Article Text
Abstract
Objective To develop a tool to assess the safety of the home environment that could produce valid measures of a child’s risk of suffering an injury.
Methods Tool development: A four-step process was used to develop the CHASE (Child Housing Assessment for a Safe Environment) tool, including (1) a literature scan, (2) reviewing of existing housing inspection tools, (3) key informants interviews, and (4) reviewing the National Electronic Injury Surveillance System to determine the leading housing elements associated with paediatric injury. Retrospective case–control study to validate the CHASE tool: Recruitment included case (injured) and control (sick but not injured) children and their families from a large, urban paediatric emergency department in Baltimore, Maryland in 2012. Trained inspectors applied both the well-known Home Quality Standard (HQS) and the CHASE tool to each enrollee’s home, and we compared scores on individual and summary items between cases and controls.
Results Twenty-five items organised around 12 subdomains were included on the CHASE tool. 71 matched pairs were enrolled and included in the analytic sample. Comparisons between cases and controls revealed statistically significant differences in scores on individual items of the CHASE tool as well as on the overall score, with the cases systematically having worse scores. No differences were found between groups on the HQS measures.
Conclusion Programmes conducting housing inspections in the homes of children should consider including the CHASE tool as part of their inspection measures. Future study of the CHASE inspection tool in a prospective trial would help assess its efficacy in preventing injuries and reducing medical costs.
- environmental modification
- case-control study
- mixed methods
- health disparities
- home
- child
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Introduction
Children experience injuries in their home environments at unacceptably high rates: an average of 1870 children younger than 15 die in a home injury annually in the USA.1 An additional estimated 2.8 million children younger than 12 experience non-fatal home injuries every year. For every death, there are almost 1600 non-fatal home injuries.2 The WHO recognises unintentional injuries as a leading cause of death to children and identify their reduction as a priority.3 The poor and certain minority populations are disproportionately affected by home injuries, although racial disparities seen in injury rates most likely have more to do with living in unhealthy environments and a host of social disparities rather than race or ethnicity.4–8 Housing conditions in low-income neighbourhoods (eg, poor-quality structures, faulty electrical wiring) likely contribute to low-income families’ increased risk for home injury.9–11 Residents of substandard housing are at increased risk for fire, electrical injuries, lead poisoning, falls, rat bites and other injuries.12–16 Several studies in the USA, UK and Europe have found that children living in socioeconomically disadvantaged neighbourhoods are at increased risk of home injury, even after accounting for individual-level background factors.9 11 17 18 Moreover, a case–control study in New Zealand19 measured the association between home injury hazards and home injury. With each additional injury hazard observed in the homes, there was a 22% increase in the odds of injury occurrence, suggesting that addressing injury hazards in the home may be effective in reducing home injury.
Decades of research and practice have led to an extensive body of evidence about effective home safety modifications20 21 (eg, smoke alarms cut the risk of death in a house fire in half).22 23 Studies of smoke alarm canvassing and installation programmes provide successful examples of modifying the home environment to reduce home injury risk to children.24–27 Another widely cited example of successfully modifying housing conditions to reduce child injury is New York City’s ‘Children Can’t Fly’ programme,28 which installed window guards on high-rise apartments and is credited with significant reductions in morbidity and mortality due to falls from windows. The success of the programme resulted in a legislative change that required landlords to provide window guards and further reductions in falls from windows were achieved.28
The benefits of home safety modifications have not reached all segments of society. Socioeconomic inequalities have been documented in the adoption and use of specific home safety products (ie, smoke alarms and stair gates).7 Low-income families face many barriers, including limited access to safety products and injury prevention information, and along with the poverty-related housing conditions described above these can be significant barriers to child safety.29–32 Data from our own observations in low-income areas of East Baltimore found the presence of at least one working smoke alarm ranged from 55% to 82%,33 34 41% of homes had unsafe water temperatures,35 and only 10% of families with young children kept any of their poisonous substances locked.29 34 Almost all (97%) of the families in one study reported keeping their prescription medications unlocked.36
Housing programmes provide a promising opportunity to deliver evidence-based home safety modifications. The US Department of Housing and Urban Development (HUD) is the largest provider of housing assistance in the USA with approximately five million subsidised units available.37 HUD’s primary mission is to ‘create strong, sustainable, inclusive communities and quality affordable homes for all’.38 Since 1999 HUD has been transitioning from a focus on lead hazard control to a more comprehensive approach aimed at reducing multiple environmental hazards in homes, including lead, mould, asthma and injury risks. This transition was marked by an expansion of the name to the Office of Healthy Homes and Lead Hazard Control. This office (still known as ‘HUD’) ensures homes have acceptable indoor air quality, and do not expose occupants to toxic chemicals, biological contaminants and injury hazards, which are known to affect the health and safety of residents.
