Study On The Unintentional Injury Intervention Of Rural Preschooler Based On Mobile Health Technology

Objective:(1)To develop the theory-based and evidence-based mobile health intervention mode that is appropriate to the rural context,designed for caregivers of rural preschoolers concerning the prevention of common unintentional injury among rural preschoolers based on the characteristics and needs of rural preschooler caregivers and the spectrum of common unintentional injury among rural preschoolers.(2)To assess the effectiveness of the mobile health intervention mode on comprehensively reducing the occurrence of common unintentional injury among rural preschoolers using the incidence rate of unintentional injury as the primary outcome through a cluster randomized controlled trial.Methods:(1)Intervention mapping approach was used to develop the mobile health intervention mode for common unintentional injury among rural preschoolers based on theories and evidence with following the steps and requirements of intervention mapping strictly,including the following 6 steps.(1)Health issues and community characteristics evaluation: literature review and focus group discussion were used to evaluate the specific health problems,find the behavioral,environmental,and other influencing factors,understand the specific community characteristics,and explore the solutions.(2)Intervention objectives and expected results identification: focus group discussion was used to clarify the primary and secondary intervention objectives,the intervention form,as well as the anticipated changes from the intervention.(3)Intervention program design: literature review,focus group discussion,and expert consultation were used to identify and adopt the injury intervention and behavior change theories to impact the influencing factors and design the intervention program tailored to the target population and cultural context based on relevant theories and evidence.(4)Intervention materials production: literature review and news case retrieval were used to design and produce the attractive and culturally adaptable intervention materials combined with the culture and context.(5)Intervention program optimization: pre-experiment was conducted to evaluate the preliminary feasibility of intervention program and further optimize and refine the intervention program.(6)Intervention evaluation formulation: focus group discussion was used to formulate the evaluation strategies of intervention effectiveness and intervention process.Focus group discussions were organized among 16 child-safety stakeholders and research group respectively,while expert consultation was carried out among 3 experts from the injury prevention and control field,2 experts from the child health and hygiene field,and 1 expert from the environmental health and risk assessment field.(2)A cluster randomized controlled trial was implemented to assess the effectiveness of intervention study via the incidence rate of unintentional injury among rural preschoolers as the primary outcome and 3 categories of secondary outcomes.(1)This study was a single-blind,9-month,parallel-group,cluster randomized controlled trial with 1:1 cluster allocation ratio,and 1918 rural preschooler caregivers from 12 eligible preschools in rural areas of Changsha County who met the inclusion and exclusion criteria were recruited to participate in the study.(2)The clusters were randomized at the preschool level and allocated to relevant group.All enrolled preschooler caregivers from one preschool entered the same group to avoid contamination.The intervention group received the app-based health education including child unintentional injury prevention daily and the control group received the app-based health education excluding child unintentional injury prevention daily.Both groups did not restrict the routine preschool-based health education regarding diverse teaching themes.The implementation of the app-based intervention was identical for both groups except for the contents of health education.(3)Prior to commencing the formal intervention,child safety stakeholders were involved in establishing the coordinating group in each enrolled preschool.The coordinating group provided consistent and sufficient external support for preschooler caregivers in both groups.Furthermore,various incentive plans from multiple aspects to strengthen and reinforce the implementation of intervention were developed.(4)After completing the baseline survey,the 9-month intervention period and follow-up were conducted.The follow-up evaluations were conducted every 3 months.The primary outcome was the incidence rate of unintentional injury among rural preschoolers in the past 3 months and the secondary outcomes comprised caregiver’s safety attitudes and caregiver’s supervision behaviors over the prior week surrounding child unintentional injury prevention,as well as preschooler’s home environment safety over the last week.