Tailoring a Child Injury Prevention Program for Low-Income U.S. Families

Abstract

Objective.

Unintentional injuries are the leading cause of death for children in the United States (U.S.), and young children ages (1–4) are particularly at risk. Supervising for Home Safety (SHS) is a Canadian intervention that has been shown to reduce children’s injury risk by increasing caregiver supervision. Given that low-income children are at greatest risk for injury, this study describes a process of modifying the SHS program to be culturally appropriate for low-income families of U.S. preschool children.

Methods.

Two rounds of focus groups were completed; feedback from the first round of focus groups was used to modify program materials prior to the second round.

Results.

Caregivers gleaned important take-away messages from both the original and modified materials, including the idea that injuries can happen quickly and that caregivers can prevent injuries. Modifications to the intervention included increased diversity in the families represented in the videos as well as inclusion of U.S. injury statistics. Caregivers in both rounds of focus groups noted that the program messages were relatable and realistic and that the materials were impactful in increasing their awareness of children’s injury risk.

Conclusion.

We were able to successfully modify the SHS program to be appropriate for low-income U.S. families while preserving the core program messages.

Unintentional injuries are the most common cause of death for children ages 1–19 years in the U.S. (Centers for Disease Control, National Center for Injury Control and Prevention, 2020). Moreover, nonfatal injuries can result in significant physical and emotional injuries that cost taxpayers a high price. Indeed, estimated costs for injuries treated in the emergency department in 2010 reached $47 billion (CDC, 2020). For children ages 1–4, the most frequent causes of fatal unintentional injury are drownings, motor vehicle accidents, and burns; the most common non-fatal injuries for this same age group include falls, being struck by or against something, or bite/stings (CDC, 2020). Given the scope and the negative repercussions of child injuries, prevention has emerged as a public health priority (Sleet, 2018).

Risk factors for unintentional child injuries include both child and family variables. Young children (ages 1–4 years) are at higher risk for unintentional injury compared to older peers (with the exception of adolescents; CDC, 2020). In addition, low family socioeconomic status is a major risk factors for injuries (Mahboob et al., 2021). In fact, children living in families with lower socioeconomic status comprise the highest risk group for injury (McClure et al., 2015). Hence, identifying ways to prevent child injuries in low-income families is critical.

Preventing Unintentional Child Injuries

The majority of unintentional injuries among young children occur in the home (Phelan et al., 2005), suggesting that primary caregivers can play a significant role in reducing such injuries. Both adequate caregiver supervision and eliminating access to hazards are essential to prevent child injuries in the home, with supervision being especially critical (Damashek & Corlis, 2017). “Supervision” is defined based on proximity, attention (visual, auditory) and continuity (i.e., continuous versus intermittent; Morrongiello, 2005). Continuous supervision is particularly important for younger children (Morrongiello et al., 2004a). When caregivers show high levels of supervision (watchful, proximal, continuous), children experience fewer and less severe injuries (Damashek & Corlis, 2017; Morrongiello et al., 2004b). Conversely, lower caregiver proximity and visual supervision predict greater risk for injury (Damashek & Corlis, 2017; Schnitzer et al., 2014). Therefore, finding effective ways to increase caregiver supervision is critical for reducing child injury risk.

Given the high risk for injury among low-income children it is critical to find injury prevention approaches that are effective for such families. Two studies examining the role of caregiver supervision in preventing injuries among low-income children using a case crossover deign found that children were at significantly greater risk for injury when their caregivers were further away and providing lower levels of visual supervision (Damashek & Corlis, 2017; Schnitzer et al., 2014). Several other studies have found that caregivers of children living in poverty face significant barriers to preventing unintentional child injuries (McClure et al., 2015). Low-income parents report high levels of stress and low social support, which limits their ability to be responsive to their children’s needs, such as providing close supervision (Middlemiss, 2003; Ward & Lee, 2020). In particular, research with low-income families has found that barriers include the perceived cost of safety devices as well as the inability to modify home environments for families who rent, rather than own their living space (Smithson et al., 2010). Moreover, low-income families often are not be able to pay for quality daycare that would provide a break from the demanding task of closely supervising a young child (Olsen et al., 2008) and are more likely to rely on older children in the home to supervise younger children (Ablewhite et al., 2015) These findings clearly indicate the need to assist low-income caregivers in providing appropriate levels of supervision for their young children.

