The impact of a home visitation programme on household hazards associated with unintentional childhood injuries: a randomised controlled trial

Keeping our children safe: piloting a hospital-based home-visitation program in Israel

Background

Unintentional childhood injuries are a leading cause of morbidity and mortality worldwide. Attempts to prevent child home injuries have rarely been implemented in hospital settings which present an important opportunity for intervention. The SHABI (‘Keeping our Children Safe; SHomrim Al BetIchut Yeladenu’) program recruits at-risk families presenting with child injury to the Emergency Department. Medical/nursing students conduct two home visits and provide safety equipment and guidance. The objective of this study was to investigate the impact of SHABI on participating families’ home-safety.

Methods

The pilot was conducted between May 2019 and March 2020 in northern Israel, an area with high child injury rates. Eligibility included families with preschool children who incurred a home injury. Home-safety was assessed by observation through the ‘Beterem’ checklist. Parents' views, knowledge, awareness of dangers and report of home injuries were assessed at the start of each visit.

Results

352 of 773 eligible families agreed to be contacted. 135 participated, 98 completed both home visits. Significant improvement in home-safety items was observed 4 months after the first visit (14 [IQR12-16]) vs. (17 [IQR15-19]; p < 0.001), accompanied by an overall increase in home safety (Mean ± SD 71.9% ± 9.5% vs. 87.1% ± 8.6%; p < 0.001). 64% reported greater awareness of dangers, 60% affirmed home was safer, and 70% valued the equipment. No difference was found in the prevalence of injuries (14 of 98 families prior and 8 after the visit; p = 0.17). Home visitors reported benefiting from the experience of working with disadvantaged families.

Conclusion

The program, which included recruitment in a hospital emergency setting and use of healthcare students as home visitors, was successfully implemented and accompanied by significant improvement in home safety with a non-significant trend of child injury decrease.

Better safe than sorry: Evaluating the implementation process of a home-visitation intervention aimed at preventing unintentional childhood injuries in the hospital setting

Background

Child home injuries prevention interventions have rarely been implemented in hospitals. The SHABI program ("Keeping our Children Safe"; in Hebrew: "SHomrim Al BetIchut Yeladenu") recruits at-risk families arriving with child injury to the Emergency Department. Medical/nursing students conduct two home visits four months apart, providing safety equipment and guidance. One hundred thirty-five families had a first visit and 98 completed the second. Fifty percentage of families were ultra-Orthodox Jews, 11% Arab, and 28% had ≥3 preschool children. We investigated SHABI's implementation using the Consolidated Framework for Implementation Research (CFIR).

Methods

Between May 2018 and March 2021 SHABI was implemented in the Emergency Department of a hospital in Israel's northern periphery, an area with high child injury rates. The Implementation process was examined through Emergency Department medical records and tracking registries, hospital management, nurses', and home visitors' meetings notes (n = 9), and a research diary. Hospital's inner setting and SHABI's characteristics were evaluated through interviews with hospital management, nurses, and home visitors 8 months after baseline (n = 18). Home visitors' characteristics were evaluated through interviews, post-visit questionnaire on challenges encountered (n = 233), families' perceptions of SHABI and home visitors' skills through telephone interviews (n = 212); and home visitors awareness of dangers at home (n = 8) baseline and 8 months later. Qualitative data were analyzed through explanatory content analysis according to CFIR constructs. Quantitative data were analyzed using X2 and Wilcoxon test for dependent subgroups.

Results

Despite alignment between SHABI and the hospital's mission, structural hospital-community disconnect prevented implementation as planned, requiring adaptation and collaboration with the medical school to overcome this barrier. Recruitment was included in the initial patient triage process but was only partially successful. Medical/nursing students were recruited as home visitors, and following training proved competent. Children were a distraction during the visits, but home visitors developed strategies to overcome this.

Conclusions

Injury prevention programs in hospitals have significant benefits. Identifying implementation barriers and facilitators allowed implementers to make adaptations and cope with the innovative implementation setting. Models of cooperation between hospital, community and other clinical settings should be further examined.

Assessing the effectiveness of an app-based child unintentional injury prevention intervention for caregivers of rural Chinese preschoolers: protocol for a cluster randomized controlled trial

Background

Compared to urban children, children living in rural areas of most countries, including China, are at higher risk of suffering unintentional injuries. Most proven injury prevention interventions, however, are rarely implemented in rural China due to lack of resources. Mobile health interventions are low-cost and easy-to-implement, facilitating implementing injury prevention in resource-limited areas (e.g., rural areas). This study is designed and implemented to examine the effectiveness of an app-based intervention for unintentional injury prevention among rural preschoolers in China.

Methods

A single-blind, 18-month, parallel-group cluster randomized controlled trial with 1:1 allocation ratio will be implemented in 2 rural areas of China (Yang County, Shaanxi Province, and Shicheng County, Jiangxi Province). In total, at least 3508 rural caregivers of preschoolers aged 3–6 years old who own a smartphone will be recruited from 24 preschools. Clusters will be randomized at the preschool level and allocated to the control group (receiving routine school-based education plus app-based parenting education excluding unintentional injury prevention) or the intervention group (receiving routine school-based education plus app-based parenting education including unintentional injury prevention). External support strategies will be adopted by local partners to minimize user fatigue, non-compliance, and attrition. Data collection will be conducted at baseline and then every 3 months during the 18-month follow-up time period. Intention-to-treat data analysis will be implemented. Missing values will be imputed by using the Expectation Maximization algorithm. Generalized estimating equation will test the overall effectiveness of the app-based intervention. A per-protocol sensitivity analysis will be conducted to test the robustness of results. Subgroup analyses will follow the strategies for primary analyses. The primary outcome measure is the incidence rate of unintentional injury among preschoolers during the study period. Secondary outcome measures comprise longitudinal changes in caregiver’s attitudes, caregiver-reported supervision behaviors, and caregiver-assessed home environment safety surrounding child unintentional injury prevention in the last week using a standardized audit instrument.

