Risk factors of in-home unintentional injuries among 0-6-year-old children in China: a cross-sectional survey based on Bronfenbrenner’s ecological system theory

Risk factors of in-home unintentional injuries among 0-6-year-old children in China: a cross-sectional survey based on Bronfenbrenner’s ecological system theory | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk factors of in-home unintentional injuries among 0-6-year-old children in China: a cross-sectional survey based on Bronfenbrenner’s ecological system theory Yihan Ma, Juan Song, Ming Hu, Rusi Yang, Panzi Yang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1565282/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background In-home unintentional injuries (IUIs) seriously threatened children’s safety. Three factors, including risky behaviors, parental supervision, and home environmental risks, have been identified as major causes for IUIs. Studies considering the interrelations between the three were limited and no relative studies has been carried out among Chinese children. Objective To fully explore the influences of behavioral, supervisory and environmental risk factors on IUIs and their associations among Chinese children on the bases of our self-developed scales. Methods Through stratified cluster sampling, a cross-sectional survey was conducted with 798 parents of children aged 0 ~ 6 years in Changsha, China. Social demographics and IUIs history in the past year were collected by self-administered questionnaires. Three IUI-related scales, which had been developed and validated by our team, aimed to measure risks from children behavior, parental supervision and in-home environment. Structural equation models were constructed to analyze the relationship of these factors and their influences on IUIs using SPSS 26.0 and AMOS 22.0. Results 798 parents were surveyed in total, and 33.58% of them reported with IUIs history of their children. The comparative fit index (CFI), goodness-of-fit index (GFI) and the root-mean-square error of approximation (RMSEA) for the model of the whole children were 0.879, 0.878 and 0.069 respectively, indicating an acceptable level of model fit. Direct influences were discovered between risky behaviors and children’s IUIs. Home environmental risks indirectly exerted impacts on IUIs by the mediating effect of risky behaviors, while the significant effect of parental supervision only existed in children aged 4–6 and girls. Conclusions Risky behaviors played a mediating role in IUIs among children. Supervision and environmental risks affected IUIs indirectly by the exposure to risky behaviors. Parental supervision may not be able to offset the risks posed by the environmental and behavioral factors, so effective IUIs prevention strategies should focus on behavioral and environmental interventions, with appropriate supervision strategies based on the age and sex characteristics of the child. In-home unintentional injury Risky behavior Parental supervision In-home environment Children Figures Figure 1 Figure 2 Figure 3 Background Childhood unintentional injuries (UIs) have been a significant public health problem worldwide. According to the Global Burden of Diseases report [ 1 ], more than 200 thousand children’s death occurred due to UIs each year across the global, and at least half of these injuries occurred at home. In-home unintentional injuries (IUIs) are major contributors to the global disease burden. It was reported that IUIs were responsible for 12.49% mortality and nearly 1.9 million Disability-Adjusted Life Years (DALYs) of Chinese children and adolescents (aged 0 to14 years) in 2019 [ 2 ]. Moreover, younger children (0 ~ 6 years), who lack adequate self-protective abilities and comprehensive understanding of surrounding conditions, thus their IUIs are more severe comparing with other age groups [ 3 ]. Hazards of child IUIs come from many sources, from the individual to the environmental level, which makes it too complex to adequately understand IUIs at a single level. To provide important reference for injury prevention, exploration of the associations between risk factors of IUIs is essential. Bronfenbrenner’s ecological theory, which emphasized that interactions between organism and environment promote human health [ 4 ], has been widely applied in studies considering child development, as showing in Walker’s and Zahra’s research [ 5 , 6 ]. According to the theory, we assumed that children’s IUIs as the result of a combination of multiple factors involving with children’s risky behaviors, parental supervision and home environment risks, as shown in Fig. 1 . Regarding behavioral factors, studies reported numerous injuries while children engaging in risky behaviors [ 7 – 9 ]. Also, due to the aggregation effect, the impact of risky behavior on IUIs may be doubled and redoubled [ 9 ]. Previous studies shed light on the role of gender, temperament, personality and cognitive development to injury-related behaviors. They emphasized that boys, aggression, impulsivity, sensation seeking and mental disorder can promote children to adopt more frequent or serious behaviors [ 8 , 10 , 11 ], which suggested that risky behavior played a special role in childhood UIs. Parental supervision is another decisive factor to child IUIs. Past studies [ 12 – 14 ] indicated that parental supervision can counteract the potential injury hazard. In the presence of high-quality adult supervision, injuries may occur at a lower rate, although the effect is split between parents [ 15 , 16 ]. Moreover, reports from Morrongiello [ 7 , 9 ] revealed that parents would differ greatly in their actual supervisory performance when driven by inconsistent risk perception and safety knowledge. Thus, the protective effect of parental supervision was not cast in stone and may be influenced by other factors. In terms of home environment, children exposed to domestic factors are more vulnerable to IUIs, such as open-air burning coal, absence of balcony guardrail, lack of safe storage area and etc. [ 17 , 18 ]. Historically, child IUIs programs have largely reduced risk to children by improving the home environment. A systematic evaluation [ 19 ] demonstrated the effectiveness of environmental change interventions in reducing the risk of IUIs. In addition, the combined effects of different factors on the IUIs occurrence had been observed. Zhou [ 20 ]and Zhang [ 21 ] have reported that higher levels of parental knowledge, attitudes and kills on supervising predicted lower injury risks when children were engaging in unusual behavior. Other studies [ 22 , 23 ] on child injuries in farms have found that disquieting behavior for children aged 0 ~ 6 was more likely to lead to injury in high-risk environments. However, the existing studies still have some limitations: on the one hand, foreign studies could not be well derived to China to represent the IUIs situation of Chinese children because of the cultural diversity and regional disparity; on the other hand, associations that between the IUI-related behaviors, supervision and environmental risks have not been fully explored yet. To fill the knowledge gap, we used structural equation model (SEM) to statistically analyze the variables that we interested in and to further explore the associations between the three factors under the ecological system above. Measurement tools for the present study stems largely from our previous research program, in which scales for injury-related risky behaviors, parental supervision and home environment risks of Chinese children have been developed and validated. Findings of this study along with other information might may help to provide a scientific basis for targeted IUIs prevention and control among children aged 0 ~ 6. Methods Participants This study was a cross-sectional study conducted from October to November in 2017 and the subjects were children aged 0 ~ 6 and their families in the urban area of Changsha. According to the gross national product of each district in Hunan province in 2015, six administrative districts in Changsha are divided into two layers (layer 1: Furong district, Yuhua district and Tianxin district; layer 2: Kaifu district, Yuelu district and Wangcheng district). In each district, community health service centers (children under 3) and kindergartens (3-6-year-old children) served as research site to recruit participants, consistent with our previous studies under this program [ 24 – 26 ]. Data collection The survey contained demographic information about children and their families (children’ gender was defined based on self-report), the history of IUIs in the past year and three IUI-related scales, in which measured the risky behavior, parental supervision, and home environmental risk targeting different kinds of injuries using 5-point Likert scales. All the scales were developed based on the prevalence of injuries among urban children in China and had been verified with good reliability and validity with our teamwork [ 24 – 26 ]. The standard for IUIs diagnosing: (a) children need to visit a medical unit and diagnose a certain type of injury; or (b) children need emergency treatment or care by family members; or (c) children has restricted activity or suspension of more than half a day. For those reported with IUIs, more specific injury registration cards were required to complete to fully explore the frequency and severity of injuries. Questionnaires completed over 80% were considered valid and complemented with the median or mean. This study was approved by the ethics committee of the School of Xiangya Public Health at Central South University, and all participants signed informed consent. Statistical Analysis We described respondents’ demographics with SPSS 26.0 and examined the direct and indirect relationship between latent constructs by the SEM of AMOS 22.0. Through item parceling procedure, dimensional variables were regarded as observation variables to estimate the corresponding construct with the average scores of assembled items, as it can maintain parsimony and stable estimates of the model [ 27 ]. Confirmatory factor analysis (CFA) was conducted initially to ascertain reliability and validity of the indicators used to operationalize the constructs. In the SEM analysis, we first proposed a hypothetical structure model and then modified through deleting non-significant paths and consulting modification indices. Maximum likelihood estimation was used with robust standard errors to provide better estimates and bootstrap-based methods were used to analyze the magnitude and significance of the direct, indirect and total effects of the constructs [ 28 ]. Considering that the contributions of behaviors, supervision and environmental risks to IUIs varies by gender and age, the samples were divided into subgroups for further discussion, after we established the model of the general sample with an adequate fit. Results General Information A total of 845 participants were involved in and the valid questionnaires were 798 with the response rate of 94.44%. The mean age for children participated in was 3.357 (SD 1.677). 