Parenting programmes for the prevention of unintentional injuries in childhood
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
The objectives of the review are as follows;
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to evaluate the effectiveness of parenting programmes in preventing unintentional injury in childhood
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to evaluate the effectiveness of parenting programmes in increasing possession and use of home safety equipment and parental safety practices.
Background
Injuries are an important public health problem. In industrialised countries they are the leading cause of death in childhood, accounting for 40% all child deaths between the ages of 1 to 14 years (UNICEF 2001). In the United Kingdom more than 350 children die from an injury (ONS 2005), there are more than 119,000 hospital admissions (DH 2004) and almost two million attendances at accident and emergency departments amongst children each year following injury (DTI 2003). There is a steep social class gradient in child injury mortality (Roberts 1997) and morbidity (Hippisley‐Cox 2002); and some evidence that the gradient in injury mortality may be widening (Roberts 1996).
Parenting programmes are now being offered in a variety of settings which are aimed at improving 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. Several recent systematic reviews have shown that they are effective in improving behaviour problems in infants and toddlers (Barlow 2002a), in 3 to 10 year old children (Barlow 2000) and also in improving maternal psychosocial health in the short term, including reducing scores measuring anxiety and depression (although it is unclear whether this applies to clinical levels of depression and anxiety) and improving self‐esteem (Barlow 2002b). There is also evidence to show that they are effective in improving outcomes for both teenage mothers and their children (Coren 2002). We have been unable to find any systematic reviews examining the effect of parenting programmes on the prevention of childhood unintentional injury.
There are several mechanisms by which parenting programmes could help prevent childhood unintentional injury. Firstly there is growing evidence that maternal psychosocial health is associated with childhood unintentional injury. Higher unintentional injury rates have been found amongst children whose mothers were defined as having a psychiatric disorder (Brown 1978), were suffering from depression (Beautrais 1981; Harris 1994; O'Connor 2000) or anxiety (Bradbury 1999), had experienced a higher number of life events, such as separation from their partner, recent bereavement or moving household (Beautrais 1982; O'Connor 2000) or who reported higher levels of stress (Harris 1994). A recent large US cohort study found 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 be able to help reduce childhood unintentional injury by improving maternal psychosocial health. Secondly child behavioural problems including aggressive and overactive behaviour have been found to be associated with increased unintentional injury rates (Bijur 1986; Bijur 1988a; Bijur 1988b; Bussing 1996) and parenting programmes, through reducing child behavioural problems, may help to reduce such injuries. Data from a recent systematic review of home visiting programmes provides some evidence to support both of these suggested mechanisms as home visiting programmes were found to be effective in improving parenting, maternal psychosocial health, child behavioral problems and in reducing childhood unintentional injuries (Elkan 2000; Kendrick 2000). More recent work suggests that particular styles of parenting may themselves help to prevent childhood unintentional injury as aspects of positive parenting such as frequency of praise and of playing with children have been found to be 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 through the development of particular styles of parenting. We are therefore interested in assessing the effectiveness of parenting programmes in preventing childhood injury.
Objectives
The objectives of the review are as follows;
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to evaluate the effectiveness of parenting programmes in preventing unintentional injury in childhood
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to evaluate the effectiveness of parenting programmes in increasing possession and use of home safety equipment and parental safety practices.
Methods
Criteria for considering studies for this review
Types of studies
Individually and cluster randomised controlled trials, non‐randomised controlled trials and controlled before and after studies will be included.
Types of participants
Studies will be eligible for inclusion in the review if the intervention has been provided for parents of children (aged 0 to 18 years).
Types of interventions
Studies evaluating the effectiveness of individual and group‐based parenting programmes will be 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.
Types of outcome measures
The outcome measures that will be assessed are:
(i) self reported or medically attended unintentional injury or injury of unspecified intent
(ii) possession and use of home safety equipment
(iii) safety practices (e.g. storage of hazardous objects and substances, use of baby walkers, unsafe hot water temperature, etc)
Intentional injury outcomes will be excluded as these are the focus of an on‐going Cochrane review (Barlow 2005).