The Supervising for Home Safety (SHS) Program

The Supervising for Home Safety Program (SHS) is an intervention that was designed to educate and empower caregivers to supervise their children more closely (Morrongiello et al., 2013). Focus groups conducted with middle- to upper income Canadian caregivers who viewed the original SHS materials reported that the program materials increased their awareness of children’s susceptibility to injuries as well as their motivation to supervise their children more closely (Morrongiello et al., 2009). Moreover, randomized-controlled trial evaluations indicate that the intervention is effective in improving caregiver supervision of young children (ages 1–5) among middle-upper income families in Canada, with effects maintaining up to 1-year post-intervention (Morrongiello et al., 2012; 2013). Similar outcomes (i.e., increase in caregiver reported supervision of treatment group relative to control group) were found when the program was delivered in a group setting (Morrongiello et al., 2017). Whether the same effects can be attained by delivery of the program to a lower-income sample, as well as in a U.S. sample, however, remains to be determined. For example, it is unclear whether the intervention materials would be deemed as culturally relevant and acceptable to low-income families in the U.S. or whether these materials would successfully convey the intended messages of the program.

Present Study

The present study represents the first phase of a program of research that will extend the SHS program to a low-income, high-risk population in the U.S. using the Map of Adaptation Process (McKleroy et al., 2006). The process emphasizes the need to maintain fidelity of the core elements of evidence-based intervention while increasing its relevance for a new population. This is achieved via four steps, including: (1) assessing the target population’s needs; (2) selecting an intervention to address those needs; (3) preparing the intervention for adaptation; (4) piloting and testing the intervention. Step 1 has been achieved by identifying the need for effective injury prevention approaches among low-income families in the U.S., and step 2 has been accomplished by identifying the SHS program for adaptation. The present paper will focus on step 3, which involves preparing the intervention for adaptation. The results will be used in future research to complete step 4 (i.e., examine the efficacy of the adapted intervention).

Focus groups were conducted with low income caregivers of preschool children in the U.S. and their service providers to gather information about the cultural appropriateness and acceptability of the SHS program for this population. We deemed it important to examine the relevance and cultural acceptability of the program to these families due to probable cultural differences between middle-upper income Canadian families and low-income U.S. families based on both country of residence and socioeconomic status (SES). Moreover, the population from which the present study draws is more racially and ethnically diverse than the populations with which the SHS intervention has been tested (Morrongiello et al., 2009; 2013; 2017). We also wished to examine whether low-income caregivers of preschool children in the U.S. gleaned similar take-away messages from the intervention materials as did middle to upper-income Canadian caregivers.

Methods

There were two phases of focus groups. The first phase of focus groups was used to identify modifications that were needed to adapt the SHS program to a low-income population in the United States. The feedback from this round of focus groups was used to make modifications to the SHS intervention materials. Then, a second round of focus groups was conducted to assess whether the changes that were made improved the cultural relevance of the program materials for low-income families in the U.S. and to assess whether any additional changes were needed. The methods for the first and second rounds of focus groups differed; thus, we will first include a description of the procedures for the first round of focus groups followed by a description of the second round. This study was approved by the Human Subjects Institutional Review Board.

SHS Intervention.

The SHS program is delivered in 1-hour weekly sessions for 5 weeks and can be delivered individually or in a group format (Morrongiello et al., 2013; 2017) by trained facilitators with at least an undergraduate level education. A primary component of the program is providing education via videos. The introductory video (20 minutes in length) is presented in session one and is intended to raise caregivers’ awareness about their children’s susceptibility to injury and the role that caregivers can play in preventing injuries (Morrongiello, 2009). In subsequent weeks families view injury-specific videos (i.e., drowning, falls, burns, poisoning), with one injury type covered each of four weeks. The videos present 3-minute vignettes that depict home-based injury risk situations in which children engage in risky behavior (e.g., approaching a lit candle, retrieving a bottle of open pills on the counter) in the absence of close caregiver supervision. The vignettes include prompts to encourage caregivers to anticipate what the child might do next and to encourage active problem solving to reduce injury risk.

