Unintentional injury has emerged as a critical public health challenge worldwide, primarily attributed to its status as the leading contributor to mortality among children and adolescents (1, 2). Beyond the profound health impacts, it also inflicts substantial disease burden and economic strain on governments, communities, and individual families (3). In China, injury ranks first as the cause of death for children and adolescents aged 1–19 years (4). According to official statistics, the child injury mortality rate in 2021 was 10.28 per 100,000, representing a 7.1% reduction compared with the prior year (5). While time-series studies have documented a gradual downward trend in the incidence and mortality of childhood unintentional injuries (6, 7), the absolute burden remains significant, highlighting the urgent need for implementing targeted and effective preventive measures to further mitigate the occurrence of unintentional injuries in this population.

Mounting evidence indicates that unintentional injuries can be effectively prevented and managed through targeted interventions (8). Globally, the 5E strategy has emerged as a standard framework for injury prevention, comprising five key components: Education, Environmental modification, Enforcement of safety regulations, Engineering improvements, and Evaluation of intervention outcomes. Among these, educational interventions are the most frequently implemented. For instance, Moore et al. (9) enhanced parental knowledge of burn first aid through educational video-based interventions, and Feng et al. (10) successfully reduced injury risks in children aged 0–3 years by providing parent-focused educational programs via social networking platforms. Beyond education, environmental modifications have been shown to improve safety: household environmental upgrades enhance home safety (11–13), and road infrastructure improvements significantly decrease traffic injury rates (14). Additionally, legislation and stricter enforcement are widely acknowledged as critical and effective tools for injury prevention and control. Niu et al. (15) found that 98.5% of participants perceived legislation as a key driver for increasing child safety seat utilization and reducing traffic injuries; similarly, Shafiq et al. (16) reported that 34.2% of Malaysian parents endorsed legislative mandates for Child Restraint System (CRS) use. Despite the proven efficacy of individual 5E components, the multifactorial etiology of injuries means that single-strategy interventions typically produce modest or inconsistent effects, highlighting the need for comprehensive, multi-component approaches.

As a foundational theoretical framework for health behavior interventions, the Knowledge-Attitude-Behavior (KAP) model has been widely adopted as a critical tool in global child injury prevention research. By constructing a logical chain that connects knowledge acquisition, attitude transformation, and behavioral adoption, the model offers robust scientific rationale for designing interventions to reduce childhood injury rates. Drawing on this theoretical basis, the present study integrated the KAP model into child injury prevention interventions. First, we assessed the baseline status of injury prevention KAP among 6-17-year-old children. Subsequently, we implemented targeted, multi-component comprehensive interventions, including strengthened child supervision, tailored health education programs, and environmental improvement initiatives. We further evaluated the intervention effectiveness across different age subgroups. The primary objectives of this study are to enhance children’s injury prevention knowledge, positive attitudes, and protective behaviors; reduce the overall childhood injury incidence rate; and provide empirical evidence to inform the formulation of targeted child injury prevention policies and practice guidelines.

This study employed a cluster randomized controlled trial design to demonstrate the effectiveness of integrated interventions—combining enhanced child supervision, health education, and environmental improvement—in reducing childhood injury rates while improving children’s knowledge of injury prevention and their protective behaviors. However, no statistically significant difference was observed between the intervention and control groups regarding injury-related attitudes. This finding underscored the resistance of established attitudes to short-term interventions, highlighting the need for prolonged or targeted strategies to modify injury-related belief systems (10, 20).

The results indicated that the incidence of injuries in the intervention group decreased by 0.13%, while that in the control group increased by 2.00%. The rise in injury incidence among the control group may be attributed to the high randomness of childhood injury events, weakened awareness of injury risks due to the absence of intervention measures, and the prolonged follow-up period that exposed participants to greater external injury risk factors, leading to a natural increase in childhood injury incidence over time. In contrast, the implementation of intervention measures in the intervention group effectively suppressed the natural upward trend of childhood injury incidence and achieved a slight decrease, exerting a positive effect on preventing injury occurrence. From the perspective of health burden, childhood injuries rank among the leading causes of disability and death in children. Even a modest reduction in injury rates can significantly decrease emergency department visits, hospital stays, and long-term health needs, thereby alleviating pressure on pediatric healthcare resources. From the economic burden perspective, a decrease in childhood injury rates can reduce medical expenses, emergency care, and rehabilitation costs associated with injuries, alleviating the financial burden on families. It also minimizes lost workdays for parents caring for injured children and reduces future labor supply gaps caused by childhood disabilities.

