Modification of the home environment for the reduction of injuries: Cochrane systematic review

Abstract

Assessed as up to date: 2009/11/30

Background

Injury in the home is common, accounting for approximately a third of all injuries. The majority of injuries to children under five and people aged 75 and older occur at home. Multifactorial injury prevention interventions have been shown to reduce injuries in the home. However, few studies have focused specifically on the impact of physical adaptations to the home environment and the effectiveness of such interventions needs to be ascertained.

Objectives

To determine the effect of modifications to the home environment on the reduction of injuries due to environmental hazards.

Search strategy

We searched The Cochrane Library, MEDLINE, EMBASE and other specialised databases. We also scanned conference proceedings and reference lists. We contacted the first author of all included randomised controlled trials. The searches were last updated to the end of December 2009, and were not restricted by language or publication status.

Selection criteria

Randomised controlled trials.

Data collection and analysis

Two authors screened all abstracts for relevance, outcome and design. Two authors independently assessed methodological quality and extracted data from each eligible study. We performed meta-analysis to combine effect measures, using a random-effects model. We assessed heterogeneity using an I2 statistic and a Chi2 test.

Main results

We found 28 published studies and one unpublished study. Only two studies were sufficiently similar to allow pooling of data for statistical analyses. Studies were divided into three groups; children, older people and the general population/mixed age group. None of the studies focusing on children or older people demonstrated a reduction in injuries that were a direct result of environmental modification in the home. One study in older people demonstrated a reduction in falls and one a reduction in falls and injurious falls that may have been due to hazard reduction. One meta-analysis was performed which examined the effects on falls of multifactorial interventions consisting of home hazard assessment and modification, medication review, health and bone assessment and exercise (RR 1.09, 95% CI 0.97 to 1.23).

Authors' conclusions

There is insufficient evidence to determine whether interventions focused on modifying environmental home hazards reduce injuries. Further interventions to reduce hazards in the home should be evaluated by adequately designed randomised controlled trials measuring injury outcomes. Recruitment of large study samples to measure effect must be a major consideration for future trials. Researchers should also consider using factorial designs to allow the evaluation of individual components of multifactorial interventions.

Author(s)

Turner Samantha, Arthur Geri, Lyons Ronan A, Weightman Alison L, Mann Mala K, Jones Sarah J, John Ann, Lannon Simon

Summary

More evidence is needed to show whether or not altering the physical home environment by removing potential hazards reduces injuries

Injuries in the home are very common. Most of the injuries to older people and children under five occur at home. Many people are encouraged to alter their home to try and reduce injury and injury risk. Common alterations include the fitting of locks on cupboards, installing stair gates, improvement of lighting in halls and stairways, and the removal of trip hazards. The review found that there is insufficient evidence from studies to show that such changes reduce the number of injuries in the home but does not conclude that these interventions are ineffective. Home alterations need to be evaluated by larger and better designed studies which include injuries in their outcomes.

Reviewer's Conclusions

Implications for practice

The conclusion of this systematic review is that there is very little high-grade evidence that interventions to modify the home physical environment affect the likelihood of sustaining an injury in the home.

Injuries occur as a result of complex interactions between individuals and the environment and can always be considered multifactorial in nature. The results of this systematic review of modifying the physical environment in the home to reduce injuries (with the exception of the provision and promotion of smoke alarm ownership, which was excluded from the review) demonstrate a paucity of evidence on which to base current practice. Whilst it is logical to deduce that physical hazards and poor design and layout contribute to a sequence of events culminating in an injury, it is not possible to conclude that the amelioration of such hazards will definitely reduce the number of injuries. Nor is it possible to determine which aspects of multifactorial interventions are most cost effective. In the absence of good quality evidence, it is human nature for individuals to use interventions in the hope that they might be effective. This review has not shown that such interventions do not work. Limitations within the studies meant it was difficult to reach definitive conclusions in most cases.

Implications for research

RCTs provide the gold standard for the assessment of the effectiveness of interventions. This review shows the paucity of appropriately designed and sized studies to test the effectiveness of interventions to remove or reduce physical hazards in the home environment in reducing injury occurrence.

Studies were generally too small to have sufficient power to detect anything but a very large effect and rarely employed a factorial design that would allow an assessment of specific interventions as part of a multifactorial intervention. Most studies had very low uptake rates for interventions. The active involvement of participants in the design of studies might improve this. The challenge to the global injury research community is to collaborate to design and implement studies of a sufficient size, rigorous design and acceptability to participants to answer these important questions.

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