In addition to the videos, the program teaches caregivers to use a problem solving approach to address barriers to providing supervision to young children. The problem solving approach involves applying the mnemonic ALTER. This approach aims to increase supervision by having caregivers select and enact one of five strategies to reduce injury risk in any situation they encounter: A = change Activity of child or caregiver; L = change Location of child or caregiver; T = change Timing of what the caregiver wants to do (e.g., do it when child naps); E = change Environment to reduce access to hazards; and R = use Resources (e.g., trade off supervising with a friend). Caregivers practice using ALTER in each session by applying ALTER to the vignettes, and formulate their own solutions to children’s risky behavior. Between sessions, caregivers practice ALTER at home.

Round 1 Focus Groups

Participants

Caregivers.

In round 1, we conducted 3 focus groups with Head Start caregivers (total n = 20) and one focus group with Head Start family advocates (i.e., home visitors, n =10). We approached Head Start about partnering because they aim to support low income families and provide free preschool for low-income families of children ages 3–5 years. Families who are eligible for Head Start services must be at 100% of the poverty level or lower. The federal government defines low-income as families whose income does not exceed 150% of the federal poverty level (https://www2.ed.gov/about/offices/list/ope/trio/incomelevels.html).

See Table 1 (supplemental material) for participant demographics. The majority of participants in the caregiver focus groups (95%) were female and were primarily non-Hispanic (55%) and either Caucasian (35%) or African American (35%). The largest portion of caregivers reported that they had attended grade school or some high school or were high school graduates (45%), and participants were primarily low-income (75% earned less than $30,000 annually).

Family Advocates.

In addition to preschool, Head Start provides home visiting services via family advocates to all caregivers whose children are enrolled in services. Family advocates link families to needed services, promote caregiver involvement in the child’s preschool, and ensure that children receive health screenings. We conducted focus groups with the family advocates because we believed that they could provide a valuable perspective about aspects of the materials that may need to be modified. The educational level of the home visitors ranges from Bachelor’s to Master’s Degree in the fields of social work, education, child and family studies, and psychology. All of the family advocates (n = 10) attended the focus group.

Procedures

Caregiver and family advocate focus groups were two hours in length and were facilitated by a clinical psychologist (the primary author of this paper) using a structured discussion guide and a participatory-action approach that was used when developing the SHS program (Morrongiello et al., 2009). A graduate student assisted with group facilitation, and the intervention developer (separate from the primary author) observed the focus groups via videoconference. At the beginning of the groups, we notified participants that the materials were designed for Canadian families and that we wanted their feedback about how the program materials could be made to be helpful for U.S. Head Start parents. As caregivers viewed the program materials, we asked them to specifically comment on aspects of the materials that they liked and aspects that may need to be changed. We also asked participants to comment on “take away messages” from the introductory video. Participants completed a demographic measure at the beginning of each focus group. Childcare was provided during the caregiver focus groups by graduate research assistants. Focus groups were video and audio-recorded; recordings were later transcribed by undergraduate research assistants.

Recruitment

Caregiver focus groups.

The family advocates assisted in recruiting Head Start caregivers by providing a flyer to caregivers during home visits. Caregivers who were interested in learning more about the study signed a release for their information to be shared with study personnel. We received a total of 28 referrals and recruited 20 families to participate in the focus groups. Caregivers were consented at the beginning of the focus group. The facilitator reviewed the consent form orally and then allowed the participants time to review the consent form individually while also taking a snack break. The facilitator notified participants that they could leave during the snack break if they did not wish to consent. None of the participants left the focus group during the snack break. After the break, the facilitator explained the purpose of the intervention, and participants were shown several representative portions of the intervention. Participants first viewed and then discussed the 20 minute introductory video, followed by presentation and discussion of several of the short video vignettes that focus on particular injury types. Given that caregivers were recruited from preschool programs, vignettes were chosen that primarily featured children in the preschool age range. Each focus group viewed vignettes from each injury category; a variety of vignettes were shown over the course of the focus groups to get participant feedback on as many vignettes as possible. Participants also viewed printed program material about ALTER and completed an ALTER worksheet used during the intervention. Caregivers were provided with a $50 gift card to a grocery store chain.

Family advocate focus group.

The family advocate focus group was conducted during the time of a regularly scheduled staff meeting. The Head Start director sent an email message to the family advocates about the focus group, indicating that participation was voluntary. The investigators attended the staff meeting and provided information about the study. The director was not present during this meeting, and the family advocates were notified that their participation was voluntary and that their decision about whether or not to participate would not be communicated to their supervisor. The investigators consented the participants and then presented the intervention materials and sought feedback in a sequence that was similar to that followed in the caregiver focus groups.