268 (33.58%) reported with IUI history in the past year and 52 participants (6.52%) had at least 2 IUIs. The mean of IUIs was 0.400 ( SD = 0.681). The distribution of gender, age, whether had a separate room, was descripted, as shown in Table 1 . Table 1 Distribution of 0-6-year-old children and their families (n, %) Characteristics With IUIs history Without IUIs history \({\chi ^2}\) P Gender Male 150(35.63) 271(64.37) 4.785 0.029 Female 107(28.38) 270(71.62) Age(years) 13.646 < 0.001 0 ~ 3 88(24.79) 267(75.21) 4 ~ 6 164(37.02) 279(62.98) Having separate room 14.605 < 0.001 Yes 158(37.53) 263(62.47) No 94(24.93) 283(75.07) Confirmatory Factor Analysis Through item parceling procedure, IUIs, risky behaviors, parental supervision and home environmental risks were measured by the dimensions of each scale; and these constructs thus, adopted 4, 10, 7 and 6 indicators as observational variables respectively. All factor loadings were statistically significant ( P < 0.05), ranging from 0.384 to 0.959. All latent variables the composite reliabilities were higher than 0.8 and the average variance extracted (AVE) of each construct was greater than its squared correlations with other constructs. Next, the square roots of all AVEs were above 0.6. The GFI, CFI and RMSEA of CFA was 0.870, 0.862 and 0.073, respectively. Specific results are shown in more detail [see Additional file 1 and 2]. Structural Equation Model Referring to previous experience, we first proposed the IUIs model for all children aged 0 ~ 6. The goodness-of-fit of the model was 4.832, 0.879, 0.878, 0.069 for \({\chi ^2}\) /df, CFI, GFI and RMSEA, respectively. The standardized path coefficients between parental supervision and IUIs, home environmental risks and IUIs, and risky behaviors and IUIs were − 0.095, 0.173 and 0.328, respectively, which suggested the parental supervision had negative effects on IUIs, and home environmental risk as well as risky behaviors had positive effects on IUIs. Relationships involving potential mediation effects were discovered, as shown in Table 2 . A statistically significant mediated effect existed from parental supervision to IUIs through risky behaviors (-0.043). Similarly, the home environmental risks via children’s risky behavior had an indirect effect on IUIs (0.146). The total effect of risky behaviors on IUIs was 0.328, higher than that of home environmental risks (0.319) and parental supervision (-0.137). All path coefficients above were statistically significant ( P < 0.05), as shown in Fig. 2 . Similar to SEM model for the whole children, models in each subgroup were fitted in an acceptable way. Indirect pathways of supervision as well as environment were found, which were shown in Fig. 3 . Children aged 4 ~ 6 (0.426) and boys (0.384) displayed greater behavioral effects than children aged 0 ~ 3 (0.231) and girls (0.232). For all subgroups, the effects of home environmental risks were statistically significant, among which environmental risks had greater indirect impacts on IUIs of children aged 4 ~ 6 (0.201) than that of children aged 0 ~ 3 (0.108). Further, the greater direct effects of environmental risks on IUIs were examined in girls (0.241) than in boys (0.115), but the indirect effect did the opposite. In terms of parental supervision, there were greater negative impacts found in children aged 4 ~ 6 (-0.158) and girls (-0.249) than children aged 0 ~ 3 (-0.116) and boys (-0.038), respectively. Except for boys, the effects of parental supervision proved statistical significance, as follows in Table 2 . Table 2 The standardized indirect, direct, and total effects of risky behavior, parental supervision, and home environmental risks on IUIs for the whole children and each subgroup. Group Home environmental Risks Parental Supervision Risky Behavior General children Indirect effects 0.146* -0.043* - Direct effects 0.173* -0.095* - Total effects 0.319* -0.137* 0.328* Children aged 0 ~ 3 Indirect effects 0.108* -0.022 - Direct effects 0.161* -0.093 - Total effects 0.269* -0.116* 0.231* Children aged 4 ~ 6 Indirect effects 0.201* -0.038 - Direct effects 0.215* -0.120* - Total effects 0.416* -0.158* 0.426* Boys Indirect effects 0.184* -0.001 - Direct effects 0.115* -0.036 - Total effects 0.299* -0.038 0.384* Girls Indirect effects 0.095* -0.063* - Direct effects 0.241* -0.186* - Total effects 0.336* -0.249* 0.232* Note: * indicates that the path estimate is significant ( P < 0.05). Discussions In our study, the incidence of IUIs was 33.42%, higher than the results in other studies [ 17 , 29 ], which may be the result that our subjects were children aged 0 ~ 6, who occupied a higher injury risk than other age groups. In addition, children aged 0 ~ 3 in this study were investigated by face-to-face interview, which made the data of younger children more reliable and had a certain influence on the incidence rate. Meanwhile, this finding confirmed the necessity of special attention and targeting preventions towards IUIs among Chinese urban children, which need to be carried out with adequate evidence bases. Thus, based on Bronfenbrenner’s ecosystem theory and our previous efforts, we systematically explored the causes of children’s IUIs in Chinese urban areas and revealed significant relationships among risky behaviors, parental supervision, home environmental risks and IUIs through SEM. The CFA exhibited that all latent variables had good reliability and discriminant validity through the results of composite reliabilities and the AVEs of each construct. GFI, CFI and RMSEA were all acceptable, so we considered that the measurement tools used in this study met the conditions for the structural model. Results of SEM of the general sample revealed that the total value of effect from risky behavior was much higher when compared with parental supervision and home environmental risks, though behavior was influenced by the latter two to some extent. Home environmental risks played direct and indirect roles in children’s IUIs, whereas parental supervision could only influence special groups, such as children aged 4 ~ 6 years and girls. Our investigation tool for risky behaviors involved animal bites, burns, falls, suffocation and many other injury types, all of which corresponded to the relevant child IUIs, for example, the behavior of a child poking a power socket was in corresponding to the unintentional burns. SEM of subgroups showed the contribution of risky behaviors with aging, because the better motor control and coordination of older children, the higher possibility for hazard situations [ 30 ], which was similar to the fact that children who climb frequently were vulnerable to falls. Likewise, the behavioral effect was greater for boys than for girls, which may be due to the gender differences in early developmental trajectories for emotional expression. Boys are more inclined to express anger-related emotions and have greater tendency to engage in rough and tumble play than girls [ 31 ], which leads to more frequent conduct problems and more serious IUIs. Similarly, multimethod strategies study [ 32 ] revealed that most of the boy’s injuries followed misbehaviour (i.e., mothers reported that 60% of boys suffered significantly more injuries when they engaged in inappropriate behavior). Also, boys express more optimistic bias and tend to attribute injuries to bad luck, while girls express more considerations about the consequences of their actions in the same situation [ 33 ]. Thus, our results served as reminders for IUIs prevention programs, in which appropriate efforts according to age and gender characteristics may be needed. Despite risky behaviors occupied the strongest effect on children’s IUIs, reducing risks caused by risky behaviors required more reasonable parental supervision and better home environment. The direct effects of environmental risks and supervision were validated across the entire sample, similar to previous studies [ 29 , 34 ]. More importantly, we proved the indirect role of the both on IUIs. The underlying mechanism may be that parents who provided direct attention, with closest proximity on a continual basis were able to moderate their children’s injury-prone tendencies and ensure child safety in the home setting [ 35 ], and home environments may influence the emergence of externalized behavior problems in children and thus create favorable conditions for being exposed to IUIs, in line with other studies [ 36 , 37 ]. The indirect effects of the home environmental risks implied that the hazards of IUIs were