Discussion

The app-based intervention is expected to be feasible and effective over the 18-month intervention period. If the app is demonstrated effective as hypothesized, we will initiate processes to generalize and popularize it broadly to rural child caregivers across China.

Trial registration

ChiCTR2000037606, registered on August 29, 2020.

Burn injury prevention in low- and middle- income countries: scoping systematic review

BACKGROUND

Burn injuries are a leading cause of morbidity and disability, with the burden of disease being disproportionately higher in low- and middle-income countries (LMIC). Burn prevention programmes have led to significant reductions in the incidence of burns in high-income countries. However, a previous systematic review published in 2015 highlighted that implementation and evaluation of similar programmes has been limited in LMIC. The objective of this scoping review and narrative synthesis was to summarise and understand the initiatives that have been carried out to reduce burn injuries in LMIC and their effectiveness.

METHODS

We aimed to identify publications that described studies of effectiveness of burn prevention interventions applied to any population within a LMIC and measured burn incidence or burns-related outcomes. Suitable publications were identified from three sources. Firstly, data was extracted from manuscripts identified in the systematic review published by Rybarczyk et al. We then performed a search for manuscripts on burn prevention interventions published between January 2015 and September 2020. Finally, we extracted data from two systematic reviews where burn evidence was not the primary outcome, which were identified by senior authors. A quality assessment and narrative synthesis of included manuscripts were performed.

RESULTS

In total, 24 manuscripts were identified and categorized according to intervention type. The majority of manuscripts (n = 16) described education-based interventions. Four manuscripts focused on environmental modification interventions and four adopted a mixed-methods approach. All of the education-based initiatives demonstrated improvements in knowledge relating to burn safety or first aid, however few measured the impact of their intervention on burn incidence. Four manuscripts described population-based educational interventions and noted reductions in burn incidence. Only one of the four manuscripts describing environmental modification interventions reported burns as a primary outcome measure, noting a reduction in burn incidence. All mixed-method interventions demonstrated some positive improvements in either burn incidence or burns-related safety practices.

CONCLUSION

There is a lack of published literature describing large-scale burn prevention programmes in LMIC that can demonstrate sustained reductions in burn incidence. Population-level, collaborative projects are necessary to drive forward burn prevention through specific environmental or legislative changes and supplementary educational programmes.

The distinctive roles of urban community health workers in low- and middle-income countries: a scoping review of the literature

Addressing urban health challenges in low- and middle-income countries (LMICs) has been hampered by lack of evidence on effective mechanisms for delivering health services to the poor. The urban disadvantaged experience poor health outcomes (often worse than rural counterparts) and face service barriers. While community health workers (CHWs) have been extensively employed in rural communities to address inequities, little attention has been given to understanding the roles of CHWs in urban contexts. This study is the first to systematically examine urban CHW roles in LMICs. It aims to understand their roles vis-à-vis other health providers and raise considerations for informing future scope of practice and service delivery models. We developed a framework that presents seven key roles performed by urban CHWs and position these roles against a continuum of technical to political functions. Our scoping review included publications from four databases (MEDLINE, EMBASE, CINAHL and Social Sciences Citation Index) and two CHW resource hubs. We included all peer-reviewed, CHW studies situated in urban/peri-urban, LMIC contexts. We identify roles (un)commonly performed by urban CHWs, present the range of evidence available on CHW effectiveness in performing each role and identify considerations for informing future roles. Of 856 articles, 160 met the inclusion criteria. Programmes spanned 34 LMICs. Studies most commonly reported evidence on CHWs roles related to health education, outreach and elements of direct service provision. We found little overlap in roles between CHWs and other providers, with some exceptions. Reported roles were biased towards home visiting and individual-capacity building, and not well-oriented to reach men/youth/working women, support community empowerment or link with social services. Urban-specific adaptations to roles, such as peer outreach to high-risk, stigmatized communities, were limited. Innovation in urban CHW roles and a better understanding of the unique opportunities presented by urban settings is needed to fully capitalize on their potential.

Incidence of childhood injuries and modifiable household risk factors in rural Ghana: a multistage, cluster-randomised, population-based, household survey

OBJECTIVE

We aimed to describe the incidence of childhood household injuries and prevalence of modifiable household risk factors in rural Ghana to inform prevention initiatives.

SETTING

357 randomly selected households in rural Ghana.

PARTICIPANTS

Caregivers of children aged <5 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Childhood injuries that occurred within 6 months and 200 metres of the home that resulted in missed school/work, hospitalisation and/or death. Sampling weights were applied, injuries were described and multilevel regression was used to identify risk factors.

RESULTS

Caregivers from 357 households had a mean age of 35 years (SD 12.8) and often supervised ≥2 children (51%). Households typically used biomass fuels (84%) on a cookstove outside the home (79%). Cookstoves were commonly <1 metre of the ground (95%). Weighted incidence of childhood injury was 542 per 1000 child-years. Falls (37%), lacerations (24%), burns (12%) and violence (12%) were common mechanisms. There were differences in mechanism across age groups (p<0.01), but no gender differences (p=0.25). Presence of older children in the home (OR 0.15, 95% CI 0.09 to 0.24; adjusted OR (aOR) 0.26, 95% CI 0.13 to 0.54) and cooking outside the home (OR 0.28, 95% CI 0.19 to 0.42; aOR 0.25, 95% CI 0.13 to 0.49) were protective against injury, but other common modifiable risk factors (eg, stove height, fuel type, secured cabinets) were not.

CONCLUSIONS

Childhood injuries occurred frequently in rural Ghana. Several common modifiable household risk factors were not associated with an increase in household injuries. Presence of older children was a protective factor, suggesting that efforts to improve supervision of younger children might be effective prevention strategies.

