Table 2.
Data extraction for included risk factor studies aimed to examine the association between an exposure and playground injury, or injury-related outcomes
| Title (author, year of publication) | Study (design, duration, year(s), country) | Participants (age, sample size, sex) (SD = standard deviation) | Exposure | Outcome | Data analysis | Effect estimates [presented as odds ratios (OR), relative risk (RR) with 95% confidence intervals (CI)] | QA* score |
|---|---|---|---|---|---|---|---|
| Height and surfacing as risk factors for injury in falls from playground equipment: a case control study (Chalmers et al. 1996) | Case control design, 1989–1992, New Zealand | Cases: children (< 14 years old) injured from a fall from playground equipment at an early childhood education centre or school and received medical attention (n = 110). Controls: children (< 14 years old) with no medically attended injury from falling from playground equipment (n = 190), total n = 300 | Non-compliant playgrounds to NZS 5828 (New Zealand) standards (including playground surfacing, equipment height | Injuries from falls from playground equipment | Multivariable logistic regression |
Adjusted† results: non-impact (concrete, asphalt, grass, earth) vs. impact surfacing (loose + rubber), OR = 2.28 (95% CI 1.04–4.96), non-impact vs. loose fill surfacing (bark chips, pea gravel, sand), OR = 2.27 (95% CI 1.04–4.97) Adjusted‡ results: in impact-absorbing surfaces, fall height over 1.5 m increased risk of injury, OR = 3.80 (95% CI 2.01–7.17) and in non-impact-absorbing surfaces by 14 times, OR = 14.89 (95% CI 3.33–66.54) |
17 |
| Severity of playground fractures: play equipment vs. standing-height falls (Fiissel et al. 2005) | Case control design, 1995–2002, Canada | Cases and controls: children (≤ 4 ≥ 15 years of age) were age matched, 54.7% male. Cases were children with a fracture from standing height (n = 351, 32.8%) and controls were children with a fracture from falls from playground equipment (n = 719, 67.2%) | Playground equipment height | Severity of the fracturesustained (severity classification determined by treatment received). Major fracture defined as those that required emergency or operating room reduction, minor, those that did not | A logistic regression was used to determine the odds of a major fracture comparing playground equipment height falls to standing-height falls | The odds of sustaining a major fracture was 3.91 (95% CI 2.76–5.54) times greater when the fall was from a piece of playground equipment, compared to standing-height falls | 15 |
| Playground equipment injuries at home vs. those in public settings: differences in severity (Keays and Skinner 2012) | Case control design, 1995–2008, Canada | Cases were children (ages 36–143 months) injured in private homes (n = 6549), and controls were children (ages 36–143 months) injured in a public space including schools parks and other institutions (n = 33,181). Cases and controls reported to a Canadian ER (participating in CHIRPP§) from a playground-related injury, 53% were male | Playground type (home vs. public) | Severe injury (defined by level of treatment received), defined as any injury requiring admission, remaining in the emergency department | A logistic regression was used to determine the odds of sustaining a severe injury or fracture, at home compared to a public setting | Children falling from playgrounds at home had greater odds of severe injuries (OR = 1.30; 95% CI 1.23–1.37) and fractures (OR = 1.47; 95% CI 1.39–1.55) than those from public playgrounds. Children ages 3–5 years falling off slides at home, compared to slides in public settings, had the greatest odds of severe injuries (OR = 1.72; 95% CI 1.41–2.09) and fractures (OR = 2.17; 95% CI 1.79–2.64) | 16 |
| Severity of fall injuries on sand or grass in playgrounds (Laforest et al. 2000) | Retrospective cohort design, May–September, 1991 and 1995, Canada | Children (n = 930) presenting to two Montreal Children’s Hospitals, ages 1–14 years (mean = 5.8 years) involved in a playground fall injury, 54% male | Playground surfacing (sand, grass, other), playground type (municipal, school, daycare, residential), equipment type, age, supervision, location, sex, playground use | Nature of injury was the reported outcome (in two categories): fracture and head injury (includes concussions, skull fractures, and contusions) and fractures and dislocations). Other injury was defined as all other injuries | Multivariable logistic regression was used to estimate the association with surface, nature, and severity of injury, adjusting for age, location of the accident, month of the injury, number of medical visits for an injury per year, playground use | Falls onto grass surfaces had a 1.74 increased odds of having a fracture or head injury (95% CI 1.21–2.0) over sand. When controlling for surface type, residential playgrounds increased the odds of injury over municipal playgrounds, although this was not statistically significant (OR = 1.29, 95% CI 0.91–1.84) | 12 |
