Health Education Research Advance Access published online on January 17, 2008
Health Education Research, doi:10.1093/her/cym083
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Does targeting injury prevention towards families in disadvantaged areas reduce inequalities in safety practices?
1 Division of Primary Care, University of Nottingham, Floor 13, Tower Building, University Park, Nottingham, NG7 2RD, UK
2 Broxtowe and Hucknall Primary Care Trust, Hucknall Health Centre, Curtis Street, Hucknall, Nottingham, NG15 7JE, UK
3 School of Nursing, University of Nottingham, Nottingham, NG7 2HA, UK
Correspondence to: * Correspondence to: D. Kendrick. E-mail: denise.kendrick{at}nottingham.ac.uk
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Abstract |
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Inequalities in childhood injury and safety practices exist, but there is little evidence that targeted interventions can reduce such inequalities. This study examines the effect of a home safety intervention on reducing inequalities in safety practices using a secondary analysis of data from a randomized controlled trial. Families with children <5 years from disadvantaged areas were randomized to receive a standardized health visitor safety consultation and free or low-cost safety equipment fitted in the home or to usual care. The impact of the intervention in terms of stair gate use and functioning smoke alarms was compared by ethnic group, maternal age, housing tenure, family type and receipt of state-provided means-tested benefits at 1-year follow-up. Marked inequalities were found for both safety practices by each socio-economic characteristic prior to the intervention. The intervention significantly reduced inequalities in stair gate use by housing tenure (P = 0.006) and receipt of benefits (P = 0.04), but did not reduce inequalities in functioning smoke alarms. We conclude that a home safety intervention targeted at deprived areas addressing the barriers of cost and needing help to fit equipment was only partially successful in reducing inequalities in safety practices. Other strategies will be required to reduce inequalities especially in relation to functioning smoke alarms.
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Introduction |
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There are steep social gradients in child injury mortality and morbidity. These gradients exist for a variety of social groups including occupational class [1], deprivation of area of residence [2–4], family type [5–7], housing tenure [8, 9], low income [6, 9–11] and young maternal age [9, 12–14]. There is conflicting evidence regarding ethnic group and injury morbidity with lower rates of self-reported injury [15] and lower hospitalization rates in areas with a high ethnic minority group population [16] but higher rates of child pedestrian injury [17].
One of the potential explanations for differential injury rates by social group is differential access to, or uptake of, injury prevention interventions across social groups [18, 19]. There is evidence that families living in disadvantaged areas [20], those on a low income [20], in rented accommodation [21, 22], those with young mothers [23], single parents [23] and from ethnic minority groups [24], are less likely to engage in a range of safety practices, including having lower rates of safety equipment usage. In an attempt to address child injury inequalities, prevention programmes are frequently targeted at families, neighbourhoods or communities considered to be at high risk of injury [25–28]. Such programmes often involve providing safety advice and increasing access to low-cost safety equipment, which has the potential to reduce inequalities in safety practices. Despite this, recent systematic reviews highlight the lack of evidence relating to the effect of targeting injury prevention programmes on reducing inequalities in child injury or in safety practices [29–31].
The objective of the analyses presented here is to examine the effect of targeting health visitor safety advice and increasing access to safety equipment to low-income families living in disadvantaged areas on reducing inequalities in child safety practices.
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Methods |
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We undertook a randomized controlled trial to evaluate the effect of health visitor advice, plus providing and fitting safety equipment to families living in deprived areas in Nottingham, UK. The methods and results of the trial have been presented elsewhere [32].
All health visitors working in practices within Nottingham Health Authority boundary with Townsend scores (an area-based deprivation score based on four census indicators: rented accommodation, unemployment, lack of access to a car and household overcrowding) above zero were invited to participate in the trial and 62 health visitors from 47 practices participated. The trial population comprised families with children aged <5 years from health visitors’ caseloads. Families were recruited using postal invitations and were excluded if any child was on the Child Protection Register or if there had been a fatal childhood unintentional injury.
