Assessed as up to date: 2009/05/07
In industrialised countries injuries (including burns, poisoning or drowning) are the leading cause of childhood death and steep social gradients exist in child injury mortality and morbidity. The majority of injuries in pre-school children occur at home but there is little meta-analytic evidence that child home safety interventions reduce injury rates or improve a range of safety practices, and little evidence on their effect by social group.Objectives
We evaluated the effectiveness of home safety education, with or without the provision of low cost, discounted or free equipment (hereafter referred to as home safety interventions), in reducing child injury rates or increasing home safety practices and whether the effect varied by social group.Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2009, Issue 2) in The Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Social Sciences Citation Index (SSCI), ISI Web of Science: Conference Proceedings Citation Index- Science (CPCI-S), CINAHL (EBSCO) and DARE (2009, Issue 2) in The Cochrane Library. We also searched websites and conference proceedings and searched the bibliographies of relevant studies and previously published reviews. We contacted authors of included studies as well as relevant organisations. The most recent search for trials was May 2009.Selection criteria
Randomised controlled trials (RCTs), non-randomised controlled trials and controlled before and after (CBA) studies where home safety education with or without the provision of safety equipment was provided to those aged 19 years and under, and which reported injury, safety practices or possession of safety equipment.Data collection and analysis
Two authors independently assessed study quality and extracted data. We attempted to obtain individual participant level data (IPD) for all included studies and summary data and IPD were simultaneously combined in meta-regressions by social and demographic variables. Pooled incidence rate ratios (IRR) were calculated for injuries which occurred during the studies, and pooled odds ratios were calculated for the uptake of safety equipment or safety practices, with 95% confidence intervals.Main results
Ninety-eight studies, involving 2,605,044 people, are included in this review. Fifty-four studies involving 812,705 people were comparable enough to be included in at least one meta-analysis. Thirty-five (65%) studies were RCTs. Nineteen (35%) of the studies included in the meta-analysis provided IPD.
There was a lack of evidence that home safety interventions reduced rates of thermal injuries or poisoning. There was some evidence that interventions may reduce injury rates after adjusting CBA studies for baseline injury rates (IRR 0.89, 95% CI 0.78 to 1.01). Greater reductions in injury rates were found for interventions delivered in the home (IRR 0.75, 95% CI 0.62 to 0.91), and for those interventions not providing safety equipment (IRR 0.78, 95% CI 0.66 to 0.92).
Home safety interventions were effective in increasing the proportion of families with safe hot tap water temperatures (OR 1.41, 95% CI 1.07 to 1.86), functional smoke alarms (OR 1.81, 95% CI 1.30 to 2.52), a fire escape plan (OR 2.01, 95% CI 1.45 to 2.77), storing medicines (OR 1.53, 95% CI 1.27 to 1.84) and cleaning products (OR 1.55, 95% CI 1.22 to 1.96) out of reach, having syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.44) or poison control centre numbers accessible (OR 3.30, 95% CI 1.70 to 6.39), having fitted stair gates (OR 1.61, 95% CI 1.19 to 2.17), and having socket covers on unused sockets (OR 2.69, 95% CI 1.46 to 4.96).
Interventions providing free, low cost or discounted safety equipment appeared to be more effective in improving some safety practices than those interventions not doing so. There was no consistent evidence that interventions were less effective in families whose children were at greater risk of injury.Authors' conclusions
Home safety interventions most commonly provided as one-to-one, face-to-face education, especially with the provision of safety equipment, are effective in increasing a range of safety practices. There is some evidence that such interventions may reduce injury rates, particularly where interventions are provided at home. Conflicting findings regarding interventions providing safety equipment on safety practices and injury outcomes are likely to be explained by two large studies; one clinic-based study provided equipment but did not reduce injury rates and one school-based study did not provide equipment but did demonstrate a significant reduction in injury rates. There was no consistent evidence that home safety education, with or without the provision of safety equipment, was less effective in those participants at greater risk of injury. Further studies are still required to confirm these findings with respect to injury rates.
Kendrick Denise, Young Ben, Mason-Jones Amanda J, Ilyas Nohaid, Achana Felix A, Cooper Nicola J, Hubbard Stephanie J, Sutton Alex J, Smith Sherie, Wynn Persephone, Mulvaney Caroline A, Watson Michael C, Coupland Carol
Home safety education and providing safety equipment for injury prevention
Injuries are the leading cause of childhood death in industrialised countries. People living in disadvantaged circumstances are at greater risk of injury than those who are more advantaged. This review examined whether home safety education and providing safety equipment reduced injuries and increased safety behaviours and safety equipment use. It also looked at whether home safety education was more or less effective in disadvantaged families. The review authors found 98 studies involving 2,605,044 participants which reported many different safety behaviours, but relatively few studies included information on injuries.
