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PEDIATRICS Vol. 108 No. 2 August 2001, pp. 382-388
,
,
From the * Department of Pediatrics and Children's Hospital of
Eastern Ontario Research Institute, University of Ottawa, Ottawa,
Ontario, Canada; Objective. To examine the
effectiveness of a home visit program to improve home safety and
decrease the frequency of injury in children. We examined the effects
of the program on 1) parental injury awareness and knowledge; 2) the
extent that families used home safety measures; 3) the rate of injury;
and 4) the cost effectiveness of the intervention.
Design. A randomized, controlled trial.
Setting. A multicenter trial conducted at 5 hospitals in 4 Canadian urban centers.
Participants. Children <8 years old, initially enrolled
in an injury case-control study, were eligible to participate.
Intervention. Subsequent to a home inspection conducted to
determine baseline hazard rates for both groups, participants in the
intervention group received a single home visit that included the
provision of an information package, discount coupons, and specific
instruction regarding home safety measures.
Main Results. The median age was 2 years, with males
comprising ~60% of participants. The experimental groups were
comparable at outset in terms of case-control status, age, gender, and
socioeconomic status. Parental injury awareness and knowledge was high;
73% correctly identified injury as the leading cause of death in
children, and an intervention effect was not demonstrated. The adjusted odds ratios (ORs) for the home inspection items indicated that significant safety modifications only occurred in the number of homes
having hot water not exceeding 54°C (OR: 1.31, 95% confidence interval [CI]: 1.14, 1.50) or the presence of a smoke detector (OR:
1.45, 95% CI: 0.94, 2.22). However, the intervention group reported
home safety modifications of 62% at 4 months and significantly less
injury visits to the doctor compared with the nonintervention group
(rate ratio: 0.75; 95% CI: 0.58, 0.96). The total costs of care for
injuries were significantly lower in the intervention group compared
with the nonintervention group with a cost of $372 per injury
prevented.
Conclusions. An intervention using a single home visit to
improve the extent to which families use safety measures was found to
be insufficient to influence the long-term adoption of home safety
measures, but was effective to decrease the overall occurrence of
injuries. Future programs should target a few, well-focused,
evidence-based areas including the evaluation of high-risk groups and
the effect of repeated visits on outcome.
Department of Pediatrics, University of Alberta,
Edmonton, Alberta, Canada; § Department of Pediatrics, Dalhousie
University, Halifax, Nova Scotia; Department of Pediatrics,
University of Montreal, Montreal, Quebec, Canada; ¶ Direction de la
sante publique de Montreal-Centre, Montreal, Quebec, Canada;
# Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada;
** Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba;
Department of Pediatrics, McGill University, Montreal, Quebec,
Canada.
ABSTRACT
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Abstract
Methods
Results
Discussion
Conclusion
References
Injuries are the leading cause of death in childhood and a
significant cause of morbidity.1,2 Although the home
should be a haven of safety, for children <15 years old, and
especially for preschoolers, this setting represents the most frequent
site of injury occurrence.2,3 Among the most serious of
potential hazards are falls, suffocation, burns, and
poisoning.4-8 Such injuries are numerous, not only
because of increased exposure, but also because young children's rapid
physical development surpasses their ability to recognize and avoid
potential dangers in their environment.9 As many injuries
sustained by children in the home are related to a lack of appropriate
safety measures,10-13 prevention efforts directed toward
the reduction of household hazards should be implemented and evaluated.
Evidence from randomized, controlled trials supports the notion that
anticipatory guidance by physicians may decrease the risk of an injury
at home.14-16 A trial of nurse home visit services has
been shown to be effective in improving a variety of health and social
outcomes, including injury prevention.17 Furthermore, a
systematic review of randomized trials has shown that home visit
program have the potential to significantly reduce rates of child
injury.18 As such, home visits may be an important
addition to injury prevention strategies, and the role of home visitors
and nonprofessionals in the prevention of child injury deserves
additional attention.
The present study was conducted to explore the extent to which a home
visit program would improve the safety of the home environment and
decrease the frequency of injuries. We examined the effects of the
program on 1) parental injury awareness and knowledge; 2) families'
use of home safety measures; 3) the rate of injury; and 4) the
cost-effectiveness of the intervention.
