Unintentional Injuries in Children Up to Six Years of Age and Related Parental Knowledge, Attitudes, and Behaviors in Italy

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Unintentional Injuries in Children Up to Six Years of Age and Related Parental Knowledge, Attitudes, and Behaviors in Italy Gabriella Santagati, MD, Luigi Vezzosi, MD, and Italo F. Angelillo, DDS, MPH Objectives To describe risk factors associated with unintentional injuries among children aged <6 years and to examine parents’ level of knowledge, attitudes, and behaviors about pediatric injuries and related preventive measures.

Study design A cross-sectional survey was conducted between May and July 2015 on a random sample of 794 parents of 3- to 6-year-old children through a self-administered anonymous questionnaire. Results A total of 409 parents participated. Two-thirds of the children had experienced at least 1 unintentional injury in the previous 12 months. More than one-half of these children were boys. The leading cause was falls; the injuries occurred mainly at home, and only 9.2% were brought for attention to an emergency department. Parents who did not believe that it is possible to prevent unintentional injuries were more likely to have had a child injured. Approximately 70% of respondents were aware of security measures to prevent pediatric injuries, and this knowledge was more prevalent in older parents and in those with at least a college level of education compared with those with a middle school education. The perceived utility of education about preventive measures of pediatric injuries had a mean value of 8.9 on a Likert scale of 1-10 (1, not useful, to 10, very useful) and was significantly higher in mothers. Conclusions This study highlights a clear need for public health educational programs for parents regarding prevention of unintentional injuries in children as a valuable tool to increase safety and injury prevention and to reduce risks, because the majority of such injuries occur at home. (J Pediatr 2016;■■:■■-■■).

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nintentional injuries among all age groups of children and adolescents is a well-recognized global public health problem with a sustained high rate of disability, death, and health care expenses.1 There is substantial evidence that young children are the most vulnerable age group and that injuries occur mostly at home, in school, on roads, and in recreational and sports areas.2,3 The most common unintentional injuries are falls, pedestrian and bicycling accidents, drowning, poisoning, fire-related burns, and suffocation. The vast majority of these injuries are preventable.4 Parents and other caregivers have a primary role in supervising and keeping the children at lower risk for injury. Parents’ knowledge and practices are essential for behavior-forming of children and an appropriate use of interventions to prevent unintentional injuries. Previous epidemiologic studies conducted in different countries have focused on assessing the frequency of unintentional injuries and associated risk factors in healthy populations of children.5-21 Few studies have examined the knowledge level and behaviors of parents regarding child injury prevention,8,21-28 and there is no current literature of this kind in Italy. Understanding the frequency of and risk factors for children’s unintentional injuries and the related level of knowledge, attitudes, and behaviors of their parents can lead to optimized implementation of prevention strategies. The primary objective of the present investigation was to describe the characteristics of unintentional injuries and to analyze the associated risk factors in a sample of Italian children aged <6 years. A secondary objective was to describe parents’ level of knowledge, attitudes, and behaviors regarding unintentional injuries in their children.

Methods Between May and June 2015, a cross-sectional survey was conducted in the city of Naples, Italy. Five kindergartens and primary public schools were selected at random, and in each kindergarten and school, 8 classes were selected at random. A random sample of 794 parents of 3- to 6-year-old children was available to participate. The sample size was determined using a formula for estimating a single population proportion with the assumption of a 95% CI, a 5% margin of error, and a prevalence of 50% of subjects with an adequate knowledge level about pediatric injuries. To compensate for a nonresponse rate of 50%, the invited sample size was found to be 768 subjects. Permission was secured from each institution through a formal letter with a description and objectives of the study. Before study commencement, a package From the Department of Experimental Medicine, Second was sent, addressed at random to either the mother or the father, containing a letter University of Naples, Naples, Italy explaining the objectives of the study and the role of the participants, a 2-page The authors declare no conflicts of interest. anonymous and confidential self-administered questionnaire, an informed consent 0022-3476/$ - see front matter. © 2016 Elsevier Inc. All rights form, and a self-addressed envelope for returning the questionnaire to the rereserved. search team. The letter also indicated that parents received the questionnaire because http://dx.doi.org10.1016/j.jpeds.2016.06.083 1 FLA 5.4.0 DTD ■ YMPD8502_proof ■ August 1, 2016

