Canadian Journal of Public Health

, Volume 109, Issue 1, pp 134–149 | Cite as

A systematic review of the risk factors and interventions for the prevention of playground injuries

  • Sarah A. Richmond
  • Tessa Clemens
  • Ian Pike
  • Alison Macpherson
Systematic Review



The primary objectives of this work were to (1) identify the risk and/or protective factors associated with playground injuries among children less than 18 years of age and (2) identify interventions/programs/policies aimed at preventing playground-related injuries among children less than 18 years of age. Secondary objectives include a summary of the data that reflect alignment with current playground standards.


For the primary outcome, 4 databases and 12 online resources were systematically searched to include observational and experimental studies examining risk and/or protective factors or interventions associated with playground injury or outcomes related to playground injury (e.g., risky playground behaviour). Data extraction included study design, participants, outcome, exposure or intervention, data analysis, and effect estimates. The quality of evidence for all studies was assessed using the Downs and Black criteria.


This review included studies of moderate quality, revealing a number of risk factors and effective interventions for playground injury. Risk factors included absence of handrails and guardrails on playground equipment, non-impact-absorbing surfacing, and critical fall heights. Effective interventions included modifying playground surfacing and reducing equipment height to less than 1.5 m.


Equipment- and structure-based playgrounds should adhere to and maintain playground standards in order to reduce the risk of serious injury. Organizations responsible for installing and maintaining playgrounds should consider alternative play spaces that allow children to play outdoors, in a natural environment that supports healthy child development and promotes physical activity.


Interventions Playgrounds Systematic review Play and playthings Wounds and injuries Risk factors 



Les principaux objectifs de l’étude consistaient : 1) à dresser la liste des facteurs de risque et/ou de protection associés aux blessures sur les terrains de jeux chez les enfants de moins de 18 ans et 2) à dresser la liste des interventions, des programmes ou des politiques visant à prévenir les blessures sur les terrains de jeux chez les enfants de moins de 18 ans. Le résumé des données en phase avec les normes en vigueur pour les terrains de jeux était un objectif secondaire.


Pour les objectifs principaux, nous avons systématiquement interrogé 4 bases de données et 12 ressources en ligne pour repérer les études observationnelles et expérimentales portant sur les facteurs de risque et/ou de protection associés aux blessures sur les terrains de jeux (p. ex., les comportements dangereux sur les terrains de jeux), sur les interventions ou sur les résultats des blessures sur les terrains de jeux. Nous avons extrait les données sur le protocole d’étude, les participants, le résultat, l’exposition ou l’intervention, l’analyse de données et les estimations des effets. La qualité des données probantes de chaque étude a été évaluée selon les critères de Downs et Black.


Les études de cette revue étaient de qualité moyenne; elles ont mis au jour des facteurs de risque de blessures sur les terrains de jeux et des interventions efficaces. Les facteurs de risque étaient l’absence de mains courantes et de garde-corps sur les équipements de jeu, les surfaces n’absorbant pas les impacts, ainsi que les hauteurs de chute critiques. Les interventions efficaces consistaient à modifier la surface des terrains de jeux et de réduire la hauteur des équipements à moins de 1,5 m.


Les terrains de jeux qui comportent des équipements et des structures devraient être conformes aux normes pour les terrains de jeux afin de réduire les risques de blessures graves. Les organismes chargés de l’installation et de l’entretien des terrains de jeux devraient envisager des aires de jeu différentes qui permettent aux enfants de jouer à l’extérieur, dans un milieu naturel propice à leur développement sain et à l’activité physique.


Interventions Terrains de jeux Revue systématique Jeu et accessoires de jeu Plaies et blessures Facteurs de risque 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.