on the rise when children with high behavioral risks are in unsafe households, particularly 4-6-year-old children and boys. The reason may be that high-risk settings would stimulate children to show more externalized behavioral problems and fostered interactions with hazards. Similarly, Schwebel [ 38 ] revealed that in a complicated housing environment, children with higher behavioral risk might judge environmental hazards with a rushed, impulsive manner, which might lead to misestimation of the risk involved in a particular activity, and in turn lead to injury. Therefore, the co-existence of direct and indirect paths highlighted the dual value of addressing risk factors in house. However, contrary to previous results, the direct impact of home risk varied more in girls than boys. A possibility involved greater perceptual sensitivity in girls. If girls are more attuned to the fine details of their environment, they will experience more stressors and curiosity, which can trigger their susceptibility to more injury events around them [ 39 ]. Also, this finding suggested that injury risk for girls arose more from poor conditions that already existed at home than motivation of child’s behaviors from home environment, while the opposite was true for boys. Hence, reducing IUIs risk in girls necessitates more complete disengagement from dangerous situations, and for boys, timely home inspection and regulating children’s behavioral tendencies may be more important. Results suggested that parental supervision was not significant to deter younger children’s injury risk, either directly or indirectly. We speculated that this may be associated with differences in child care. Morrongiello [ 40 ] reported that parents of younger children only focused on increasing the frequency and proximity of observations and routinely overestimate desired effect of their supervision strategies. By contrast, parents of older children exercised safety education and fear-inducing strategy, in which parents would stress the serious consequences if children did not follow their guidance. In addition, the early IUI experiences of 4-6-year-old children reminded their parents of the relative necessity for parental supervision, which made the roles of supervision reported by parents more prominent. We did not find any significant effects on parental supervision of boys, but did of girls, which was beyond our expectations. One possible explanation was that specific societal expectations for males and females. Boys are always expected to protect their families and to overcome dangers that interfere with their ability to provide for their families, whereas girls are allowed to show more emotions to take on the traditional role of caregivers [ 31 ]. Thus, more encouragements to participate in risky games are given to boys, while more caution about safety to girls, which relatively weakened the roles of supervision. Whether in the general population or each subgroup, risky behavior was involved as an intermediary, and meanwhile, the effects of risky behavior and home environment were greater than that of parental supervision, which made we acknowledge the relative materiality of all three in preventing IUIs. Although parental supervision has been advocated as a protective method in the past, we found that it separately cannot completely offset the crisis caused by environmental risks and behaviors with limited power. Consequently, the best strategy to moderate risk for IUIs is an effective combination of behavioral regulations and environmental interventions, and measures targeting parental supervision are considered as promising remedies. For younger children, this means keeping the consistency of space as much as possible to timely take behavioral modification and reasonable planning of indoor activity space. For older children with increased cognitive awareness, this signified necessity of regular health education and improvement of risk perception. Besides, specific efforts, such as caregivers’ safety education and enhanced safety equipment (e.g., child-resistant container, cabinet latches, stair gates), will be better able to contain crises from environment and supervision. In terms of gender, girls are highly sensitive to environmental risks, so it is critical to carry out a thorough screening of the risk of home from the perspective of children. At the same time, moderate behavioral constraints and verbal reminders may yield better results, because girls are more compliant with their parents [ 31 ]. For boys, efforts should be directed towards positive regulation of impulsive behavioral traits. Traditional didactic education should also be changed and more participatory activities can be adopted, such as training tasks in hazard perception, sound decision-making, and safety rules, which will be better targeted to ameliorate boys’ potential risks. To decrease child IUIs more efficiently, more efforts need to be done besides the above measures. Current data of Chinese children’s IUIs stemmed mainly from the China’s Disease Surveillance Points system and National Injury Surveillance System consisted of 127 sentinel hospitals [ 41 ]; but due to the relatively low proportion of deaths and hospital visits caused by injury events, IUIs disposed of by family members were often missed. It is a call to attach importance to the collection, analysis and utilization of basic IUIs information. Measures to expand the monitoring sites to primary units (e.g., schools, kindergartens, and communities), standardize the information collection process, and formulate multi-sector strategies involving the whole society will be good complement to Chinese’s non-medical treatment IUIs. Moreover, parents in Chinese urban areas generally lacked sufficient recognition of the IUIs’ controllability, and especially parents who belong to floating families were basically in the blind spot of child IUIs prevention [ 42 ]. Therefore, further strengthening investment in home safety publicity, focusing on children with weaker parental supervision and larger needs of injury prevention, such as migrant children who often be left at home alone, urging parents to enhance literacy of IUIs may be the key to future injury control program. Limitations There were still limitations in this study. Firstly, recall bias may be inevitable, as the study mostly was based on parents’ recollections. Secondly, the cross-sectional design limits the possibility of establishing causal relationships and can only explain the associations between factors. Thirdly, we did not investigate the influence of other potentially important factors, such as experience for past injuries and interventions from communities and kindergartens, were not available, and these factors might affect the outcomes as potential confounders. Fourthly, the disparities in IUIs between different cities and rural-urban areas cannot be ignored. Our inference, including what we described as mediation, relied on statistical indicators of model fit. Therefore, the model was an attempt for preliminary exploration. Further verification and enrichment on populations of different regions and prospective studies from large samples may be needed. Conclusion Based on Bronfenbrenner’s ecological system theory, the present study revealed relations between risky behaviors, parental supervision, home environmental risks and IUIs among 0-6-year-old children in Chinese urban areas. The direct effects of the all three was demonstrated on IUIs of all children aged 0 ~ 6. Through the mediator of risky behaviors, parental supervision and home environmental risks indirectly influenced hazards of IUIs, although which varied by ages and genders. The results could provide favorable reference for targeting interventions to cut down IUIs’ rates and improve the quality of life of 0-6-year-old children. For children aged 0 ~ 3, strengthening behavior guidance and safe spatial planning is essential. With the growth of age, children’s IUIs prevention may call for a perfect combination of enhanced safety education, increased awareness of parental supervision and effective home safety equipment. Further, parental supervision of IUI is weak in boys, and efforts to improve their impulsive behavior characteristics are more important, while for girls, it is more urgent to eliminate environmental risks across the board. Abbreviations UIs: Unintentional Injuries IUIs: In-home Unintentional Injuries CFI: Comparative Fit Index GFI: Goodness-of-Fit Index RMSEA: Root-Mean-Square Error of Approximation DALYs: Disability-Adjusted Life Years SEM: Structural Equation Model CFA: Confirmatory Factor Analysis AVE: Average Variance Extracted Declarations Ethics approval and consent to participate This project had been performed in accordance with the Declaration of Helsinki and was approved by the ethics committee of the School of Xiangya Public Health at Central South University in Hunan Province, China (Approval Number: CTXY-140002-4). A written informed consent was obtained from the custodians of each participant. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to privacy and confidentiality agreements but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research was funded by the National Natural Science Foundation of China (No. 81402770) and Graduates’ Free Exploration and Innovation Program of Central South University (No. 2020ZZTS812). Authors’ contribution MH contributed to the study conception and design. All analyses were conducted by YM. YM and JS contributed to the acquisition and interpretation of the study results. YM drafted the manuscript, with revisions made by JS, RY and PY. All authors have read and approved the final version of the manuscript. Acknowledgements We would like to express gratitude to all the children and their parents. References Institute for Health Metrics and Evaluation. 