THE JOURNAL OF PEDIATRICS • www.jpeds.com their child was selected at random in the kindergarten/ school and included instructions to return the completed questionnaire to the kindergarten/school within 7 days of receipt. The parents were informed that their participation was voluntary, that all information gathered would be anonymous, and that confidentiality of information would be maintained by omitting any personal identifying information from the questionnaire. A parent from each family completed the questionnaire at home. If the questionnaire was not returned within the prescribed time period, the research team made a reminder phone call to the head teacher. No incentives were offered for completion of the survey. Respondents were never contacted directly by the research team. Ethical approval of the study protocol and of the survey instrument was obtained from the Ethical Committee of the Second University of Naples. All participants were asked to provide written informed consent before collection of data, and all had a right to decline to complete the questionnaire without any threat or disadvantage. The self-administered structured questionnaire was developed and pilot-tested in a convenience sample of 40 parents for feedback on its overall acceptability in terms of length, clarity, and question formats. The internal consistency reliability was estimated using the Cronbach a. The questionnaire consisted of 25 questions grouped into 4 topics of interest covering: (1) demographic and socioeconomic information of the respondent parent, including sex, age, highest attained educational qualification, marital status, occupational level, number of children, and characteristics of the selected child, such as sex, age, and birth order; (2) knowledge of the leading causes of pediatric unintentional injuries, home environment at greater risk, security measures for preventing pediatric unintentional injuries, and related most common channels of information; (3) attitudes toward pediatric unintentional injuries, by measuring the perception of risk, the possibility of preventing injuries, and the importance of being informed about their preventive measures; and (4) frequency of unintentional injuries. Study participants were queried about whether their child had experienced an unintentional injury in the 12 months preceding the interview date. An unintentional injury was defined as an event that was not deliberately caused, for which the child received medical care from a doctor at a hospital or a private office or first aid from someone or was not treated but caused the child to miss one-half day or more of regular activities. If the child had been injured, participants were asked about the last 3 episodes of injury, the external cause of injury, body parts injured, setting where the injury occurred, activity at the time of injury, and medical treatment after the injury. The final questionnaire is provided in the Appendix (available at www.jpeds.com). Statistical Analyses The statistical analysis was conducted in 2 stages using the model-building strategy suggested by Hosmer et al.29 First, the Student t test was used for independent samples to assess differences between means, and the c2 test was used to assess differences between categories to determine their association with the outcomes of interest. Second, variables found to be asso-

Volume ■■ ciated at the P ≤ .25 level were introduced into multivariate logistic and linear regression models to investigate independent characteristics associated with the dichotomous and continuous outcomes of interest. Three models were constructed: knowledge about the availability of security regulations for preventing unintentional pediatric injuries (model 1), perception of utility of being informed about preventive measures of unintentional pediatric injuries (model 2), and profile of parent whose child had experienced at least 1 unintentional injury in the previous 12 months (model 3). For the purpose of analysis, outcome variables originally consisting of multiple categories were dichotomized into 2 levels. In model 1, parents were classified as those aware of the availability of security measures for preventing pediatric unintentional injuries and all others; in model 3, they were grouped according to whether the child had experienced at least 1 unintentional injury in the previous 12 months vs all others. A stepwise backward elimination process was used, and the final models included only variables providing a significant explanation of outcomes, in which the criterion for entering into the model was a P >.20 and that for exiting the model was a P <.40. The following independent variables were included in all models: age, sex, education level, and number of children of the respondent and age, sex, and birth order of the selected child. The knowledge of prevention measures and physicians as a source of information also were included in models 2 and 3. The variable perception of the utility of education about preventive measures was included in models 1 and 3. The variable number of child injuries occurring in the previous 12 months was included in model 2. The variable knowledge of the most frequent cause of accidents in children aged <15 years, knowledge of the domestic environment as increasing the risk of injury, and perception that it is possible to prevent pediatric unintentional injuries were included in model 3. In the logistic regression models, ORs and their 95% CIs were calculated. Standardized regression coefficients (b) and SEs were presented in the linear regression model. All statistical tests were 2-tailed and differences were considered to be statistically significant at a P value ≤ .05. All analyses were conducted using Stata 10.1 statistical software (StataCorp, College Station, Texas).30

