Children who lived in housing units that were randomly assigned to the intervention group had significantly fewer injury hazards and a 70% reduction in the rate of modifiable, medically-attended injury compared with children in control households. Thirty seven percent (16/43) of all medically-attended housing related injuries in the control group met our definition of ‘modifiable’. In the intervention group, we observed a 70% reduction of modifiable, medically-attended housing related injuries. Thus, if confirmed, this trial suggests that large-scale implementation of this type of intervention could result in a 30% reduction in all medically attended, housing-related injuries estimated at about 5 million medically attended visits for injury in US children less than 5 years of age each year.1, 17-19
This is the first trial of home safety we are aware of that installed and maintained safety devices in all intervention homes of children to reduce exposure to prevalent hazards across multiple mechanisms of injury.9, 10, 20, 21
A recent Cochrane Review summarized findings from prior trials of home safety, noting that “there was a lack of evidence that interventions reduced rates…(over) a range of injuries.” 22
There are two conflicting trials that have reported housing-related injury outcomes in children. The two published RCTs examined the effect of counseling, home safety checks, free equipment giveaways, or installation of home safety devices on injuries for enrolled children. The first study, a multi-center trial recruiting participants presenting to 5 Canadian pediatric emergency departments conducted by King,et.al.23
enrolled children <8 years with specific injuries, including home-related hazards (i.e. tap water scalds) in addition to bicycle crashes and other injuries outside the home. Children in the intervention arm of this trial underwent a home survey for hazards and their parents were educated about hazard exposure amelioration and were given coupons to purchase safety devices (including car seats and bicycle helmets). This trial found that the intervention was effective in reducing the overall occurrence of injury visits (inside and outside the home) at 4 months of follow-up (7 vs.11% between intervention and controls, p<0.05) and the rate ratio of self-reported injury between intervention and control groups (rate ratio 0.75, 95%CI 0.58, 0.96 per person-year of follow-up) at 12-months. However, they concluded that a single home visit was insufficient to influence the long-term adoption of home safety measures. Home safety modifications were present in less than 15% of intervention homes (2 of 16 safety modifications measured). A follow-up report at 36 months showed a persistence of improvement in parental safety knowledge and a significant but declining effect on self-reported doctor visits for injury in intervention compared with control households (rate ratio 0.80, 95%CI 0.64, 1.00).24
In a larger controlled trial in the United Kingdom (UK), Watson and colleagues randomized more than 3400 families in 47 general practices in Nottingham to receive a standardized safety consultation and provision of free and fitted stair gates, fire guards, smoke alarms, cupboard locks, and window locks for low income families and reduced cost equipment to families with relatively higher income.8
Control families received usual care. A total of 1163 (68%) families in the intervention arm received safety counseling, 619 (36%) had free equipment fitted, and 26 (1.5%) bought equipment at low cost. Primary outcome measures included whether a child younger than 5 years in the family had at least one medically attended injury, rates of attendance in primary and secondary care, and hospital admission over a 2-year follow up period. Paradoxically, the attendance rate for a medically-attended injury visit was 37% higher for children in the intervention compared to control arms (p=0.003).
There are important differences in the study design and interventions of these prior trials that make it difficult to compare directly to this study. The mutlicenter study, conducted by King, et.al., included older children up to 8 years of age, interventions outside the indoor environment (e.g. bicycle helmets and child automobile seat restraints), and did not install the safety products. In the second, UK study, that showed an increase in injury rates in the intervention group, only about a third of families randomized to the intervention arm actually had safety products installed and differences in safety practices from baseline to 12 and 24-month follow-up for all intervention and control families were small (<10% for most practices). Also, this study measured all medically attended injuries in children younger than 5 years (as opposed to hazards and mechanisms directly related to the products provided or ‘fitted’), possibly diluting the ability to measure the maximal effect of the intervention on modifiable injuries among younger children. Although these investigators did not find a significant interaction of randomized group status with child age, other investigators have found age to be a significant risk factor for injury in the home environment. 25, 26
Thus, while we found differences in effect size and direction of effect with these two studies, there were important differences in the design, populations of children enrolled, and interventions which make them difficult to compare with this study.
There were several limitations of the current study. First, it is not possible to conduct a double-blind trial for this type of study. Nevertheless, while the participants were not masked to group assignment, research interviewers who assessed medically attended injuries by telephone were blinded to group assignment. Furthermore, intervention technicians performing installation and maintenance visits were not used as research interviewers and were maintained as separate, functioning teams throughout the study. Second, we relied on maternal report of injuries. However, we verified parental report using a county-wide surveillance system for emergency visits. Third, although mothers participating in this study were representative in age and racial background of those who gave birth in the 5 county region from which they were enrolled, this sample of children and their families may not be representative of U.S. households.
The installation of multi-faceted home safety devices led to a significant reduction in injury hazards and a 70% in medically-attended and modifiable injury among children in the first 2 years of life. Healthcare expenditures for injury in US children amount to more than $2.3 billion annually and emergency visits for children due to injury cost on average about $800 per visit.19, 27
As US children younger than 5 years account for more than 1.7 million emergency visits and 5 million ambulatory visits annually for injury in the home environment1, 19, 28
, this intervention, if replicated in larger populations of mothers and their children, could reduce pain and suffering and save millions of dollars in healthcare costs.