Methods of Health Education Delivery to the Parents and 1 Caregivers on Preventing Childhood Injuries: A Systematic 2 Review

7 Background: Unintentional injuries to children have significant impact on child mortality and 8 mortality. Health education is one of the important strategies in the childhood injury prevention 9 which involve various methods and techniques. The aim of the review is to provide narrative 10 findings of systematic review of different methods of delivery for health education intervention 11 to reduce unintentional childhood injuries among parents and caregivers in primary care 12 setting. 13 Methods: The systematic review was guided by PRISMA guidelines. The searched databases 14 included Medline, CINAHL, PubMed, ProQuest and Ovid. All report titles and abstracts were 15 screened using pre-defined criteria. Peer-reviewed journal and grey literature published from 1 16 January 2010 to 31 May 2020 were included. Two independent reviewers select studies, 17 extracted data, checked accuracy, assessed risk of bias and assessed the quality of each article 18 selected. Articles were included if they were peer-reviewed and published in English language. 19 Data was extracted and analysed using narrative synthesis approach. 20 Results: 325 articles were identified during initial search strategy. Duplicates were removed 21 and article were screened by title and abstract. Final eight articles were selected and reviewed. 22 Risk of bias for each study were assessed using Cochrane Risk of Bias tool. The systematic 23 review synthesized the characteristics of the selected studies and features of delivery methods 24 of health education intervention. All the reviewed paper concluded their intervention was 25 effective in achieving their objectives which is improving the knowledge, attitude, and safety 26 practice for injury prevention. Majority of the intervention supplemented their education 27 intervention with printed materials such as pamphlets and booklets. Half of the intervention 28 were delivered by healthcare professionals. This review provides fresh narrative evidence on 29 the latest delivery methods for health education in injury prevention to the parents and 30 caregivers. 31 Conclusion: Majority of the studies reported using a combination of various methods of 32 delivery in their intervention and proven to be effective. However, there is a gap in term of use 33 of technology and economic evaluation of each methods that can be addressed in future 34 research and practice. 35 Study registration: The study was registered with PROSPERO International Prospective 36 Register of Systematic Review (CRD:42020202753). 37

review synthesized the characteristics of the selected studies and features of delivery methods 24 of health education intervention. All the reviewed paper concluded their intervention was 25 effective in achieving their objectives which is improving the knowledge, attitude, and safety 26 practice for injury prevention. Majority of the intervention supplemented their education 27 intervention with printed materials such as pamphlets and booklets. Half of the intervention 28 were delivered by healthcare professionals. This review provides fresh narrative evidence on 29 the latest delivery methods for health education in injury prevention to the parents and 30 caregivers. 31

Conclusion:
Majority of the studies reported using a combination of various methods of 32 delivery in their intervention and proven to be effective. However, there is a gap in term of use 33 of technology and economic evaluation of each methods that can be addressed in future 34 research and practice. 35

INTRODUCTION 46
Background 47 Childhood injuries are now a growing global public health concern as it carries a significant 48 burden with wide range of personal, social and economic implications. Injury related causes 49 are one of the major cause of death among children below 14 years old worldwide and leading 50 cause of death and long term morbidity among children under five years old in the last decade 51 (1). From all injuries related deaths, unintentional injuries accounted for more than 90% of 52 these deaths and this is alarming as unintentional injuries are preventable when all the 53 appropriate safety measures are taken. Young children are exceptionally vulnerable to 54 unintentional injuries because of their nature of curiosity to explore the environment yet they 55 are not capable of protecting themselves or understand the consequences and danger of their 56 behaviour. 57 Sustainable Development Goals (SDG) calls for concentrated effort to ensure better health of 58 the children by ending preventable deaths for children under five years old and reducing 59 number of deaths from traffic accidents for older children (5-18 years old) under the health 60 targets (2). Therefore, countries are now looking at reducing the burden of childhood injury as 61 the main agenda to improve child health as the burden has shifted away from the communicable 62 diseases that causes from sanitation and hygiene factors. Prevention and control of 63 unintentional injuries in childhood age often use a combination of passive and active strategies 64 where the passive strategies are referring to the environmental and products change and active 65 strategies directed towards behavioural changes by means of health education (3). Health 66 education is defined as any set of planned activities using combination of methods with the aim 67 of improving target audience's knowledge and health behaviours (4), and methods of delivery 68 referring to the mechanism of how the content of the education can be transferred to the target 69 audience. 70 Evidence suggest that health education alone can achieve the most modest gain but legislation 71 alone without education component will result in non-compliance and objective not being met 72 (5). This emphasize on the importance of health education as main strategy in preventing 73 childhood injuries. Various studies have evaluated impact of health education regarding home 74 injury among children (6,7). Some focus on target injuries, while some other focus single injury 75 type. Specific prescription of health education given during routine health checks and linked 76 to developmental abilities of children are shown to be more acceptable to parents as compared 77 to general safety advice (8). Study has shown that injury prevention education can be 78 effectively delivered to families in clinic setting by utilizing time spend in waiting room (9). 79 However, there are limited mention in the literature with regards to the methods of delivery for 80 the health education on preventing childhood injuries in the health clinic settings. Previous 81 systematic review by Kendrick et al (10) to assess the effects of parenting interventions for 82 preventing childhood injury also include methods of program delivery but the studies included 83 in the review were outdated since it were published before the year 2010. It is also hypothesized 84 that the delivery methods might be different with the recent advancement in technology and 85 use of social media in health education. 86 Therefore the purpose of this review will specifically look at the recent delivery methods of 87 health education intervention in primary care setting which include primary health care clinic, 88 paediatric primary care clinic, child health clinics and community clinics as the existing 89 childhood injury prevention program in Malaysia based in primary health care clinics. 90