Comparison of childhood household injuries and risk factors between urban and rural communities in Ghana: A cluster-randomized, population-based, survey to inform injury prevention research and programming

BACKGROUND

Childhood household injuries incur a major proportion of the global disease burden, particularly in low- and middle-income countries (LMICs). However, household injury hazards are differentially distributed across developed environments. Therefore, we aimed to compare incidence of childhood household injuries and prevalence of risk factors between communities in urban and rural Ghana to inform prevention initiatives.

METHODS

Data from urban and a rural cluster-randomized, population-based surveys of caregivers of children <5 years in Ghana were combined. In both studies, caregivers were interviewed about childhood injuries that occurred within the past 6 months and 200 meters of the home that resulted in missed school/work, hospitalization, and/or death. Sampling weights were applied, injuries and incidence rate ratios (IRRs) were described, and multi-level regression was used to identify and compare risk factors.

RESULTS

We sampled 200 urban and 357 rural households that represented 20,575 children in Asawase and 14,032 children in Amakom, Ghana, respectively. There were 143 and 351 injuries in our urban and rural samples, which equated to 594 and 542 injuries per 1,000 child-years, respectively (IRR 1.09, 95%CI 1.05-1.14). Toddler-aged children had the highest odds of injury both urban and rural communities (OR 3.77 vs 3.17, 95%CI 1.34-10.55 vs 1.86-5.42 compared to infants, respectively). Urban children were more commonly injured by falling (IRR 1.50, 95%CI 1.41-1.60), but less commonly injured by flame/hot substances (IRR 0.51, 95%CI 0.44-0.59), violence (IRR 0.41, 95%CI 0.36-0.48), or motor vehicle (IRR 0.50, 95%CI 0.39-0.63). Rural households that cooked outside of the home (OR 0.36, 95%CI 0.22-0.60) and that also supervised older children (OR 0.33, 95%CI 0.17-0.62) had lower odds of childhood injuries than those that did not.

CONCLUSIONS

Childhood injuries were similarly common in both urban and rural Ghana, but with different patterns of mechanisms and risk factors that must be taken into account when planning prevention strategies. However, the data suggest that several interventions could be effective, including: community-based, multi-strategy initiatives (e.g., home hazard reduction, provision of safety equipment, establishing community creches); traffic calming interventions in rural community clusters; and passive injury surveillance systems that collect data to inform violence and broader prevention strategies.

Prevention of childhood unintentional injuries in low- and middle-income countries: A systematic review

Injuries are a leading cause of death and disability among children. Numerous injury prevention strategies have been successful in high-income countries, but the majority of unintentional injuries happen to children living in low- and middle-income countries (LMICs). This project aims to delineate the childhood injury prevention initiatives in LMICs. For inclusion, peer-reviewed articles needed to address unintentional injury, include children <18, assess a prevention-related intervention, contain a control group, and be published after 1988. Two pairs of reviewers evaluated articles independently to determine study eligibility. 74 articles were included. 30 studies addressed road traffic injuries, 11 drowning, 8 burns, 3 falls, 8 poisonings, and 21 an unspecified injury type. The findings show positive effects on injury outcome measures following educational interventions, the need for longer follow-up periods after the intervention, the need for effectiveness trials for behavior change, and the need for an increase in injury prevention services in LMICs. This is the first systematic review to summarize the prevention initiatives for all types of childhood unintentional injuries in LMICs. Increased attention and funding are required to go beyond educational initiatives with self-reported measures and little follow-up time to robust interventions that will reduce the global burden of unintentional injuries among children.

Presentation of Pediatric Unintentional Injuries at Rural Hospitals in Rwanda: A Retrospective Study

Background:

Injuries are a leading cause of mortality among children globally, with children in low- and middle-income countries more likely to die if injured compared to children in high-income countries. Timely and high-quality care are essential to reduce injury-related morbidity and mortality.

Objectives:

This study describes patterns, management, and outcomes of children 0–15 years presenting with unintentional injuries at three district hospitals in rural Rwanda between January 1 and December 31, 2017.

Methods:

Using a retrospective cross-sectional study design, we assessed the demographic and clinical characteristics, care provided, and outcomes of the children using data extracted from patient medical charts. We describe the patient population using frequencies and proportions as well as median and interquartile ranges.

Findings:

Of the 449 injured children who sought care at the three rural district hospitals, 66.2% (n = 297) were boys. The main causes of injury were falls (n = 261, 58.1%), burns (n = 101, 22.5%), and road traffic injuries (n = 67, 14.9%). Burns were the most common injury among children aged 0–5 years while falls were the leading injury type among the 5–15 years age group. Vital signs were inconsistently completed ranging between 23.8–89.1% of vital sign items. Of the injured children, 37.0% (n = 166) received surgery at the district hospital, general practitioners performed 80.9% (n = 114) of surgeries, 87.4% (n = 145) of operated patients received no anesthesia, and 69.3% (n = 311) were admitted to the district hospital, while 2.7% (n = 12) were transferred to tertiary facilities for higher-level care.

Conclusions:

The presentation of child injuries—namely falls, burns, and road traffic accidents—is similar to what has been reported in other sub-Saharan African countries. However, more needs to be done to improve the completion and documentation of vital signs and increase availability of surgical specialists. Finally, targeted strategies to prevent burns and motorcycle-related injuries are recommended prevention interventions for this rural population.

Environmental change interventions to prevent unintentional home injuries among children in low- and middle-income countries: A systematic review and meta-analysis

INTRODUCTION

Unintentional home injury is an important cause of death and disability among children, especially those living in low- and middle-income countries (LMICs). This systematic review aimed to synthesize evidence about the effectiveness of environmental interventions to prevent unintentional child injury and/or reduce injury hazards in the home in LMICs.

METHODS

Seven electronic databases were searched for randomized controlled trials (RCTs) and controlled before and after (CBA) studies published up to 1 April 2018. Potentially eligible citations were screened by title and abstract and full texts of studies obtained. Synthesis was reported narratively, and where possible, meta-analysis was conducted.