The intervention comprised a standardized safety consultation in which parents completed a questionnaire on the safety needs of their family [32]. The health visitor discussed parental responses, provided positive feedback by reinforcing current safety practices, discussed safety issues not currently being addressed by parents, difficulties experienced by parents in implementing safety practices and possible solutions and offered free or low-cost safety equipment. Parents and the health visitor agreed a plan for making the home safer and parents were given a copy of this plan. Parents were also given a home safety checklist so they could check the safety of their home 1 week later. Stair gates, fire guards, smoke alarms, cupboard locks and window locks were offered, and fitted, free of charge to families receiving state provided means-tested benefits. Families not receiving such benefits were offered equipment at cost price and a delivery service to their home. Families randomized to the control arm of the trial received usual care from their health visitor and did not have access to the free or low-cost safety equipment. We have previously demonstrated that only one-fifth of ‘usual care’ consultations undertaken by health visitors participating in the trial included discussion of safety topics [33].
Safety practices, reasons for not possessing items of safety equipment and socio-economic characteristics were assessed at recruitment. Injury prevention practices were assessed 1 year after commencement of the intervention, by validated postal questionnaires to random samples of 1000 families from each study arm [34]. Ethical approval was obtained from the Queen's Medical Centre Research Ethics Committee, Nottingham, UK.
As the arms of the trial were well balanced at baseline, (Table I) intervention and control arm data were combined for baseline comparisons by socio-economic characteristics. We assessed the effect of the intervention on home injury prevention practices and safety equipment use for five socio-economic characteristics: ethnic group, maternal age, family type, housing tenure and receipt of state provided means-tested benefits. These were chosen because it is theoretically plausible that they may influence the effect of the intervention and because there were marked inequalities at baseline in home injury prevention practices by these social variables. We chose two injury prevention practices to examine: having a fitted and always used stair gate and having a fitted and working smoke alarm. Although the intervention was effective in increasing six home safety practices [32], we restricted our analyses to these two practices to reduce the risk of Type 1 error, to focus on the safety practices showing the most marked inequalities at baseline and to those with high sensitivity and positive predictive values in the validation study [34].
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We compared safety practices and reasons for not having items of safety equipment by socio-economic variables using logistic regression analyses. To assess whether the relationship between the social variable and the injury prevention practice differed at 1-year follow-up between the arms of the trial, we included a term for the interaction between trial arm and each social variable. We used random effects models to take account of any clustering by health visitor and a significance level of 0.05 for all analyses. As stair gate use is only recommended below the age of 3 years [35], a sensitivity analysis was undertaken adjusting analyses of stair gate use by whether all children in the family were aged <36 months or not. Analyses were undertaken using Stata version 8.0.
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Results |
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Table I illustrates that the trial arms were well balanced at baseline. Participants experienced a high degree of socio-economic disadvantage and the prevalence of most home injury prevention practices was relatively low, with the exception of safe storage of medicines and having at least one fitted and working smoke alarm. Response rates to the survey of safety practices at Year 1 were high and similar between trial arms [771/988 (78%) and 744/980 (76%) in the intervention and control arms, respectively]. A total of 518 (30%) intervention arm families received the safety consultation, 619 (36%) received the safety consultation and had equipment provided and fitted for free and 26 (2%) received the safety consultation plus purchased low-cost equipment.
The relationship between having a fitted and used stair gate and socio-economic characteristics at baseline and at 1-year follow-up are shown in Table II. There were marked inequalities for having a fitted and used stair gate for each of the socio-economic characteristics at baseline (all P values <0.001). This was most marked for ethnic group where families from an ethnic group other than white had 52% reduction in the odds of having a fitted and always used stair gate compared with white families. Inequalities in relation to ethnic group, maternal age, housing tenure and family type persisted at 1-year follow-up for control group families, but not for intervention group families. The intervention significantly reduced inequalities in terms of stair gate possession by housing tenure and receipt of means-tested benefits. There were reductions in inequalities in relation to maternal age (P = 0.06 for interaction term) and family type (P = 0.07 for interaction term) of borderline statistical significance. These findings were robust to adjusting for child age.