Intervention Modifications

Data from the first round of focus groups were analyzed (see results section below) to determine which aspects of the intervention needed to be modified. The investigators then made modifications to the program material. More information about the changes are included in the results section. Round 2 focus groups were conducted to examine the adequacy of these changes.

Round 2 Focus Groups

After making the program modifications, we conducted two additional focus groups with a total of nine caregivers to obtain feedback about the appropriateness of the revised program content. Due to some changes in leadership, we were no longer able to recruit from the same program that we recruited from for round 1 focus groups. As a result, families in this second round of focus groups represented a greater range of SES and included middle income families as well as low-income families. Moreover, we did not recruit home visitors for the second round of focus groups because agencies were overwhelmed with organizational challenges related to Covid-19. The two focus groups for round 2 were recruited from separate sources.

Caregivers for the first focus group were recruited from a local preschool program that serves low income caregivers (KC Ready 4’s Great Start Readiness Program). Eligibility for the program is based on income. The program prioritizes registration of children who are at 100% or lower of the federal poverty level; however, children in families whose income is up to 250% of the poverty level are eligible to enroll. The families who participated in the first focus group served on a family advisory team (FAT), which is a group of caregivers of preschool-aged children enrolled in the GSRP preschool program. The focus group occurred during the time of a regularly scheduled FAT meeting. Caregivers were provided with information about the study in advance by the family liaison and were notified that their participation was voluntary. A total of 7 caregivers were invited to attend, and six attended.

Participants for the second focus group were recruited from a local community voice panel. The community voice panel is a group of mothers who have volunteered to be available to participate in focus groups to inform the work being conducted by a local initiative to reduce racial disparities in infant mortality. The administrator of the community voice panel asked mothers via email if they were interested in learning about opportunities to participate in research studies. Those who said “yes,” (n =11) were provided with information about the study. Those who indicated interest in the study provided consent (via email) for the investigators to contact them. A total of 6 participants agreed to participate, but only 3 participants attended the group.

Both focus groups in round two were conducted virtually to observe social distancing recommendations in response to the Covid-19 pandemic. Google meet was used to conduct and record the focus groups. Video content and printed materials were shown via screen sharing. The focus groups procedures and sequence was simlar to those described above for the round 1 focus groups. However, the consent form was viewed in an electronic format, and the demographics form was completed using Qualtrics, a secure online survey tool.

Sample Demographics

Demographics can be seen in Table 1 (supplemental material). The majority of caregivers were female (78%), non-Hispanic/Latino (45%) and identified as primarily either African American (33%) or Caucasian (33%). Approximately two thirds of participants were college graduates, and caregivers were less representative of low-income families; 66% of participants had a gross household income of more than $50,000 per year. There was no difference in demographic characteristics between round 2 groups. Bivariate analyses indicated that the only demographic variable that differed significantly from round 1 to round 2 was income (p = .002).

Data Coding

Theoretical thematic analysis was used to analyze the qualitative data. This type of analysis was appropriate because guiding questions that were asked during the focus groups were used to organize our results. These guiding questions included asking caregivers about aspects of the program materials that they liked, aspects of the materials that participants thought could be improved, and “take-away” messages from the program material. Three coders, including the intervention developer, primary, and second authors independently reviewed the focus group transcripts using memos to identify potential codes. The investigators then met together and developed a codebook. The codebook included themes that fell within each of the 3 primary questions noted above (positive aspects, things to improve, take-away messages). The study investigators (excluding the intervention developer) then used the codebook to independently code the transcripts. Coders met periodically to discuss and resolve inconsistencies between coding decisions. The primary author examined the data and organized the codes into broader themes. The primary author then examined the frequency of the occurrence of each theme, and themes that occurred with the greatest frequency as well as illustrative quotes are reported below.

The themes are organized by the overarching questions that we used to organize the results, including positive aspects of the program, take-away messages, and aspects to improve. There was a great deal of similarity in themes for both rounds of focus groups, with the exception of the aspects to improve category. Given the similarity of themes from both rounds of focus groups, we present them together in the results section below. We use the term “R1” to indicate when a quote came from a participant in round 1 focus groups and “R2” to indicate when a quote came from a participant in round 2 focus groups.

Results

Positive Aspects of the Program

In both rounds of focus groups, the same two primary themes emerged with regard to aspects of the intervention that participants liked, including the following: (1) examples were relatable and realistic and (2) the material was eye opening (i.e., evoked insights) and impactful.