RESULTS

Four studies met the inclusion criteria: One CBA study reported changes in injury incidence, and three RCTs reported changes in frequency of home hazards. In one study, child resistant containers were found effective in reducing the incidence of paraffin ingestion by 47% during and by 50% postintervention. A meta-analysis of two trials found that home inspection, safety education and safety devices reduced postintervention mean scores for poisoning hazards [mean difference (MD) -0.77; 95% CI [-1.36, -0.19]] and burn-related unsafe practices (MD -0.37; 95% CI [-0.66, -0.09]) but not for falls or electrical and paraffin burn hazards. A single trial found that home inspection and safety education reduced the postintervention mean scores for fall hazards (MD -0.5; 95% CI [-0.66, -0.33]) but not for ingestion hazards.

CONCLUSION

There is limited evidence that environmental change interventions reduce child injuries but evidence that they reduce some home hazards. More evidence is needed to determine if altering the physical home environment by removing potential hazards reduces injuries in LMICs.

A Systematised Review of the Health Impact of Urban Informal Settlements and Implications for Upgrading Interventions in South Africa, a Rapidly Urbanising Middle-Income Country

Informal settlements are becoming more entrenched within African cities as the urban population continues to grow. Characterised by poor housing conditions and inadequate services, informal settlements are associated with an increased risk of disease and ill-health. However, little is known about how informal settlement upgrading impacts health over time. A systematised literature review was conducted to explore existing evidence and knowledge gaps on the association between informal settlement characteristics and health and the impact of informal settlement upgrading on health, within South Africa, an upper-middle income African country. Using two databases, Web of Science and PubMed, we identified 46 relevant peer-reviewed articles published since 1998. Findings highlight a growing body of research investigating the ways in which complete physical, mental and social health are influenced by the physical housing structure, the psychosocial home environment and the features of the neighbourhood and community in the context of informal settlements. However, there is a paucity of longitudinal research investigating the temporal impact of informal settlement upgrading or housing improvements on health outcomes of these urban residents. Informal settlements pose health risks particularly to vulnerable populations such as children, the elderly, and people with suppressed immune systems, and are likely to aggravate gender-related inequalities. Due to the complex interaction between health and factors of the built environment, there is a need for further research utilising a systems approach to generate evidence that investigates the interlinked factors that longitudinally influence health in the context of informal settlement upgrading in rapidly growing cities worldwide.

Interventions to reduce accidents in childhood: a systematic review

OBJECTIVE

To review the literature on interventions planned to prevent the incidence of injuries in childhood.

SOURCE OF DATA

The PubMed, Web of Science, and Bireme databases were searched by two independent reviewers, employing the single terms accidents, accident, injuries, injury, clinical trial, intervention, educational intervention, and multiple interventions, and their combinations, present in the article title or abstract, with no limits except period of publication (2006-2016) and studies in human subjects.

SYNTHESIS OF DATA

Initially, 11,097 titles were located. Fifteen articles were selected for the review. Eleven were randomized trials (four carried out at the children's households, five in pediatric healthcare services, and two at schools), and four were non-randomized trials carried out at the children's households. Four of the randomized trials were analyzed by intention-to-treat and a protective effect of the intervention was observed: decrease in the number of risk factors, decrease in the number of medical consultations due to injuries, decrease in the prevalence of risk behaviors, and increase of the parents' knowledge regarding injury prevention in childhood.

CONCLUSION

Traumatic injuries in childhood are amenable to primary prevention through strategies that consider the child's age and level of development, as well as structural aspects of the environment.

Palestinian Nurses' and Doctors' Perceptions and Practices Regarding the Prevention of Injuries to Children in the Home: An Explorative Qualitative Study

Unintentional injuries are a growing global public health problem that causes mortality, morbidity, and disability among children. These injuries are common among under-fives and form a significant burden on healthcare systems, particularly in low- and middle-income countries. Nurses and doctors have a major role to play in the prevention of home injuries, as expressed in many international reports. In Palestine, there is a paucity of research in this area. Therefore, this study aims to explore nurses' and doctors' perceptions and practices regarding the prevention of home injuries among children aged under-five years. A qualitative approach was followed, whereby semi-structured interviews were undertaken with 24 nurses and doctors who worked with children in a primary health care setting. The derived data were analyzed using thematic analysis. This study found that most of the nurses and doctors who were interviewed reported positive attitudes toward working on this topic; the majority of them attempted to work on injury prevention. Nevertheless, they needed further support to fulfil this potential role, as they faced many barriers in their daily practice in this area. Policy makers could potentially take advantage of this attitude and support them by providing training, resources, and time for them to implement this role.

Risk Factors for Acute Unintentional Poisoning among Children Aged 1-5 Years in the Rural Community of Sri Lanka

Background

Acute poisoning in children is a major preventable cause of morbidity and mortality in both developed and developing countries. However, there is a wide variation in patterns of poisoning and related risk factors across different geographic regions globally. This hospital based case-control study identifies the risk factors of acute unintentional poisoning among children aged 1−5 years of the rural community in a developing Asian country.

Methods

This hospital based case-control study included 600 children. Each group comprised three hundred children and all children were recruited at Anuradhapura Teaching Hospital, Sri Lanka, over two years (from February 2012 to January 2014). The two groups were compared to identify the effect of 23 proposed risk factors for unintentional poisoning using multivariate analysis in a binary logistic regression model.

Results

Multivariate analysis identified eight risk factors which were significantly associated with unintentional poisoning. The strongest risk factors were inadequate supervision (95% CI: 15.4–52.6), employed mother (95% CI: 2.9–17.5), parental concern of lack of family support (95% CI: 3.65–83.3), and unsafe storage of household poisons (95% CI: 1.5–4.9).