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The relationship between having a fitted and working smoke alarm and the five socio-economic characteristics at baseline and at 1-year follow-up are shown in Table III. There were marked inequalities for having a fitted and working smoke alarm for each of the socio-economic characteristics (all P values <0.001), and again this was most marked for families from an ethnic minority group, whose odds of having a fitted and working alarm were 67% lower than that for white families. Inequalities in relation to ethnic group, maternal age, housing tenure and low income persisted at 1-year follow-up among both control and intervention group families. There was no evidence that the intervention significantly reduced these inequalities.
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Table IV shows the three reasons most commonly reported at baseline for not having a fitted and used stair gate and a functioning smoke alarm. There were clear social gradients for not having equipment because of cost and needing help to fit it, but there was little evidence of a social gradient for not wanting items of equipment. Forgetting to buy or fit a smoke alarm was positively associated with older maternal age, two-parent families and families not receiving benefits. In terms of whether the intervention addressed the barriers of cost and difficulty fitting equipment, the majority of intervention arm families giving cost as a reason for not having a stair gate (87/123, 71%) or smoke alarm (63/92, 68%) requested these items of equipment, and the majority of those requesting stair gates (79/87, 91%) and smoke alarms (58/63, 92%) had these fitted as part of the intervention. Half of the families giving difficulty fitting as a reason for not having a stair gate (17/32, 53%) and two-thirds of the families giving difficulty fitting as a reason for not having a smoke alarm (66/99, 67%) requested these items of equipment and the majority of those requesting stair gates (16/17, 94%) and smoke alarms (60/66, 91%) had these fitted as part of the intervention.
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Discussion |
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Principal findings
Marked inequalities in both safety practices by all socio-economic characteristics were found at baseline. These were most marked for possession and use of stair gates and smoke alarms by ethnic group. The intervention was effective in reducing inequalities in possession and use of stair gates among families living in rented accommodation and those on a low income. The intervention was not effective in reducing inequalities in smoke alarm possession and use by any socio-economic characteristics. There were marked social gradients in not having equipment because it cost too much or because the family needed help to fit the equipment but these were not evident for not wanting items of equipment. Forgetting to buy or fit a smoke alarm was positively associated with older maternal age, two-parent families and not receiving benefits.
Strengths and limitations of the study
This is the first study to examine the impact of an intervention to reduce inequalities in a range of safety practices by a range of socio-economic characteristics. We used data from the largest published trial to date examining the effect of home safety education and the provision of safety equipment and we used a questionnaire that had previously been validated by home observations of safety practices. Although our analyses represent the most powerful published examination of this research question using individual patient-level data to date, the power to detect a significant reduction in inequalities will have been limited where numbers in sub groups were small, e.g. by ethnic group, or where data on social variables were missing. In addition where the prevalence of safety practices was high at baseline among most social groups, e.g. smoke alarms, a ceiling effect may have limited the ability to demonstrate an impact on inequalities. Examining effects across five social variables increased the chance of Type 1 error, and our findings should be interpreted in this context. However, Type 1 error is unlikely to explain the consistent findings relating to social group inequalities in possession and use of stair gates and smoke alarms at baseline or the lack of impact on inequalities in smoke alarm ownership at 1-year follow-up.
The trial on which this analysis is based was a pragmatic trial with an intention to treat analysis, and hence its findings should represent the likely impact of providing safety advice and free fitted safety equipment in the community. However, as only two-thirds of participants received the safety consultation and only one-third received free fitted safety equipment, it is possible that a greater impact on inequalities could be achieved with greater penetration of the intervention. Nonetheless, our findings reflect the actual impact on inequalities of delivering home safety advice and safety equipment, targeted at low-income families in disadvantaged areas, in the manner in which they were delivered in the trial.
