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Logic model, based on Langford 2014
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Figure 1

Logic model, based on Langford 2014

PRISMA flow chart detailing the process of study selection for all studies included in the review. CBA: controlled before‐and‐after study; RCT: randomised controlled trial.
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Figure 2

PRISMA flow chart detailing the process of study selection for all studies included in the review. CBA: controlled before‐and‐after study; RCT: randomised controlled trial.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 4

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Forest plot of comparison: 1 Injury rates, outcome: 1.1 Injury rates at follow‐up.
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Figure 5

Forest plot of comparison: 1 Injury rates, outcome: 1.1 Injury rates at follow‐up.

Comparison 1 Medically attended or non‐medically attended injury rates, Outcome 1 Injury rates at follow‐up, adjusted for baseline injury rates in non‐randomised studies.
Figures and Tables -
Analysis 1.1

Comparison 1 Medically attended or non‐medically attended injury rates, Outcome 1 Injury rates at follow‐up, adjusted for baseline injury rates in non‐randomised studies.

Summary of findings for the main comparison. School injury prevention programmes compared to controls for the prevention of unintentional injuries in children and young people

School injury prevention programmes compared to controls for the prevention of unintentional injuries in children and young people

Patient or population: children and young people
Setting: schools
Intervention: school injury prevention programmes aimed at preventing multiple injury mechanisms
Comparison: control

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Injury rate, adjusted for clustering, with control

Injury rate, adjusted for clustering, with School injury prevention programmes

Self‐reported medically or non‐medically attended unintentional injuries or injuries with an unspecified intent (injury rates adjusted for clustering)
assessed with: self‐report
follow‐up: range 12 months to 24 months

367 per 1000 person‐years

243 per 1000 person‐years

Rate ratio 0.76
(0.49 to 1.17)

12,977

(2073 person‐years adjusted for clustering)
(2 RCTs, 1 CBA)

⊕⊕⊝⊝
Low 1

We excluded 4 studies from the meta‐analysis due to varied interventions (e.g. sports, agriculture or risk‐taking injury prevention). Their findings were consistent with the meta‐analysis studies.

Safety skills
assessed with: observations
follow‐up: range 4 months to 5 months

Both studies found an improvement in observed safety skills (Kendrick 2007 ‐ fire and burn prevention skills: odds ratio 8.93 (95% CI 1.67 to 47.78, P = 0.01); Frederick 2000 ‐ basic life support skills, P < 0.005 for assessment of danger, responsiveness and circulation).

1751
(1 RCT, 1 CBA)

⊕⊕⊝⊝
Low 2

Interventions and safety skills observed were varied in these 2 studies.

Behaviour
assessed with: observations and self‐reported
follow‐up: range 2 weeks to 36 months

All 4 studies (5 articles) reported that observed safety behaviour showed evidence of improved practices and 13/19 studies describing self‐reported behaviour reported improved practices.

52,950
(9 RCTs, 4 non‐RCTs, 6 CBA)

⊕⊝⊝⊝
Very low3

Behaviours included safety equipment wearing, road risk‐taking behaviour, agriculture and sports‐related injury behaviours.

Safety knowledge
assessed with: surveys and self‐completion tests
follow‐up: range 1 month to 36 months

Of the 21 studies assessing changes in safety knowledge, 19 reported an improvement in at least 1 question domain in the intervention compared to the control group.

55,732

(9 RCTs, 5 non‐RCTs, 7 CBA)

⊕⊝⊝⊝
Very low4

Outcomes included a wide range of knowledge testing instruments and topics.

Cost‐effectiveness
assessed with: cost:benefit ratio
follow‐up: 1 years

For every 1 Chinese Yuan spent, 13.90 was saved (cost:benefit ratio 1:13.9)

4639
(1 CBA)

⊕⊝⊝⊝
Very low5

Only 1 study reported economic outcomes and should, therefore, be interpreted with caution.

CI: confidence interval; CBA: controlled before‐and‐after study; RCT: randomised controlled trial; non‐RCT: non‐randomised controlled trial.