Despite this understanding of the burden of injuries in the home environment and the evidence base for reducing injury risks via modifications, the housing inspection tools used by HUD have few items related to injury. Housing inspections are a required component for homes to qualify as rental assistance properties. The largest of HUD’s housing assistance programmes is the Housing Choice Voucher Program (‘Section 8’ housing) with 2.2 million properties.39 The Housing Choice Voucher Program provides financial assistance in the form of a monthly voucher to assist with the rental payments. In order to qualify for rental assistance, properties must be deemed ‘decent, safe and sanitary’ according to HUD’s housing quality standards as determined by their inspection system. The form used to guide inspections is the HOME Housing Quality Standards (HQS) Inspection Form, and trained housing inspectors are certified to complete annual assessments.40 The 120 HQS items focus primarily on structural housing elements and some neighbourhood features, along with a few injury prevention measures. We undertook a study to improve the HQS (and other similar housing hazard assessment tools) to systematically identify and remediate child injury hazards in the home, something that has not been previously reported in the peer-reviewed literature.
This paper reports on the development and utilisation of the CHASE (Child Housing Assessment for a Safe Environment) housing inspection tool designed to reduce injury risks in the homes of children. In a small retrospective study, we assessed the ability of the CHASE and HQS tools to discriminate between homes that are associated with a child injury versus not. In the Tool development section, we describe the development of the CHASE tool. In the Prospective case–control study section, we describe the methods and the results of the case–control study in a sample of low-income, urban households with children. We tested the null hypothesis that both the new CHASE tool and the existing HQS tool would have similar capability to distinguish homes where there had been a recent injury versus homes where there had not.
Methods
Tool development
We developed the CHASE tool through a four-step process: (1) a scan of the currently available literature to determine the epidemiology and risk factors for the leading causes of unintentional home injury and death among children; (2) a review of existing housing inspection tools to identify items for inclusion on the CHASE housing inspection tool; (3) phone and inperson interviews with key informants in the healthy housing and housing inspection community to determine how items were chosen for inclusion on their inspections tools; and (4) a review of the housing elements in the National Electronic Injury Surveillance System to determine the leading housing elements associated with child injury emergency department visits and hospitalisations.29 The investigators then developed an inspection protocol for each of the items selected for inclusion on the CHASE tool and a training programme for inspectors (data collectors). Finally, cost estimates for each CHASE item were determined by searching online for product prices and discussing labour costs with home maintenance professionals.
Prospective case–control study
Study population
We recruited children from a large, urban paediatric emergency department (PED) in Baltimore, Maryland. Families were enrolled between January and December 2012 if they met the following enrolment criteria: (1) child aged from birth to 7 years, (2) child had a PED visit that was not a follow-up visit, (3) child was discharged home, (4) home address in Baltimore city or county, (5) parent/guardian spoke English, (6) child lived with the parent/guardian most of the time, and (7) the injury occurred in the home where the child lived most of the time (cases). Controls met all of the above inclusion criteria except that their chief complaint for the PED visit was for illness-related symptoms, not an injury. Participants were matched on variables associated with injury risk, including, age, gender, race and type of housing during recruitment.
Recruitment
We recruited parents in person in the PED or by mail or phone if the child visited the PED during hours when the study staff were not available or were discharged before the study staff approached the parent. In the PED, potentially eligible children were identified by reviewing the PED tracking board. Parents of age-eligible children were approached if the child presented with a chief complaint consistent with a home injury and one of the following four injury categories: (1) fall, (2) struck by/against, (3) fire/burn, or (4) cut/pierce or one of the following illness-related chief complaints: (1) fever, (2) wheezing, (3) vomiting, (4) seizure, (5) ear pain, (6) difficulty breathing, (7) cough, (8) rash, (9) abdominal pain or (10) congestion. For parents who were missed in the PED, potentially eligible children were identified by reviewing patient discharge records. A child was excluded from the study if suspicion of abuse was noted on the tracking board or on child’s medical record.
CHASE tool training and inspection protocol
Data collectors were trained to inspect and code items according to a standardised inspection protocol for both CHASE and HQS. A field inspection guide was developed with pictures to demonstrate the pass and fail criteria. Data collectors completed human subjects training, standard data collection training and 10 hours of training in conducting the home inspection protocol. Data collectors were observed completing the inspection protocol by the research team prior to being eligible to complete it on their own.