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Morrongiello BA, Ondejko L, Littlejohn A. Understanding toddlers’ in-home injuries: I. Context, correlates, and determinants. J Pediatr Psychol. 2004;29(6):415–31. Morrongiello BA, Rennie H. Why do boys engage in more risk taking than girls? The role of attributions, beliefs, and risk appraisals. J Pediatr Psychol. 1998;23(1):33–43. Drachler M, Leite J, Marshall T, Almaleh C, Feldens CA, Vitolo MR. Effects of the home environment on unintentional domestic injuries and related health care attendance in infants. Acta Pædiatr. 2007;96(8). Petrass L, Blitvich JD, Finch CF. Parent/Caregiver Supervision and Child Injury: A Systematic Review of Critical Dimensions for Understanding This Relationship. Fam Community Health. 2009;32(2). Khatlani K, Alonge O, Rahman A, Hoque DME, Bhuiyan A-A, Agrawal P, et al. Caregiver Supervision Practices and Risk of Childhood Unintentional Injury Mortality in Bangladesh. Int J Environ Res Public Health. 2017;14(5). Morrongiello BA, Bryant L, Cox A. Validation of a measure of injury-risk behaviors in the first 2 years of life: Infant/Toddler-Injury Behavior Questionnaire (IT-IBQ). Infant Behav Dev. 2021;63:101561. Schwebel DC, Plumert JM. Longitudinal and concurrent relations among temperament, ability estimation, and injury proneness. Child Dev. 1999;70(3):700–12. Else-Quest NM, Hyde JS, Goldsmith HH, Van Hulle CA. Gender differences in temperament: a meta-analysis. Psychol Bull. 2006;132(1):33. Morrongiello BA, Widdifield R, Munroe K, Zdzieborski D. Parents teaching young children home safety rules: Implications for childhood injury risk. J Appl Dev Psychol. 2014;35(3):254–61. Duan L, Deng X, Wang Y, Wu C, Jiang W, He S, et al. The National injury surveillance system in China: a six-year review. Injury. 2015;46(4):572–9. Xu T, Gong LM, Wang HS, Zhang R, Wang XY, Kaime-Atterhog W. Epidemiology of Unintentional Injuries Among Children Under Six Years Old in Floating and Residential Population in Four Communities in Beijing: A Comparative Study. Matern Child Health J. 2014;18(4):911–9. Additional Declarations No competing interests reported. Supplementary Files Additional1.xls Additional 1. Standardized factor loading for latent variables in the measurement model. Additional2.xls Additional 2. AVE, correlations, and squared correlations of the latent variables. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 14 Jul, 2022 Reviews received at journal 09 Jul, 2022 Reviewers agreed at journal 27 Jun, 2022 Reviewers invited by journal 23 Jun, 2022 Editor assigned by journal 21 May, 2022 Editor invited by journal 21 Apr, 2022 Submission checks completed at journal 21 Apr, 2022 First submitted to journal 16 Apr, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1565282","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":100310465,"identity":"e772b687-1932-4c23-b592-893721362a1d","order_by":0,"name":"Yihan Ma","email":"","orcid":"","institution":"Central South University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yihan","middleName":"","lastName":"Ma","suffix":""},{"id":100310467,"identity":"b802cd32-43ad-452b-b5de-af92d97d0452","order_by":1,"name":"Juan Song","email":"","orcid":"","institution":"Central South University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Juan","middleName":"","lastName":"Song","suffix":""},{"id":100310468,"identity":"b687b00d-8dad-4b49-af70-5451355cf516","order_by":2,"name":"Ming Hu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYBACAyA+wMAgwcPP3gBkVkjIyROpxUZGsgdIMZyxMDZsIEILEKTZGNxIYGBgbKtIBJmAF5hLZCceLvh1mIfhRvLjz7zzJBIYG5gfPrqBR4vljNwNh2f2HeZh7HlmJs27TSKPnYHN2DgHn8NuALXw9hzmYWbPYWMGailmbOBhkyZKCxtDDvNn3jkSiQ0HiNHC8yONh4cjh0Gat4EYLWfeAm1psOGR4DlmJjnnmISxYTMhvxzP3fyZ54+Evf3x5scf3tTUycmzNz98jE8LGDC2IfOYCSkHgz9EqRoFo2AUjIKRCgBgxE3xvBFxfgAAAABJRU5ErkJggg==","orcid":"","institution":"Central South University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ming","middleName":"","lastName":"Hu","suffix":""},{"id":100310469,"identity":"386256f9-15ac-43aa-850b-f6a877222644","order_by":3,"name":"Rusi Yang","email":"","orcid":"","institution":"Central South University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rusi","middleName":"","lastName":"Yang","suffix":""},{"id":100310473,"identity":"64777f9c-9b35-43ce-9858-ea169f48f188","order_by":4,"name":"Panzi Yang","email":"","orcid":"","institution":"Central South University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Panzi","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2022-04-17 03:14:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1565282/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1565282/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":20671310,"identity":"1500f2e0-f3de-4d9a-8bf2-4ef06c825b49","added_by":"auto","created_at":"2022-04-22 19:30:18","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":65235,"visible":true,"origin":"","legend":"\u003cp\u003eModel of influencing factors of IUIs among children\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1565282/v1/a2d23f4ce0700e090c201cf0.jpg"},{"id":20671368,"identity":"2a6278ad-94f6-4e32-8fa3-775b33427bbc","added_by":"auto","created_at":"2022-04-22 19:35:18","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":122760,"visible":true,"origin":"","legend":"\u003cp\u003eSEM of Chinese children’s risky behavior, parental supervision, home environmental risks and IUIs. Notes: * indicates that the path estimate is significant (\u003cem\u003eP\u003c/em\u003e\u0026lt; 0.05).\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1565282/v1/014e1d80b355267bab68768d.jpg"},{"id":20671313,"identity":"281bc9fa-9b57-4051-a9c9-8959fec64670","added_by":"auto","created_at":"2022-04-22 19:30:18","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":452383,"visible":true,"origin":"","legend":"\u003cp\u003eSEM of risky behavior, parental supervision, home environmental risks and IUIs in children aged 0~3, children aged 4~6, boys and girls, respectively. Notes: * indicates that the path estimate is significant (\u003cem\u003eP\u003c/em\u003e\u0026lt; 0.05). a, b, c and d represents children aged 0~3, children aged 4~6, boys and girls, respectively.\u0026nbsp;\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1565282/v1/e2d45df8f0d105068c8ab27c.jpg"},{"id":20671369,"identity":"ed022387-c40e-4f61-b5ef-d5af3542a881","added_by":"auto","created_at":"2022-04-22 19:35:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":422564,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1565282/v1/acc16e1a-3d38-4021-9f63-79a1ef6788cb.pdf"},{"id":20671314,"identity":"181770d7-96e6-41d7-8392-0d44a6e28242","added_by":"auto","created_at":"2022-04-22 19:30:18","extension":"xls","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25088,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional 1. Standardized factor loading for latent variables in the measurement model.\u003c/p\u003e","description":"","filename":"Additional1.xls","url":"https://assets-eu.researchsquare.com/files/rs-1565282/v1/e1461d86af8ba5d766102f88.xls"},{"id":20671311,"identity":"6161429e-21f8-4991-94e0-b32ab115b58b","added_by":"auto","created_at":"2022-04-22 19:30:18","extension":"xls","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20480,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional 2. AVE, correlations, and squared correlations of the latent variables.\u003c/p\u003e","description":"","filename":"Additional2.xls","url":"https://assets-eu.researchsquare.com/files/rs-1565282/v1/8fa06fb3e8c1d3833e69febd.xls"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk factors of in-home unintentional injuries among 0-6-year-old children in China: a cross-sectional survey based on Bronfenbrenner’s ecological system theory","fulltext":[{"header":"Background","content":"\u003cp\u003eChildhood unintentional injuries (UIs) have been a significant public health problem worldwide. According to the Global Burden of Diseases report [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e], more than 200 thousand children\u0026rsquo;s death occurred due to UIs each year across the global, and at least half of these injuries occurred at home. In-home unintentional injuries (IUIs) are major contributors to the global disease burden. It was reported that IUIs were responsible for 12.49% mortality and nearly 1.9\u0026nbsp;million Disability-Adjusted Life Years (DALYs) of Chinese children and adolescents (aged 0 to14 years) in 2019 [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]. Moreover, younger children (0\u0026thinsp;~\u0026thinsp;6 years), who lack adequate self-protective abilities and comprehensive understanding of surrounding conditions, thus their IUIs are more severe comparing with other age groups [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]. Hazards of child IUIs come from many sources, from the individual to the environmental level, which makes it too complex to adequately understand IUIs at a single level. To provide important reference for injury prevention, exploration of the associations between risk factors of IUIs is essential.