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Downgraded twice because of inconsistency as the I2 = 63%, indicating substantial heterogeneity and because there was imprecision in the results (the rate ratio was 0.76 but the confidence intervals spanned 1). Two of the studies were RCTs with a low risk of bias.

2 Downgraded twice because of a serious risk of bias (one of the two studies was a CBA resulting in selection biases relating to which schools participated in studies) and inconsistency, which was rated as serious because the two studies had different intervention types with different outcome measures. Imprecision was serious as there were wide confidence intervals in one of the two included studies, as well as a paucity of data. However, the effect sizes were classed as large as there was a nearly nine times greater odds of fire and burn prevention skills in the Risk Watch programme (Kendrick 2007), and 33% greater skills assessment in the Injury Minimisation Programme for Schools (IMPS) relating to assessment of danger (Frederick 2000).

3 Downgraded three times because 10 studies were CBA or non‐RCT design with high risk of selection bias of included schools, there was serious inconsistency in methods of collecting data and intervention types, and this may have contributed to the wide range of effect sizes and directions seen (no effect or some effect), There was often wide confidence intervals in results presented.

4 Downgraded three times because 11 studies were CBA or non‐RCT design with high risk of selection bias of included schools; there was serious inconsistency in knowledge tested, questionnaire designs and methods of collecting data, a wide range of intervention types and pedagogical approaches and this may have contributed to the wide range of effect sizes and directions seen (no effect or some effect). Results were presented in a way that often made precision difficult to compare.

5 Downgraded three times because this was one study, limited in applicability with high or unclear risk of bias across multiple domains.

Figures and Tables -
Summary of findings for the main comparison. School injury prevention programmes compared to controls for the prevention of unintentional injuries in children and young people
Table 1. Age ranges included in the studies

Study ID

Age (years)

4/5

5/6

6/7

7/8

8/9

9/10

10/11

11/12

12/13

13/14

14/15

15/16

16/17

17/18

Azeredo 2003

Buckley 2010

Campbell 2001

Carmel 1991

Chapman 2013

Collard 2010

Cook 2006

Falavigna 2012

Frederick 2000

Grant 1992

Greene 2002

Gresham 2001

Kendrick 2007

Lee 2004

Lu 2000

Martinez 1996

Morrongiello 1998

Reed 2001

Richards 1991

Sun 2004

Terzidis 2007

Twisk 2013

Wang 2009

Wesner 2003

Wright 1995

Zhao 2006

Zirkle 2005

‐: not applicable; ●: age range covered.

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Table 1. Age ranges included in the studies
Table 2. Injury mechanisms targeted for included studies

Study ID

Injury mechanism

Pedestrian

Cycle

Motorcycle

Vehicle (non‐specific)

Falls

Swimming/ drowning/ diving

Smoke/ fire/ flames

Heat and hot surfaces

Sport/ physical activity

Sun

Household safety

Agricultural injuries

Poisoning

Azeredo 2003

Buckley 2010

Campbell 2001

Carmel 1991

Chapman 2013

Collard 2010

Cook 2006

Falavigna 2012

Frederick 2000

Grant 1992

Greene 2002

Gresham 2001

Kendrick 2007

Lee 2004

Lu 2000

Martinez 1996

Morrongiello 1998

Reed 2001

Richards 1991

Sun 2004

Terzidis 2007

Twisk 2013

Wang 2009

Wesner 2003

Wright 1995

Zhao 2006

Zirkle 2005

‐: outcome not measured; ●: outcome measured.

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Table 2. Injury mechanisms targeted for included studies
Comparison 1. Medically attended or non‐medically attended injury rates

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Injury rates at follow‐up, adjusted for baseline injury rates in non‐randomised studies Show forest plot

3

2073

Rate Ratio (Random, 95% CI)

0.73 [0.49, 1.08]

Figures and Tables -
Comparison 1. Medically attended or non‐medically attended injury rates