Accident Analysis and Prevention 50 (2013) 587–595

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Accident Analysis and Prevention

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Results of a randomized controlled trial assessing the efficacy of the Supervising

for Home Safety program: Impact on mothers’ supervision practices
Barbara A. Morrongiello ∗ , Daniel Zdzieborski, Megan Sandomierski, Kimberly Munroe
Psychology Department, University of Guelph, Guelph, Ontario N1G 2W1, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Unintentional injury constitutes a major health risk for young children, with many injuries occurring in
Received 27 March 2012 the home. Although active supervision by parents has been shown to be effective to prevent injuries,
Received in revised form 3 June 2012 evidence indicates that parents do not consistently apply this strategy. To address this issue, a random-
Accepted 5 June 2012
ized controlled trial was conducted to evaluate the impact of the Supervising for Home Safety program on
parent supervision practices in the home and when unobtrusively observed in a naturalistic laboratory
Keywords:
setting. Using a participant-event monitoring procedure, parents of children aged 2 through 5 years com-
Childhood injury
pleted supervision recording sheets weekly both before and after exposure to the intervention program;
Prevention
Supervision
Control parents completed the same measures but received a program focusing on child nutrition and
Intervention active lifestyles. Unobtrusive video recordings of parent supervision of their child in a room containing
RCT contrived hazards also were taken pre- and post-intervention. Results indicated that groups did not differ
in demographic characteristics. Comparisons of post- with pre-intervention diary reported home super-
vision practices revealed a significant decrease in time that children were unsupervised, an increase in
in-view supervision, and an increase in level of supervision when children were out of view, with all
changes found only for the Intervention group. Similarly, only parents in the Intervention group showed
a significant increase in attention to the child in the contrived hazards context, with these differences
evident immediately after and 3 months after exposure to the intervention. These results provide the
first evidence that an intervention program can positively impact caregiver supervision.
© 2012 Elsevier Ltd. All rights reserved.

1. Introduction in the home (Gielen et al., 2002; Watson et al., 2005), active supervi-
sion by caregivers also has emerged as an important risk-reducing
1.1. Childhood injury strategy for young children (Morrongiello et al., 2009a).

In the United States and Canada, as in most developed coun-
tries, unintentional injury is the leading cause of death for children
between 1 and 19 years of age (Canadian Institute of Child Health,
2002; Grossman, 2000; National Center for Injury Prevention and
Control [NCIPC], 2007; World Health Organization [WHO], 2005).
In fact, it has been predicted that by the year 2020 injury will be
the leading single reason for loss of healthy years of human life
(WHO, 1996). Not only is injury the leading cause of child mortality,
but injury related visits to emergency departments and hospital-
izations are commonplace, with estimates indicating that as many
as one in four children in the United States are seen annually for
medical treatment due to injury (Scheidt et al., 1995). For young
children under six years of age, many injuries occur in the home
(McDonald et al., 2003; Shanon et al., 1992). In addition to environ-
mental modifications that reduce access to and eliminate hazards
∗ Corresponding author.
E-mail address: bmorrong@uoguelph.ca (B.A. Morrongiello).
1.2. Caregiver supervision: definition, measurement, and findings
Although there are challenges in defining supervision (see
Morrongiello, 2005, for extensive discussion), three dimensions
(proximity, attention, and continuity) have been shown to relate
to children’s risk of injury (Morrongiello et al., 2004a,b, 2006a,b,
2009a,b,c). Hence, a popular definition of supervision is that it refers
to the extent to which caregivers provide sustained attention and
proximity to children (Gitanjali et al., 2004; Morrongiello, 2005).
Maximum active supervision and lowest risk of injury presum-
ably occurs when a supervisor is attentively watching, the child
is in close proximity (i.e., within reach), and these behaviors are
sustained over time.
With regard to measuring supervision, developing methods that
yield reliable and valid data can be quite challenging (Morrongiello,
2005). Observational indices can be very useful but parents’ knowl-
edge that they are being observed can lead to distortions in their
behavior, producing results that represent best behavior rather than
typical behavior. An innovative way to manage this issue is by

