Conclusion: Strong indications for effectiveness
A systematic review by Di Guiseppi et al. (2000) concludes that for most safety practices evaluated, counseling and other interventions in the clinical setting resulted in a greater likelihood of safety practice. For example, practices including motor vehicle restraint use, smoke alarm ownership, and maintenance of a safe hot tap water temperature were more likely to be adopted following interventions delivered in the clinical setting, and these differences were statistically significant. However, clinical interventions were not effective at increasing bicycle helmet use or increasing the use of practices designed to protect young children in the home. Only two RCTs in this systematic review collected data on the effect of counseling in the clinical setting on childhood injuries. These studies reported little or no effect on minor injuries, and the reduction in hospitalizations, though clinically important, was not statistically significant.
A systematic review by Bass et al. (1993) found twenty articles including original reports of unintentional injury prevention counseling in a primary care setting. Of these, 18 showed positive effects of injury prevention counseling. Positive outcomes as measured by increased knowledge, improved behavior, or decreased injury occurence were reported for both motor vehicle and non-motor vehicle injuries like burns, falls and poisoning.
A benefit-cost camparison by Miller et al. (1995) of The Injury Prevention Program (TIPP) developed by the American Academy of Pediatrics (concluded that this is an effective program from the perspective of annual medical spendings in unintentional injuries in children. They calculated that TIPP pediatric injury counseling sessions could achieve estimated savings of 880 US dollars per child. Gardner et al (2007) provide updated information on the TIPP program.
Recommendations (for research & practice)
For further research
Bass et al. (1993) point out four steps in designing a counseling program:
1. Identifications of an educational need
2. Demonstration of a positive educational effect
3. Demonstration of a positive behavioral effect
4. Demonstration of decreased injury occurrence
Each step is progressively more difficult to achieve and document, resulting in fewer studies at each successive tier. Research that focuses on all of these steps is still rare.
DiGuiseppi et al. (2000) point out that many of the trials identified in their review were conducted more than a decade ago, before legislation and regulations regarding infant safety seats, bicycle helmets, smoke alarm installation, and preset hotwater heater temperatures were implemented. They conclude that 'It is doubtful that the brief, simple interventions evaluated in the past would have the same impact today. The identification of efficient and cost-effective clinical interventions that improve safety practices in the current regulatory and legislative environment is needed.'
DiGuiseppi et al. (2000) also point out that 'The review supports previous research showing that studies with weaker evaluation methods, on average, report larger effect estimates than do studies with stronger methods. Hence, while the best available evidence supports counseling to promote certain safety practices, the benefit may be less than that reported here because many of the trials reviewed did not use adequate study methods. Additional RCTs that adhere to rigorous design principles would be useful to supplement the results reported in this systematic review. Also, studies are needed to examine the effects of interventions in the clinical setting on safety practices aimed at reducing other causes of childhood injuries, including pedestrian, firearm, drowning, recreational, and alcoholrelated injuries. Because hospitalizations are costly, clinical interventions that produce even modest effects would be worthwhile if the interventions could be implemented cost effectively. Sufficiently large trials that identify beneficial effects of counseling on injuries, that also consider costs in relation to effect and benefit, are therefore needed.'
A systematic review by Woods (2006) found that health professionals' knowledge is variable, although generally they have a positive attitude towards childhood injury prevention. Even with adequate knowledge and positive attitudes there appear to be barriers in prevention practice. E.g. personalexperience, lack of materials/ resources, lack of time, other priorities, non-interested patients or lack ofconfidence. Woods (2006) points out that 'no matter how knowledgeable nor how positive healthprofessionals' attitudes to childhood injury prevention, if barriers to practice are not adressed we willmove no closer to reducing the burden of injuries in childhood. Those professionals who are positive about their role may be best suited to continue to raise the issue campaigning for legislative andengineering changes which can reduce childhood injuries.
The article by Gardner (2007) aims to provide guidance on the content of unintentional injury-prevention counseling for different ages and stages: infants, preschool-aged children, school-aged children and adolescents. A detailed description of which issues should be included for each age group is provided.
Gielen et al (2002) found that for low-income families, coupling injury prevention counseling with convenient access to low-cost safety supplies and personalised information was useful.
Articles (reviews) and reports were included that were published between 1990 and 2010, in English and Dutch. The outcomes of the study were reviewed by the Dutch Consumer Safety Institute.
Strategy: An online literature search was performed by a researcher of the Consumer Safety Institute and after this a more thorough search was performed by the documentation centre of CSI (Catalog CenV, Pubmed, Injury lit, Google, Websites, 'Grey' literature). Results of each search were compared on differences and potential missed studies were added. First the titles and then abstracts were scanned in order to include relevant studies. In the case of insufficient information obtained from abstracts the full text articles were obtained. Relevant articles were scrutinized and background documents were created. In addition, relevant references of included articles were checked on new and relevant articles (i.e., snowball search).
The outcomes of the study were reviewed by an expert in the field of child safety in 2011.
Chilhood injury prevention counseling in primary care settings : a critical review of the literature (version 1.0)
Joel L. Bass, Katherine Kaufer Christoffel, Mark Widome ...[et al.] (1993)
Individual-level injury prevention strategies in the clinical setting (version 1.0)
Carolyn DiGuiseppi, Ian G. Roberts (2000)
Injury prevention counseling by pediatricians : a benefit-cost comparison (version 1.0)
Ted R. Miller, Maury Galbraith (1995)
The role of health professionals in childhood injury prevention: a systematic review of the literature (version 1.0)
Amanda J. Woods (2006)
Office-based counseling for unintentional injury prevention (version 1.0)
H.G. Gardner (2007)
Effects of improved access to safety counseling, products, and home visits on parents' safety practices : results of a randomized trial (version 1.0)
Andrea Carlson Gielen, Eilee M. McDonald, Modena E.H. Wilson ...[et al.] (2002)