This multicenter, randomized controlled trial was conducted
within the context of a case-control study. The following sites participated in the trial: the Montreal Children's Hospital, Montreal, Quebec, Canada; Hôpital Ste Justine, Montreal, Quebec, Canada; IWK-Grace Health Center, Halifax, Nova Scotia, Canada; the Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; the Winnipeg Children's Hospital, Winnipeg, Manitoba, Canada. The research ethics
committees of each institution approved the study protocol.
Participants
Participants <8 years old presenting to the emergency
department (ED) of each participating center from September 1994 to October 1996, were identified using ED logs and the Canadian Hospitals Injury Reporting and Prevention Program of the Health Protection Branch, Health Canada. Children were eligible for the case-control study if they presented with 1 of the following targeted injuries: tap
water scald; burn from a household fire; poisoning or ingestion; choking from the ingestion of a foreign object; fracture, sprain, strain, cut, or bruise from a fall from a height; and head injury while
riding a bicycle. Two controls, matched for gender and within 6 months
of age, were selected for each targeted case. The first control was
selected with a nontargeted injury (ie, one occurring either outside
the home or a home injury not listed above). The second control was
chosen from patients with a medical illness presenting to the same ED.
Intervention and Study Design
A research assistant contacted the family by telephone within 3 days of the ED visit to confirm eligibility and to arrange a home visit
within 1 week. To ensure uniformity, the research assistants were
trained to make a series of specific, structured observations regarding
home safety hazards that included the following: ready access by
children to small objects, matches, lighters, cleaning supplies, beauty
supplies, medications, or electrical cords; windows which open easily
beyond 6 inches; the absence of child resistant caps on medicines; tap
water >54°C; the presence of a functioning smoke detector on each
house level; a fire extinguisher; safety gates at stairs; the presence
of a infant walker; ease of opening basement door; the absence of
certified bicycle helmets; child seat restraints; and by report only,
the failure to use bicycle helmets and automobile restraints at all
times. After the observations were completed, the home visitor
administered a questionnaire regarding parental knowledge and awareness
of injuries, the child's history of past injuries requiring medical treatment, and the number of injuries involving other children in the
family. After all the above measures were completed, an additional
informed consent for the randomized, controlled trial was obtained from
the child's parents.
Children were randomized by the following method: an equal number of
intervention and nonintervention identification cards were placed in
sealed envelopes, mixed in an opaque container, sequentially numbered
as they were withdrawn, and distributed in aliquots to each study site.
Each home was assigned to 1 of 2 groups. Parents in the intervention
group received an information package on injury prevention. The
findings of the home visit were reviewed, and the family instructed on
how to correct any deficiencies in home safety. As well, a set of
coupons from a national retail store (Canadian Tire) for a $10 discount
per item (to a maximum of $50) when purchasing recommended safety
devices were given to each family. Finally, detailed instructions
regarding each of the targeted injuries, along with demonstrations of
the appropriate use of the safety device(s), were provided. This
information was reinforced by follow-up telephone calls at 4 and 8 months after the initial home visit. A letter from each site's project
director stressing the need to maintain the preventive behaviors was
also sent to all intervention families.
Parents of children in the nonintervention group received a general
pamphlet on safety but did not receive the information package, review
of the home safety findings, discount coupons, or any specific
instruction regarding safety measures. One exception was the
notification of families in the nonintervention group of the finding of
a nonfunctioning smoke detector. All participants were contacted by
telephone at 4 and 8 months, and a research assistant blinded to the
intervention assignment completed a final home visit 1 year after the
initial home visit.
Sample size was calculated based on the desire to observe a 10%
difference in the adoption of the home safety behaviors between the
intervention groups assuming a type I error (2-sided) of 0.05 and a
type II error of 0.20 (ie, statistical power of 80%). These calculations resulted in a desired sample of 375 participants in each
group.19
Statistical Analysis
Participants' characteristics, including injury awareness and
knowledge, were compared between intervention groups using the Wilcoxon
rank sum test for ordinal or interval scale variables and
The intervention with respect to the likelihood of adopting a given
prevention strategy was compared using the desired outcomes of a
reduction in potential hazards in the various home areas targeted by
the intervention (eg, the hazard of choking by having small objects
within children's reach in the living room). Each outcome was analyzed
separately, taking into account its baseline hazard rate, intervention,
center, mechanism of injury, age, and gender using logistic regression
models. Odds ratios (ORs) of intervention effects and their 95%
confidence intervals (CIs) were derived from the fitted models.