Results Of the 794 parents who were asked to complete the questionnaire, 409 accepted, for an overall response rate of 51.5%. Selected characteristics of the study participants are presented in Table I. Two-thirds of the respondents were mothers, the mean age was 38.3 years, the vast majority were married, and the most common educational level was a college degree or higher. The mean age of the selected children was 4.9 years, more than one-half were male, and roughly one-half were first born. Internal consistency reliability assessed using the Cronbach a was respectively 0.6 for the attitudes subscale and 0.7 for the knowledge subscale. The majority (70.2%) of respondents were aware of security measures to prevent pediatric

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Table I. Self-reported characteristics of the study participants Characteristics

Value

Respondent parents Sex, n (%) (n = 408) Male Female Age, y, mean ± SD (range) (n = 398) 18-30, n (%) 31-35, n (%) 36-40, n (%) 41-45, n (%) >45, n (%) Marital status, n (%) (n = 402) Married Other Education level, n (%) (n = 400) No formal education, elementary, or middle school High school College degree or higher Number of children, n (%) (n = 397) 1 2 ≥3 Selected children Sex, n (%) (n = 406) Male Female Age, y, mean ± SD (range) (n = 408) Birth order, n (%) (n = 408) First Second Third Fourth

127 (31.1) 281 (68.9) 38.3 ± 5.7 (22-58) 34 (8.5) 87 (21.9) 139 (34.9) 102 (25.6) 36 (9.1) 332 70

(82.6) (17.4)

103 150 147

(25.7) (37.5) (36.8)

92 225 80

(23.2) (56.7) (20.1)

216 (53.2) 190 (46.8) 4.9 ± 0.9 (3-6) 205 149 48 6

(50.2) (36.5) (11.8) (1.5)

The number in parentheses is the number of those answering the question, except where noted otherwise.

unintentional injuries. The most common sources of information were physicians (40.3%), television/newspapers (35.3%), the Internet (18.3%), and relatives (17.3%). The results of multivariate logistic and linear regression analyses estimating the strength of the independent associations between several factors and the different outcomes are shown in Table II. Model 1 was fitted to assess the overall factors associated with the knowledge of security measures for preventing pediatric unintentional injuries. Age and educational level of the respondent were significant independent predictors of this knowledge for older parents (OR, 1.06; 95% CI, 1.01-1.11) and those with a college degree or higher educational level (OR, 8.52; 95% CI, 3.96-18.32). The responses to the questions about attitudes toward unintentional pediatric injuries showed that more than onehalf (55%) of the respondents do not believe that injuries are preventable. However, the perceived utility of being informed about the preventive measures, based on response options ranging from “not useful” (1) to “very useful” (10), was very high (mean, 8.9). In the fully adjusted multivariable linear regression model, only female sex of the respondent was independently associated with the perceived utility (model 2 in Table II). The main characteristics of the injuries that parents reported in previous 12 months are shown in Table III. Accord-

ing to parent reports, 250 children (63.3%) sustained a total of 612 unintentional injuries, and in this group, 166 (66.4%) had multiple episodes, with an overall mean number of 3.2 injuries per child (range, 2-20). More than one-half of the injuries occurred in boys, the leading cause was falls (70.5%), almost one-half occurred in the spring (49.7%), and the injuries occurred in various places, mainly at home (45.4%), in the road/street (24.3%), and at a sports facility/field (20.3%). The main consequence was a contusion/abrasion; in more than three-quarters of the events, the injuries occurred in the foot/ leg or head. Only 9.2% of the injuries led to a visit to an emergency department. Multivariate logistic regression analysis revealed that parents who did not believe that it is possible to prevent unintentional injuries were more likely to have an injured child (OR, 0.61; 95% CI, 0.40-0.95) (model 3 in Table II).

Discussion Overall, 63.3% of the parents in our study reported at least 1 episode of nonfatal unintentional injury in their child during the 12 months preceding the interview date. A similar occurrence rate of 68% was reported in a previous study conducted in a large sample of 18-month-old children in Japan.9 This frequency was considerably higher than the values reported in other studies. Indeed, a survey of Chinese children aged <6 years old revealed a self-reported frequency of 12.9%,17 and 3% of Nepalese children aged 1-4 years experienced a nonfatal injury during the 12 months preceding the survey that required treatment or made the child unable to take part in usual activities for 3 or more days.19 In a survey of parents of children aged 0-6 years in Greece, 23% reported that their child had experienced an injury in the past, although only home accidents were considered,8 and parents of children aged 1-4 years in Peru reported 26% rate of serious injury.7 Several factors could explain the variability of injury rates reported in studies from different countries. The most significant factors are likely differences in data collection methods and in the population samples in terms of sociodemographic (age, sex, education, income), cultural (health care system), and lifestyle (health care-seeking behavior) characteristics. Our findings of injury incidence are in accordance with the literature values. In our study, the most common mechanism of unintentional injuries was falls (70.5%). Previous studies have shown frequencies ranging from 1%19 to 61%.6 These results may be related to children’s poor balance and the onset of independent mobility.5,31 Almost one-half of our children’s injuries occurred within the home environment (45.4%). In similar previous studies, the rate of occurrence at home ranged from 44%16 to 57%,14 because children spend most of their time at home.4,8,32 Family homes may be thought of as a safe place for children, and the need to prevent injuries might not be considered.12 Therefore, it is extremely important for parents and caregivers to improve home safety and teach preventive measures of unintentional injuries from an early age. In almost one-third

