getting adults to
buckle up may also result in more restrained children. For detailed analyses of the data in
this publication, as well as additional data and information on the survey design and
analysis procedures, see Child restraint use in 2004 – analysis, available at http://tinyurl.com/
g8xm.

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