0001-4575/$ – see front matter © 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.aap.2012.06.007
588 B.A. Morrongiello et al. / Accident Analysis and Prevention 50 (2013) 587–595
unobtrusively video recording caregiver supervision and doing so
when the child and parent are together in the presence of contrived
hazards (i.e., presenting items that look like real injury hazards but
that have been modified so that they pose no real threat of injury,
such as placing blue dyed water in a Windex bottle, or providing
scissors that look sharp but have been glued shut). This methodol-
ogy has proved very useful for studying how caregivers supervise
and react to children’s hazard interaction attempts (Cataldo et al.,
1992; Morrongiello and Dawber, 1998), but one limitation is that
not all hazard contexts can be represented using this method.
A popular approach to measuring supervision in more diverse
contexts involves utilizing self-report measures of caregiver behav-
ior (Morrongiello, 2005). Checks of the validity of self-report data
indicate good agreement between what caregivers report and how
they behave. For example, research comparing self-reports with
observations in a laboratory setting (Kochanska et al., 1989), as
well as with observations in a supermarket (Holden et al., 1992),
has found that maternal self-reports provide accurate and valid
indications of numerous caregiver parenting behaviors. Similarly,
a study comparing maternal self-reports about supervision with
unobtrusively observed supervision in park settings also supports
the validity of using self-reports about supervision (Morrongiello
and House, 2004). Finally, there is very good agreement (89%)
between periodic reports of supervision obtained via random tele-
phone calls and diary entries completed in the 5 min preceding a
call (Morrongiello et al., 2006a). Overall, these diverse results sug-
gest that using a participant event-recording methodology in which
parents complete diary records of supervision can provide accurate
information about caregiver supervision in a variety of contexts.
The application of these methods has yielded important insights
into how caregivers routinely supervise, and how these practices
relate to childhood injury. Although greater continuity in attention
and closer proximity are associated with fewer injuries for young
children, studies examining how parents routinely supervise young
children at home indicate that they are often unable or unwilling to
provide sustained active supervision. For example, in a prospective
study in which parents completed diaries to track home supervi-
sion over several weeks, it was found that young children regularly
spend up to 8% of their awake time unsupervised (i.e., supervisor
does not know where the child is or what s/he is doing, and has not
checked on the child in over 5 min). Moreover, children are out-
of-view of their supervisor an additional 20% of the time, and the
level of supervision is much poorer for out-of-view than in-view
times (Morrongiello et al., 2006a). Poorer supervision is associated
with more frequent minor injuries (Morrongiello et al., 2004a,b,
2006a,b), as well as medically attended injuries (Morrongiello et al.,
2009a). The pattern of these findings suggests, therefore, that par-
ents routinely supervise in ways that can elevate young children’s
risk of injury. What is notably lacking, however, are evidence-based
programs that are effective to promote active supervision. The cur-
rent study addresses this gap in the literature.
1.3. Present study
The Supervising for Home Safety program was developed for par-
ents of children 2 through 5 years (Morrongiello et al., 2009c).
The program comprises a video presentation, structured follow-
up discussion that is tailored to the individual, and a one-month
series of activities that serve to change habitual patterns of supervi-
sion and promote more active strategies. Recent research confirms
the efficacy of the program for positively impacting parent atti-
tudes towards injury prevention, beliefs about the need to actively
supervise young children, and commitment to actively supervising,
with these effects persisting 1 year post-intervention (Morrongiello
et al., in press). The aim of the present study was to extend this
research by conducting a randomized controlled trial (RCT) and
evaluating the impact of the Supervising for Home Safety program
on caregivers’ actual supervision practices; the Control condition
targeted healthy eating habits and physical activity (i.e., a healthy
lifestyle).
The study was limited to mothers because they are often the
primary supervisor of young children at home (Morrongiello et al.,
2009a), past research has not found any supervision differences
between mothers and fathers (Morrongiello and Dawber, 1998;
Morrongiello et al., 2009b), and many supervision measures have
been validated for mothers but not fathers. Both the Intervention
and Control conditions utilized a video to present key material
because past research indicates that parents favor this medium
(Barone et al., 1986; Metchikian et al., 1999). To assess home super-
vision, a participant-event recording procedure was used in which
parents were trained to record aspects of their own supervision
behavior in real time and in real life situations (Ferguson, 2005;
Morrongiello et al., 2004a,b; Peterson et al., 1991), both before and
after exposure to the intervention. Unobtrusive video recordings of
the parent and child in a contrived hazards room within a labora-
tory setting were completed at three time points (pre-intervention;
post-immediate; post-3 months later). It was hypothesized that
after intervention exposure, diary recordings of home-supervision
practices would show a decrease in the time the child was left unsu-
pervised (i.e., the parent does not know where child is and what
s/he is doing for more than 5 min), an increase in the time the child
is in-view, and improvement in the quality of supervision when
the child is out-of-view. In the contrived hazards room, parents in
the Intervention but not the Control group were expected to show
an increase from pre- to post-intervention in attentiveness to their
child.
2. Methods
2.1. Study overview
2.1.1. Design
In this efficacy RCT, parent volunteers were recruited from the
community and then randomly assigned to either an Intervention
or Control group (see flow diagram in Fig. 1; CONSORT, 2010). The
aim was to recruit broadly and obtain a representative sample of
parents of young children in the community. The same home super-
vision measures (i.e., diary records of home supervision practices)
and unobtrusive supervision measures (i.e., video recordings of the
parent and child in a contrived hazards room) were taken pre- and
post-intervention in each group.
2.1.2. Intervention condition
The Supervising for Home Safety intervention program took 4
weeks to complete and began with presentation of the Watchful
Parents, Safe Children video (20 min) and a Post-Video Structured
Discussion (40 min) in a laboratory setting, followed by one month
of the parent practicing solutions in the home that addressed
self-identified barriers to actively supervising, as well as track-
ing their self-talk and strategies related to close supervision. The
program was manualized and included extensive training mate-
rials to ensure consistent and rigorous program delivery, with
random checks on fidelity of program delivery (e.g., checking
audiotapes of program delivery sessions). The intervention was
implemented within two weeks of parents completing the base-
line pre-intervention diary based supervision recordings. Diary
based recording of post-intervention supervision practices began
once the mother completed the one-month intervention program.
Observations of parent supervision in the contrived hazards room
were completed pre-intervention, and at two time points post-
intervention (immediately after, and three months later).
 B.A. Morrongiello et al. / Accident Analysis and Prevention 50 (2013) 587–595 589