Conclusions

Since inadequate supervision, unsafe storage, and unsafe environment are the strongest risk factors for childhood unintentional poisoning, the effect of community education to enhance vigilance, safe storage, and assurance of safe environment should be evaluated.

Keeping Children Safe: a multicentre programme of research to increase the evidence base for preventing unintentional injuries in the home in the under-fives

Background

Unintentional injuries among 0- to 4-year-olds are a major public health problem incurring substantial NHS, individual and societal costs. However, evidence on the effectiveness and cost-effectiveness of preventative interventions is lacking.

Aim

To increase the evidence base for thermal injury, falls and poisoning prevention for the under-fives.

Methods

Six work streams comprising five multicentre case–control studies assessing risk and protective factors, a study measuring quality of life and injury costs, national surveys of children’s centres, interviews with children’s centre staff and parents, a systematic review of barriers to, and facilitators of, prevention and systematic overviews, meta-analyses and decision analyses of home safety interventions. Evidence from these studies informed the design of an injury prevention briefing (IPB) for children’s centres for preventing fire-related injuries and implementation support (training and facilitation). This was evaluated by a three-arm cluster randomised controlled trial comparing IPB and support (IPB+), IPB only (no support) and usual care. The primary outcome was parent-reported possession of a fire escape plan. Evidence from all work streams subsequently informed the design of an IPB for preventing thermal injuries, falls and poisoning.

Results

Modifiable risk factors for falls, poisoning and scalds were found. Most injured children and their families incurred small to moderate health-care and non-health-care costs, with a few incurring more substantial costs. Meta-analyses and decision analyses found that home safety interventions increased the use of smoke alarms and stair gates, promoted safe hot tap water temperatures, fire escape planning and storage of medicines and household products, and reduced baby walker use. Generally, more intensive interventions were the most effective, but these were not always the most cost-effective interventions. Children’s centre and parental barriers to, and facilitators of, injury prevention were identified. Children’s centres were interested in preventing injuries, and believed that they could prevent them, but few had an evidence-based strategic approach and they needed support to develop this. The IPB was implemented by children’s centres in both intervention arms, with greater implementation in the IPB+ arm. Compared with usual care, more IPB+ arm families received advice on key safety messages, and more families in each intervention arm attended fire safety sessions. The intervention did not increase the prevalence of fire escape plans [adjusted odds ratio (AOR) IPB only vs. usual care 0.93, 95% confidence interval (CI) 0.58 to 1.49; AOR IPB+ vs. usual care 1.41, 95% CI 0.91 to 2.20] but did increase the proportion of families reporting more fire escape behaviours (AOR IPB only vs. usual care 2.56, 95% CI 1.38 to 4.76; AOR IPB+ vs. usual care 1.78, 95% CI 1.01 to 3.15). IPB-only families were less likely to report match play by children (AOR 0.27, 95% CI 0.08 to 0.94) and reported more bedtime fire safety routines (AOR for a 1-unit increase in the number of routines 1.59, 95% CI 1.09 to 2.31) than usual-care families. The IPB-only intervention was less costly and marginally more effective than usual care. The IPB+ intervention was more costly and marginally more effective than usual care.

Limitations

Our case–control studies demonstrate associations between modifiable risk factors and injuries but not causality. Some injury cost estimates are imprecise because of small numbers. Systematic reviews and meta-analyses were limited by the quality of the included studies, the small numbers of studies reporting outcomes and significant heterogeneity, partly explained by differences in interventions. Network meta-analysis (NMA) categorised interventions more finely, but some variation remained. Decision analyses are likely to underestimate cost-effectiveness for a number of reasons. IPB implementation varied between children’s centres. Greater implementation may have resulted in changes in more fire safety behaviours.

Conclusions

Our studies provide new evidence about the effectiveness of, as well as economic evaluation of, home safety interventions. Evidence-based resources for preventing thermal injuries, falls and scalds were developed. Providing such resources to children’s centres increases their injury prevention activity and some parental safety behaviours.

Future work

Further randomised controlled trials, meta-analyses and NMAs are needed to evaluate the effectiveness and cost-effectiveness of home safety interventions. Further work is required to measure NHS, family and societal costs and utility decrements for childhood home injuries and to evaluate complex multicomponent interventions such as home safety schemes using a single analytical model.

Trial registration

Current Controlled Trials ISRCTN65067450 and ClinicalTrials.gov NCT01452191.

Funding

The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 14. See the NIHR Journals Library website for further project information.

Home-based neonatal care by community health workers for preventing mortality in neonates in low- and middle-income countries: a systematic review

The objective of this review is to assess the effect of home-based neonatal care provided by community health workers (CHWs) for preventing neonatal, infant and perinatal mortality in resource-limited settings with poor access to health facility-based care. The authors conducted a systematic review, including meta-analysis and meta-regression of controlled trials. The data sources included electronic databases, with a hand search of reviews, abstracts and proceedings of conferences to search for randomized, or cluster randomized, controlled trials evaluating the effect of home-based neonatal care provided by CHWs for preventing neonatal, infant and perinatal mortality. Among the included trials, all from South Asian countries, information on neonatal, infant and perinatal mortality was available in five, one and three trials, respectively. The intervention package comprised three components, namely, home visits during pregnancy (four trials), home-based preventive and/or curative neonatal care (all trials) and community mobilization efforts (four trials). Intervention was associated with a reduced risk of mortality during the neonatal (random effects model relative risk (RR) 0.75; 95% confidence intervals (CIs) 0.61 to 0.92, P=0.005; I(2)=82.2%, P<0.001 for heterogeneity; high-quality evidence) and perinatal periods (random effects model RR 0.78; 95% CI 0.64 to 0.94, P=0.009; I(2)=79.6%, P=0.007 for heterogeneity; high-quality evidence). In one trial, a significant decline in infant mortality (RR 0.85; 95% CI 0.77 to 0.94) was documented. Subgroup and meta-regression analyses suggested a greater effect with a higher baseline neonatal mortality rate. The authors concluded that home-based neonatal care is associated with a reduction in neonatal and perinatal mortality in South Asian settings with high neonatal-mortality rates and poor access to health facility-based care. Adoption of a policy of home-based neonatal care provided by CHWs is justified in such settings.