  1. American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. (2011). Caring for our children: national health and safety performance standards; guidelines for early care and education programs, 3rd edn. Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American Public Health Association.Google Scholar
  2. (CDC), Centers for Disease Control and Prevention. (1999). Playground safety—United States, 1998-1999. MMWR Recomm Rep, 48(16), 329–332.Google Scholar
  3. Acik, Y., Gulbayrak, C., & Turaci, C. G. (2004). Investigation of the level of safety and appropriateness of playgrounds in Elazig city in Turkey. Int J Environ Health Res, 14(1), 75–82.CrossRefPubMedGoogle Scholar
  4. Allen, E. M., Hill, A. L., Tranter, E., & Sheehan, K. M. (2013). Playground safety and quality in Chicago. Pediatrics, 131(2), 233–241.CrossRefPubMedGoogle Scholar
  5. Brussoni, M., Gibbons, R., Gray, C., et al. (2015). What is the relationship between risky outdoor play and health in children? A systematic review. Int J Environ Res Public Health, 12(6), 6423–6454.CrossRefPubMedPubMedCentralGoogle Scholar
  6. Canadian Standards Association (2015). CAN/CSA-Z614-14. Children’s playspaces and equipment.Google Scholar
  7. Chalmers, D. J., Marshall, S. W., Langley, J. D., et al. (1996). Height and surfacing as risk factors for injury in falls from playground equipment: a case-control study. Inj Prev, 2(2), 98–104.CrossRefPubMedPubMedCentralGoogle Scholar
  8. Chalmers, D. J., Parry, M. L., Crawford, A. I., & Wright, C. S. (2001). Compliance of Dunedin school playground equipment with the New Zealand playground standard. Aust N Z J Public Health, 25(3), 253–255.CrossRefPubMedGoogle Scholar
  9. Chelvakumar, G., Sheehan, K., Hill, A. L., Lowe, D., Mandich, N., & Schwebel, D. C. (2010). The stamp-in-safety programme, an intervention to promote better supervision of children on childcare centre playgrounds: an evaluation in an urban setting. Inj Prev, 16(5), 352–354.CrossRefPubMedGoogle Scholar
  10. Cradock, A., O'Donnell, E., Benjamin, S. E., Walker, E., & Slining, M. (2010). A review of state regulations to promote physical activity and safety on playgrounds in child care centers and family child care homes. J Phys Act Health, 7(Suppl 1), S108–S119.CrossRefPubMedGoogle Scholar
  11. Downs, S. H., & Black, N. (1998). The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health, 52(6), 377–384.CrossRefPubMedPubMedCentralGoogle Scholar
  12. Fiissel, D., Pattison, G., & Howard, A. (2005). Severity of playground fractures: play equipment versus standing height falls. Inj Prev, 11(6), 337–339.CrossRefPubMedPubMedCentralGoogle Scholar
  13. Fisher, L., Harris, V. G., VanBuren, J., Quinn, J., & DeMaio, A. (1980). Assessment of a pilot child playground injury prevention project in New York State. Am J Public Health, 70(9), 1000–1002.CrossRefPubMedPubMedCentralGoogle Scholar
  14. Fuselli, P., & Yanchar, N. L. (2012). Preventing playground injuries. Paediatr Child Health, 17(6), 328.CrossRefPubMedPubMedCentralGoogle Scholar
  15. Heck, A., Collins, J., & Peterson, L. (2001). Decreasing children’s risk taking on the playground. J Appl Behav Anal, 34(3), 349–352.CrossRefPubMedPubMedCentralGoogle Scholar
  16. Herrington, S., & Nicholls, J. (2007). Outdoor play spaces in Canada: the safety dance of standards as policy. Critical Social Policy, 27(1), 128–138.CrossRefGoogle Scholar
  17. Howard, A. W., MacArthur, C., Willan, A., Rothman, L., Moses-McKeag, A., & MacPherson, A. K. (2005). The effect of safer play equipment on playground injury rates among school children. CMAJ, 172(11), 1443–1446.CrossRefPubMedPubMedCentralGoogle Scholar