Parent volunteers assessed for

ELIGIBILITY
(N = 670)
Did not meet
eligibility criteria
(N = 442)
Randomly Assigned
(N = 228)

INTERVENTION CONTROL
Group Group
(N = 116) SEE DEMOGRAPHIC TABLE (N = 112)
(TABLE 1)

Lab Visit #1 Lab Visit #1

(N = 116) (N = 112)
PRE-INTERVENTION MEASURES

8 weeks of home 8 weeks of home

recording recording

Lab Visit #2 Lab Visit #2

+ 1 month + 1 month
INTERVENTION DELIVERED
(N = 102) (N = 95)

8 weeks of home 8 weeks of home

recording recording

Lab Visit #3 Lab Visit #3

(N = 96) POST-INTERVENTION FOLLOW-UP (N = 90)
MEASURES

Fig. 1. Flow Diagram for the Study.

2.2. Sample size
Because of the lack of intervention research in this area, there
was no direct estimate of effect size to guide a power analysis.
Therefore, past research that aimed to impact other types of par-
ent safety practices was considered instead (Kendrick et al., 2008).
Based on this literature, we anticipated obtaining medium effect
sizes, and with Type I error rate set at .05 and power of .80, this
resulted in needing a sample size of 65 parents per group (Cohen,
1992). Because no differences due to child age or sex were obtained
in the initial research that led to development of the interven-
tion (Morrongiello et al., 2009c) or in the RCT assessing the impact
of the intervention on mothers’ injury and supervision appraisals
(Morrongiello et al., in press), and given that we planned to bal-
ance groups for age and sex, these factors were not considered in
estimating sample size.
2.3. Randomization
Parent volunteers were recruited throughout the local commu-
nity (e.g., general information letters distributed at daycare centers
and kindergarten classes, posters hung at locations where child-
centered activities occurred) and then randomly assigned to the
Intervention or Control group via a stratified randomization pro-
cedure (cf. Kernan et al., 1999) to ensure comparability across
groups based on the child’s sex and age. In assigning parents to
groups, a computer generated random numbers table was used and
a concealed method of randomization was used to eliminate any
potential biases in treatment effects (Schulz, 1995; Schulz et al.,
1995). Assignment to group was done by someone not involved in
data collection.
2.4. Participants
The final sample comprised 186 mothers, including 96 hav-
ing a son in the target age range of 2.0–5.5 years (M = 3.70 years,
SD = 1.02 years; minimum = 2.09 years; maximum = 5.36 years)
and 90 having a daughter in this age range (M = 3.67 years,
SD = 1.03 years; minimum = 2.07 years; maximum = 5.32 years).
Intervention (n = 96) and Control (n = 90) groups were approxi-
mately equal with respect to child sex and age. An additional 20
parents in the Intervention group and 22 in the Control group
were recruited but then unable to participate due to scheduling
conflicts.
Of the participating mothers, the majority (93%) were Caucasian,
95% were in two-parent homes, and 68% of the mothers worked
outside the home (M = 32.39 h/week, SD = 10.89 h). Table 1 pro-
vides a summary of income and education demographics for the
Intervention and Control groups separately, as well as for the sam-
ple overall. Procedures were approved by the university Research
Ethics Board and consent was obtained from all participants at
every point of contact.
590 B.A. Morrongiello et al. / Accident Analysis and Prevention 50 (2013) 587–595