Community perceptions of unintentional child injuries in Makwanpur district of Nepal: a qualitative study

Background

In Nepal, childhood unintentional injury is an emerging public health problem but it has not been prioritised on national health agenda. There is lack of literature on community perceptions about child injuries. This study has explored community perceptions about child injuries and how injuries can be prevented.

Methods

Focus group discussions were conducted with mothers, school students and community health volunteers from urban and rural parts of Makwanpur district in Nepal. FGDs were conducted in Nepali languages. These were recorded, transcribed and translated into English. A theoretical framework was identified and thematic analysis conducted.

Results

Three focus group discussions, with a total of 27 participants, took place. Participants were able to identify examples of child injuries which took place in their community but these generally related to fatal and severe injuries. Participants identified risk factors such as the child’s age, gender, behaviours and whether they had been supervised. Consequences of injuries such as physical and psychological effects, impact on household budgets and disturbance in household plans were identified. Suggestions were made about culturally appropriate prevention measures, and included; suitable supervision arrangements, separation of hazards and teaching about safety to the parents and children.

Conclusion

Community members in Nepal can provide useful information about childhood injuries and their prevention but this knowledge is not transferred into action. Understanding community perceptions about injuries and their prevention can contribute to the development of preventive interventions in low income settings.

Home safety education and provision of safety equipment for injury prevention (Review)

BACKGROUND

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.

A study of energy-related injuries from hospital admissions among children and adults in South Africa

INTRODUCTION

Burn and ingestion injuries are common in developing countries because of poor access to safe energy sources, crowded living conditions, and insufficient knowledge of potential risks. The purpose of this study is to understand the scope of burn and ingestion injuries due to various energy source usages in South Africa.

METHODS

Patients at 16 regional hospitals throughout South Africa presenting with an energy-related injury between 2006 and 2012 were interviewed to obtain demographics and injury characteristics.

RESULTS

A total of 12,443 patients were included in this study. Children aged 1-2 years predominantly experienced burn and ingestion injuries (21%). Liquid burns (30%) were more common than flame burns (14%). Chi-squared tests show that age was significantly related to degree of burn, type of burn, and severity of burn (p<0.001). Non-intentional injuries (45%) were more frequent than self-inflicted or assault injuries. Temporal and seasonal injury trends reflect usage patterns. Burn injuries result in longer hospital length of stay than ingestion injuries.

CONCLUSION

Non-intentional liquid burns and ingestions to infants and babies were most common in this study, with many injuries also occurring among young adults. It is advised that interventions targeting low-income communities be conducted to increase awareness of burn and ingestion injuries.

Effectiveness of home visiting in improving child health and reducing child maltreatment

BACKGROUND AND OBJECTIVE

The Patient Protection and Affordable Care Act established the Maternal, Infant, and Early Childhood Home Visiting Program, which provides $1.5 billion to states over 5 years for home visiting program models serving at-risk pregnant women and children from birth to age 5. The act stipulates that 75% of the funds must be used for programs with evidence of effectiveness based on rigorous evaluation research. Home Visiting Evidence of Effectiveness reviewed the home visiting research literature and provided an assessment of the evidence of effectiveness for program models that serve families with pregnant women and children from birth to age 5.

METHODS

Home Visiting Evidence of Effectiveness included a systematic search and screening process, a review of the research quality, and an assessment of program effectiveness. Reviewers rated studies' capacity to provide unbiased estimates of program impacts and determined whether a program met the Department of Health and Human Services' criteria for an evidence-based model.

RESULTS

As of July 2012, 32 models were reviewed, of which 12 met the Department of Health and Human Services criteria. Most of these models were shown to have favorable effects on child development. Other common favorable effects included health care usage and reductions in child maltreatment. Less common were favorable effects on birth outcomes.

CONCLUSIONS

Home visiting is a promising way to serve families who may be difficult to engage in supportive services. Existing rigorous research indicates that home visiting has the potential for positive results among high-risk families, particularly on health care usage and child development.

Preventing childhood falls within the home: overview of systematic reviews and a systematic review of primary studies

In most countries falls are the most common medically attended childhood injury and the majority of injuries in pre-school children occur at home. Numerous systematic reviews have reviewed evidence of the effectiveness of falls prevention interventions, but this evidence has not been synthesised into an overview, making it difficult for policy makers and practitioners to easily access the evidence. To synthesise all available evidence, we conducted an overview of reviews of home safety interventions targeting childhood falls, extracted data from primary studies included in the reviews and supplemented this with a systematic review of primary studies published subsequent to the reviews. Bibliographic databases, websites, conference proceedings, journals and bibliographies of included studies were searched for systematic reviews of studies with experimental or controlled observational designs. Thirteen reviews were identified containing 24 primary studies. Searches for additional primary studies identified five further studies not included in reviews. Evidence of the effect of interventions on falls or fall injuries was sparse, with only one of three primary studies reporting this outcome finding a reduction in falls. Interventions were effective in promoting the use of safety gates and furniture corner covers. There was some evidence of a reduction in baby walker use. The effect on the use of window safety devices, non-slip bath mats/decals and the reduction of tripping hazards was mixed. There was limited evidence that interventions were effective in improving lighting in corridors, altering furniture layout and restricting access to roofs. Most interventions to prevent childhood falls at home have not been evaluated in terms of their effect on reducing falls. Policy makers and practitioners should promote use of safety gates and furniture covers and restriction of baby walker use. Further research evaluating the effect of interventions to reduce falls and falls-related injuries is urgently required.