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Table II. Multivariate logistic and linear regression indicating associations between variables and outcomes regarding pediatric unintentional injuries Variables

OR

SE

95% CI

P value

1* 1.66 8.52 1.06 1.44 1.37

0.48 3.33 0.02 0.41 0.34

0.95-2.93 3.96-18.32 1.01-1.11 0.83-2.51 0.84-2.23

.077 <.001 .016 .191 .203

Model 1: Knowledge of the availability of security regulations for preventing pediatric unintentional injuries (n = 381) Log likelihood = −194.77; c2 = 71.97 (5 df ); P < .0001 Educational level of the respondent parent No formal education/elementary/middle school High school College degree or higher Age of the respondent parent Sex of the respondent parent Sex of the selected child Variables

Coefficient

SE

t

P value

−0.67

0.19

−3.45

.001

1* 0.22 −0.37 0.28

0.23 0.25 0.20

0.95 −1.47 1.41

.345 .142 .16

Model 2: Perception of utility of being informed about preventive measures of pediatric unintentional injuries (n = 378) F (4,373) = 4.77; P = .0009; R2 = 0.05%; adjusted R2 = 0.04% Sex of the respondent parent Educational level of the respondent parent No formal education/elementary/middle school High school College degree or higher Physician as source of information on security regulations for preventing unintentional pediatric injuries Variables

OR

SE

95% CI

P value

0.61 1.62

0.13 0.44

0.40-0.95 0.95-2.76

.027 .075

Model 3: Profile of parent whose child has had at least 1 unintentional injury in the last 12 months (n = 368) Log likelihood = −235.96; c2 = 8.44 (2 df ); P = .0147 Perception that it is possible to prevent pediatric unintentional injuries Knowledge of the most frequent cause of unintentional injury in children aged <15 years *Reference category.

of cases, the injuries occurred in the lower limbs and the head. Similar results were found in China and the US.18,21 A key theme emanating from the present survey is the parents’ source of information on child safety (eg, health care provider). Although education on unintentional injury prevention in the medical school curriculum in Italy and elsewhere is infrequent,33,34 physicians—mainly pediatricians—have a prominent role in providing anticipatory guidance to parents about security meaures to prevent pediatric injuries. Parents then are expected to educate their children. Thus, a disappointing finding in this study was that although physicians were ranked as the most frequently used source, only 40.3% of the respondents reported receiving such information about measures to prevent unintentional injuries. In Greece, physicians also were the main source of information on injury prevention,8 but in other studies the physicians’ role was more marginal.22,32,35 Physicians are poised to provide age-appropriate practical advice. Their role in providing parental knowledge to prevent injuries must be strengthened. Previous research conducted in the general population in the same geographic area has demonstrated a higher knowledge level in those who had received information and referral services by physicians.36-39 Our study respondents reported a 70% awareness of the security measures to prevent injuries. Lower values have been observed in The Netherlands22 and in Greece, where almost

one-half of parents considered their knowledge to be insufficient.8 Of interest, however, is that we found that 45% of parents believed that it is possible to prevent unintentional injuries, which is in accordance with rates reported in studies conducted in the US35 and Greece.8 A more positive attitude has been observed in The Netherlands, where threequarters of parents agreed that most injuries involving children could be avoided.22 Several independent predictive factors of parents’ knowledge and attitudes were identified. Sociodemographic variables, including parental age and educational level, were directly related to parents’ knowledge of injury prevention. This can be explained by the fact that those with a college degree or higher level of education were more likely to read, comprehend, and consider messages in newspapers, on television, and from physicians, which is consistent with evidence that education is a powerful tool that empowers people to make decisions for themselves and influence their families.24 The finding regarding age is in line with the result of a previous study in which parents of older age were more likely to identify household safety hazards.40 Female sex also was associated with a higher likelihood of perceiving the utility of preventive measures. An important novel finding in our study was that parents who did not believe it possible to prevent pediatric injuries were more likely to report an unintentional injury to their child in