Table 1 (2) An In-View Recording Sheet was completed every time a “child
Summary demographics for the Intervention (n = 96) and Control (n = 90) groups, and
in view of supervisor” entry was made on the Master Time Use
overall sample (N = 186). Mean values are shown with standard deviations within
parentheses. Information Sheet. Parents indicated the room the child was in,
who was supervising, and whether the supervisor was doing
Attribute Control Intervention Overalla
something with the child (“doing” or “not doing”). If “doing” was
Child age (years) selected, then parents indicated what type of activity the super-
% male 3.76 (1.04) 3.64 (1.01) 3.70 (1.02) visor was engaged in with the child (e.g., helping or teaching
% female 3.69 (1.07) 3.64 (0.99) 3.67 (1.03)
the child, playing with or entertaining the child, sharing non-
Highest education for mothers play time together such as talking). If “not doing” was selected,
% high school 5.4 6.6 5.9
then mothers indicated the level of supervision being exhibited
% university/college 54.2 65.9 60.0
% graduate 40.4 27.5 34.1
(i.e., supervisor has the child within constant view, watching
him/her intermittently, not watching at all but listening, not
Family income
watching at all or listening at all, or do not know).
% at or under $40,000 4.3 5.5 4.9
% between $40,000 and $60,000 10.8 8.8 9.8 (3) An Out-of-View Recording Sheet was completed if the mother
% between $60,000 and $80,000 21.5 22.0 21.7 indicated that the child was out-of-view of the supervisor. The
% $80,000 and above 63.4 63.7 63.6 mother indicated the rooms the child and supervisor were in,
a
One-way Analyses of Variance were conducted comparing groups for each factor the activity each was engaged in, and the level of supervision
separately and results revealed no significant group differences for any demographic being exhibited.
factor.
2.6.2. Contrived hazard rooms
2.5. Inclusion and exclusion criteria To unobtrusively measure supervision pre- and post-
intervention (immediate, long term), three rooms (same size
Inclusion criteria were: (1) one child in the family is between 2.0 and general layout) were set up as waiting areas and at each lab
and 5.5 years of age; (2) child and participating parent are fluent visit, parents spent 10 min with their child in one of these rooms.
in English; (3) if there is an older child in the home, this child is at The order of room assignment was randomized such that at the
least 2 years older than the target child because smaller intervals conclusion of the study the parent and child had visited each room.
between cohabiting children can elevate injury risk for the younger In addition to child appropriate toys, each room contained 12
child (Nathens et al., 2000); (5) mother (biological, stepmother, contrived hazards (i.e., objects that appeared hazardous but that
adoptive) who the child predominantly resides with agrees to be were modified so they posed no real risk of injury). There were
the participating parent; (6) if adopted, the child has lived with the three hazards for each of four types of injury (falls, cuts, burns, poi-
mother a majority of time for at least the last 3 months; and (7) soning), with different hazard items in each room. Video cameras
mother will be available and agrees to participate repeatedly over were hidden in the ceiling and provided unobtrusive recording of
the full study period. Exclusion criteria were: (1) the child is not parent and child behaviors and verbalizations. None of the videos
developing normally as reported by the mother; (2) twins; and (3) were viewed until study completion when the parent was debriefed
if the family previously participated in any of the projects related about the recordings and consent was obtained; all parents granted
to this research including pilot testing of measures and procedures. consent for their videotapes to be included in the study.