Standard residual diagnostics were used to check for goodness-of-fit of
the models. Rates of injury-prone hazards were derived in the control
group to aid in the interpretation of the ORs of intervention effect
estimates.
The extent to which the intervention decreased the frequency of injury
requiring a physician visit was evaluated by comparing injury frequency
between intervention groups using Economic Analysis
The objective of the economic analysis was to assess the
cost-effectiveness of the intervention in terms of the incremental cost
per injury prevented, therefore, all health care costs incurred as a
direct result of the preventive program and all costs avoided through
the reduction in injuries were estimated.21,22 The cost of
the preventive program was estimated by combining the salary and
infrastructure costs for the home visitors with the costs of the
information packet provided to parents. The costs associated with
treatment of injuries were calculated from a typical resource profile
for each type of injury obtained from a panel of physicians. The costs
of the injury treatment resources were derived from the Children's
Hospital of Eastern Ontario cost model and from the Ontario Health
Insurance Plan Schedule of Fees and Benefits. The cost model follows
accepted guidelines whereby the direct costs of treatment (eg, staff,
consumables) are allocated to the treatments received, while indirect
costs (eg, overheads) are allocated to treatments through a
simultaneous equation allocation methodology.23 All costs
are reported in 1999 Canadian dollars.
Participant Characteristics
Figure 1 outlines the flow of
participants from the point of being randomized through to the last
follow-up contact. Baseline characteristics of the participants are
displayed in Table 1 and detailed
elsewhere.24 The median age in both groups was 2 years,
with males comprising ~60% of each group. The experimental groups
were comparable at the outset in terms of case-control status,
socioeconomic status, and injury awareness and knowledge (Table
2). Seventy-three percent of participants
in both groups correctly identified injury as the leading cause of
death in children <8 years old, and median scores for the perception
of accident preventability were 7 and 8 (out of 10) for the
intervention and nonintervention groups, respectively. The median score
for perceived control over decreasing accident risk was 7 (out of 10)
in both groups.
TABLE 1 TABLE 2
METHODS
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Abstract
Methods
Results
Discussion
Conclusion
References
2 test for categorical variables. Similarly,
dropouts and completers were compared for any differences in their
baseline characteristics. Injury knowledge and awareness were compared
between interventions using an analysis of variance with the dependent
variable the change at 1 year expressed as a percentage of the baseline
score. The analysis of variance included intervention, center, and
their interaction. Least-square estimates of intervention effect were derived from the fitted models. Standard residual diagnostics were used
for model goodness-of-fit.
2 test and
the ratio of injury per-person year was derived assuming a Poisson
distribution for the number of injuries.20
RESULTS
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Abstract
Methods
Results
Discussion
Conclusion
References
View larger version (28K):
[in a new window]
Fig. 1.
Flow chart of participants from point of randomization to last
contact.
Participant Characteristics
Injury Knowledge and Awareness
Before the 1-year follow-up, 19% of randomized participants were lost to attrition. Participants who dropped out of the study (dropouts) had: 1) significantly younger parents; 2) younger age at which mother had her first child; and 3) fewer years of minimum parental education compared with those who completed the trial (P < .001). Additionally, dropouts were less likely to identify injury as the leading cause of death (P = .004). There were no major differences between the dropouts randomized to intervention (N = 118) and control (N = 103).
Table 3 indicates that there were no significant changes in parental injury awareness and knowledge from baseline between the intervention and control groups. Adjusted ORs for the home inspection items are given in Table 4, along with the baseline rates in the control groups. Significant changes were observed in the number of participant homes who had hot water not exceeding 54 degrees centigrade (OR: 1.31; 95% CI: 1.14, 1.50) and who had smoke detectors on some or all levels (OR: 1.45; 95% CI: 0.94, 2.22). However, there was no difference whether all or some smoke detectors were fully functional (OR: 1.01; 95% CI: 0.79, 1.30). There was a significant difference, favoring the group without intervention, in the number of participant homes who had a fire extinguisher (OR: 0.81; 95% CI: 0.67, 0.97). There were no interactions between intervention and institution in any of the presented outcomes.