\u003c/p\u003e\n\u003cp\u003eBronfenbrenner\u0026rsquo;s ecological theory, which emphasized that interactions between organism and environment promote human health [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e], has been widely applied in studies considering child development, as showing in Walker\u0026rsquo;s and Zahra\u0026rsquo;s research [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]. According to the theory, we assumed that children\u0026rsquo;s IUIs as the result of a combination of multiple factors involving with children\u0026rsquo;s risky behaviors, parental supervision and home environment risks, as shown in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Regarding behavioral factors, studies reported numerous injuries while children engaging in risky behaviors [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. Also, due to the aggregation effect, the impact of risky behavior on IUIs may be doubled and redoubled [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. Previous studies shed light on the role of gender, temperament, personality and cognitive development to injury-related behaviors. They emphasized that boys, aggression, impulsivity, sensation seeking and mental disorder can promote children to adopt more frequent or serious behaviors [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e], which suggested that risky behavior played a special role in childhood UIs. Parental supervision is another decisive factor to child IUIs. Past studies [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e] indicated that parental supervision can counteract the potential injury hazard. In the presence of high-quality adult supervision, injuries may occur at a lower rate, although the effect is split between parents [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. Moreover, reports from Morrongiello [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e] revealed that parents would differ greatly in their actual supervisory performance when driven by inconsistent risk perception and safety knowledge. Thus, the protective effect of parental supervision was not cast in stone and may be influenced by other factors. In terms of home environment, children exposed to domestic factors are more vulnerable to IUIs, such as open-air burning coal, absence of balcony guardrail, lack of safe storage area and etc. [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. Historically, child IUIs programs have largely reduced risk to children by improving the home environment. A systematic evaluation [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e] demonstrated the effectiveness of environmental change interventions in reducing the risk of IUIs. In addition, the combined effects of different factors on the IUIs occurrence had been observed. Zhou [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]and Zhang [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e] have reported that higher levels of parental knowledge, attitudes and kills on supervising predicted lower injury risks when children were engaging in unusual behavior. Other studies [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e] on child injuries in farms have found that disquieting behavior for children aged 0\u0026thinsp;~\u0026thinsp;6 was more likely to lead to injury in high-risk environments. However, the existing studies still have some limitations: on the one hand, foreign studies could not be well derived to China to represent the IUIs situation of Chinese children because of the cultural diversity and regional disparity; on the other hand, associations that between the IUI-related behaviors, supervision and environmental risks have not been fully explored yet.\u003c/p\u003e\n\u003cp\u003eTo fill the knowledge gap, we used structural equation model (SEM) to statistically analyze the variables that we interested in and to further explore the associations between the three factors under the ecological system above. Measurement tools for the present study stems largely from our previous research program, in which scales for injury-related risky behaviors, parental supervision and home environment risks of Chinese children have been developed and validated. Findings of this study along with other information might may help to provide a scientific basis for targeted IUIs prevention and control among children aged 0\u0026thinsp;~\u0026thinsp;6.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eParticipants\u003c/h2\u003e\n\u003cp\u003eThis study was a cross-sectional study conducted from October to November in 2017 and the subjects were children aged 0\u0026thinsp;~\u0026thinsp;6 and their families in the urban area of Changsha. According to the gross national product of each district in Hunan province in 2015, six administrative districts in Changsha are divided into two layers (layer 1: Furong district, Yuhua district and Tianxin district; layer 2: Kaifu district, Yuelu district and Wangcheng district). In each district, community health service centers (children under 3) and kindergartens (3-6-year-old children) served as research site to recruit participants, consistent with our previous studies under this program [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003ch2\u003eData collection\u003c/h2\u003e\n\u003cp\u003eThe survey contained demographic information about children and their families (children\u0026rsquo; gender was defined based on self-report), the history of IUIs in the past year and three IUI-related scales, in which measured the risky behavior, parental supervision, and home environmental risk targeting different kinds of injuries using 5-point Likert scales. All the scales were developed based on the prevalence of injuries among urban children in China and had been verified with good reliability and validity with our teamwork [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. The standard for IUIs diagnosing: (a) children need to visit a medical unit and diagnose a certain type of injury; or (b) children need emergency treatment or care by family members; or (c) children has restricted activity or suspension of more than half a day. For those reported with IUIs, more specific injury registration cards were required to complete to fully explore the frequency and severity of injuries. Questionnaires completed over 80% were considered valid and complemented with the median or mean. This study was approved by the ethics committee of the School of Xiangya Public Health at Central South University, and all participants signed informed consent.\u003c/p\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n\u003cp\u003eWe described respondents\u0026rsquo; demographics with SPSS 26.0 and examined the direct and indirect relationship between latent constructs by the SEM of AMOS 22.0. Through item parceling procedure, dimensional variables were regarded as observation variables to estimate the corresponding construct with the average scores of assembled items, as it can maintain parsimony and stable estimates of the model [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. Confirmatory factor analysis (CFA) was conducted initially to ascertain reliability and validity of the indicators used to operationalize the constructs. In the SEM analysis, we first proposed a hypothetical structure model and then modified through deleting non-significant paths and consulting modification indices. Maximum likelihood estimation was used with robust standard errors to provide better estimates and bootstrap-based methods were used to analyze the magnitude and significance of the direct, indirect and total effects of the constructs [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. Considering that the contributions of behaviors, supervision and environmental risks to IUIs varies by gender and age, the samples were divided into subgroups for further discussion, after we established the model of the general sample with an adequate fit.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003cp\u003e\u003cstrong\u003eGeneral Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 845 participants were involved in and the valid questionnaires were 798 with the response rate of 94.44%. The mean age for children participated in was 3.357 (SD 1.677). 268 (33.58%) reported with IUI history in the past year and 52 participants (6.52%) had at least 2 IUIs. The mean of IUIs was 0.400 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.681). The distribution of gender, age, whether had a separate room, was descripted, as shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDistribution of 0-6-year-old children and their families (n, %)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCharacteristics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eWith IUIs history\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eWithout IUIs history\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({\\chi ^2}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGender\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e150(35.63)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e271(64.37)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4.785\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.029\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e107(28.38)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e270(71.62)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge(years)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13.646\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u0026thinsp;~\u0026thinsp;3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e88(24.79)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e267(75.21)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u0026thinsp;~\u0026thinsp;6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e164(37.02)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e279(62.98)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHaving separate room\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14.605\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e158(37.53)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e263(62.47)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e94(24.93)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e283(75.07)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConfirmatory Factor Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eThrough item parceling procedure, IUIs, risky behaviors, parental supervision and home environmental risks were measured by the dimensions of each scale; and these constructs thus, adopted 4, 10, 7 and 6 indicators as observational variables respectively. All factor loadings were statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), ranging from 0.384 to 0.959. All latent variables the composite reliabilities were higher than 0.8 and the average variance extracted (AVE) of each construct was greater than its squared correlations with other constructs. Next, the square roots of all AVEs were above 0.6. The GFI, CFI and RMSEA of CFA was 0.870, 0.862 and 0.073, respectively. Specific results are shown in more detail [see Additional file 1 and 2].