Inhome data collection protocol
A team of two data collectors completed the home visits within 1–8 weeks following the PED visit. The home visit included an interview with the parent/guardian who accompanied the child to the PED and an inspection of the home with the CHASE tool. Parents were informed about the study at the time of initial contact and written informed consent was obtained from the parent/guardian at the time of the home visit. The inspection involved completing both the HQS and the CHASE by observing each floor of the household, including specifically selected rooms: kitchen, living room (or room where the child spent the most time), child’s bedroom and bathroom most often used by the child. Data collectors also looked for (and tested) smoke alarms on every floor, including attics and basements whenever possible.
Measures
Sociodemographics
The inhome parent interview assessed demographic information, including parent self-reported race and ethnicity, parent education level, and estimated household income. We classified families as being above or below the federal poverty level (FPL) based on the reported household income and the number of people supported with that income.
Household characteristics
The home was classified based on parent self-report during the recruitment process into one of four housing categories: (1) row house, town house or duplex; (2) detached, single family home; (3) apartment in a house; and (4) apartment in a building.
Housing inspection measures
Data collectors were kept blinded about the case/control status of enrollee households. When they reached the home, they were instructed not to ask about the child’s case/control status. Each data collector completed both HUD’s HQS Inspection Form40 and the CHASE tool. A total of 20 HUD HQS subdomains were included. HQS subdomains cover a comprehensive group of measures related to the adequacy and structural integrity of the home, including an inspection of the condition of windows, floors, walls, ceiling, plumbing, stairs, cooking facilities and so on. HQS subdomains also include examination for electrical hazards, lead-based paint, security risks and smoke alarms. Exterior items (ie, roof, gutters, chimney) from the HQS were not included in our inspection because our focus was on inhome injuries. A total of 25 CHASE items within 12 subdomains were also inspected. HQS and CHASE items were coded as pass or fail based on the study protocol and the existing HQS standards. Failing any item within a subdomain resulted in a failure on that subdomain (eg, failing on a book case and entertainment centre hazard resulted in failing the subdomain ‘tipping hazards’ on the CHASE; any broken window resulted in failing the corresponding subdomain ‘window condition’ on the HQS).
Statistical analysis
All statistical analyses were performed using SPSS V.25 statistical software. Frequency distributions were used to report on the pass/fail rate on the CHASE and HQS. Univariate comparisons of sociodemographic characteristics between the cases (injured) and controls (sick, not injured) were made using the χ2 statistic for categorical variables. The primary analyses were the comparison between the cases and controls of the CHASE subdomain and the HQS subdomain score, using the average pass rate across all subdomains. Children were matched on age, gender and type of housing. Matched conditional logistic regression was performed in SPSS V.25, which is analogous to a paired t-test. Each estimated beta coefficient is interpreted as a standard regression estimate. Separate models were run for the CHASE subdomains and the HQS subdomains. The matched logistic regression models were adjusted by including education level, poverty status and rental status, such that the resulting regression estimate accounts for these key covariates.
Results
CHASE housing inspection tool development
Twenty-five items organised around 12 subdomains were included on the CHASE tool. Pass criteria, inspection protocol, inspection recommendations, supporting literature and cost estimates were provided for each CHASE item. Consistent with the organisation of the HQS, the CHASE items were similarly organised around the subdomains of different injury causes: household water temperature (one item), bathroom fall hazards (two items), fire escape (three items), electrical safety concerns (four items), electrical tripping hazards (one item), protruding nails (one item), tipping hazards (five items), carbon monoxide alarms (one item), poison storage (two items), interior stair safety (two items), window fall safety (two items) and smoke alarms (one item) (see online supplementary file l).
Supplemental material
Sample
A total of 1023 families were invited to participate in the study; 176 families were enrolled and completed the home visit. Of the non-participants, 97 were screened eligible but did not complete the home visit, 162 were ineligible, 191 refused screening and 397 were never reached. Among the 176 families enrolled, 71 matched pairs were identified for inclusion in the analytic sample; 34 families (2 cases, 32 controls) were not included because a suitable match was not identified. Children included in the analytic sample were predominately African–American (82.9%) boys (60.6%), with a mean age of 2.5 years. The majority of parents/guardians were unmarried (64.3%), women (93%), with a high school education or greater (74.6%), lived above the FPL (55.6%), and in rented (81%) and row (78.2%) houses. No significant differences were found between the cases and controls on demographic factors (see table 1).
CHASE tool
Individual item pass rates varied greatly across CHASE items, from 0% having medication locked and 13% having window guards, to 88% being free of furniture crowding and 87% having proper exits. The majority of households had safe water temperatures (54%) and carbon monoxide alarms (68%). However, most households also had failure rates greater than 50% for bathroom fall hazards (89%), furniture and television tipping hazards (99%), lack of a secure place to store medications and household poisons (100%), issues with stair safety (80%), window fall risks (85%), and window choking hazards (61%). The overall per cent of subdomains passed was 54% for cases and 59% for controls (see table 2).