  18. Howard, A. W., Macarthur, C., Rothman, L., Willan, A., & Macpherson, A. K. (2009). School playground surfacing and arm fractures in children: a cluster randomized trial comparing sand to wood chip surfaces. PLoS Med, 6(12), e1000195–e1000195.CrossRefPubMedPubMedCentralGoogle Scholar
  19. Hudson, S. D., Olsen, H. M., & Thompson, D. (2008). An investigation of school playground safety practices as reported by school nurses. J Sch Nurs, 24(3), 138–144.CrossRefPubMedGoogle Scholar
  20. Keays, G., & Skinner, R. (2012). Playground equipment injuries at home versus those in public settings: differences in severity. Inj Prev, 18(2), 138–141.CrossRefPubMedGoogle Scholar
  21. Kotch, J. B., Hussey, J. M., & Carter, A. (2003). Evaluation of North Carolina child care safety regulations. Inj Prev, 9(3), 220–225.CrossRefPubMedPubMedCentralGoogle Scholar
  22. Laforest, S., Robitaille, Y., Dorval, D., Lesage, D., & Pless, B. (2000). Severity of fall injuries on sand or grass in playgrounds. J Epidemiol Community Health, 54(6), 475–477.CrossRefPubMedPubMedCentralGoogle Scholar
  23. Laforest, S., Robitaille, Y., Lesage, D., & Dorval, D. (2001). Surface characteristics, equipment height, and the occurrence and severity of playground injuries. Inj Prev, 7(1), 35–40.CrossRefPubMedPubMedCentralGoogle Scholar
  24. Macarthur, C., Hu, X., Wesson, D. E., & Parkin, P. C. (2000). Risk factors for severe injuries associated with falls from playground equipment. Accid Anal Prev, 32(3), 377–382.CrossRefPubMedGoogle Scholar
  25. MacKay, M. (2003). Playground injuries. Inj Prev, 9, 194.CrossRefPubMedPubMedCentralGoogle Scholar
  26. Macpherson, A. K., Jones, J., Rothman, L., Macarthur, C., & Howard, A. W. (2010). Safety standards and socioeconomic disparities in school playground injuries: a retrospective cohort study. BMC Public Health, 10, 542–542.CrossRefPubMedPubMedCentralGoogle Scholar
  27. Martin, J., & Cooper, C. D. (2005). Playground safety in south western Sydney. J Paediatr Child Health, 41(11), 587–591.CrossRefPubMedGoogle Scholar
  28. Morrongiello, B. A., & House, K. (2004). Measuring parent attributes and supervision behaviors relevant to child injury risk: examining the usefulness of questionnaire measures. Inj Prev, 10(2), 114–118.CrossRefPubMedPubMedCentralGoogle Scholar
  29. Morrongiello, B. A., & Kane, A. (2015). An evaluation of the Cool 2 Be Safe program: an evidence-based community-disseminated program to positively impact children's beliefs about injury risk on playgrounds. Prev Sci, 16(1), 61–69.CrossRefPubMedGoogle Scholar
  30. Morrongiello, B. A., & Mark, L. (2008). “Practice what you preach”: induced hypocrisy as an intervention strategy to reduce children’s intentions to risk take on playgrounds. J Pediatr Psychol, 33(10), 1117–1128.CrossRefPubMedGoogle Scholar
  31. Morrongiello, B. A., & Matheis, S. (2007). Addressing the issue of falls off playground equipment: an empirically-based intervention to reduce fall-risk behaviors on playgrounds. J Pediatr Psychol, 32(7), 819–830.CrossRefPubMedGoogle Scholar
  32. Mott, A., Evans, R., Rolfe, K., Potter, D., Kemp, K. W., & Sibert, J. R. (1994). Patterns of injuries to children on public playgrounds. Arch Dis Child, 71(4), 328–330.CrossRefPubMedPubMedCentralGoogle Scholar
  33. Mott, A., Rolfe, K., James, R., et al. (1997). Safety of surfaces and equipment for children in playgrounds. Lancet (London, England), 349(9069), 1874–1876.CrossRefGoogle Scholar
  34. Mowat, D. L., Wang, F., Pickett, W., & Brison, R. J. (1998). A case-control study of risk factors for playground injuries among children in Kingston and area. Inj Prev, 4(1), 39–43.CrossRefPubMedPubMedCentralGoogle Scholar
  35. Norton, C., Nixon, J., & Sibert, J. (2004). Playground injuries to children. Arch Dis Child, 89, 103–108.CrossRefPubMedPubMedCentralGoogle Scholar