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Table III. Characteristics of children’s unintentional injuries occurring in the previous 12 months Characteristics

Value

Total number of injuries Number of injuries per child, mean ± SD (range) (n = 395) Episodes of injury, n (%) 0 1 2 3 >3 Sex of the selected children, n (%) (n = 248) Female Male Season of occurrence, n (%) (n = 165) Winter Spring Summer Autumn External cause, n (%) (n = 512) Fall Collision/crash Burn Stab wound Choking Other Location, n (%) (n = 478) Home Road/street Sports facility/field School Consequence of the event, n (%) (n = 491) Contusion/abrasion Trauma Cut Burn Other None Part of the body injured, n (%) (n = 193) Foot/leg Head Arm/hand Other

612 1.5 ± 1.9 (0-20)* 145 84 59 84 23

(36.7) (21.3) (14.9) (21.3) (5.8)

112 136

(45.2) (54.8)

41 82 28 14

(24.8) (49.7) (17) (8.5)

361 101 17 15 4 14

(70.5) (19.7) (3.3) (2.9) (0.8) (2.8)

217 116 97 48

(45.4) (24.3) (20.3) (10)

135 115 24 16 5 196

(27.5) (23.4) (4.9) (3.2) (1) (40)

73 72 41 7

(37.8) (37.3) (21.3) (3.6)

*The number of parents reporting the information is in parentheses, except where noted otherwise. The number for each item may not add up to the total number of the study population because of missing values.

the 12 months before the interview. A possible explanation for this finding is that these parents do not pay sufficient attention to their children because they believe it is not possible to prevent unintentional injuries. This study has some limitations. First, because the study was strictly cross-sectional, a causal effect of identified risks is not possible. Second, the moderate response rate may have caused selection bias favoring parents who are more knowledgeable and motivated to learn about the topic. The response rate is within the range recommended for surveys of high importance concerning decisions on key policies or resource allocation.41 Third, the frequency and the characteristics of the unintentional injuries were obtained through a self-administered questionnaire from parents, who may have attempted to give socially acceptable responses. The anonymous questionnaire likely mitigated this limitation. Fourth, parental reporting may be subject to recall bias, leading to underestimation of injuries. To reduce this possibility, the recall period for the unintentional injuries was limited to the previous 12 months.

Our study highlights the clear need for public health education programs of parents regarding unintentional injuries in their children as a valuable tool to enhance safety and injury prevention and to reduce injuries, the majority of which occur in the home environment. ■ We thank all authorities of the kindergartens and primary schools for giving permission to collect the data and all the study participants for generously contributing their time. Submitted for publication Mar 30, 2016; last revision received May 31, 2016; accepted Jun 28, 2016 Reprint requests: Italo F. Angelillo, DDS, MPH, Department of Experimental Medicine, Second University of Naples, Via Luciano Armanni, 5, 80138 Naples, Italy. E-mail: [email protected]