2.6. Materials
2.6.1. Home Supervision Recording Sheets
To measure home supervision for the pre-intervention period,
four days were selected over the course of eight weeks (max = 1
in a week; recording days represented different days of the week,
and were selected to occur approximately every other week) for
which the parent was to complete the supervision recording sheets,
as in past research on home supervision (Morrongiello et al.,
2006a, 2006b). For post-intervention measurement, after parents
had practiced solutions and tracked their self-talk and strategies
about close supervision for one month, another four supervision
recording days were similarly selected for the next eight weeks.
Three types of supervision recording sheets were used (cf.
Morrongiello et al., 2006a,b).
(1) A Master Time Use Information Sheet was completed to record
how the mother and child spent time at home together start-
ing from the moment the child was awake in the morning
until her/his bedtime, with the major focus on supervision. The
mother created a new entry and recorded the corresponding
clock time whenever the child’s activity, room, supervisor (i.e.,
person most responsible for the child), or type of supervision
changed, as well as when the parent and/or child left the home.
For each entry, the mother indicated who was supervising and
whether the child was in or out of view of the supervisor. If the
child was in view, the mother indicated whether the supervisor
and child were doing something together.
2.7. Videos
2.7.1. Intervention video
The theoretical basis for and steps taken in developing the 20-
min Watchful Parents, Safe Children video that the Intervention
group received is fully described elsewhere (Morrongiello et al.,
2009c). This was developed with messaging based on reviews of
theoretical and empirical literature. The messaging strategies were
selected based on childhood injury literature and research on fac-
tors shown to affect attitude change (Petty et al., 1997; Wegener
et al., 1994), processing of health information (Petty and Cacioppo,
1986, p. 123; Wegener et al., 1994), readiness for behavior change
(Janz and Becker, 1984; Rosenstock, 1974), attention to warnings
and risk information (Morrongiello et al., 2006a,b; Morrongiello
and Kiriakou, 2004), and parent responsiveness to parenting inter-
ventions (Brown et al., 2005; Kerr and Stattin, 2000; Steinberg et al.,
1994). Experts at Safe Kids Canada also shared their test-marketing
results regarding effective ways to promote the impact of safety
messaging on parents’ safety attitudes and practices.
Based on these diverse sources of information, the video com-
prised 12 messaging strategies: (1) graphic images of childhood
injury to evoke emotions of fear; (2) text on the screen that was also
read aloud to promote information processing using both visual and
auditory modalities; (3) sound effects (e.g., children crying, sirens)
to evoke strong emotions in parents; (4) Canadian child-injury
statistics depicted using graphs; (5) mention of long-term social
and emotional difficulties as a result of childhood injures; (6) pre-
sentation of information about individual types of injury (i.e., falls,
burns, drowning, and poisoning); (7) testimonials by mothers (one
 B.A. Morrongiello et al. / Accident Analysis and Prevention 50 (2013) 587–595
per injury type) about when their child was unsupervised for ‘just
a second’ that led to the child dying or being seriously injured; (8)
after the testimonials, viewers were asked to reflect on how similar
their supervisory practices were to this mother; (9) developmental
milestones were discussed to emphasize that children’s behav-
ioral competencies and cognitive curiosity continuously change,
making their behavior unpredictable; (10) supervising in ways to
promote readiness to intervene but not dependency; (11) no task is
as important as a parent’s duty to keep their child safe; and (12) sug-
gested strategies to improve supervisory behaviors to evoke a sense
of empowerment and personal problem solving about barriers to
actively supervise and keep their child in view.
The video was organized to evoke different emotions through-
out the viewing. The initial tone was positive and playful and the
messaging emphasized that children are constantly developing
and, therefore, can behave unpredictably. The tone then shifted
to become more serious and fear-evoking, emphasizing: injury
vulnerability and severity, long-term consequences of injury, and
children’s specific risks for falls, drowning, poisonings, and burns.
The tone shifted again to become more positive, and parents were
presented with messages aimed at empowering them to keep their
child in view and to promote a sense of self-efficacy to do so. The
positive tone continued and mothers were then presented with
ways to help them actively supervise and keep their child in view
when faced with common barriers to doing so. They were also
encouraged to formulate their own strategies for keeping their child
in view, and the video concluded with empowering messages and
reminders to actively supervise by keeping the child in view.
2.7.2. Control video
The Control group video (Healthy Lifestyles, Healthy Children)
was identical in all ways (e.g., density of photos, length, emotional
tone) except that the content focused on child nutrition and active
lifestyles. It too was finalized based on extensive input from parents
of young children.
2.8. Post-Video Structured Discussion: tailoring the intervention
Immediately following video viewing, the parent rated how
emotionally arousing she found the video. The examiner then
conducted a structured interview with the mother that focused
on active supervision for Intervention parents and on child
nutrition and exercise for Control parents. This interview was
audio-recorded and, to ensure consistency and fidelity of pro-
gram delivery, a random sample of these for each interviewer was
checked biweekly by a supervisor not involved in data collection.
The format of the Intervention and Control discussions was the
same, but only procedural details and results from the Intervention
discussion will be presented herein.
Each mother in the Intervention group was asked to create a
radio message in which she was to act as a spokesperson advocat-
ing for active parent supervision of young children in the home. To
do this, the mother was asked to generate and write out up to three
key messages for convincing other parents to actively supervise
their children and to compile these into a radio ad. The mother then
recited her radio ad three times, and after each recital, the examiner
provided positive encouragement. Each radio message was audio
recorded and played back for the mother to hear so refinements
could be made over practices. This aspect of the program was based
on evidence showing that public endorsement of behavior that
one is not practicing leads to feelings of dissonance (i.e., induced
hypocrisy) and negative self-concept that are unpleasant but effec-
tive to evoke instantiation of the desired behavior (Morrongiello
