Table 2.

Review of the selected articles from PubMed

Reference	Location	Methods	Main findings	Conclusions	Approach*
					Eq.	Env	Ch
Fiissel14	Toronto Canada	Case-control study Data-gathering based on pediatric records at Toronto Hospital 1995–2002 Study of playground falls and related fractures according to gathered data Cases included those who fell from a height in playgrounds; controls were those who fell from a standing height Study of minor and major fractures	Likelihood of equipment falls and related fractures were 3.91 times more than fractures resulting from standing height falls No significance difference found between two types of falls 48% (n = 3155) of all cases treated at the hospital had fractures, 1070 of which were detected as playground fall-related fractures More than 85% of fractures were of the upper extremities	Falls from playground equipment known to be a prominent cause of childhood fractures Prevention of play-related fractures among children should be defined as one of the main goals of safety promotion in playgrounds	*
Heck et al18	Columbia	Interventional study, a multiple baseline design, across three classrooms (5379 children) Recording of child behavior during play (especially for slides and climbers) 5-day safety training course for children	Obvious changes in children’s behavior recognized during slide playing Among second graders who had lower intervention, higher baseline rates detected	Children’s play behavior affected by presence of observers, but year-long supervision impractical Duration of intervention and supervision important	*		*
Howard16	Ontario Canada	Interventional study changing unsafe to safe play. Study of injuries before and after intervention in 86 schools	Decreasing rate of injury in intervention schools was 0.93 injuries/1000 students/month	One of the safety promotion approaches might be replacing safe equipment	*
Lafores30	Montreal Canada	Case-control study in 102 selected playgrounds Field observation in summers of 1991–1995 Assessment of playground surface materials Interview of 1286 parents by telephone questionnaire	35% of falls occurred on surfaces with high-risk injury according to g level Occurrence of injuries during play with equipment 2 m in height occurred 2.56 times more often than 1.5 m ones Surface material and height of equipment have some relationship with risk of injury; surface resilience can be a predictor of risk severity	Selection of playground surfaces should consider material resilience when planning safety promotion in playgrounds	*
Mahadev31	Singapore	Retrospective study of play-related fractures in 390 patient records in a children’s hospital during May 1997–December 1998 Samples categorized into 4 age groups (<2, 2–5, 5–12, and 12–15 years)	19.5% total treated fractures (n = 2001) were related to playgrounds Fractures in boys were twice as common as in girls; 68% of cases were Chinese, 17% Malay, 11% Indian, and 4% others Most fractures (70.7%) occurred in children aged 5–12 years Most of fractures occurred during play with monkey bars and other upper body devices.	Playground surface materials and monkey bar height need evaluation	*
Mitchell33	New South Wales Australia	Descriptive study of hospitalization data (1992/93 to 2003/04) of children (aged ≤ 14 years) who had suffered injuries related to a fall from playground equipment	Rate of 106.6/100,000 children for injuries related to falls Statistical analysis showed increased trend of injuries from 83.3 to 130.3 per 100,000 children, highest in 5–9-year-old boys (198.4/100,000 children)	Decreasing incidence of head injuries, but increasing upper extremity injuries, so safety auditing and risk assessment needed Playground safety standards have an important role in injury prevention	*
			Upper extremity injuries and fractures recorded as common injuries for all age groups , with an upward trend; head injury rate decreased	Better implementation of safety standards necessary
Nixon9	Brisbane Australia	Case study of playground equipment-related injuries in children Assessment of emergency data from 2 hospitals over 2 years focusing on children Random sampling and selection of 16 playgrounds and one hour observation in each sample during spring, winter, and autumn	Numbers of times equipment used in playgrounds sampled were 3762, 2309, and 825 for climbing, horizontal ladders, and slides, respectively Frequency of use was different between schools and park playgrounds Injury rate for school playgrounds was 59/100,000 per year and 0.26/100,000 per year for park playgrounds	Distribution of equipment was not obvious between school and park playgrounds; comparison of equipment within the samples was not possible; however, the overall rate of injuries was low Intervention could reduce this low injury rate further	*