References 1. Peden M, Oyegbite K, Ozanne-Smith J, Hyder AA, Branche C, Fazlur Rahman AKM, et al, eds. World report on child injury prevention. World Health Organization, UNICEF. Available at http://apps.who.int/iris/ bitstream/10665/43851/1/9789241563574_eng.pdf. Accessed February 23, 2016. 2. Audit Commission; Healthcare Commission. Health; National report; February 2007. Better safe than sorry. Preventing unintentional injury to children. Available at https://www.bipsolutions.com/docstore/pdf/15817.pdf. Accessed February 23, 2016. 3. Smith D, Kirkwood G, Pott J, Kourita L, Jessop V, Pollock AM. Childhood injury in Tower Hamlets: audit of children presenting with injury to an inner city A&E department in London. Injury 2015;46:11316. 4. Ablewhite J, Peel I, McDaid L, Hawkins A, Goodenough T, Deave T, et al. Parental perceptions of barriers and facilitators to preventing child unintentional injuries within the home: a qualitative study. BMC Public Health 2015;15:280. 5. Agran PF, Anderson C, Winn D, Trent R, Walton-Haynes L, Thayer S. Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics 2003;111(6 Pt 1):e683-92. 6. Pickett W, Streight S, Simpson K, Brison RJ. Injuries experienced by infant children: a population-based epidemiological analysis. Pediatrics 2003;111(4 Pt 1):e365-70. 7. Donroe J, Gilman RH, Brugge D, Mwamburi M, Moore DA. Falls, poisonings, burns, and road traffic injuries in urban Peruvian children and adolescents: a community based study. Inj Prev 2009;15:390-6. 8. Tsoumakas K, Dousis E, Mavridi F, Gremou A, Matziou V. Parent’s adherence to children’s home-accident preventive measures. Int Nurs Rev 2009;56:369-74. 9. Fujiwara T, Okuyama M, Takahashi K. Paternal involvement in childcare and unintentional injury of young children: a population-based cohort study in Japan. Int J Epidemiol 2010;39:588-97. 10. Saadat S, Mafi M, Sharif-Alhoseini M. Population based estimates of nonfatal injuries in the capital of Iran. BMC Public Health 2011;11:608. 11. Shi H, Yang X, Huang C, Zhou Z, Zhou Q, Chu M. Status and risk factors of unintentional injuries among Chinese undergraduates: a crosssectional study. BMC Public Health 2011;11:531. 12. Hu M, Hu GQ, Sun ZQ, He X. Epidemiological survey of the prevalence of non-fatal injury among children aged 5-14 years in China. Biomed Environ Sci 2012;25:407-12. 13. Zhou L, Chen D, Dong G. Characteristics and related factors of nonfatal injuries among adolescents and college students in Shenzhen City of China. BMC Public Health 2013;13:392. 14. He S, Lunnen JC, Puvanachandra P, Amar-Singh, Zia N, Hyder AA. Global childhood unintentional injury study: multisite surveillance data. Am J Public Health 2014;104:e79-84. 15. Keyes KM, Susser E, Pilowsky DJ, Hamilton A, Bitfoi A, Goelitz D, et al. The health consequences of child mental health problems and

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16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

parenting styles: unintentional injuries among European schoolchildren. Prev Med 2014;67:182-8. Shi XQ, Qi YH, Shi D, Yan C, Shi J, Cao BL, et al. Features and risk factors of nonfatal injury among the rural children: a survey of seven schools in a mountain area in Southwest China. PLoS ONE 2014;9:e102099. Xu T, Gong L, Wang H, Zhang R, Wang X, Kaime-Atterhög W. Epidemiology of unintentional injuries among children under six years old in floating and residential population in four communities in Beijing: a comparative study. Matern Child Health J 2014;18:911-9. Fang Y, Zhang X, Chen W, Lin F, Yuan M, Geng Z, et al. Epidemiological characteristics and burden of childhood and adolescent injuries: a survey of elementary and secondary students in Xiamen, China. BMC Public Health 2015;15:357. Pant PR, Towner E, Ellis M, Manandhar D, Pilkington P, Mytton J. Epidemiology of unintentional child injuries in the Makwanpur district of Nepal: a household survey. Int J Environ Res Public Health 2015;12:1511828. Peltzer K, Pengpid S. Unintentional injuries and psychosocial correlates among in-school adolescents in Malaysia. Int J Environ Res Public Health 2015;12:14936-47. Schnitzer PG, Dowd MD, Kruse RL, Morrongiello BA. Supervision and risk of unintentional injury in young children. Inj Prev 2015;21(e1):e6370. Vincenten JA, Sector MJ, Rogmans W, Bouter L. Parents’ perceptions, attitudes and behaviours towards child safety: a study in 14 European countries. Int J Inj Contr Saf Promot 2005;12:183-9. Guilfoyle SM, Karazsia BT, Langkamp DL, Wildman BG. Supervision to prevent childhood unintentional injury: developmental knowledge and self-efficacy count. J Child Health Care 2012;16:141-52. Wang X, Chen N, Shi Z, Zhao Z. An investigation on knowledge-attitudepractice about injury and the related factors among school children’s parents in Jinan, China. Int J Inj Contr Saf Promot 2012;19:267-71. Brussoni M, Creighton G, Olsen LL, Oliffe JL. Men on fathering in the context of children’s unintentional injury prevention. Am J Mens Health 2013;7:77-86. Khanom A, Hill RA, Brophy S, Morgan K, Rapport F, Lyons R. Mothers’ perspectives on the delivery of childhood injury messages: a qualitative study from the growing up in Wales, environments for healthy living study (EHL). BMC Public Health 2013;13:806. Brcˇina N, Mujkic´ A, Miloševic´ M, Miškulin M, Wallis AB. Comparison of knowledge, attitudes and behaviour of health professionals and parents regarding child injuries. Cent Eur J Public Health 2014;22:245-50.