Relatable and realistic.

First, participants indicated that the program content included helpful examples that were realistic and “relatable” (i.e., clients could relate to their own lives). They provided this feedback with regard to the program videos as well as the worksheets and activities. For example, one caregiver (R1) reported:

“These are real life situations. You hear things in the news about furniture toppling over. And I just never thought of it as that big of a deal because I never saw my children climb furniture. But one day I was in the other room and I heard a scream, a crash, glass, crying. And when I entered the room, a really heavy six drawer dresser had toppled over and my six year old is crying but she wasn’t hurt. It like nicked her in the leg, but she got out of the way in time.”

Another caregiver (R2) commented specifically on the diversity of families in the videos and how that made the content more relatable:

“I also like the part where the kids were from all different ethnic backgrounds and different nationalities, everything. So that when it’s exposed to families, there’s something in there that you can identify with and that you can connect with. And so I think that was a really good representation of different backgrounds.”

Family advocates (R1) also indicated that they thought the examples would be helpful for caregivers. In response to the video vignettes, one family advocate reported, “It gave examples for parents, like how to- what to watch, where like you don’t have to answer the phone call right away. You don’t have to answer the door right away.”

Eye opening and impactful.

A second primary theme was that caregivers reported that the introductory video was “eye opening and impactful” with regard to increasing their awareness of their children’s risk for injury. One of the family advocates (R1) commented on the caregiver testimonials that were included in the video and reported that, “The testimonials from the parents, that was impactful.” Several participants noted that the graphic images of injured children in the introductory video were difficult to watch but made a significant impact on the caregivers. For example, one caregiver (R1) reported, “I didn’t necessarily like the pictures but I feel like they should be there.” Another caregiver (R1) related the pictures of injured children to a memory of a situation in which her child almost got injured:

“The pictures were actual full pictures. Real incidents that could really happen- the one with the kid and the pot on the stove kept making me cringe because my son did that one recently. He hadn’t even turned two at the time. He got a pull out chair and went up to the stove with the boiling pot and was calling me, ‘mommy look’. And I lost my nuts, and started screaming and he just calmly got off the chair and I think that was enough for him to not attempt it again, but like if I had not looked when he called - so it kind of makes me cringe every time I see that.”

Take-Away Messages

Focus group participants were also asked about what they “took away” from the program videos, or what messages from the videos stood out to them. In both rounds of focus groups (prior to and after program modification), there were two primary themes that emerged with regard to “take away” messages: caregivers can prevent injuries by modifying their behavior and injury events happen quickly because children’s behavior is often unpredictable.

Caregivers can prevent injuries.

Both caregivers and family advocates expressed the sentiment that caregivers need to modify their behavior to prevent child injuries, by supervising more closely, removing hazards, and generally being aware of children’s circumstances. After viewing the introductory video, one family advocate (R1) noted, “constant supervision is a must.” One caregiver (R2) reported, “Oh, I was going to say it kept emphasizing that you can keep your children safe. You know? It kept emphasizing that these accidents do happen, but you have the power to keep your kids safe by keeping them in view.” Another caregiver (R1) noted the fact that the injuries depicted in the introductory video made her realize the importance of watching her child more closely:

“I think that nothing is really more important than your child’s safety. Like your housework or your friends cause I’m always on Facebook and I let him do his own thing and I’m on my phone. He could be in his room with a little tiny toy and choke on it and I wouldn’t even know. Just being more aware. It was an eye opener. It was like a hint to get it together.”

Injury events happen quickly.

A second theme that emerged as a “take away” message was that injury event happen quickly due to the unpredictability of children’s behavior. Caregivers resonated with the sayings in the introductory video that “it only takes a second” for an injury to happen and that children often act in unpredictable ways that can lead to an injury. For example, one caregiver (R1) noted, “When they said that the child will be capable of today is different from what they’ll be capable of tomorrow. So you never know what will happen tomorrow.” Another caregiver (R1) reported, “I was thinking of how many times I say ‘I’ll be there in a minute’, ‘just a second’.”

Aspects to Improve – Round 1

In round 1 focus groups, three primary themes emerged regarding aspects to improve the program, including the importance of: representing U.S. injury statistics; depicting additional types of injury hazards; and depicting more diverse families.

U.S. injury statistics.