and Marks, 2008; Son Hing et al., 2002).
The mother was then asked to identify three barriers that
she personally experiences that prevent her from actively
591
supervising her own child at home; these were written down in
point form. Then she was asked to generate realistic strategies
that she would consider either implementing to address each bar-
rier or implementing more often if she had done so before. The
examiner then provided mothers with a printed laminated card
with the mnemonic ‘ALTER’ that provided a structured approach
to identifying changes that could be made to address barriers to
actively supervising (i.e., ALTER: A = activities of the child or par-
ent, L = location of the child or parent, T = timing of an activity,
E = environment change, use R = resources). Using the ALTER card
the examiner and mother then brainstormed to identify other sug-
gestions for overcoming her unique barriers, with the goal of having
the mother practice using the ALTER approach in problem solving
about supervision barriers. The feasibility of each of these sugges-
tions was then discussed with mothers in order to identify ones
that she believed were both feasible and likely to be implemented.
Possible solutions were then written down next to each barrier
to illustrate that one could address each barrier and more actively
supervise if desired. Parents were given the barriers/solutions sheet
and the ALTER card to take home as a reminder of the solutions to
barriers that were discussed and that would allow them to actively
supervise their young child. They were then asked to sign a one-
month ‘Practice Solutions’ contract indicating that over the course
of the next four weeks they would use the ALTER card and prac-
tice the solutions generated. Lastly, they were presented a sheet
on which they were to write down other solutions they tried and
all instances of ‘self-talk’ about what they said to themselves that
motivated them to make a change so they could keep their child in
view and/or near them; the self-talk data are not considered herein.
2.9. Procedure
Parents who volunteered were invited to participate in a lon-
gitudinal research study examining parenting practices and how
these change and affect children’s health as the child develops. They
understood there would be a variety of types of activities for them
to complete (some at home and some in the lab, including diary
recordings about parenting on select days) and repeated contacts
over six months, but were not told that the focus was on supervision
or that an intervention was part of the research.
During an initial laboratory visit (see Fig. 1), parents granted
written consent and completed questionnaires about family demo-
graphics and their child’s health and development; these data are
not pertinent to this publication and are not considered herein.
Questionnaires were begun during a 10-min ‘waiting period’ in a
contrived hazards room (pre-intervention) and completed at the
end of the session while the child played with a research assistant.
A home visit was then scheduled to occur within two weeks. Dur-
ing this home visit, mothers were given calendar pages that showed
their supervision recording days, a binder containing supervision
diary recording sheets, and detailed instructions on how to com-
plete these. The mothers also received training in how and when
to complete the sheets (i.e., every time there was an entry on the
Master Time Use Information Sheet the mother was also to complete
either the In View or Out-of-view Recording Sheet, and all sheets had
to be time synchronized with all the time accounted for until the
child’s bedtime; see Morrongiello et al., 2006a,b, for further details).
Mothers were told that we were interested in how parents and
children spend their time at home and how parents balance pro-
moting independence with monitoring their child. On a recording
day, sheet completion was to begin when they and their child were
both awake and was to end when their child went to bed at night;
recording was to cease during periods when the mother or child
left the house or were sleeping. Parents received a call from the
researcher assistant the day before each recording day to remind
them of this and to address any questions.
592 B.A. Morrongiello et al. / Accident Analysis and Prevention 50 (2013) 587–595
The intervention program began when parents made their sec-
ond lab visit, which took place after they completed the supervision
diary recording forms for an eight-week baseline period; parents
brought the binder with the completed diary recording forms to
this visit. Upon arrival, the mother was asked to view a 20-min
video that had to do with some aspect of child health. She watched
this video on a 19-in. flat-screen computer monitor, while listen-
ing to the sound through speakers; a research assistant was in
the room but faced away from the parent and appeared distracted
with paperwork. After viewing the video, the parent immediately
rated the level of emotional arousal evoked by the video (1 = not
at all emotionally arousing, 7 = extremely emotionally arousing).
The examiner then conducted and audio-recorded the Post-Video
Structured Discussion. The parent was told they could keep the
ALTER card and was asked, for the next month, to: (1) imple-
ment the agreed upon strategies indicated on the barriers/solutions
listing; (2) initial the ‘Practice Solutions’ contract each day as a
reminder of what was discussed and agreed to; and (3) write down,
on a provided sheet, ‘self-talk’ about things they said to themselves
to motivate them to change their supervisory practices and keep
their child in view and/or near them. Lastly, the parent and child
spent 10 min in the contrived hazards room, with the parent again
given questionnaires to complete about their child’s health and
development.
The self-talk recording sheets and initialed ‘Practice Solutions’
contract were picked up at the parent’s home after one month. At
this time, parents were given new Home Supervision Recording
Sheets for their binder on which to record their home supervi-
sion for another four days that were selected by the researcher to
occur over the course of the next eight consecutive weeks. After
this eight-week recording interval the parent made a final visit to
the lab, at which time she returned the Home Supervision Record-
ing Sheets and spent 10 min with her child in the contrived hazards
room (post-intervention: 3 months) while completing some ques-
tionnaires. Throughout the study, upon completion of each point
of face-to-face contact with parents, they were given a gift card or
monetary compensation.
2.10. Data coding and measures taken
2.10.1. Home Supervision Recording Sheets
Only entries indicating that the mother was the supervisor were
included in the analysis (97% of all entries), and any entries made
when the child was sleeping or when the mother indicated “don’t
know” for the reported level of supervision were excluded from
analysis (<1% of all entries). Hence, the time estimates computed