Olsen17	Iowa USA	Case study and comprehensive survey Description of significance of plan for injury prevention in school playgrounds Using of a safety model as a basic plan for development of injury prevention in schools	Effectiveness of a safety model for children’s safety; health care experts and elementary schools should be aware about school supervisory approaches for injury cost reduction Appropriately trained school nurses are essential for playground safety promotion in schools	Understanding of importance of safety should be communicated in addition to playground safety training School playground safety involves a system for proper safety supervision	*		*
Powell et al20	Chicago, IL	Description of hazards in 78 playgrounds including 42 cases in low-income neighborhoods and 26 cases in very low-income neighborhoods	Some playground equipment had problems regarding adequate surrounding space Inadequate space around 30% of swings, 83% of ladders, 69% of sliding poles, 54% of cargo nets, 49% of spiral climbers, 46% of arch climbers, 40% of chinning bars, and also 50% of slides with a height more than 4 feet Comparison between playgrounds in low-income and very low-income neighborhoods showed that playground hazards were similar	Improving playground safety needs planned endeavors Effective maintenance should be implemented in all playgrounds Inadequate spaces around equipment should be checked and improved Local residents should be encouraged to clean and remove trash, broken equipment and debris, involves local and neighborhood municipal bodies	*
Schwebel et al34	USA	Case study of 49 girls and 51 boys, mostly Caucasian, who attended in a laboratory for motor ability tests, measured by balancing block on head, balance beam walking, bead stringing Unintentional injury questionnaire filled out by mothers	Rate of injuries in boys higher during laboratory-based tests. Age and gender differences were not significant No correlation between motor ability and injury risk Motor ability had a high correlation with diary-recorded injuries	No relationship between somatic abilities and injury, findings might be useful for playground equipment and toy manufacturers	*		*
Sherker15	Melbourne Australia	Validated methods of biomechanics and epidemiology Development of a case-control study Development of a designed dummy for simulation of accidental falls Main focus group was children aged < 13 years who suffered a play-related fracture 5 hospitals selected for study	Most costly group of playground-related problems were upper extremity fractures	Potential bias towards more serious falls among controls To assist with compliance, upon completion of the schools’ commitment to the study, free playground surface materials were provided to control schools	*
Sherker32	Victoria Australia,	Unmatched case-control study in 5 hospitals and 78 randomly selected control schools, data gathered October 2000–December 2002 Cases were 402 children (< 13 years) who had fallen while playing in school playgrounds and suffered an arm fracture. Controls (n = 283) had no or minor injuries. Children were interviewed in the playground regarding interventions. Measurement of playground equipment dimensions	Risk of upper arm fracture greatest for equipment heights > 1.5 m and for fall heights > 1.0 m Depth beneath equipment not enough for accident prevention	Recommendations for playground surfaces should be revised Equipment height needs revision to a safe level with maximum 1.5 m for height	*	*
Tan et al6	Singapore	Cross-sectional descriptive study and assessment of data documented during February 2002–January 2004 in emergency departments of three hospitals Assessment of recorded data for 19,094 injured children < 16 years	1617 of 19,094 recorded injuries were playground-related Falls were the most common injury (70.7%), but most (99.4%) were minor; around 37% occurred at 1800–2100 hours, and 27.6% at 1500–1800 hours. Incidence rates were different between weekdays, and also for months Most were upper extremity fractures and occurred in children aged 6–10 years	Falls from monkey bars were the most common injuries and occurred during weekends and vacation months, ie, June and December, so interventional planning needed Redesigning of playground equipment with consideration of safety guidelines necessary	*	*	*

^*denotes satisfied criteria.

Abbreviations: Ch, children; env, environment; eq, equipment.