Comparisons with previous research
Few studies have examined the effect of child safety interventions on home safety practices by a variety of socio-economic variables [36–40]. Two randomized controlled trials found that the intervention appeared to be at least as effective, if not more effective, in families considered to be at greater risk of injury through low income [36], lower levels of maternal education [39] or single parenthood [39]. However, while this may indicate that the intervention may have the potential to reduce inequalities, neither specifically assessed the effect of their intervention on reducing such inequalities. Other studies have found no evidence of a differential effect of the intervention by parity, income, parental educational level or socio-economic status [37, 38, 40]. Our study demonstrates that home safety interventions targeted at families in disadvantaged areas reduce social inequalities in some, but not all, safety practices.
Possible explanations for our findings
The intervention provided in this trial addressed the barriers of cost and needing help to fit equipment, which may explain the reduction in some of the inequalities in stair gate possession. The intervention had less impact on reducing inequalities relating to maternal age, single parenthood and ethnic group than on those related to low income and housing tenure. This suggests that despite cost and difficulty fitting equipment frequently being reported as reasons for not having equipment at baseline, there may be other, possibly more important reasons why young mothers, single parents and families from ethnic groups other than white were less likely to have stair gates than older mothers, two-parent and white families. These require further exploration, but may include differences in perceptions (e.g. of risk, self-efficacy to prevent injuries or the inconvenience of stair gates), understanding of child development, supervisory practices, beliefs about the ‘learning value’ of injuries, the role of safety equipment in relation to other strategies used for promoting child safety and acceptability of the intervention which involved (usually male) workers fitting the safety equipment in families homes. In addition, despite the intervention being delivered by the families’ usual health visitor, using the interpreting services available for providing routine care, language barriers may have limited access to the intervention, for example, if interpreters were unavailable or if family members acted as interpreters. If this did occur, this may help explain the lack of impact of the intervention on reducing inequalities by ethnic group. Differences in child age by social group did not explain inequalities in stair gate possession as adjusting for this had little impact on our findings.
Cost and difficulty in fitting smoke alarms and stair gates are frequently cited reasons for not having such equipment [20, 41–43] and most intervention group families citing these reasons had alarms and stair gates fitted within the trial. Previous work suggests that inconvenience or annoyance of alarm activation when cooking or smoking, uncertainty about or difficulty in silencing alarms or replacing batteries, and concerns about alarm noise disturbing neighbours [42] are important factors in determining smoke alarm use. Such factors may be particularly relevant to the disadvantaged families in our study, who are more likely to live in smaller accommodation [44] requiring the smoke alarm to be installed closer to the kitchen and to be smokers [45]. Also as the prevalence of smoke alarm ownership in some social groups was very high at baseline, those not having a smoke alarm may be those most difficult to influence.
Finally, it is important to remember that the trial intervention was aimed at changing families’ behaviour and improving access to services and it did not attempt to strengthen communities or to achieve economic or cultural change. It is therefore possible that an intervention addressing all these approaches may be more effective in reducing socio-economic inequalities.
Implications for policy, practice and future research
Our results have shown that targeting a home safety intervention to low-income families in disadvantaged areas which provides and fits free equipment is effective in reducing some inequalities in safety practices for some social groups. While overcoming the barriers of cost and installation of safety devices was effective in reducing some inequalities in stair gate possession and use, this strategy is not sufficient for reducing inequalities in stair gates in relation to black and ethnic minority families, families with young mothers or single parents or in relation to functioning smoke alarms. Strategies which address other barriers to smoke alarm use, such as reducing the frequency of nuisance alarms, designing alarms that can be fitted in such a position where they can easily be reached or that can be more easily silenced, may be needed in order to further reduce inequalities in smoke alarm ownership. Further research is required to explore barriers to stair gate use among black and minority ethnic groups, single-parent families and young mothers. Further research is also required to evaluate the impact of injury prevention interventions addressing the range of approaches to tackling socio-economic inequalities.
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Funding |
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Funding was provided by NHS Executive Trust. DK was funded by a Department of Health Public Health Career Scientist Award.
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Conflict of interest statement |
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None declared.
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References |
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Received on July 14, 2006; accepted on November 16, 2007
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