The authors found that home safety interventions provided in the home may reduce injury rates, but more research is needed to confirm this finding. The results often varied between studies but, overall, families who received home safety interventions were more likely to have a safe hot tap water temperature, a working smoke alarm, a fire escape plan, fitted stair gates, socket covers on unused sockets, syrup of ipecac, poison control centre numbers accessible, and to store medicines and cleaning products out of reach of children. The authors found that home safety education was equally effective in the families whose children were at greater risk of injury.
Implications for practice
Our evidence that home safety education and the provision of safety equipment is effective in increasing a range of safety practices, and possibly also in reducing child injury rates, suggests that child health and social care providers should provide home safety interventions including education and access to free, low cost or discounted safety equipment as part of their child health and well-being programmes. It is important that practitioners provide interventions that are as similar as possible to those we included in our meta-analyses otherwise they may not achieve similar effects. For example, most of the studies included in our meta-analyses were based on one-to-one, face-to-face education delivered either at home or in a clinical setting, so our findings cannot necessarily be extrapolated to different methods of delivery in different settings.
Home safety education and modifying the home environment by the provision of safety equipment can only ever be one part of a strategy to reduce home injuries in children. Other engineering approaches are also important components of such a strategy, for example the design of products or components of the structure of the house to increase safety, especially as these often provide passive protection (Pless 1993; Towner 2001). Strategies also need to encompass enforcement approaches such as the use of standards, regulations and legislation as these have also been found to be effective in reducing child injury rates (Erdmann 1991; Sibert 1977).
Implications for research
Our findings suggest that home safety education, especially with the provision of safety equipment, is effective in increasing a range of safety practices and it may also reduce injury rates. Further evidence is needed in relation to this latter outcome, in particular to the role of the provision of safety equipment and the effects of home-based interventions as opposed to those delivered in other settings. There are two possible options for addressing the question of whether home safety interventions are effective in reducing child injury rates. The first, and most preferable, is that further large trials or multiple smaller trials that are sufficiently clinically homogenous to combine in future meta-analyses are undertaken measuring injury outcomes. The second, but less preferable option, is that a series of methodologically rigorous observational studies that measure and adjust appropriately for a wide range of potential confounding factors are undertaken. The first option would provide the strongest evidence but at a much greater cost over a longer time period. The second would provide evidence at a lesser cost over a shorter time period, but the quality of the evidence could be limited, especially by selection bias, recall bias and confounding.
Multi-faceted home visiting programmes aimed at improving a range of maternal and child health outcomes have been found to be effective in reducing child injury rates (Elkan 2000; Roberts 1996b). Most of these programmes did not provide home safety interventions similar to that provided in the studies included in our review. It would therefore be useful to assess whether adding a home safety education and equipment component to a multi-faceted home visiting programme further reduces child injury rates.
The importance of ensuring that interventions do not widen existing inequalities in child injuries suggests that future studies should consider this possibility in their design, analysis and in the reporting of their findings. As we were unable to demonstrate differential effects for many outcomes for most demographic and social variables, some of which may have been due to a lack of power, these relationships can be re-examined if future studies measure and report these variables. Standardisation of methods of measuring social variables would be helpful as this would maximise the number of studies whose data could be included in such meta-analyses.
In relation to outcome measurement, one recent RCT (Phelan 2010) demonstrating a significant reduction in injury rates, defined injury outcomes in terms of whether they were potentially preventable by safety equipment provided as part of the intervention, and future studies should consider using such outcomes. The studies included in our review used a wide range of tools, some of which were validated, to measure a wide range of safety practices. Use of existing validated tools in future studies would maximise the potential for future meta-analyses. Furthermore, we found that standardising IPD datasets across studies required a large amount of time, and the use of standard measures would make this task considerably easier and less time consuming. As the power of meta-regression analysis is considerably greater in analyses containing IPD than in those using only summary data for participant level covariates (Lambert 2002), it is also important that the community of injury researchers is willing to share their IPD for such future research.
The model we developed for examining the effect of interventions by demographic and social variables was restricted to binary and continuous outcome measures, which comprised most of the outcomes included in our review. Whilst our model is not immediately generalisable to rate outcomes, future work may develop such models which may be useful in fields other than injury prevention.Get full text at The Cochrane Library
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