Volume ■■ 28. Setien MA, Han D, Zuniga GC, Mier N, Lucio RL, Treviño L. Does injury prevention education initiate household changes in a Spanish-speaking minority population? J Community Health 2014;39:167-72. 29. Hosmer DW Jr, Lemeshow S, Sturdivant RX. Applied logistic regression. 3rd ed. New York: Wiley; 2013. 30. Stata Corp. Stata 10 base reference manual. College Station (TX): Stata Press; 2007. 31. Ferrante P, Marinaccio A, Iavicoli S. Home injuries in Italy: patterns of injury and the most exposed people. Int J Inj Contr Saf Promot 2013;20:3641. 32. Ablewhite J, Kendrick D, Watson M, Shaw I. The other side of the story— maternal perceptions of safety advice and information: a qualitative approach. Child Care Health Dev 2015;41:1106-13. 33. Villaveces A, Kammeyer JA, Bencevic H. Injury prevention education in medical schools: an international survey of medical students. Inj Prev 2005;11:343-7. 34. Crnica V, Mujkic´ A, Young T, Miškulin M, Peek-Asa C. Healthcare providers’ knowledge, attitudes and counselling on injury prevention for preschool children in Croatia. Matern Child Health J 2013;17:171824. 35. Bennet Murphy LM. Adolescent mothers’ beliefs about parenting and injury prevention: results of a focus group. J Pediatr Health Care 2001;15:1949. 36. Abbate R, Di Giuseppe G, Marinelli P, Angelillo IF. Knowledge, attitudes, and practices of avian influenza, poultry workers, Italy. Emerg Infect Dis 2006;12:1762-5. 37. Pelullo CP, Di Giuseppe G, Angelillo IF. Human papillomavirus infection: knowledge, attitudes, and behaviors among lesbian, gay men, and bisexual in Italy. PLoS ONE 2012;7:e42856. 38. Di Giuseppe G, Sessa A, Mollo S, Corbisiero N, Angelillo IF. Knowledge, attitudes, and behaviors regarding HIV among first-time attenders of voluntary counseling and testing services in Italy. BMC Infect Dis 2013;13:277. 39. Tedesco LM, Di Giuseppe G, Napolitano F, Angelillo IF. Cardiovascular diseases and women: knowledge, attitudes, and behavior in the general population in Italy. Biomed Res Int 2015;324692. 40. Mayes S, Roberts MC, Stough CO. Risk for household safety hazards: socioeconomic and sociodemographic factors. J Safety Res 2014;51:87-92. 41. Public Works and Government Services Canada. Best practices in public opinion research. Available at http://www.tpsgc-pwgsc.gc.ca/rop-por/ rapports-reports/comitephone-panelphone/page-06-eng.html. Accessed February 23, 2016.