HQS tool
Individual item pass rates ranged from a low of 61% having a working smoke alarm on all levels to a high of 98% being free of signs of garbage. Pass rates on the HQS measures were generally high, with 91% on average of subdomains passed for the total group (90% for cases, 92% for controls) (see table 3).
Comparison between cases and controls
Significant differences in pass rates were found between the cases and controls on the following CHASE items: overloaded electrical outlets (58% vs 76%), inadequate or missing handrails (47% vs 65%), unsafe steps (18% vs 38%), and electrical tripping hazards (70% vs 79%), with the cases being significantly less likely to pass. No differences were found between groups on the HQS measures. In the adjusted paired regression analysis of the overall average pass rates, case status was significantly associated with the CHASE subdomains such that cases compared with controls were significantly less likely to pass, −4.527 (2.13) (p=034) (see table 4). The HQS subdomain model analyses suggest no difference in scores between cases and controls (see table 4).
Discussion
These results add to the literature by demonstrating the potential of an improved home inspection tool to contribute to child injury prevention.41 Our findings also demonstrate that not all tools are equal in terms of identifying injury hazards and injury risk. The CHASE tool was statistically significantly more likely to result in a non-passing score in homes of injured children compared with homes of matched non-injured controls. The CHASE tool differs from the HQS in that it explores areas which are specifically related to housing conditions that are hazardous to children, that is, securing furniture tipping hazards and locking medicines. The authors believe that assisting parents by addressing injury measure with the same attention as the HQS is used to address failures in measures of structural housing condition would greatly reduce injury risks in homes. Our findings in the current study are consistent with our own previous work as well as the work of others. Data from our own observations in low-income areas of East Baltimore found that 41% of homes had unsafe water temperatures and only 10% of families with young children kept any of their poisonous substances locked.32 34 Almost all (97%) of families in one study reported keeping their prescription medications unlocked, which is consistent with the finding in the current study which found that no families were storing their medicines in a locked place.35
While the results offer important insights about home inspection tools and identifying injury risks, they should be interpreted in the context of several limitations. The proportion of those recruited and enrolled was low (17%). Reasons for refusal and differences between those who enrolled and those who did not are unknown. Resources limited our control sample to one per case; having multiple controls per case would have strengthened our findings. We included children with four types of injuries and did not attempt to associate the type of injury with specific inspection failures. Findings suggest an overall association, which may be due to other unmeasured factors. Even though the multivariate analysis controlled for household economic status, there may be other unmeasured confounders that correlate with both injury and items on the CHASE tool. For instance, the intensity of parental monitoring is known to correlate with child injury and may also be associated with a lack of vigilance against household hazards. It cannot be assumed that structural hazard correction will also ameliorate parental monitoring. Findings from this study are based on a sample of homes in an urban environment. The extent to which these results are generalisable to other environments (eg, rural, newer construction and so on) is unknown. An additional consideration is the fact that we used non-injured patients as controls. This allowed us to explore the hypothesis that injury status could be associated with household injury measures, which was a strength of the design. However it may be the case that there are inherent differences between families of children seeking non-urgent healthcare in the emergency department and families of injured children which were not fully anticipated or controlled for with our study design. Future work with a larger sample might be able to examine associations between the types of injury in relation to explanatory hazards in the home.
The recognition of the relationship between housing and health and the existence of home inspection programmes offers opportunities for injury prevention professionals concerned with home injuries to collaborate with the growing healthy housing community to reduce home injuries. Housing professionals’ access to and knowledge about homes and their ability to inform housing policy complement injury prevention professionals’ understanding of injury and associated risks. Broad dissemination and use of the CHASE tool has the potential to decrease injury risk in homes served by existing inspection programmes that are not currently addressing injury hazards in the home.
Conclusion
Programmes conducting housing inspections in the homes of children should consider including the CHASE tool as part of their inspection measures. Future research should use the CHASE inspection tool in a prospective sample of homes to determine its efficacy in preventing injuries and reducing medical costs.
What is already known on the subject
Children experience injuries in their home environments at unacceptably high rates: an average of 1870 children younger than 15 die in a home injury annually in the USA.
Housing inspection tools do not routinely include a comprehensive assessment of home injury risks.
What this study adds
Housing programmes provide a promising opportunity to deliver evidence-based home safety modifications.
Programmes conducting housing inspections in the homes of children should consider including the CHASE (Child Housing Assessment for a Safe Environment) tool presented in this manuscript as part of their inspection measures.
References
Footnotes
Funding This study was funded by National Center for Injury Prevention and Control, CDC (1R49CE002466).
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval The study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.
Provenance and peer review Not commissioned; externally peer reviewed.