First, both caregivers and family advocates appreciated the injury statistics and saw value in reporting these, but noted that the introductory video (which shows statistics for injury frequency in Canada) should be changed to show U.S. injury statistics.

Additional types of injury hazards.

Second, caregivers recommended that the videos should show additional types of injury hazards in the home, specifically, the risk of dog bites and access to guns. They also suggested even more emphasis on distraction from cell phones.

Including more diverse families.

Third, both caregivers and family advocates in round 1 indicated that the videos should be more diverse in several ways, including greater representation of families of color, as well as increased representation of multigenerational families and fathers as primary caregivers. With regard to inclusion of multigenerational families in the same home, one participant (R1) reported, “Maybe a video representing a culture where they all live in the same household so there is a situation where there’s tons of people in the house.” Caregivers also noted that more fathers should be included than were currently shown. One participant (R1) commented, “Why all the scenarios with moms?...Are there more stay at home moms in Canada?... sometimes it’s their [fathers] fault too. Not always the moms!”

Family advocates noted the importance of including more racial and ethnic diversity to keep families engaged in the program. For example, one family advocate (R1) reported, “Definitely make it more culturally sensitive, definitely. Because if you have all Caucasian families, you’re going to lose our families very quickly.”

Specific Intervention Modifications

As noted in the methods section, changes were made to the intervention based on feedback from the first round of focus groups. First, the investigators changed the introductory video content that was specific to Canada to be relevant to a U.S. audience by replacing Canadian statistics with U.S. statistics. The second modification involved creating additional injury vignette videos to include other injury threats (i.e., dog bites, gun access). The third modification was to create video vignettes that included families who were more diverse with regard to race, ethnicity, gender, and family composition (e.g., homes including multiple generations). To develop these video vignettes, we recruited families from the local community and recorded vignettes in their homes. Fathers were included in some original videos, but we added additional vignettes showing them as the primary supervisor. We also included cell phones as a caregiver distraction in some of the new videos.

Aspects to Improve – Round 2

Given that we made significant modifications to the intervention materials as a result of feedback from round 1 groups, round 2 groups differed from round 1 groups in terms of reported aspects to improve. The most common suggestions were related to technical aspects of the program materials and included: the design of the ALTER examples worksheet and the impression that some of video vignettes appeared “staged.” Specifically, participants reported that the sheet with examples for ALTER strategies included too much text and was somewhat overwhelming. Finally, a few participants reported that some of the revised video vignettes appeared staged; this concern, however, may reflect their lack of awareness of how injuries occur. For instance, these caregivers noted that the vignette includes a dog that looked friendly and didn’t appear to be a risk for biting the children. However, most dog bites occur by family pets in the home; thus, depicting a friendly looking dog is a realistic injury risk scenario (Ashby et al., 1998).

Discussion

Previous research has shown that the SHS program is effective in increasing caregiver supervision so that children’s risk of unintentional injuries in the home is reduced (Morrongiello et al., 2012; 2013; 2017). The present study reports on an application of the CDC’s Map of Adaptation Process to modify this program and make it applicable to low-income U.S. caregivers (McKleroy et al., 2006). Our process included two rounds of focus groups to establish the cultural acceptability of the intervention materials and to determine whether the materials were successful in conveying core program messages to low-income U.S. caregivers. The first round of focus groups examined caregivers’ and home visitors’ perceptions of the original, unmodified intervention. Based on this feedback the intervention materials were modified, and the second round of focus groups were used to determine whether the modifications were successful in improving the appropriateness of the intervention materials.

Although the first round of focus groups of the unmodified intervention found that changes to program materials were needed, caregivers reporting of “take-away” messages indicated that they received the key intended core messages from the program. Some of the primary goals of the video content are to increase caregivers’ perception of their children’s vulnerability to injury and to empower caregivers to take steps to prevent injuries from occurring (Morrongiello et al., 2009). Indeed, the most frequent themes regarding take-away messages for caregivers in both rounds of focus groups were that injuries can happen quickly, children do unpredictable things that create vulnerability to injury, and that caregivers have an important role to play in preventing injuries. Thus, the core program content was effective in delivering important injury prevention messages to the focus group participants.

