Association between obtaining injury prevention information and maternal and child health services during COVID-19

Unintentional child injuries, often home-based and largely preventable, are a major cause of death and disability worldwide [1, 2]. Educating caregivers, particularly when their children are infants and predominantly stay home, is crucial. Effective interventions include home visits, hospital-based programs, and smartphone apps that subsequently improve knowledge, promote safety practices, and decrease injury-related medical visits [3, 4].

In Japan, public health nurses (PHNs) are tasked with providing injury prevention information through existing maternal and child health services such as infant health checkups [5], aligned with national and local policies [6]. These services are widely utilized, with approximately 95% of infants receiving postpartum home visits and developmental checkups [7]; they serve as key channels for disseminating injury prevention education. For example, at 4-month health checkups, the implementation rate of injury prevention education was 90% (including panel displays or leaflet distribution) [8]. Additionally, over 75% of municipalities offer antenatal classes [9]. Following the issuance of Maternal and Child Health Handbook, many municipalities have begun conducting interviews with pregnant women on such issues as existing medical conditions, whether they have any concerns, whether they have someone to help them [10]. This reveals that these public maternal and child health services are critical for information dissemination from pregnancy onwards.

However, the coronavirus 2019 (COVID-19) pandemic severely disrupted these services. Social distancing led to the suspension of group classes and activities in early 2020 and significantly lowered participation rates [11]. The declaration of the first emergency on April 7, 2020 [12] resulted in postponed group health examinations, affecting 43.3% of local governments for 4-month checkups and over 70% for 18-month and 3-year-old child checkups [13]. Despite recommendations to provide online guidance and providing funding for digital transitions, only half of the surveyed municipalities adapted the online method [14]. The pandemic also impacted traditional birthing practices, such as giving birth at the mothers’ parents’ home and birthing with a partner [15]. It diverted PHNs to COVID-19 duties and there was concern that the maternal and child health services would be compromised [16, 17].

Internationally, reports indicated an increase in emergency visits due to inadequate supervision [18] and changes in injury types among children [19, 20]. In Japan, the public authorities reported an increase in product-related accidents involving infants and young children [21], despite the Consumer Affairs Agency cautioning caregivers about the possible surge in indoor accidents [22]. Therefore, it is crucial to ensure timely education for all families, even during emergencies.

Against this background, we hypothesize that the pandemic-induced reduction in caregiver educational opportunities led to an information gap in injury prevention. Our study aims to identify mothers with difficulties accessing information, their use of maternal and child health services, and their preferences for information regarding type, timing, and delivery methods during the pandemic.

Of the 12,192 registered monitors to whom Rakuten Insight distributed the screening surveys, 4,250 mothers raising their first child aged 0-2 during the COVID-19 pandemic agreed to participate. The internet research firm conducted screening distributions until the required number was reached. Please see Fig. 1 for more information. Of the 4,250 mothers who agreed to participate, 921 monitors responded (21.7% response rate). We received data for 750 individuals grouped by the age of their child. A total of 75 respondents were excluded, including “no spouse” and “multiple births,” who would have already received outreach services and follow-up from the municipality as they were high-risk. Additionally, those who had incorrectly entered a second child (less than seven months between births with the first child) were also excluded.

Finally, the data of 675 respondents were analyzed, with descriptive statistics on the child’s injury status and the mother’s injury prevention information preferences calculated based on the age of the child (Table 1).

The average age of the mothers was 32.3 years. Mothers of children the age of 0 were significantly younger than mothers of other ages. A total of 167 children (24.7%) experienced a medically attended injury. The most common causes of injury, in descending order, were falls, cuts or strikes, and tripping (Table 2).

Regarding when they first wanted to know about injury prevention, more than half (52.7%) the respondents said it was when they were pregnant. Excluding 39 respondents who did not want to know about injury prevention, we asked the remaining 636 respondents what they wanted to know and how they wanted the information to be provided. As many as 87.4% of the respondents wanted to know about “Frequent injuries by age and their prevention,” regardless of the child’s age. However, only 36.6% of the total respondents wanted to know more about individualized environmental care. The most common method of receiving information was through antenatal classes (50.7%), followed by magazines (43.6%), and stories from senior mothers (34.7%).

When asked only about non-face-to-face digital tools, 73.2% of the respondents indicated a preference for using LINE, with no differences by age. The next most popular choice was YouTube (41.2%), which mothers of 0-year-olds significantly preferred, compared to mothers of 2-year-olds.

Table 3 shows the responses to “Did you get the injury prevention information you needed when you needed it?”. The relationship between mother/child demographics and the use of maternal and child health services and information sources is presented. A total of 217 (34.1%) mothers reported that they could not obtain injury prevention information when needed.

Over 50% of the mothers could not attend antenatal classes at a public health center or hospital owing to COVID-19. Of those who wished to have their partner present at birth, 40.5% were unable to do so because of COVID-19; 16.7% did not receive parenting information from family or friends when pregnant with their first child, and 7.2% did not use parenting apps.

Univariate logistic regression analysis revealed that being unemployed, age of the infant/child, infant/child having diseases requiring hospital visits, having a medically attended injury (any injury), medically attended injury (accidental ingestion), not having a pregnancy notification interview, delays or unavailability of vaccination, not receiving information from friends or family, and higher General Health Questionnaire and lower resilience scores were significantly associated with the response “did not receive information on injury prevention.” A multivariate logistic regression analysis with all significant variables was conducted, and the results remained significant for “not employed,” “[had a] child 0–1 year-old,” and “[had a] child with a disease” (Table 4).