Search methods for identification of studies
The search strategy will identify randomised and non‐randomised studies (as defined above) using terms to identify parenting programmes, and injuries, safety equipment and safety practices. The following search strategy will be used for MEDLINE and adapted as necessary for other databases;
infan* or child* or teen* or adolesc* or minor* or toddl* or bab*
AND
(parent* near program*) or (parent* near train*) or (parent* near educat*) or (parent* near promot*) or parent* near skill*) or (parent* near intervent*) or (parent* near group) or (parent* near support*) or (parent‐child relations or parent‐child interaction or object attachment)
AND
(accident* near prevent*) or (safety) or (safe* near device*) or (safe* near equipment*) or (infan* near equipment*) or (protective near 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* near inhal*)
AND
randomised controlled trial or random allocation or double blind method or clincial trial or control group or evaluat* or intervent* or comparative study
We will search the following sources;
Bibliographic databases
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Cochrane Central Register of Controlled Trials (CENTRAL)
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Cochrane Database of Systematic Reviews
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MEDLINE
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EMBASE
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Biological Abstract
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PsychINFO
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Sociofile
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Social Science Citation Index
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CINAHL
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Dissertation Abstracts
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ERIC
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Database of Abstracts of Reviews of Effectiveness
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ASSIA
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Web of Science
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SIGLE
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ZETOC
Websites
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Injury Prevention Research Centers at the Centers for Disease Control (USA)
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The National Institute for Health and Clinical Excellence (NICE) Public Health website (UK)
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Children's Safety Network (USA)
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International Society for Child and Adolescent Injury Prevention (International)
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Child Accident Prevention Trust (UK)
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Injury Control Resource Information Network (USA)
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National Injury Surveillance Unit (Australia)
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Injury Prevention Web and SafetyLit (USA)
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Barnado's Policy Research and Influencing Unit (UK)
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NCH (UK)
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National Children's Bureau (UK)
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Children in Wales ( UK)
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Homestart (UK)
Hand s earching
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Abstracts from the 1st to 7th World conferences on injury prevention and control
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Injury Prevention
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Reference lists of articles identified through database searches, and bibliographies of systematic and non‐systematic reviews.
Unpublished studies will be identified using the following sources:
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The Cochrane Library
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Current Controlled Trials
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National Research Register (NRR)
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Register of the Medical Editors Trial Amnesty
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Authors of papers included in the review will be also be contacted to identify unpublished research.
There will be no restriction by language or publication status.
Data collection and analysis
Selection of studies
We will have a two stage screening process. Two authors will independently scan titles and abstracts of articles to identify which articles to retrieve in full. If there is disagreement between authors, we will retrieve the full article. Two authors will independently review the selected articles using a standard form listing inclusion criteria. Disagreement between authors will be dealt with by consensus involving a third member of the research team.
Data management
Two authors will independently extract data using a data extraction form. If data are not available in the published reports, we will contact study authors to obtain missing information.
Quality Assessment
Two authors will undertake critical appraisal of the included studies according to the criteria listed below:
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'A' will be used to indicate the use of an adequate method of allocation concealment (for example, by telephone randomisation, or use of consecutively numbered, sealed, opaque envelopes);
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'B' will be used to indicate uncertainty about whether the allocation was adequately concealed (for example, where the method of concealment is not known);
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'C' will be used to indicate that the method of allocation was not adequately concealed (for example open random number lists).
The following aspects of the study will also be appraised: the numbers of participants for whom follow‐up data are available and blinding of outcome assessment. The quality of non‐randomised studies will be assessed using the tool developed by Reisch and colleagues (Reisch 1989).
Data analysis/synthesis
We will undertake statistical tests of homogeneity using χ2 tests (with significance defined as a P‐value of <0.1) and the I2 statistic will be presented. Heterogeneity will be explored using subgroup analyses (these will include separate analyses of randomised and non randomised studies) and meta‐regression as appropriate. If there is clinical heterogeneity, the results of individual studies will be presented individually, that is, not combined in a meta‐analysis.
Data synthesis
If there are sufficient studies, we will pool results and present them as relative risks and 95% confidence intervals (CI) for the binary outcomes of possession of items of safety equipment, safety practices and occurrence of at least one self reported or medically attended injury. A random‐effect model will be used to allow for and quantify the degree of statistical heterogeneity present between individual studies. If cluster randomised studies have been reported without appropriate adjustment for clustering, we will adjust the reported treatment effect for clustering using the intra class correlation coefficient (ICC) of the study if available, otherwise we will use the ICC of similar cluster randomised studies. 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. If there are insufficient clinically homogenous studies to combine in a meta‐analysis, the results from individual studies will be combined in a narrative review.
Handling of missing data
We will assess missing data and dropouts for each included study and the review will report the number of participants who are included in the final analysis as a proportion of all participants in each study. Reasons for missing data will be provided in the narrative summary, and we will assess the extent to which the results of the review could be altered by the missing data. Best‐case and worst‐case scenario analyses will be attempted to assess the effect of the missing data. Assessment will be made of the extent to which studies have conformed to an intention‐to‐treat analysis and the effects of this on the results.
Sensitivity analysis
If there are sufficient studies and there has been uncertainty or disagreement regarding the inclusion of studies, data extraction, missing data etc., or in the event of one or more studies dominating the results, a sensitivity analysis will be undertaken to investigate the robustness of the overall findings. Where there are sufficient randomised studies, sensitivity analysis will be undertaken for individual aspects of study quality as discussed in the section on quality assessment.
Publication bias
If appropriate, the possibility of publication bias will be assessed using funnel plots and Egger's test. Such a relationship could be due to publication bias or systematic differences between small and large studies. If a relationship is identified, clinical diversity of the studies will be further examined as a possible explanation.