Disseminating childhood home injury risk reduction information in Pakistan: results from a community-based pilot study

Background: Most childhood unintentional injuries occur in the home; however, very little home injury prevention information is tailored to developing countries. Utilizing our previously developed information dissemination tools and a hazard assessment checklist tailored to a low-income neighborhood in Pakistan, we pilot tested and compared the effectiveness of two dissemination tools. Methods: Two low-income neighborhoods were mapped, identifying families with a child aged between 12 and 59 months. In June and July 2010, all enrolled households underwent a home hazard assessment at the same time hazard reduction education was being given using an in-home tutorial or a pamphlet. A follow up assessment was conducted 4–5 months later. Results: 503 households were enrolled; 256 received a tutorial and 247 a pamphlet. The two groups differed significantly (p < 0.01) in level of maternal education and relationship of the child to the primary caregiver. However, when controlling for these variables, those receiving an in-home tutorial had a higher odds of hazard reduction than the pamphlet group for uncovered vats of water (OR 2.14, 95% CI: 1.28, 3.58), an open fire within reach of the child (OR 3.55, 95% CI: 1.80, 7.00), and inappropriately labeled cooking fuel containers (OR 1.86, 95% CI: 1.07, 3.25). Conclusions: This pilot project demonstrates the potential utility of using home-visit tutorials to decrease home hazards in a low-income neighborhood in Pakistan. A longer-term randomized study is needed to assess actual effectiveness of the use of allied health workers for home-based injury education and whether this results in decreased home injuries.

Home safety education and provision of safety equipment for injury prevention

BACKGROUND

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.

Developing the evidence-base for Safe Communities: a multi-level, partly randomised, controlled trial

Safe Communities, representing a global activation of the public health logic, may be strengthened through theoretical, methodological and empirical support. In the spirit of this Special Issue that aims to analyse the achievements and challenges inherent to Safe Communities, we offer our contribution in the form of a methodology of a multi-country child safety, peace and health promotion study. The study, situated within an African-centred initiative called Ukuphepha - an isiZulu word meaning demonstrating African safety - is underpinned by four theoretical claims that frame injury and violence prevention as a multi-disciplinary issue to be addressed through a suite of interventions to family and extended social systems. The interventions, sensitive to the priorities of each participating country, have been informed by the literature on effective interventions and the authors' joint experiences of community development. The study is designed as a population-based, multi-level, multi-intervention partly randomised controlled trial, and there are potentially 24 participant communities representing South Africa, Mozambique, Egypt, Zambia, Uganda, Bangladesh, Malaysia and Australia - over three commencement phases. Whereas process evaluation will focus on community engagement, impact evaluation will consider risk and protective factors, and outcome evaluation will examine the overall effectiveness of the interventions. Notwithstanding the many challenges, the study will provide insights into the methodology and mechanisms of ecologically-oriented interventions that locate injury and violence prevention as an activity arising from safety, peace and health promotion.

Childhood unintentional injuries: need for a community-based home injury risk assessments in pakistan

Background. A substantial proportion of the annual 875,000 childhood unintentional injury deaths occur in the home. Very few printed tools are available in South Asia for disseminating home injury prevention information. Methods. Three tools were planned: an injury hazard assessment tool appropriate for a developing country setting, an educational pamphlet highlighting strategies for reducing home injury hazards, and an in-home safety tutorial program to be delivered by a trained community health worker. Results. The three tools were successfully developed. Two intervention neighborhoods in Karachi, Pakistan, were mapped. The tools were pretested in this local setting and are now ready for pilot testing in an intervention study. Conclusion. Planning for an innovative, community-based pilot study takes considerable time and effort in a low-income setting like Pakistan. The primary outcome of the pre-testing phase of the study was the development of three important tools geared for low-income housing communities in Pakistan.

Population attributable risk of unintentional childhood poisoning in Karachi Pakistan

Background

The percentage of unintentional childhood poisoning cases in a given population attributable to specific risk factors (i.e., the population attributable risk) which can be calculated; determination of such risk factors associated with potentially modifiable risk factors, are necessary to focus on the prevention strategies.

Methods

We calculated PARs, using 120 cases with unintentional poisoning and 360 controls in a hospital based matched case- control study. The risk factors were accessibility to hazardous chemicals and medicines due to unsafe storage, child behavior reported as hyperactive, storage of kerosene and petroleum in soft drink bottles, low socioeconomic class, less education of the mother and the history of previous poisoning.

Results

The following attributed risks were observed: 12% (95% confidence interval [CI] = 8%–16%) for both chemicals and medicines stored unsafe, 19% (15%–23%) for child reported as hyperactive, 40% (38%–42%) for storage of kerosene and petroleum in soft drink bottles, 48% (42%–54%) for low socioeconomic status, 38% (32%–42%) for no formal mothers education and 5.8% (2%–10%) for history of previous poisoning. 48% of cases for overall study population which could be attributed to at least one of the six risk factors. Among girls, this proportion was 23% and 43% among boys. About half of the unintentional childhood poisoning cases in this Pakistani population could be avoided.

Conclusion

Exposure to potentially modifiable risk indicators explained about half of the cases of unintentional poisoning among children under five years of age in this Pakistani population, indicating the theoretical scope for prevention of the disease.

Modification of the home environment for the reduction of injuries

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 I(2) statistic and a Chi(2) 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.

Home visits reduce the number of hazards for childhood home injuries in Karachi, Pakistan: a randomized controlled trial

Background

Although unintentional injuries are major causes of morbidity and mortality in less developed countries, they have received scant attention, and injury prevention policies and programs have just begun to be addressed systemically.

Aims

To reduce hazards associated with home injuries due to falls and ingestions through an injury prevention program administered by home visitors.

Methods

Non-blinded randomized controlled trial design of two interventions where one branch of the study group served as the control for the other in an urban neighborhood in Karachi, Pakistan. The study participants included 340 families with at least one child aged 3 years or less, discharged home from the Emergency Department following a visit for any reason other than an injury. The interventions included: (1) counseling to reduce falls; (2) counseling to reduce poisoning and choking. The primary outcome measure for each intervention was the relative risk of change in the home status from “unsafe” to “safe” after the intervention.