Aspects of the program that focus group participants liked in round one and two were also very similar. Although the intervention was not created specifically for low-income U.S. families, participants who viewed the unmodified intervention in round 1 reported that the program materials included examples that were realistic and that related to caregivers’ real-life experiences. This theme also emerged in the second round of focus groups. These findings are consistent with focus group data from a sample of Canadian caregivers who viewed the program materials during its creation and also reported that they could relate to the realistic nature of the experiences depicted in the videos (Morrongiello et al., 2009). A second theme that emerged regarding aspects that caregivers liked about the program was that the content was eye opening and impactful. Caregivers in both focus groups reported that the depictions of children who were injured in the introductory video were impactful and effective in increasing their awareness of children’s risk for injury. These results are consistent with the developer’s goal of increasing caregivers’ perception of their children’s vulnerability to injury (Morrongiello et al., 2009). Moreover, caregivers in both rounds of focus groups, as well as those in the Canadian focus groups, reported that the graphic images of injured children were difficult to view but effective in increasing their awareness of children’s injury risk (Morrongiello et al., 2009).

Finally, three primary themes emerged in the first round of focus groups with regard to aspects of the program that could be improved, including suggestions to: change the injury statistics presented in the videos to be US specific; update some of the injury situations to include technological advances (e.g., cell phones) and to add other injury categories (i.e., dog bites, guns injuries); and change the families who were depicted in the videos to be more similar to the focus community (with regard to race, ethnicity, multigenerational families, and depiction of fathers). Based on the cultural compatibility hypothesis, these modified materials are more likely to result in behavior change for low-income U.S. caregivers than are materials that do not reflect the circumstances of this population (Bernal et al., 2009).

In response to these suggestions, we made modifications to the intervention materials by changing the injury statistics to reflect U.S. injury patterns, in addition to creating new injury vignettes that included additional injury scenarios and more diverse families. Our second round of focus groups using the modified intervention materials resulted in nearly identical themes regarding take-away messages and aspects of the program that caregivers liked. However, the suggestions for improvement were quite minimal, reflecting only technical (i.e., changing the format of a handout), rather than substantive suggestions for changes. These data suggest that we were able to successfully modify the intervention to be more culturally appropriate to a low-income population in the United States without changing the core message of the intervention. These findings are important, given that low-income families are at significantly greater risk of sustaining injuries than are other children (McClure et al., 2015). Close supervision in households of low-income children is also particularly important given that most injuries to young children occur in the home, and that low-income caregivers may have difficulty acquiring the materials needed to safety proof their home and may be subject to poorer housing quality that can present additional environmental barriers (Olsen et al., 2008; Phelan et al., 2005).

Limitations.

Some limitations of the present study are important to note. Unfortunately, we were not able to recruit participants for round 2 from the same site from which we recruited participants for round 1 (i.e., Head Start). We were able to recruit from another preschool program targeting low-income caregivers and from a community voice panel; however, our numbers were lower for the second round. This is partially due to the effects of Covid-19. The family liaison for the preschool program noted that programs were busy making plans for the Fall and felt too overwhelmed to disseminate information about the focus groups widely. Relatedly, the income level for the second round of focus groups was higher than the income level for the first round and was less representative of low-income families. However, families in the second round were diverse with regard to race and ethnicity, and it was still valuable to seek their feedback as families residing in the U.S., rather than Canada. Community based participatory research (CBPR) is one method that may prove more beneficial in future research when attempting to collaborate with agencies serving low-income families. In the CBPR approach, researchers involve community stakeholders in all aspects of the research process, which creates a stronger collaborative relationship (Israel et al., 2012). Another limitation is that our focus group questions were broad, and we did not specifically ask people about the cultural relevance of the program materials; however, our questions did result in participant feedback related to the cultural relevance of the materials. A final limitation is that the intervention developer was one of the data coders in round 1, which may have biased the data interpretation.

Implications for Impact Statement:

Focus groups with caregivers from U.S. preschool programs serving low-income children found that a child injury prevention program was successful in increasing caregivers’ awareness of the importance of supervising children more closely to prevent injuries. Based on caregiver feedback, changes to the program were made to make it more culturally relevant to low-income U.S. families.

Clinical Implications.

The SHS program in its modified form (i.e., depicting more diverse families in video materials as well as additional injury scenarios) appears to be acceptable to low-income U.S. caregivers of preschool-aged children. Additional research will determine whether this modified intervention is as effective as the original in improving caregiver supervision of young children. However, given that the intervention is relatively easy to implement, it may be beneficial to disseminate more broadly via home visiting services or within primary care contexts.