| Surface characteristics, equipment height, and the occurrence and severity of playground injuries (Laforest et al. 2001) | Nested case control design, May–September 1991 and 1995, Canada | Cases (n = 111) were children who suffered a severe injury and controls (n = 74) suffering a minor injury from a playground fall, both presenting to two Montreal Children’s Hospitals, ages 1–14 years (mean = 5.8 years) | Playground surfacing (g-max, recommended/not recommended), sex, age, supervision, playground use, equipment type, equipment height | Injury occurrence (yes/no) and injury severity (cases-controls) | Logistic regression was used to determine predictors of injury severity and occurrence of injury | Injury occurrence (adjusted|| results): Injuries were 2.56 times more likely (95% CI 1.07–6.14) to occur on equipment higher than 2 m compared with equipment lower than 1.5 m. Falls occurring on a surface exceeding 200 g had a risk of injury 3.03 (95% CI 1.45–6.35) times greater than for < 150. For surfaces between 150 and 200 g, injuries were 1.8 times higher (95% CI 0.91–3.57) | 14 |
| Risk factors for severe injuries associated with falls from playground equipment (Macarthur et al. 2000) | Case control design, May–October, 1995–1996, Canada | Cases (n = 67) were children with at least one severe injury from playground fall. Controls (n = 59) were children with a minor injury. Cases and controls were matched on age (> 18 months–14 years), sex (males, 51%; females, 49%), day of presentation | Playground equipment height, condition (wet vs. dry), use, prior to playground injury, supervision, surfacing (impact vs. non-impact) | Severe injury was defined as an injury with an AIS score ≥ 2, minor injury was defined as an injury with an AIS score < 2 | Multivariable logistic regression | The majority of cases (73%) fell from heights greater than 150 cm, compared to 54% of controls. The odds of severe injury was 2.30 (95% CI 1.09–4.84) times higher for falls over 150 cm, compared to falls lower than 150 cm | 18 |
| Safety standards and socioeconomic disparities in school playground injuries: a retrospective cohort study (Macpherson et al. 2010) | Retrospective cohort design, 1998–1999 (pre) and 2004–2007 (post), Canada | Study involved 374 elementary schools (population ≈ 145,000). Students attending the schools ranged from 62 to 1600 students (mean = 388 students) | Socio-economic status (SES) (via Learning Opportunity Index—LOI) | Injuries reported to the Ontario School Board Insurance Exchange. Injuries categorized as outdoor, outdoor non-equipment, and on play equipment | Poisson regression analysis was used to determine the relationship between the rate of playground injuries and LOI scores for both time periods | Prior to equipment upgrade, there was a significant relationship between SES and equipment-related injury, with children at poorer schools being at increased risk (RR = 1.52, 95% CI 1.24–1.86). After unsafe equipment was replaced, no relationship existed (RR = 1.13, 95% CI 0.95–1.32) | 11 |
| Measuring parent attributes and supervision behaviours relevant to child injury risk: examining the usefulness of questionnaire measures (Morrongiello and House 2004) | Cross-sectional design with observational measures, Canada | Participants were 48 parent-child dyads (46% female, 54% male children, 71% mothers, and 29% fathers) randomly selected from 7 local parks (to include variability in parental education and SES) | Parental supervision | Injury risk taking behaviour (total number of injury risk activities) | Correlation between observed behaviours and responses to behaviour checklist | Greater physical proximity to the child was associated with less risk taking (− 0.31) | 11 |
| Patterns of injuries to children on public playgrounds (Mott et al. 1994) | Retrospective cohort design, two, 6-month periods—1992–1993, Wales | Children presenting to the emergency room from playground injury (n = 162), ages 0–14 years | Playground surfacing (bark vs. concrete) | Injury was defined as one suffered on a public playground that required emergency room attention | Comparison of injury rates to expected injury rates (playground exposure) | There was a significantly different pattern of injury on bark and concrete/tarmac surfaces (p < 0.005); however, no statistically significant difference was found between surfacings | 12 |
| Safety of surfaces and equipment for children in playgrounds (Mott et al. 1997) | Retrospective cohort design, 1992–1994, Wales | Children presenting to the emergency room from playground injury 1992–1993 (summer) and all of 1994 (n = 330), ages 0–14 years | Playground surfacing (rubber, bark/rubber, bark, bark/tarmac, concrete/tarmac), equipment type, and height | Injury was defined as any injury on a public playground that required emergency room attention | A Poisson regression analysis was used to estimated the risk of injury by play surface, equipment type, and height, controlling for playground use | The risk of injury by surface type (RR, 95% CI): bark/rubber = 1.81, 0.66–4.98, bark = 1.98, 0.87–4.52, bark/tarmac = 4.63, 1.49–14.4, and concrete/tarmac = 5.11, 2.09–12.5 compared to rubber surfacing. RR of injury on equipment: swing = 1.27, 0.64–2.51; climbing frame = 3.47, 1.97–6.11; monkey bars = 7.49, 4.14–13.5. There was a linear relationship with height of fall from equipment and the number of fractures (p < 0.005) | 13 |