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Intervention Effect on Injury Rate
At 4 months, participants in the intervention group tended to report fewer injury visits to the doctor (7%) as compared with those in the control group (11%; P < .05; Table 5). At the completion of the trial, the rate of reported injury visits to the doctor was 0.23 per patient year (95% CI: 0.19, 0.29) for the intervention group and 0.31 per patient year (95% CI: 0.27, 0.37) for the control group. The rate ratio between the intervention and the control group was 0.75 (95% CI: 0.58, 0.96). In addition, the number of participants in the intervention group who reported home safety modifications was 62% at 4 months and 23% at 8 months.
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Economic Analysis
Estimates for the costs of each injury and for the costs of the home visit program are given in Table 6. The total cost of care for injuries was significantly lower in the intervention group compared with the nonintervention group ($13 481.57 compared with $7028.25). This led to a cost per participant of $23.61 compared with $11.69. However, when allowing for the costs of the home visit the incremental cost per participant was $48.11. Given the reduction in the injury rate in the intervention group the cost per injury prevented is estimated to be $372.
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DISCUSSION |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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This study, using a single home visit, was unable to demonstrate effectiveness of an intervention aimed at improving home safety modifications, but was able to demonstrate a reduction in the rate of injury related visits to the doctor. The potential impact of this prevention strategy is substantial. For each 12 homes visited, 1 injury visit to the doctor would be prevented per year at an average incremental cost of $372. Although this outcome looks promising, the finding must be interpreted cautiously.
The observed lack of adoption of the recommended prevention may have been related to aspects of the intervention that required action on the part of the caregiver. The intervention, aimed primarily at changing the environment (home) through the promotion of a combination of passive and active measures, called for the simultaneous change of many injury prevention behaviors. It is generally thought that passive strategies, ie, those involving few repeated actions, are more effective than active preventive strategies.25 The parental vigilance and responsibility demanded by these more active measures are notoriously difficult to motivate26 and it is possible that the current program was not sufficient to achieve this end.
The intervention itself may have been demanding, making compliance difficult, although self-reports suggest that the intervention group felt that they had adopted safety precautions (62% and 23% reported home safety modifications at 4 and 8 months, respectively). However, actual home visit observations found only 2 of 16 safety modifications favoring the intervention (lowering of hot water temperature to <54° C and the presence of smoke detectors). This is consistent with research indicating that easily installed safety devices are more likely to be used than more difficult ones.27 A less demanding task (ie, lowering hot water temperature) was adopted over those safety measures that may require a greater investment of time and energy (ie, keeping small objects out of a child's reach or ensuring that a bike helmet is worn regularly). Finally, baseline assessments indicated good awareness of injury risk and preventability by parents in both groups that was unaffected by the intervention. As such, it is likely that families enrolled in the study were already vigilant with respect to their children's environment.
Although it is unlikely that the home visit had an impact on the adoption of our home safety measures, self-reports by the families suggest that they felt the home visit was beneficial both in their perception of the adoption of home safety measures and the effect on injury occurrence. Although it is possible that a reporting bias accounted for the self-reported differences in injury rates, it is also likely that there is a benefit of the home visit that we were unable to demonstrate in this trial. The short visit (<1 hour) may not have been sensitive enough to identify the real change that resulted in the differential reduction in injury occurrence. To address the issue of why the intervention worked to decrease the rate of injury, without observed adoption of the specific prevention strategies, we plan to contact the families to evaluate the components of the intervention that they perceived as worthwhile and those that were less beneficial.
Injuries have enormous economic consequences with an annual cost estimated at $8.7 billion in Canada.28 Economic evaluation of health promotion strategies is essential to identify interventions that maximize health gain at the least cost to society. With limited financial resources, prevention efforts should focus on strategies that will yield the best benefit for the investment. Some strategies, such as childhood vaccines, have substantial savings in direct medical costs for each dollar spent, whereas other strategies, such as our intervention, may carry a net cost but still give considerable value in return for the investment. Previously, it has been estimated that on average, each injury generates $4000 in direct and indirect costs.28 Therefore, the direct care cost of $372 per injury prevented is likely to be small in proportion to the benefits gained by society. Also, it is important to recognize that the cost does not include the additional direct and indirect costs of the injury (such as the value of the time and foregone earnings of family members who care for the injured child) and therefore underestimates the true economic burden to the family and society.