were based on when the child and mother were both at home and
awake, and she was the primary supervisor.
The Master Time Use Information Sheets were used to determine
the amount of time in different supervision circumstances (e.g.,
child in-view versus out-of-view) and with different supervisors.
The In View Recording Sheets were used to determine how much
of the time a child and supervisor were in the same room and
“Doing Something” versus “Not Doing Something” together. Super-
vision when “Not Doing Something” together was coded as 1 = not
supervising (i.e., not watching or listening for the child at all),
2 = not watching but listening intermittently, 3 = watching him/her
intermittently and/or listening constantly, 4 = have him/her within
constant view, 0 = do not know (mother was not the supervisor and
does not know the nature of the supervision being provided but she
knows the child and supervisor were in the same room). Supervi-
sion when “Doing Something” together was coded as maximum
supervision (i.e., 4).
The Out-of-View Recording Sheets were used to determine the
nature of the activities of the child (i.e., to differentiate nap
time from awake time periods) and supervisor, and the level of
supervision provided when the child was out-of-view (0 = do not
know, 1 = not supervising, that is, not checking or listening in at
all, 2 = only going to check on the child when she hears something
that indicates the child needs to be checked, 3 = checking every
10 min or longer, 4 = checking every 8–9 min, 5 = checking every
6–7 min, 6 = checking every 4–5 min, 7 = checking every 2–3 min,
8 = listening in constantly).
For in-view and out-of-view data, mean supervision scores were
calculated by averaging entries across all days. Higher scores indi-
cated more active supervision.
2.10.2. Contrived hazards room supervision
Videos were coded for a total of 10 min, starting from the point
at which the door of the room was closed. The primary measure was
attention to the child. This was based on how closely the mother
watched the child, with scores ranging from 0 to 3 and assigned for
each of the 10 min (0 = not attentive at all, 3 = continuously atten-
tive); these 10 scores were averaged over time to provide an index
of caregiver attention during the session, with higher scores indi-
cating more active supervision. Because 10 min of videotape took
up to 12 h to fully code, the number of participants was reduced
by randomly selecting 69 Intervention and 68 Control participants
after all the data were collected from the 186 participants. A power
analysis indicated this sample size would provide sufficient power
(see Participants). All videos were coded by the same coder who
was blind to each participant’s group assignment when coding.
For estimating reliability, 25% of the videos (randomly selected)
were coded by a second independent coder, with excellent agree-
ment obtained (92% agreement overall; Kappa = .89). The data of
the primary coder were analyzed.
2.11. Analytic approach
For Analysis of Variance (ANOVA) tests, a Greenhouse–Geisser
adjustment was applied to the degrees of freedom when the need
for it was indicated in tests of sphericity. Multivariate outliers
were removed when appropriate (cf. Tabachnick and Fidell, 1989),
resulting in some slight variation in sample size across ANOVAs.
A Bonferroni correction for family wise error rate was applied for
all paired-comparisons and the results reported reflect the level of
significance obtained after applying the correction.
3. Results
3.1. Sample demographics
Demographic information for each group and the sample overall
is given in Table 1. A one-way ANOVA, with group as a between-
participants factor was conducted separately for each category and
no significant differences were noted (p > .05 for all tests). Hence,
the randomization procedure was effective in creating two groups
of parents having comparable demographic characteristics.
3.2. Was the intervention effective in improving home
supervision?
To determine if there were group differences in the amount of
time parents reported the children were awake and at home with
them, a split-plot ANOVA was conducted with group (2: Inter-
vention, Control) as a between-participants factor and time (2:
pre-intervention, post-intervention) as a within-participants fac-
tor on the total amount of time reported. Results revealed only
a significant main effect of time, F(1, 185) = 22.37, p < .001, par-
tial Á2 = .12. Thus, the daily amount of time children and mothers
were awake and home together was comparable across groups,
but declined over time from the pre- to post-intervention interval
 B.A. Morrongiello et al. / Accident Analysis and Prevention 50 (2013) 587–595
Table 2
Mean (SD) scores for different indices of supervision for Intervention and Control
groups at pre- and post-intervention periods.
Measure Group Pre-intervention Post-intervention
% Time Intervention 8.45 (6.05) 2.90 (5.33)
Unsuperviseda , b Control 6.96 (6.46) 6.28 (8.42)
% Time Intervention 83.02 (14.24) 86.83 (12.30)
in-viewb Control 83.24 (13.00) 81.35 (13.96)
Level of supervision
In-viewb , c Intervention 3.76 (0.19) 3.78 (0.18)
Control 3.74 (0.19) 3.75 (0.24)
Out-of-viewb , d Intervention 6.13 (1.79) 6.89 (1.54)
Control 6.40 (1.80) 6.03 (2.07)
a
Defined as ‘parent has no knowledge of where child is and what s/he is doing
for at least 5 consecutive minutes’; measured as percentage of total time.
b
Designates a significant group × time interaction was obtained (p < .05).
c
Max score = 4 (i.e., constantly watching).
d
Max score = 8 (i.e., constantly listening).
(overall M = 15.44 and 13.21 h/day, SD = 7.11 and 7.45 h, respec-
tively), which was approximately three months.
To determine if the intervention was effective in promoting
supervision generally, the percentage of time the child was unsu-
pervised (i.e., parent reports not knowing where the child is and
what s/he is doing for at least 5 min) was considered; these data
appear in Table 2. A split-plot ANOVA was conducted with group (2:
Intervention, Control) as a between-participants factor and time (2:
pre-intervention, post-intervention) as a within-participants fac-
tor. Results revealed a significant group x time interaction, F(1,
83) = 4.78, p < .05, partial Á2 = .06; see data in Table 2. Follow-up
tests confirmed that there were no group differences in the per-
centage of time unsupervised at pre-intervention [F(1, 83) = 1.20,
p > .05], but for the post-intervention interval, children of mothers
in the Intervention condition were unsupervised significantly less
often than children in the Control condition, F(1, 83) = 4.81, p < .05.
To determine if the main intervention message of ‘keep your
child in view’ had an impact on the percentage of time the child
was kept in view, a split-plot ANOVA was conducted, with group
(2: Intervention, Control) as a between-participants factor and time
(2: pre-intervention, post-intervention) as a within-participants
factor. Results revealed a significant time × condition interaction,