  36. Olsen, H., Hudson, S., & Thompson, D. (2010). Strategies for playground injury prevention: an overview of a playground project. Am J Health Educ, 41, 187–192.CrossRefGoogle Scholar
  37. Park, M. J., Baldwin, K., Weiss-Laxer, N., et al. (2010). Composite playground safety measure to correlate the rate of supracondylar humerus fractures with safety: an ecologic study. J Pediatr Orthop, 30(2), 101–105.CrossRefPubMedGoogle Scholar
  38. Petridou, E., Sibert, J., Dedoukou, X., Skalkidis, I., & Trichopoulos, D. (2002). Injuries in public and private playgrounds: the relative contribution of structural, equipment and human factors. Acta Paediatr, 91(6), 691–697.CrossRefPubMedGoogle Scholar
  39. Pickett, W., Carr, P. A., Mowat, D. L., & Chui, A. (1996). Playground equipment hazards and associated injuries in Kingston and area. Can J Public Health, 87(4), 237–239.PubMedGoogle Scholar
  40. Roseveare, C. A., Brown, J. M., Barclay McIntosh, J., & Chalmers, D. J. (1999). An intervention to reduce playground equipment hazards. Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention, 5(2), 124–128.CrossRefGoogle Scholar
  41. Sacks, J. J., Holt, K. W., Holmgreen, P., Colwell Jr., L. S., & Brown Jr., J. M. (1990). Playground hazards in Atlanta child care centers. Am J Public Health, 80(8), 986–988.CrossRefPubMedPubMedCentralGoogle Scholar
  42. Sacks, J. J., Brantley, M. D., Holmgreen, P., & Rochat, R. W. (1992). Evaluation of an intervention to reduce playground hazards in Atlanta child-care centers. Am J Public Health, 82(3), 429–431.CrossRefPubMedPubMedCentralGoogle Scholar
  43. Schwebel, D. C., Summerlin, A. L., Bounds, M. L., & Morrongiello, B. A. (2006). The stamp-in-safety program: a behavioral intervention to reduce behaviors that can lead to unintentional playground injury in a preschool setting. J Pediatr Psychol, 31(2), 152–162.CrossRefPubMedGoogle Scholar
  44. Sherker, S., & Ozanne-Smith, J. (2004). Are current playground safety standards adequate for preventing arm fractures? Med J Aust, 180(11), 562–565.PubMedGoogle Scholar
  45. Sherker, S., Ozanne-Smith, J., Rechnitzer, G., & Grzebieta, R. (2005). Out on a limb: risk factors for arm fracture in playground equipment falls. Inj Prev, 11(2), 120–124.CrossRefPubMedPubMedCentralGoogle Scholar
  46. Sherker, S., Ritchie, J., Eager, D., & Dennis, R. (2009). Soft landings: encouraging compliance with safety standards in local government authority playgrounds. Health Promot J Austr, 20(1), 31–36.CrossRefPubMedGoogle Scholar
  47. Tremblay, M. S., Gray, C., Babcock, S., et al. (2015). Position statement on active outdoor play. Int J Environ Res Public Health, 12(6), 6475–6505.CrossRefPubMedPubMedCentralGoogle Scholar
  48. U.S. Consumer Product Safety Commission. (2010). Public playground safety handbook.Google Scholar
  49. Uskun, E., Kisioglu, A. N., Altay, T., Cikinlar, R., & Kocakaya, A. (2008). Assessment of the current status of playground safety in the Midwestern region of Turkey: an effort to provide a safe environment for children. Turk J Pediatr, 50(6), 559–565.PubMedGoogle Scholar
  50. Vollman, D., Witsaman, R., Comstock, R. D., & Smith, G. A. (2009). Epidemiology of playground equipment-related injuries to children in the United States, 1996-2005. Clin Pediatr (Phila), 48(1), 66–71.CrossRefGoogle Scholar

Copyright information

© The Canadian Public Health Association 2018

Authors and Affiliations

  • Sarah A. Richmond
    • 1
  • Tessa Clemens
    • 1
  • Ian Pike
    • 2
  • Alison Macpherson
    • 1
  1. 1.Faculty of Health, Kinesiology and Health ScienceYork UniversityTorontoCanada
  2. 2.BC Injury Research and Prevention UnitBC Children’s HospitalVancouverCanada

Personalised recommendations