During the COVID-19 pandemic, 34.1% of mothers reported not being able to obtain necessary information on injury prevention when needed. In the multivariate analysis, mothers who reported that they could not obtain information were “not employed,” “[had a] child 0–1 year-old,” and “[had a] child with a disease.” All these mothers had physical, social, and economic disadvantages in accessing information sources.

In Japan, working mothers have priority access to childcare centers. Therefore, unemployed mothers initially do not use childcare centers and are responsible for childcare and chores at home. Consequently, they do not have time for social connections, are likely isolated, and considered disadvantaged.

Furthermore, during the COVID-19 pandemic, more than 70% of community childcare support programs, such as “childcare squares” (kosodate hiroba), were closed [30], leaving these mothers with even fewer places to go. Mothers of children with pre-existing medical conditions may have been cautious about infection prevention and refrained from going out. Furthermore, for all parents of 0-year-olds and many of the parents of 1-year-olds in this study, the pandemic coincided with the children being in gestation. It may be that those whose maternal and child health services were stopped or reduced during their pregnancy responded not having access to information. For example, as a service during pregnancy, the implementation rate of pregnancy notification interviews decreased in some cities during the COVID-19 pandemic [11]. A pregnancy notification interview is the first time PHNs and MWs meet pregnant women, assess their support needs, and provide various information. It is a significant first opportunity for childcare [31]. Antenatal classes in the community or hospital also allow mothers to exchange information with other mothers, including learning parenting skills. Interruption of these services during pregnancy can result in anxiety and discouragement [32], which not only delays the actual provision of information but also affects mothers’ willingness and behavior to obtain information.

In addition, mothers of 0-year-olds have few informal resources in the form of parenting peers, compared to mothers who have other children and have already built a network. These mothers may have had no safety net of information when the public services were discontinued. The mothers identified in this study who lacked access to information could have been vulnerable, irrespective of the pandemic. Indeed, the pandemic may have only exacerbated an information gap. Therefore, information essential for the general public, such as injury prevention, should be disseminated with a communication strategy that does not depend on social circumstances or individual capabilities, ensuring equitable access for all.

In this study, the children of 24.7% of the participants had medically attended injuries by age 2 during the COVID-19 pandemic. While some reported a decrease in overall pediatric emergency department visits and traffic accidents in the early COVID-19 period [33], others highlighted an increase, owing to inadequate supervision [18], an increase in children playing with sharp objects at home, and collisions at home [19, 20]. A pre-COVID-19 survey revealed that 16.4% had been seen by a medical professional for an injury by age 1 [34]. Although the hospital visit rate may have been estimated as low owing to the short observation period of 1 year and the economically predominant population, the results suggest that the visiting rate in the present results is high, even considering this. Japan’s universal health insurance and publicly funded medical expenses for infants ensure easy access to healthcare [35]. Mothers lacking injury prevention information were more inclined to seek medical help, reflecting their need for reassurance. Frequent hospital visits might imply mothers’ uncertainty in handling minor injuries, possibly driven by a lack of confidence.

In the analysis by type of injury, mothers of children with injuries from accidental ingestion were less likely to have obtained information. Preventing accidental ingestion demands comprehensive knowledge about easily ingestible objects within children’s reach. Timely provision of this information can promote a safer environment.

Finally, 39 mothers indicated that they did not desire information on injury prevention. This number significantly increased with age; mothers of 2-year-olds were also significantly less likely to express interest in “individualized environmental modification.” Given their expanded range of activities, 2-year-olds are the second most likely age group to be transported to the emergency room, after 1-year-olds [26]. Mothers are accustomed to childcare after 2 years of experience and may need more interest and awareness in prevention. More proactive interventions, such as push interventions, should be considered during this period.

This study has some limitations. First, this survey was conducted based on voluntary participation from respondents with a high enough affinity for non-face-to-face tools as they were registered with an internet research firm. While the respondents’ demographics, including age, educational level, and household income, approximated the national average, and the percentage of respondents’ residential areas did not deviate from the national population ratio, the characteristic of being a registered monitor may have influenced the response results. Second, the study focuses on mothers raising children aged 0–2; therefore, the findings may not be generalizable to mothers with older children. The preferences and challenges related to injury prevention information may vary across different stages of child development. Factors such as urban-rural differences and variations in healthcare infrastructure could also impact the findings. Third, the possibility of self-report bias cannot be ignored. Fourth, it is unclear to what extent and what sources of information mothers were unable to access when they needed it and why they felt it did not work. Additionally, our findings suggest disparities in access to information; however, the underlying reasons behind these disparities have not been fully investigated. Finally, this study focuses on injury prevention information. Its findings may not be applicable to other aspects of maternal and child health. A broader examination of health information needs and access could provide a more comprehensive understanding. Despite these limitations, our study offers suggestions on public maternal and child health services and the aspects that prevent some families from obtaining the necessary information during a pandemic.

More than 30% of the mothers reported being unable to obtain injury prevention information when needed during the pandemic. Those who were unemployed and had a child under the age of 1 year or a sick child who needed to go to the hospital experienced difficulties in obtaining information. Therefore, considering means of providing information not dependent on social conditions or personal attributes, and having multiple approaches so as not to create a situation where mothers are cut off from information sources, is necessary. Digital interventions that can provide timely push-type information distribution are one way to reach vulnerable populations that tend to be passive in their response to information.