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStructural Equation Model\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReferring to previous experience, we first proposed the IUIs model for all children aged 0\u0026thinsp;~\u0026thinsp;6. The goodness-of-fit of the model was 4.832, 0.879, 0.878, 0.069 for \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({\\chi ^2}\\)\u003c/span\u003e\u003c/span\u003e/df, CFI, GFI and RMSEA, respectively. The standardized path coefficients between parental supervision and IUIs, home environmental risks and IUIs, and risky behaviors and IUIs were \u0026minus;\u0026thinsp;0.095, 0.173 and 0.328, respectively, which suggested the parental supervision had negative effects on IUIs, and home environmental risk as well as risky behaviors had positive effects on IUIs. Relationships involving potential mediation effects were discovered, as shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. A statistically significant mediated effect existed from parental supervision to IUIs through risky behaviors (-0.043). Similarly, the home environmental risks via children\u0026rsquo;s risky behavior had an indirect effect on IUIs (0.146). The total effect of risky behaviors on IUIs was 0.328, higher than that of home environmental risks (0.319) and parental supervision (-0.137). All path coefficients above were statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), as shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eSimilar to SEM model for the whole children, models in each subgroup were fitted in an acceptable way. Indirect pathways of supervision as well as environment were found, which were shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. Children aged 4\u0026thinsp;~\u0026thinsp;6 (0.426) and boys (0.384) displayed greater behavioral effects than children aged 0\u0026thinsp;~\u0026thinsp;3 (0.231) and girls (0.232). For all subgroups, the effects of home environmental risks were statistically significant, among which environmental risks had greater indirect impacts on IUIs of children aged 4\u0026thinsp;~\u0026thinsp;6 (0.201) than that of children aged 0\u0026thinsp;~\u0026thinsp;3 (0.108). Further, the greater direct effects of environmental risks on IUIs were examined in girls (0.241) than in boys (0.115), but the indirect effect did the opposite. In terms of parental supervision, there were greater negative impacts found in children aged 4\u0026thinsp;~\u0026thinsp;6 (-0.158) and girls (-0.249) than children aged 0\u0026thinsp;~\u0026thinsp;3 (-0.116) and boys (-0.038), respectively. Except for boys, the effects of parental supervision proved statistical significance, as follows in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe standardized indirect, direct, and total effects of risky behavior, parental supervision, and home environmental risks on IUIs for the whole children and each subgroup.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eGroup\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eHome environmental\u003c/p\u003e\n\u003cp\u003eRisks\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eParental\u003c/p\u003e\n\u003cp\u003eSupervision\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eRisky\u003c/p\u003e\n\u003cp\u003eBehavior\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGeneral children\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIndirect effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.146*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.043*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDirect effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.173*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.095*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.319*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.137*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.328*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChildren aged 0\u0026thinsp;~\u0026thinsp;3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIndirect effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.108*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.022\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDirect effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.161*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.093\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.269*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.116*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.231*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChildren aged 4\u0026thinsp;~\u0026thinsp;6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIndirect effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.201*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.038\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDirect effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.215*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.120*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.416*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.158*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.426*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBoys\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIndirect effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.184*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDirect effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.115*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.036\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.299*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.038\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.384*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGirls\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIndirect effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.095*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.063*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDirect effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.241*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.186*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.336*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.249*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.232*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003eNote: * indicates that the path estimate is significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussions","content":"\u003cp\u003eIn our study, the incidence of IUIs was 33.42%, higher than the results in other studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], which may be the result that our subjects were children aged 0\u0026thinsp;~\u0026thinsp;6, who occupied a higher injury risk than other age groups. In addition, children aged 0\u0026thinsp;~\u0026thinsp;3 in this study were investigated by face-to-face interview, which made the data of younger children more reliable and had a certain influence on the incidence rate. Meanwhile, this finding confirmed the necessity of special attention and targeting preventions towards IUIs among Chinese urban children, which need to be carried out with adequate evidence bases. Thus, based on Bronfenbrenner\u0026rsquo;s ecosystem theory and our previous efforts, we systematically explored the causes of children\u0026rsquo;s IUIs in Chinese urban areas and revealed significant relationships among risky behaviors, parental supervision, home environmental risks and IUIs through SEM.\u003c/p\u003e \u003cp\u003eThe CFA exhibited that all latent variables had good reliability and discriminant validity through the results of composite reliabilities and the AVEs of each construct. GFI, CFI and RMSEA were all acceptable, so we considered that the measurement tools used in this study met the conditions for the structural model. Results of SEM of the general sample revealed that the total value of effect from risky behavior was much higher when compared with parental supervision and home environmental risks, though behavior was influenced by the latter two to some extent. Home environmental risks played direct and indirect roles in children\u0026rsquo;s IUIs, whereas parental supervision could only influence special groups, such as children aged 4\u0026thinsp;~\u0026thinsp;6 years and girls.\u003c/p\u003e \u003cp\u003eOur investigation tool for risky behaviors involved animal bites, burns, falls, suffocation and many other injury types, all of which corresponded to the relevant child IUIs, for example, the behavior of a child poking a power socket was in corresponding to the unintentional burns. SEM of subgroups showed the contribution of risky behaviors with aging, because the better motor control and coordination of older children, the higher possibility for hazard situations [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], which was similar to the fact that children who climb frequently were vulnerable to falls. Likewise, the behavioral effect was greater for boys than for girls, which may be due to the gender differences in early developmental trajectories for emotional expression. Boys are more inclined to express anger-related emotions and have greater tendency to engage in rough and tumble play than girls [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], which leads to more frequent conduct problems and more serious IUIs. Similarly, multimethod strategies study [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] revealed that most of the boy\u0026rsquo;s injuries followed misbehaviour (i.e., mothers reported that 60% of boys suffered significantly more injuries when they engaged in inappropriate behavior). Also, boys express more optimistic bias and tend to attribute injuries to bad luck, while girls express more considerations about the consequences of their actions in the same situation [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Thus, our results served as reminders for IUIs prevention programs, in which appropriate efforts according to age and gender characteristics may be needed.