Baseline data revealed that the injury-related knowledge scores of children and their parents in both the intervention and control groups were below 60%, whereas their belief scores exceeded 60%. This finding indicates that despite insufficient injury prevention knowledge, participants held accurate beliefs and positive attitudes toward injury prevention. Following the intervention, significant improvements in knowledge scores were observed among both parents and children. High school students exhibited the greatest increase, followed by parents of students in grades 1–3. In contrast, middle school children showed the least significant improvement in knowledge scores. The alignment between children’s cognitive development and intervention content may influence knowledge absorption efficiency. A study conducted in Jiangsu Province reported that the pass rate of injury awareness was 90.92% among high school students, 84.45% among primary school students, and 89.42% among parents—all higher than the 81.75% rate among junior high school students (21)—which is consistent with the findings of the present study. No substantial changes in belief scores were noted for either parents or children, with only a slight increase observed among upper primary school children (grades 4–6). Both children and parents demonstrated increased injury prevention protective behaviors, while a reduction in risky behaviors was only observed among upper primary school children (grades 4–6). This result is consistent with that of Mehreen et al. (22), who reported that younger children showed better performance in beliefs and injury-related risky behaviors compared to older peers.

This study focuses on children and adolescents aged 6–17 years. Compared with preschool children, this age group engages in activities across a wider range of settings, including family, school, and community environments. Thus, the development and implementation of a multi-dimensional child injury intervention model centered on the family-school-community triad are imperative. In China, basic community public services have been fully rolled out (23), laying a solid foundation for establishing cross-sectoral collaboration mechanisms for child injury prevention. Previous research has highlighted the critical role of parents and guardians in ensuring children’s safety (24), as their injury prevention-related knowledge, attitudes, and behaviors exert a significant influence on childhood injury risk. Therefore, for younger children, interventions were prioritized to strengthen parental engagement and capacity-building. Additionally, studies have confirmed the effectiveness of the Child-To-Child Approach in reducing childhood injuries and associated medical costs (25). Accordingly, our intervention strategy also adopted a child-centered approach, actively involving children in injury risk monitoring, health education initiatives, and environmental safety modifications. Such participation directly enhances children’s injury prevention KAP.

The combined interventions in this study resulted in a significant improvement in the knowledge of children and parents. The analysis of the improved knowledge scores of children of different ages suggests that, in future injury interventions, intervention toolkit should be designed to take into account the receptive and learning abilities of children of different ages, and more targeted interventions should be carried out. The present study found that injury-related beliefs and behaviors were resistant to change in the short term and were not significant in older children. These findings suggest that child injury prevention should be implemented on a long-term basis and integrated into the daily management of children’s health (26). Meanwhile, the intervention focused on modifying beliefs should be initiated among younger children to ensure optimal efficacy.

This study has several limitations. First, a questionnaire was used to collect data on childhood injuries occurring over the past 12 months, which may have introduced recall bias and thus affected the findings to a certain extent. Additionally, the injury data were not disaggregated by injury type, which may have influenced the study findings to some extent. Second, although significant improvements were observed in children’s injury prevention knowledge and protective behaviors, there was no corresponding significant reduction in childhood injury incidence. This indicates that a one-year intervention duration is insufficient to sustain long-term injury prevention effects, highlighting the need for extended intervention strategies. Third, this study did not explore the replicability of the intervention in other regions, nor did it examine the potential impacts of family background and socioeconomic factors on intervention outcomes.

This integrated intervention program, implemented in Shijiazhuang City for children aged 6 to 17, encompassing comprehensive childcare, health education and environmental improvements, has yielded positive outcomes in reducing child injury rates while enhancing both children’s and parents’ knowledge and behavioral capacity regarding injury prevention. This integrated family-school-community approach to injury prevention merits wider adoption. It overcomes the limitations of single-setting interventions, eliminates gaps in coverage, and facilitates resource complementarity, thereby enhancing the professionalism and sustainability of such programs.