inside the home
Shields WC, Gielen AC, McDonald EM, Frattaroli S, Bishai D, van Beeck EF; Munshi, R In Review Injury Prevention
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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 utilized to develop the CHASE tool, including: 1) a literature scan 2) reviewing of existing housing inspection tools 3) key informants interviews 4) reviewing the National Electronic Injury Surveillance System to determine the leading housing elements associated with pediatric injury.
Retrospective Case Control Study to Validate CHASE Tool
Recruitment included case (injured) and control (sick but not injured) children and their families from a large, urban pediatric emergency department (PED) in Baltimore, Maryland in 2012. Trained inspectors applied both the well-known Home Quality Score (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 organized around twelve 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
Programs 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.
Child Housing Assessment for a Safe Environment (CHASE)
INTRODUCTION
Children experience injuries in their home environments at unacceptably high rates: an average of 1,870 children younger than 15 die in a home injury annually
in the United States.1 An additional estimated 2.8 million children younger than
12 experience non-fatal home injuries every year. For every death, there are
almost 1,600 nonfatal home injuries.2 The World Health Organization recognizes
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, though 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 neighborhoods (e.g., poor-quality structures, faulty electrical wiring)
likely contribute to low-income families’ increased risk for home injury. 9-
11Residents 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 neighborhoods 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 Zealand 19 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 modifications 20,21 (e.g., smoke alarms cut the risk of
death in a house fire in half).22-23 Studies of smoke alarm canvassing and installation programs 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” program28 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 program resulted in a legislative change that required landlords to provide window guards and further reductions in falls from windows where achieved.28
The benefits of home safety modifications have not reached all segments of society. Socio-economic inequalities have been documented in the adoption and use of specific home safety products (i.e. smoke alarms and stair gates). 7 Low- income families face many barriersincluding limited access to safety products and injury prevention information, along with the poverty-related housing conditions described above can be significant barriers to child safety. 29-32 Data from our own observations in low income areas of East Baltimore found presence
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of at least one working smoke alarm ranged from 55% to 82%33,34, 41% of homes had unsafe water temperatures35 and only 10% of families with young children kept any of their poisonous substances locked29, 34. Almost all (97%) of families in one study reported keeping their prescription medications unlocked.36
Housing programs provide a promising opportunity to deliver evidence-based home safety modifications. The U.S. Department of Housing and Urban Development (HUD) is the largest provider of housing assistance in the United States with approximately 5 million subsidized 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, mold, 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, biologic 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 programs 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 neighborhood 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 utilization of the CHASE (Child Housing Assessment for a Safer 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 vs. not. In section one we describe the development of the CHASE tool. In section two we describe the methods and the results of the case control study s in a sample of low income, urban households
Child Housing Assessment for a Safe Environment (CHASE)
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 vs. homes where there had not. This study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.