| A case-control study of risk factors for playground injuries among children in Kingston and area (Mowat et al. 1998) | Case control design, 1995, Canada | Cases (n = 45) were children (ages 1–16 years) presenting to one of two emergency rooms. Controls (two groups, n = 45, n = 45) were defined as (1) children injured not from playgrounds and (2) children non-injured needing emergency care. Children were age (mean = 8.3 years, SD = 2.2), sex (n = 26 male, n = 19 female), and day presented matched | Playground hazards (surfacing, handrails, use, number of hazards, sharp edges, protrusion, non-encroachment zones, entrapment, pinch points) playground type (municipal vs. school) and SES (family income) | Injury was defined as any injury on a playground that required attendance to of two hospitals emergency room | A multivariable conditional logistic regression was used to estimate the association with playground hazards and injury risk | Inadequate handrails and guardrails were associated with an increased odds of sustaining an injury requiring emergency room attendance (OR = 6.7, 95% CI 2.6–7.5). Surfacing material not recommended by the Canadian Standards Association and the US Consumer Product Safety Commission (CPSC) had an increased odds of injury (OR = 21.0, 95% CI 3.4–128.1). Surface depth not meeting CPSC has an increased odds of injury (OR = 18.2, 95% CI 3.3–99.9) | 17 |
| Composite playground safety measure to correlate the rate of supracondylar humerus fractures with safety: an ecologic study (Park et al. 2010) | Retrospective cohort design, 1998–2006, USA | Children (n = 48) 3–16 years (mean = 5.9 years, SD = 3.3) who sustained supracondylar humerus fractures (ICD-9), males 52% | Compliance to safety codes using a composite safety measure (including surfacing, supervision, age-appropriate design) | Supracondylar humerus fractures | The difference in fracture rate by ZIP code was calculated using Yates Chi-squared and OR. Linear regression was used to calculate playground safety with injury rates | Children in the least safe zone had a 4.77 increased odds of injury (95% CI 2.36–9.63) compared to the most safe zone. Linear regression analysis showed thataverage playground safety value (safety index) was inversely related to injury rates (r = 0.98, p = 0.04) | 13 |
| Injuries in public and private playgrounds: the relative contribution of structural, equipment, and human factors (Petridou et al. 2002) | Nested case control design, September – December 1999, Greece | Cases (n = 777) and controls (n = 294) were children, 0–14 years presenting to the emergency room. Cases were children with a playground injury, controls were non-injured children | Nationality (Greek vs. non-nationals), playground type (public vs. private), age and sex | All injuries occurring in a public or private playground | A multivariable logistic regression analysis was used to estimate the odds of injury, controlling for age, sex, nationality | There was a 2.22 times higher risk of injury in public playgrounds over private (OR = 2.22, 95% CI 1.61–3.07). Age greater than 10 years was protective of injury (OR = 0.50, 95% CI 0.34–0.73) compared to 5–9 year olds, and those defined as non-nationals were at an increased odds of injury (OR = 2.00, 95% CI 1.13–3.54) | 16 |
| Playground hazards in Atlanta child care centers (Sacks et al. 1990) | Prospective cohort design, June 1987–October 1988, USA | Randomly selected licensed childcare centres with playgrounds (n = 66) | Playground hazards (rock, concrete, root, or stump in fall zone; inadequate clearance; sharp protrusion; contaminants in under surface, missing parts, blunt protrusions, trip-and-fall, tip-over, entrapment hazards, broken or loose parts, open S-hooks, hard swing seats), equipment height | Medically treated injury (injury treated within 48 h) | Results were presented as the number of hazards and the number of reported injuries | Of 21 centres with ≤ 5 hazards, 43% reported a playground-related injury in the previous year; of 25 centres with 6–11 hazards, 52% reported a playground-related injury; and of 20 centres with ≥ 12 hazards, 60% reported a playground-related injury. Reported that climbing equipment ≥6 ft had inadequate impact-absorbing under-surfacing and over twice the rate of fall injuries as climbing equipment ≤6 ft | 12 |
| Out on a limb: risk factors for arm fracture in playground equipment falls (Sherker et al. 2005) | Case control, design (unmatched), 2000–2002, Australia | Cases and controls were children (< 13 years) who fell from school playground equipment and landed on their arm. Cases (n = 402) sustained an upper limb fracture and controls (n = 283) had minor to no injury | Equipment height, surfacing type, surface depth, substrate material, arm load | Upper arm fractures | A multivariable logistic regression was used to estimate the association between fractures and exposures, controlling for covariates | Falls from equipment heights greater than 1.5 m had a 2-fold increased odds (OR = 2.39, 95% CI 1.49–3.84 of sustaining an arm fracture compared to 1.5 m or less. Fall heights >1 m were 2.96 times more likely to sustain an arm fracture over those who fell less than 1.0 m (95% CI 1.71–5.15 | 16 |
*Quality appraisal
†Adjusted for place of occurrence, age, gender, child weight, child height, type of equipment, and height of fall (broad categories)
‡Adjusted for age, gender, place of occurrence, child weight, child height, and type of equipment
§Canadian Hospitals Injury Reporting Prevention Program
||Adjusted for height, surface, g-max, equipment type, and density of children in the playground area