\u003c/p\u003e \u003cp\u003eDespite risky behaviors occupied the strongest effect on children\u0026rsquo;s IUIs, reducing risks caused by risky behaviors required more reasonable parental supervision and better home environment. The direct effects of environmental risks and supervision were validated across the entire sample, similar to previous studies [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. More importantly, we proved the indirect role of the both on IUIs. The underlying mechanism may be that parents who provided direct attention, with closest proximity on a continual basis were able to moderate their children\u0026rsquo;s injury-prone tendencies and ensure child safety in the home setting [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], and home environments may influence the emergence of externalized behavior problems in children and thus create favorable conditions for being exposed to IUIs, in line with other studies [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe indirect effects of the home environmental risks implied that the hazards of IUIs were on the rise when children with high behavioral risks are in unsafe households, particularly 4-6-year-old children and boys. The reason may be that high-risk settings would stimulate children to show more externalized behavioral problems and fostered interactions with hazards. Similarly, Schwebel [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] revealed that in a complicated housing environment, children with higher behavioral risk might judge environmental hazards with a rushed, impulsive manner, which might lead to misestimation of the risk involved in a particular activity, and in turn lead to injury. Therefore, the co-existence of direct and indirect paths highlighted the dual value of addressing risk factors in house. However, contrary to previous results, the direct impact of home risk varied more in girls than boys. A possibility involved greater perceptual sensitivity in girls. If girls are more attuned to the fine details of their environment, they will experience more stressors and curiosity, which can trigger their susceptibility to more injury events around them [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Also, this finding suggested that injury risk for girls arose more from poor conditions that already existed at home than motivation of child\u0026rsquo;s behaviors from home environment, while the opposite was true for boys. Hence, reducing IUIs risk in girls necessitates more complete disengagement from dangerous situations, and for boys, timely home inspection and regulating children\u0026rsquo;s behavioral tendencies may be more important.\u003c/p\u003e \u003cp\u003eResults suggested that parental supervision was not significant to deter younger children\u0026rsquo;s injury risk, either directly or indirectly. We speculated that this may be associated with differences in child care. Morrongiello [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] reported that parents of younger children only focused on increasing the frequency and proximity of observations and routinely overestimate desired effect of their supervision strategies. By contrast, parents of older children exercised safety education and fear-inducing strategy, in which parents would stress the serious consequences if children did not follow their guidance. In addition, the early IUI experiences of 4-6-year-old children reminded their parents of the relative necessity for parental supervision, which made the roles of supervision reported by parents more prominent. We did not find any significant effects on parental supervision of boys, but did of girls, which was beyond our expectations. One possible explanation was that specific societal expectations for males and females. Boys are always expected to protect their families and to overcome dangers that interfere with their ability to provide for their families, whereas girls are allowed to show more emotions to take on the traditional role of caregivers [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Thus, more encouragements to participate in risky games are given to boys, while more caution about safety to girls, which relatively weakened the roles of supervision.\u003c/p\u003e \u003cp\u003eWhether in the general population or each subgroup, risky behavior was involved as an intermediary, and meanwhile, the effects of risky behavior and home environment were greater than that of parental supervision, which made we acknowledge the relative materiality of all three in preventing IUIs. Although parental supervision has been advocated as a protective method in the past, we found that it separately cannot completely offset the crisis caused by environmental risks and behaviors with limited power. Consequently, the best strategy to moderate risk for IUIs is an effective combination of behavioral regulations and environmental interventions, and measures targeting parental supervision are considered as promising remedies. For younger children, this means keeping the consistency of space as much as possible to timely take behavioral modification and reasonable planning of indoor activity space. For older children with increased cognitive awareness, this signified necessity of regular health education and improvement of risk perception. Besides, specific efforts, such as caregivers\u0026rsquo; safety education and enhanced safety equipment (e.g., child-resistant container, cabinet latches, stair gates), will be better able to contain crises from environment and supervision. In terms of gender, girls are highly sensitive to environmental risks, so it is critical to carry out a thorough screening of the risk of home from the perspective of children. At the same time, moderate behavioral constraints and verbal reminders may yield better results, because girls are more compliant with their parents [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. For boys, efforts should be directed towards positive regulation of impulsive behavioral traits. Traditional didactic education should also be changed and more participatory activities can be adopted, such as training tasks in hazard perception, sound decision-making, and safety rules, which will be better targeted to ameliorate boys\u0026rsquo; potential risks.\u003c/p\u003e \u003cp\u003eTo decrease child IUIs more efficiently, more efforts need to be done besides the above measures. Current data of Chinese children\u0026rsquo;s IUIs stemmed mainly from the China\u0026rsquo;s Disease Surveillance Points system and National Injury Surveillance System consisted of 127 sentinel hospitals [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]; but due to the relatively low proportion of deaths and hospital visits caused by injury events, IUIs disposed of by family members were often missed. It is a call to attach importance to the collection, analysis and utilization of basic IUIs information. Measures to expand the monitoring sites to primary units (e.g., schools, kindergartens, and communities), standardize the information collection process, and formulate multi-sector strategies involving the whole society will be good complement to Chinese\u0026rsquo;s non-medical treatment IUIs. Moreover, parents in Chinese urban areas generally lacked sufficient recognition of the IUIs\u0026rsquo; controllability, and especially parents who belong to floating families were basically in the blind spot of child IUIs prevention [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Therefore, further strengthening investment in home safety publicity, focusing on children with weaker parental supervision and larger needs of injury prevention, such as migrant children who often be left at home alone, urging parents to enhance literacy of IUIs may be the key to future injury control program.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThere were still limitations in this study. Firstly, recall bias may be inevitable, as the study mostly was based on parents\u0026rsquo; recollections. Secondly, the cross-sectional design limits the possibility of establishing causal relationships and can only explain the associations between factors. Thirdly, we did not investigate the influence of other potentially important factors, such as experience for past injuries and interventions from communities and kindergartens, were not available, and these factors might affect the outcomes as potential confounders. Fourthly, the disparities in IUIs between different cities and rural-urban areas cannot be ignored. Our inference, including what we described as mediation, relied on statistical indicators of model fit. Therefore, the model was an attempt for preliminary exploration. Further verification and enrichment on populations of different regions and prospective studies from large samples may be needed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBased on Bronfenbrenner\u0026rsquo;s ecological system theory, the present study revealed relations between risky behaviors, parental supervision, home environmental risks and IUIs among 0-6-year-old children in Chinese urban areas. The direct effects of the all three was demonstrated on IUIs of all children aged 0\u0026thinsp;~\u0026thinsp;6. Through the mediator of risky behaviors, parental supervision and home environmental risks indirectly influenced hazards of IUIs, although which varied by ages and genders. The results could provide favorable reference for targeting interventions to cut down IUIs\u0026rsquo; rates and improve the quality of life of 0-6-year-old children. For children aged 0\u0026thinsp;~\u0026thinsp;3, strengthening behavior guidance and safe spatial planning is essential. With the growth of age, children\u0026rsquo;s IUIs prevention may call for a perfect combination of enhanced safety education, increased awareness of parental supervision and effective home safety equipment. Further, parental supervision of IUI is weak in boys, and efforts to improve their impulsive behavior characteristics are more important, while for girls, it is more urgent to eliminate environmental risks across the board.