(5)Intention-to-treat data analysis was adopted.Descriptive statistics for qualitative data were conducted by rate or proportion.Incidence rate of unintentional injury and its 95% confidence interval were calculated.Chi-square test was used to detect the differences between two groups in a single survey at each time point.Descriptive statistics for quantitative data were conducted by mean and standard deviation when data obeyed normal distribution while median and inter-quartile range were calculated for data not obeying normal distribution.Two-sample t-test or Wilcoxon rank sum test was used to examine the differences between two groups in a single survey at each time point.Descriptive statistics for ranked data were conducted by proportion.Chi-square test was also used to detect the differences between two groups in a single survey at each time point.Generalized estimating equation was used to fit the longitudinal data to assess the overall effectiveness of intervention,while adjusting relevant covariates.Subgroup analyses were conducted according to the gender and household size of preschoolers and also employed the same statistical analysis strategy detailed above.Results:(1)The 6 types of characteristics and needs of rural preschooler caregivers,the 10 categories of unintentional injury to be intervened,and the 3 categories of influencing factors of injury occurrence to be intervened were explored and identified.Moreover,relevant coping strategies were developed to overcome the deficiencies of previous studies from two perspectives respectively: optimizing intervention design and reinforcing intervention implementation,which is anticipated to enhance the compliance and reduce the withdrawal of participants.Haddon matrix and theory of planned behavior were adopted to guide subsequent design of intervention content.Based on App development framework consisting of 4 modules: content learning,social interaction,survey and feedback,and personalized customization,the upgrade plan of App 2.0 version was developed to improve intervention design,including content improvement,function optimization,interface refinement,and operation simplification specifically.Besides,the implementation plan of enhancing external support for reinforcing intervention implementation was also developed to provide consistent and sufficient external support for rural preschooler caregivers during the intervention period.Additionally,surrounding the rural culture and context,the intervention measure constructed in this study covered the knowledge and skills for 10 categories of unintentional injury prevention,including a total of 300 new learning materials in 5 types: short essays with pictures,videos,audio recordings,interactive games,and animations.The proportion of relevant learning materials was 3: 2: 2: 2: 1.The learning materials were delivered to rural preschooler caregivers once a day and the learning time was approximately limited to 3 minutes.(2)During the study period,the incidence rate of unintentional injury among rural preschoolers in the past 3 months of intervention group decreased from 21.7%(95% CI: 19.1%,24.3%)at baseline to 21.0%(95% CI: 17.4%,24.5%)at the end of intervention;while decreasing from 19.5%(17.0%,22.0%)to 18.7%(95% CI: 15.6%,21.7%)in control group.After adjusting measuring time factor and other covariates,the discrepancies between two groups did not have statistical significance(OR=1.15,95% CI: 0.96,1.38,P=0.12).Subgroup analyses by gender and household size of preschoolers similarly demonstrated that no statistically significant decrease in the incidence rate of unintentional injury among rural preschoolers in intervention group was observed across distinct population subgroups.(3)Baseline survey was used as reference and relevant covariates were adjusted.At the third follow-up,there were statistically significant differences between two groups(control group as the reference)in the change of the total score of caregiver’s supervision behaviors(b=1.87,95%CI: 0.49,3.24)and preschooler’s home environment safety(b=2.83,95%CI: 1.22,4.45),while these improvements principally derived from 4types of supervision behaviors and 6 types of home environments.The differences in caregiver’s safety attitudes between two groups were no statistically significant(b=-0.004,95% CI:-0.15,0.14).Subgroup analyses suggested that there were statistically significant improvements in 3 categories of secondary outcomes in some population subgroups.(4)The main occurrence categories of unintentional injury incidents investigated in this study among rural preschoolers were falls(proportion of intervention group: 28.9%-56.7%;control group: 33.9%-47.0%)and blunt force injury(proportion of intervention group: 19.3%-38.1%;control group: 21.3%-33.0%);the main activities of preschoolers while injury occurring were playing and chasing(proportion of intervention group: 47.1%-67.1%;control group: 49.1%-66.5%);the most common place of injury occurring was own or another’s home(proportion of intervention group: 36.9%-47.4%;control group: 37.7%-49.1%),followed by the outdoor public areas,such as community,park,and square(proportion of intervention group: 12.3%-25.0%;control group:15.8%-20.0%);the most common measure following an injury incident was that preschoolers were treated by non-medical staff,including family members or teachers(proportion of intervention group: 30.9%-43.3%;control group: 31.8%-42.2%);the majority of the time preschoolers spent on leave or rest due to injury was a half-day.Conclusion:(1)The mobile health intervention mode for the prevention of common unintentional injury among rural preschoolers was developed based on relevant scientific theories and research evidence,which had certain scientificity,reasonability,feasibility and cultural adaptability,considerably overcoming the deficiencies revealed in previous studies during the process of intervention development.(2)After 9-month intervention,the mobile health intervention mode developed in this study failed to effectively reduce the incidence rate of unintentional injury among rural preschoolers,but it could effectively improve the supervision behaviors of rural preschooler caregivers and the home environment safety of rural preschoolers,as well as boost the accessibility of safety education in rural areas.Therefore,it still had certain practical significance and popularization value.