Results

There were 170 families in the fall prevention and 170 families in the ingestion prevention branch of the study. The percentage of homes deemed “safe” in which the families had received fall intervention counseling was 13.5% compared to 3.5% in the control group (relative risk 3.8; 95% CI: 1.5 to 10.0; p = 0.002), whereas the percentage of homes deemed “safe” in which the families had received the ingestions intervention counseling was 18.8% compared to 2.4% in the control group (relative risk 7.8; 95% CI: 2.4 to 25.3; p < 0.001). Effectiveness did not depend on education or the socioeconomic status of the study participants. The mean number of fall hazards was reduced from 3.1 at baseline to 2.4 in the fall intervention counseling group, and the mean number of ingestion hazards decreased from 2.3 to 1.9. (p < 0.001).

Conclusions

Our study demonstrates the effectiveness of an educational intervention aimed at improving the home safety practices of families with young children.

Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases

BACKGROUND

Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. Little is known, however, about the effectiveness of LHW interventions.

OBJECTIVES

To assess the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases.

SEARCH STRATEGY

For the current version of this review we searched The Cochrane Central Register of Controlled Trials (including citations uploaded from the EPOC and the CCRG registers) (The Cochrane Library 2009, Issue 1 Online) (searched 18 February 2009); MEDLINE, Ovid (1950 to February Week 1 2009) (searched 17 February 2009); MEDLINE In-Process & Other Non-Indexed Citations, Ovid (February 13 2009) (searched 17 February 2009); EMBASE, Ovid (1980 to 2009 Week 05) (searched 18 February 2009); AMED, Ovid (1985 to February 2009) (searched 19 February 2009); British Nursing Index and Archive, Ovid (1985 to February 2009) (searched 17 February 2009); CINAHL, Ebsco 1981 to present (searched 07 February 2010); POPLINE (searched 25 February 2009); WHOLIS (searched 16 April 2009); Science Citation Index and Social Sciences Citation Index (ISI Web of Science) (1975 to present) (searched 10 August 2006 and 10 February 2010). We also searched the reference lists of all included papers and relevant reviews, and contacted study authors and researchers in the field for additional papers.

SELECTION CRITERIA

Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to improve maternal or child health or the management of infectious diseases. A 'lay health worker' was defined as any health worker carrying out functions related to healthcare delivery, trained in some way in the context of the intervention, and having no formal professional or paraprofessional certificate or tertiary education degree. There were no restrictions on care recipients.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data using a standard form and assessed risk of bias. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the study results were combined and an overall estimate of effect obtained.

MAIN RESULTS

Eighty-two studies met the inclusion criteria. These showed considerable diversity in the targeted health issue and the aims, content, and outcomes of interventions. The majority were conducted in high income countries (n = 55) but many of these focused on low income and minority populations. The diversity of included studies limited meta-analysis to outcomes for four study groups. These analyses found evidence of moderate quality of the effectiveness of LHWs in promoting immunisation childhood uptake (RR 1.22, 95% CI 1.10 to 1.37; P = 0.0004); promoting initiation of breastfeeding (RR = 1.36, 95% CI 1.14 to 1.61; P < 0.00001), any breastfeeding (RR 1.24, 95% CI 1.10 to 1.39; P = 0.0004), and exclusive breastfeeding (RR 2.78, 95% CI 1.74 to 4.44; P <0.0001); and improving pulmonary TB cure rates (RR 1.22 (95% CI 1.13 to 1.31) P <0.0001), when compared to usual care. There was moderate quality evidence that LHW support had little or no effect on TB preventive treatment completion (RR 1.00, 95% CI 0.92 to 1.09; P = 0.99). There was also low quality evidence that LHWs may reduce child morbidity (RR 0.86, 95% CI 0.75 to 0.99; P = 0.03) and child (RR 0.75, 95% CI 0.55 to 1.03; P = 0.07) and neonatal (RR 0.76, 95% CI 0.57 to 1.02; P = 0.07) mortality, and increase the likelihood of seeking care for childhood illness (RR 1.33, 95% CI 0.86 to 2.05; P = 0.20). For other health issues, the evidence is insufficient to draw conclusions regarding effectiveness, or to enable the identification of specific LHW training or intervention strategies likely to be most effective.

AUTHORS' CONCLUSIONS

LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care. For other health issues, evidence is insufficient to draw conclusions about the effects of LHWs.

Modification of the home environment for the reduction of injuries

BACKGROUND

Injury in the home is extremely common, accounting for around a third of all injuries. The majority of injuries of children under five and people aged 75 and over, 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 review the evidence for the effect on injuries of modification of the home environment with a primary focus on interventions to reduce physical hazards.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, National Research Register and other specialised databases. We also scanned conference proceedings and reference lists. In addition, we contacted experts and trialists in the field. The searches were not restricted by language or publication status. The searches were last updated in December 2004.

SELECTION CRITERIA

Randomised controlled trials.

DATA COLLECTION AND ANALYSIS

All abstracts were screened by two authors for relevance, outcome and design. Two authors independently assessed methodological quality and extracted data from each eligible study.

MAIN RESULTS

We found 18 published and one unpublished trials. Trials were not sufficiently similar to allow pooling of data by statistical analyses, so this review takes a narrative form. Studies were divided into three groups based on the primary population sample; children (five studies), older people (14 studies) and the general population/mixed age group (no studies). None of the studies focusing on children demonstrated a reduction in injuries that might have been due to environmental adaptation in the home; one study reported a reduction in injuries and in hazards but the two could not be linked. Of the 14 included studies in older people, none demonstrated a reduction in injuries due to hazard reduction, although two demonstrated a reduction in falls that could be due to hazard reduction.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effects of interventions to modify environmental home hazards. 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.