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A. Sociodemographic Characteristics of the Respondent Parent A1. Respondent □ Mother □ Father A2. How old were you on your last birthday? ___________ A3. What is your nationality? □ Italian □ Other, specify __________________________ A4. What is your highest educational level? □ None □ Elementary school □ Middle school □ High school □ Graduate degree A5. What is your current occupation? ___________________________________________________ A6. Are you currently: □ Married □ Separated\Divorced\Widowed □ Cohabitant □ Single (never married) (If you are not married or cohabitant, please go to Section B) A7. How old were your husband\wife\partner on his\her last birthday? ___________________ A8. What is the current occupation of your husband\wife\partner? ___________________________________________ A9. What is your husband\wife\partner highest educational level? □ None □ Elementary school □ Middle school □ High school □ Graduate degree B. Sociodemographic Characteristics of the Selected Child B1. How old were your child on his\her last birthday? _______ B2. Gender of your child □ Male □ Female B3. Which is the birth order of your child □ First □ Second □ Third □ Other, specify __________________ (If you do not have other children, please go to Section C) B4. How many other children do you have?_______________ B5. How old were your other child/children on the last birthday? First child_____ Second child_____ Third child_____ Fourth child_____ Fifth child_____ Sixth child_____ Other child, specify____ C. Knowledge C1. What is the leading cause of unintentional children injuries? (only one answer is allowed) □ Stab wound □Fire/Burn □ Falls □ Choking □ Road traffic accidents □ Poisoning □ Drowning □ Other, specify _____________ C2. What area in your home concerns you the most for your child’s safety? (only one answer is allowed) □ Family room □ Bedroom(s) □ Kitchen □ Bathroom □ Garden □ Other, specify_____________________ C3. What is the safest place for your child to sit in the car? (only one answer is allowed) □ Passenger seat □ Passenger seat, but only if passenger airbag is present □ Back seat □ Other, specify _____________ C4. Are available safety regulations for preventing unintentional children injuries? □ No □ Do not know □ Yes (If you answered No or Do not know, please go to Section D) C5. From which of the following sources do you receive information safety regulations for preventing unintentional children injuries? (more than one answer is allowed) □ Family members □ Friends □ Physician/Pediatrician □ TV, newspapers □ Internet □ Other, specify ____________ D. Attitudes D1. Does your child make use of a play area? □ No (go to question D3) □ Yes D2. How would you rate your fear that your child can have an unintentional injury in a play area on a 1 to 10 scale, with 1 meaning no fear at all and 10 very much fear? NO FEAR AT ALL 1 2 3 4 5 6 7 8 9 10 MUCH FEAR D3. How would you rate the utility for a parent to be informed about preventive measures of unintentional children injuries, with 1 meaning useless and 10 very useful? NOT USEFUL 1 2 3 4 5 6 7 8 9 10 VERY USEFUL D4. The unintentional children injuries may be prevented □ Agree □ Uncertain □ Disagree E. Behavior E1. During the past 12 months, how many times did an unintentional injury occur to your child? No □ Yes, ____ times (If you answered no, the questionnaire is finished, thank you for taking the time to respond and return it to the school within seven days using the self-addressed envelope) Appendix. Questionnare used in the survey. (Continues) Unintentional Injuries in Children Up to Six Years of Age and Related Parental Knowledge, Attitudes, and Behaviors in Italy FLA 5.4.0 DTD ■ YMPD8502_proof ■ August 1, 2016

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THE JOURNAL OF PEDIATRICS • www.jpeds.com

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E2. Provide the following information regarding the last three unintentional injuries that occurred to your child during the past 12 months. Injury 1

Injury 2

Injury 3

Date of injury Type of injury

______________________________ □Fall □Crash □Burn □Stab wound □Animal bite □Inhalation of foreign body □Choking □Poisoning □Drowning □Other ________________________

______________________________ □Fall □Crash □Burn □Stab wound □Animal bite □Inhalation of foreign body □Choking □Poisoning □Drowning □Other ________________________

______________________________ □Fall □Crash □Burn □Stab wound □Animal bite □Inhalation of foreign body □Choking □Poisoning □Drowning □Other ________________________

Location of injury

□Road\Street □School □Home □Play area □Sports facility/Field □Other __________________________

□Road\Street □School □Home □Play area □Sports facility/field □Other __________________________

□Road\Street □School □Home □Play area □Sports facility/field □Other __________________________

Cause of injury Consequences of injury

_______________________________ □None □Contusion\Abrasion to_____________ □Cut of _______________________ □Burn of ___________________ □Trauma at_____________________ □Fracture of ___________________ □Other __________________________

_______________________________ □None □Contusion\Abrasion to_____________ □Cut of _______________________ □Burn of ___________________ □Trauma at_____________________ □Fracture of ___________________ □Other __________________________

_______________________________ □None □Contusion\Abrasion to_____________ □Cut of _______________________ □Burn of ___________________ □Trauma at_____________________ □Fracture of ___________________ □Other __________________________

Care requested

□None □Home health care □General practitioner □Access to the emergency department □Hospitalization □Other__________________________

□None □Home health care □General practitioner □Access to the emergency department □Hospitalization □Other__________________________

□None □Home health care □General practitioner □Access to the emergency department □Hospitalization □Other__________________________

The questionnaire is finished. Thank you for taking the time to respond and please return it to the school within 7 days using the self-addressed envelope Appendix. Continued.

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Santagati, Vezzosi, and Angelillo FLA 5.4.0 DTD ■ YMPD8502_proof ■ August 1, 2016