Delivery of a home visit program should be as part of a comprehensive local initiative that combines the principle of focusing resources where they will do the most good with that of intervening on several risk factors simultaneously. In instances where injury prevention initiatives have proven to be effective, the population and/or the target behavior have been specific and well-defined.1829-33 Also, successful home visit programs are characterized by the establishment of a strong therapeutic relationship developed over frequent visits to address underlying factors associated with maternal and child health outcomes.34-39 Total costs of the intervention may be reduced if the program were combined with other home visit programs and targeted high-risk groups.
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CONCLUSION |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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An intervention using a single home visit to improve the extent to which families use passive and active measures was insufficient to influence the long-term adoption of home safety measures but was effective to decrease the overall occurrence of injuries. The home visit prevented 1 injury visit to the doctor for each 12 families participating in the program, and the cost of preventing these injuries was small in proportion to the benefits gained by society. Future programs should integrate with other home visitation programs and target a few, well-focused, evidence-based areas including the evaluation of high-risk groups and the effect of repeated visits on outcome.
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ACKNOWLEDGMENT |
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This study was supported by a grant (6605-4290-BF) from the National Health Research and Development Program, Health and Welfare Canada.
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FOOTNOTES |
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Received for publication Jun 9, 2000; accepted Feb 20, 2001.
Reprint requests to (W.J.K.) Division of Academic General Pediatrics, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Ontario, Canada K1H 8L1. E-mail: king{at}cheo.on.ca
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ABBREVIATIONS |
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ED, emergency department; OR, odds ratio; CI, confidence interval.
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REFERENCES |
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Conclusion
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This article has been cited by other articles:
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  D Kendrick, S Smith, A Sutton, M Watson, C Coupland, C Mulvaney, and A Mason-Jones Effect of education and safety equipment on poisoning-prevention practices and poisoning: systematic review, meta-analysis and meta-regression Arch. Dis. Child., July 1, 2008; 93(7): 599 - 608. [Abstract] [Full Text] [PDF]
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 L Swart, A van Niekerk, M Seedat, and E Jordaan Paraprofessional home visitation program to prevent childhood unintentional injuries in low-income communities: a cluster randomized controlled trial Inj. Prev., June 1, 2008; 14(3): 164 - 169. [Abstract] [Full Text] [PDF]
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 J. Bayreuther and I. Maconochie The evidenced-based care behind the early management of head injured children Trauma, April 1, 2008; 10(2): 85 - 92. [Abstract] [PDF]
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 K. J. Brown, M. C. Roberts, S. Mayes, and R. E. Boles Effects of Parental Viewing of Children's Risk Behavior on Home Safety Practices J. Pediatr. Psychol., October 1, 2005; 30(7): 571 - 580. [Abstract] [Full Text] [PDF]
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S G Hendrickson Reaching an underserved population with a randomly assigned home safety intervention Inj. Prev., October 1, 2005; 11(5): 313 - 317. [Abstract] [Full Text] [PDF]
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W J King, J C LeBlanc, N J Barrowman, T P Klassen, A-C Bernard-Bonnin, Y Robitaille, M Tenenbein, and I B Pless Long term effects of a home visit to prevent childhood injury: three year follow up of a randomized trial Inj. Prev., April 1, 2005; 11(2): 106 - 109. [Abstract] [Full Text] [PDF]
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 M. Watson, D. Kendrick, C. Coupland, A. Woods, D. Futers, and J. Robinson Providing child safety equipment to prevent injuries: randomised controlled trial BMJ, January 22, 2005; 330(7484): 178. [Abstract] [Full Text] [PDF]
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M Sznajder, S Leduc, M P Janvrin, M H Bonnin, P Aegerter, F Baudier, B Chevallier, and C Macarthur Home delivery of an injury prevention kit for children in four French cities: a controlled randomized trial * Commentary Inj. Prev., September 1, 2003; 9(3): 261 - 265. [Abstract] [Full Text] [PDF]
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 OTHER ARTICLES NOTED (Nov 01 to 18 Oct 02) Evid. Based Nurs., January 1, 2003; 6(1): e1 - 1. [Full Text] [PDF]
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 A. C. Gielen, E. M. McDonald, M. E. H. Wilson, W.-T. Hwang, J. R. Serwint, J. S. Andrews, and M.-C. Wang Effects of Improved Access to Safety Counseling, Products, and Home Visits on Parents' Safety Practices: Results of a Randomized Trial Arch Pediatr Adolesc Med, January 1, 2002; 156(1): 33 - 40. [Abstract] [Full Text] [PDF]
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