91
Objective 92 The aim of the paper is to systematically review the latest literature and review different 93 methods to deliver health education intervention to parents and caregivers regarding injury 94 prevention in children. 95

METHODS 96
Protocol and registration 97 The systematic review was registered with International Prospective Register of Systematic 98 Reviews (PROSPERO) with registration number CRD:42020202753; available on the registry 99 website. It was conducted and reported based on Preferred Reporting Items for Systematic 100 Reviews and Meta-Analyses (PRISMA) statement for reporting systematic reviews and meta-101 analyses. 102

Eligibility criteria 103
The inclusion criteria for study to be included in this review are English article, peer-reviewed, 104 published within the year 2010 to May 2020 and fulfil the pre-determined Population, 105 Intervention, Comparison and Outcome (PICO) study criteria. Study design that is eligible to 106 be included is limited to interventional study only. Studies with no available full text article, 107 duplicates and did not include details on the health education methods delivered to the 108 participants were excluded. 109

Population 110
The participants involved in the studies were either both parents, father, mother, or caregivers 111 of children. 112

Intervention 113
The intervention given to the selected population was specifically focused on childhood injury 114 prevention education. Setting of the intervention included in the study is primary health care 115 settings where the participants were either recruited from the clinic or the intervention is 116 conducted in the clinic itself. Other setting will be excluded from the studies for example 117 community child centre or schools. 118

Comparison 119
The comparators for the studies were different methods of delivery used to convey the 120 information regarding childhood injury prevention to the parents and caregivers. In this study, 121 methods of delivery for health education intervention is defined as technique to deliver the 122 teaching strategies which include traditional lectures, discussions, games, computer 123 technology, written materials, video, role playing (4). The delivery can be towards individual 124 or in group settings. 125 Outcome 126 The outcomes of the studies were the effectiveness of the health education intervention to 127 improve the knowledge, attitude, and practice of preventing childhood injuries among parents 128 and caregivers, as well as reducing risk and incidence of childhood injuries. The reviewer also 129 includes the discussion on the strength and limitation of each intervention methods into the 130 narrative findings of this review.

Data collection process and data items 153
Once studies were selected, data was extracted using a standard form developed for this review. 154 Extracted data items included study objectives, methods, participants, follow-up period, 155 settings, interventions, and outcomes. 156

Quality appraisal 157
All paper titles and abstracts were screened independently by one reviewer for inclusion based 158 on pre-defined inclusion criteria. A sample of 20% were screened independently by a second 159 reviewer using the same criteria. Any paper with inconclusive criteria will be reviewed by both The study characteristics are summarised in Table 1 printed materials such as pamphlets and booklets. One study used primarily printed materials 211 which is child health record book as their delivery methods of education material (18). 212 Half of the intervention were delivered by healthcare workers which were either a doctor, 213 experienced nurse or healthcare educators, one study reported having students delivered the 214 intervention (16) while the remaining three studies were delivered by application such as 215 mobile app, web-based module and self-read baby books. The primary care setting described 216 in the paper include child health clinics and primary health care centres. 217 The duration of health education session given to the parents ranging from 30-60 minutes each 218 session with a minimum number of one session in a week. The median follows up period is 219 two months. The outcome measures reported by the studies are improvement in knowledge, 220 attitude, safety practices and behavior changes. Details of the intervention methods of health 221 education delivery in this review are presented in Table 2. 222

DISCUSSION 223
The eight studies that met our inclusion criteria was explored in terms of health education 224 delivery methods however it is difficult to specify specific methods that are superior from