F(1, 182) = 7.34, p < .01, partial Á2 = .14. As seen in Table 2, and con-
firmed with follow-up tests, in-view time was at comparable levels
across both groups at the pre-intervention period, F(1, 181) = .45,
p > .05, but reached higher levels in the Intervention than Control
group at the post-intervention period, F(1, 181) = 4.44, p < .05. Inter-
vention parents also showed a significant increase from pre- to
post-intervention in the percentage of time they kept the child in
view [t(85) = 2.51, p < .01, Cohen’s d = .29], but there was no such
increase in the Control group, p > .05.
To determine if groups differed in the level of supervi-
sion provided when children were in-view and out-of-view,
split-plot ANOVAs with group (2: Intervention, Control) as
a between-participants factor and time (2: pre-intervention,
post-intervention) as a within-participants factor were applied
separately to the average level of supervision reported by par-
ents when the child was in-view and out-of-view (see Table 2).
For the in-view data, scores approached a ceiling level in both
the Intervention and Control groups and there were no group dif-
ferences (p > .05). For out-of-view supervision, the interaction of
group × time was marginally significant, F (1, 166) = 3.10, p < .06,
partial Á2 = .04. There were no group differences at pre-intervention
in the level of supervision provided when the child was out-of-
view, but at post-intervention, parents in the Intervention group
showed higher levels of supervision than in the Control group,
t(166) = 2.99, p < .01. Moreover, there was no significant increase
593
in the level of out-of-view supervision for the Control group
(p > .05), but in the Intervention group there was a significant
increase from pre- to post-intervention, t(86) = 2.10, p < .05, Cohen’s
d = .45.
3.3. Did the intervention impact unobtrusively observed
supervision?
A split-plot ANOVA with group (2: Intervention, Control)
as a between-participants factor and time (3: pre-intervention,
post-intervention: immediate, post-intervention: 3 months) as a
within-participants factor was applied to the attention-to-child
scores for the randomly selected smaller sample. Results revealed
a significant group x time interaction, F(2, 135) = 3.62, p < .05,
partial Á2 = .05. Follow-up tests confirmed that, relative to pre-
intervention levels of attention, parents in the Intervention group
showed a significant increase in attention to the child both immedi-
ately after the intervention [t(67) = 5.22, p < .01] and 3 months later,
t(67) = 3.84, p < .01 (M = 1.27, 1.50, 1.56, SD = .56, .56, .60, respec-
tively). In contrast, parents in the Control group did not show any
significant changes in attention to the child over these same time
intervals (M = 1.24, 1.30, 1.30, SD = .52, .44, .63, respectively), p > .05.
4. Discussion
Although it has been established that level of supervision influ-
ences risk of childhood injury (Morrongiello et al., 2004a,b, 2009a),
to date there are no proven interventions to promote active super-
vision of young children by parents. Brown et al. (2005) found
that exposing parents to a video of their child interacting with
contrived hazards increased their judgments about what level of
supervision was adequate and resulted in a reduction in home
hazards, however, no actual measures of supervision practices
were taken. Addressing this gap, Morrongiello et al. (in press)
recently developed and evaluated the impact of the Supervising
for Home Safety intervention program on parents’ appraisals of
young children’s risk of injury and need for supervision. The pro-
gram was shown to positively impact parent injury risk appraisals
relative to a Control group, and these changes persisted through
one year post-intervention. Although intentions to implement
a practice can predict actually doing so (Andrews et al., 2008;
Webb et al., 1996), obtaining direct evidence of behavior change
provides the best test of this and was addressed in the current
study.
Changes in several aspects of parent supervision practices
occurred in response to the Supervising for Home Safety program.
Following the intervention, parents showed a decrease in the time
their child was completely unsupervised, an increase in the time
they kept their child in view, and an increase in the level of super-
vision provided when the child was out of view. Moreover, when
parent supervision was unobtrusively observed, it was found that
mothers showed a significant increase in attention to their child,
and these effects persisted up to three months after the interven-
tion concluded. Hence, the results of this study affirm the efficacy of
the Supervising for Home Safety program for evoking improvements
in caregiver supervision practices.
Extending this research to explore more cost-effective deliv-
ery approaches, such as delivering the program to small groups
of parents, would be an important next step. Indeed this is cur-
rently underway in our research laboratory. Indeed, given that
safety interventions targeting parents have been shown to pro-
duce the best effects when delivered within a parenting program
(Kendrick et al., 2008), this might be a way not only to promote
broader dissemination of the Supervising for Home Safety program,
594 B.A. Morrongiello et al. / Accident Analysis and Prevention 50 (2013) 587–595
but to further enhance impact of the program on parent supervisory
practices. We are currently engaged in this research.
4.1. Limitations and directions for future research
Despite the important results of this study, several limitations
should be noted and addressed in future research. First, the sample
is mostly Caucasian, well educated, and affluent. These demo-
graphic characteristics may have contributed to the successful
implementation of the program, and these findings, therefore, may
not generalize to those with other demographic characteristics.
Future research should evaluate the impact of the intervention
on more diverse populations, including lower income groups. Sec-
ond, only mothers were included in the sample and, as such, these
findings may not reflect how fathers or other caregivers would
react to the intervention. Although many similarities have been
noted between mothers and fathers in studies on child safety
and supervision (Morrongiello and Dawber, 1999; Morrongiello
et al., 2009b), one cannot assume that the current intervention
would impact fathers’ supervision practices in the same way as
it did mothers’ practices. Conducting research to directly eval-
uate this important question is a necessary next step. Finally,
examining supervision practices over a longer period of time is
essential for evaluating the sustainability of increased supervision
in reaction to the intervention. In order to reduce children’s risk
of injury, it would be important not only that the intervention
improve a parent’s supervision practices but that these changes be
maintained beyond the three month interval that was evaluated
herein.
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