The literature search and review methods are described in more detail in the companion article of Jacobs et al48
in this series. Briefly, content experts were invited to serve on a panel to review scientific evidence on housing deficiencies that can result in injuries. Relevant literature was identified and provided to the panel by a team from the Centers for Disease Control and Prevention and the National Center for Healthy Housing, which determined the topics to be reviewed after preliminary searches. The interventions identified from the literature were to some extent dependent upon the search terms used. The panel (C.D. [Chair], K.J.P., A.M., and D.O.), with D.E.J., comprising experts representing academic and nongovernmental organizations, reviewed the evidence (see www.nchh.org
for details of how each study was rated), provided and reviewed additional relevant literature, and prepared a preliminary report on which this article is based (www.nchh.org/LinkClick.aspx?fileticket=2lvaEDNBIdU%3d&tabid=229
This review includes structural deficiencies, monitoring to identify structural deficiencies (eg, CO detectors), and those behavior changes specifically intended to correct structural deficiencies or increase monitoring. Structural deficiencies are defined as those deficiencies for which a builder, landlord, or homeowner would take responsibility (ie, design, construction, installation, repair, monitoring). Although home injuries often involve the complex interplay of structural hazards with human biology, psychology, and behavior, this review focuses primarily on modifications to the built environment that require limited if any behavioral change on the part of occupants. The review thus excludes many behaviors that household residents might implement to improve home safety, such as safely storing poisons, matches, or firearms; affixing loose rugs; and purchasing nonslip bath-mats. The review of evidence did not involve human subjects.
For each intervention identified, the panel of subject matter experts considered evidence regarding the efficacy of the intervention itself (ie, whether it, when correctly implemented, was efficacious in reducing injury). The panel also considered the effectiveness of methods to increase implementation, such as legislation, regulation (eg, building codes), device distribution and installation programs, and home- and community-based education. The panel recognizes that “home- or community-based education” in this context encompasses a wide range of interventions, varying in mode of delivery, content, and target audience. However, the emphasis in this review is on passive interventions rather than educational programs to enhance behavior change. The interested reader is therefore referred to the specific research publications cited to learn more about the precise educational interventions evaluated and their relative effectiveness in yielding behavioral change.
The panel placed the greatest weight on evidence from well-conducted, comprehensive systematic reviews of the literature but also included evidence from well-conducted controlled trials and observational studies. For each study examined, the panel evaluated the extent to which the magnitude and significance of the outcomes may have been influenced by various effect modifiers and confounding variables. Where particularly salient, variations in effect have been described. However, it is beyond the scope of this article to delineate this information for every study reviewed.
Formative and process evaluation studies, both in the published and unpublished literature, are important in determining knowledge, attitudes, and behaviors underpinning injury control efforts, as well as demonstrating programmatic reach. However, this research was not mined deeply because it rarely yields evidence of program effectiveness.
The following 17 interventions were identified and examined:
- smoke alarms, including installation of working smoke alarms and community smoke alarm give-away programs without steps to install them;
- safe ignition sources (eg, electrical and heating systems) and ignition source controls;
- home modification to improve fire escape (eg, egress windows and doors, exit signage, protected stairways);
- automatic fire sprinkler systems;
- 4-sided isolation pool fencing
- four-sided isolation fencing;
- three-sided perimeter fencing;
- pool covers and pool alarms;
- safe hot water heater temperatures (preset and reset);
- temperature-controlled mixer (water) faucets;
- home modifications to prevent falls (eg, installation of stair gates, window guards, handrails, grab bars, improved stair lighting, and safe stair and balcony design);
- bathtub design;
- stove and stove control design;
- carbon monoxide exposure prevention through design, engineering, legislation, and education;
- improved enforcement of building and housing codes;
- air-conditioning/cooling during heat waves;
- noise control measures; and
- design of residential construction materials.