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eUIs: Unintentional Injuries\u003c/p\u003e\n\u003cp\u003eIUIs: In-home Unintentional Injuries\u003c/p\u003e\n\u003cp\u003eCFI: Comparative Fit Index\u003c/p\u003e\n\u003cp\u003eGFI: Goodness-of-Fit Index\u003c/p\u003e\n\u003cp\u003eRMSEA: Root-Mean-Square Error of Approximation\u003c/p\u003e\n\u003cp\u003eDALYs: Disability-Adjusted Life Years\u003c/p\u003e\n\u003cp\u003eSEM: Structural Equation Model\u003c/p\u003e\n\u003cp\u003eCFA: Confirmatory Factor Analysis\u003c/p\u003e\n\u003cp\u003eAVE: Average Variance Extracted\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project had been performed in accordance with the Declaration of Helsinki and was approved by the ethics committee of the School of Xiangya Public Health at Central South University in Hunan Province, China (Approval Number: CTXY-140002-4). A written informed consent was obtained from the custodians of each participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to privacy and confidentiality agreements but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the National Natural Science Foundation of China (No. 81402770) and Graduates\u0026rsquo; Free Exploration and Innovation Program of Central South University (No. 2020ZZTS812).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMH contributed to the study conception and design. All analyses were conducted by YM. YM and JS contributed to the acquisition and interpretation of the study results. YM drafted the manuscript, with revisions made by JS, RY and PY. All authors have read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express gratitude to all the children and their parents.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eInstitute for Health Metrics and Evaluation. Global Burden of Disease (GBD) Results. University of Washington: Population Health Building/Hans Rosling Center. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.healthdata.org/gbd/2019\u003c/span\u003e\u003cspan address=\"https://www.healthdata.org/gbd/2019\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 10 April 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVos T, Lim SS, Abbafati C, Abbas KM, Abbasi M, Abbasifard M, et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990\u0026ndash;2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2020;396(10258):1204\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. World health statistics 2015: World Health Organization; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou N, Cheah CSL. Ecological risk model of childhood obesity in Chinese immigrant children. Appetite. 2015;90:99\u0026ndash;107.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalker M, Nixon S, Haines J, Mcpherson AC. Examining risk factors for overweight and obesity in children with disabilities: a commentary on Bronfenbrenner's ecological systems framework. Dev Neurorehabil. 2018:1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFathirezaie Z, Abbaspour K, Badicu G, Hojjat S, Nobari H. The Effect of Environmental Contexts on Motor Proficiency and Social Maturity of Children: An Ecological Perspective. Children. 2021;8(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorrongiello BA. Preventing Unintentional Injuries to Young Children in the Home: Understanding and Influencing Parents' Safety Practices. Child Develop. Perspect. 2018;12(4):217\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorrongiello BA, Lasenby J. Finding the daredevils: Development of a Sensation Seeking Scale for children that is relevant to physical risk taking. Accid Anal Prev. 2006;38(6):1101\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorrongiello BA, Kiriakou S. 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Interactions between child behavior patterns and parenting: Implications for children's unintentional injury risk. J Pediatr Psychol. 2004;29(2):93\u0026ndash;104.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchnitzer P, Dowd M, Morrongiello B, Kruse R. SUPERVISION AND RISK OF UNINTENTIONAL INJURY IN YOUNG CHILDREN. Inj Prev. 2015;21:A105-A.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorrongiello BA, Corbett M, Lasenby J, Johnston N, McCourt M. Factors influencing young children's risk of unintentional injury: Parenting style and strategies for teaching about home safety. J Appl Dev Psychol. 2006;27(6):560\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOchi M, Fujiwara T. Paternal Childcare In Early Childhood and Problematic Behavior in Children: A Population-Based Prospective Study in Japan. 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Matern Child Health J. 2014;18(4):911\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"In-home unintentional injury, Risky behavior, Parental supervision, In-home environment, Children","lastPublishedDoi":"10.21203/rs.3.rs-1565282/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1565282/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn-home unintentional injuries (IUIs) seriously threatened children\u0026rsquo;s safety. Three factors, including risky behaviors, parental supervision, and home environmental risks, have been identified as major causes for IUIs. Studies considering the interrelations between the three were limited and no relative studies has been carried out among Chinese children.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo fully explore the influences of behavioral, supervisory and environmental risk factors on IUIs and their associations among Chinese children on the bases of our self-developed scales.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThrough stratified cluster sampling, a cross-sectional survey was conducted with 798 parents of children aged 0\u0026thinsp;~\u0026thinsp;6 years in Changsha, China. Social demographics and IUIs history in the past year were collected by self-administered questionnaires. Three IUI-related scales, which had been developed and validated by our team, aimed to measure risks from children behavior, parental supervision and in-home environment. Structural equation models were constructed to analyze the relationship of these factors and their influences on IUIs using SPSS 26.0 and AMOS 22.0.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e798 parents were surveyed in total, and 33.58% of them reported with IUIs history of their children. The comparative fit index (CFI), goodness-of-fit index (GFI) and the root-mean-square error of approximation (RMSEA) for the model of the whole children were 0.879, 0.878 and 0.069 respectively, indicating an acceptable level of model fit. Direct influences were discovered between risky behaviors and children\u0026rsquo;s IUIs. Home environmental risks indirectly exerted impacts on IUIs by the mediating effect of risky behaviors, while the significant effect of parental supervision only existed in children aged 4\u0026ndash;6 and girls.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eRisky behaviors played a mediating role in IUIs among children. Supervision and environmental risks affected IUIs indirectly by the exposure to risky behaviors. Parental supervision may not be able to offset the risks posed by the environmental and behavioral factors, so effective IUIs prevention strategies should focus on behavioral and environmental interventions, with appropriate supervision strategies based on the age and sex characteristics of the child.\u003c/p\u003e","manuscriptTitle":"Risk factors of in-home unintentional injuries among 0-6-year-old children in China: a cross-sectional survey based on Bronfenbrenner’s ecological system theory","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-04-22 19:30:16","doi":"10.21203/rs.3.rs-1565282/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-07-14T21:14:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-07-09T09:57:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8a050c59-33a2-412f-8175-d3cfe0d8e27f","date":"2022-06-27T08:33:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-06-23T07:40:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-05-21T21:44:18+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-04-21T10:34:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-04-21T10:17:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2022-04-17T03:11:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"67568e54-b044-43ae-b795-b55f88898502","owner":[],"postedDate":"April 22nd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-09-26T10:59:33+00:00","versionOfRecord":[],"versionCreatedAt":"2022-04-22 19:30:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1565282","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1565282","identity":"rs-1565282","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}