|Preventing Injuries at Home and in the Community|
Public Health Burden
In 1998 in the United States, more than 10 million people were injured at home severely enough to warrant an emergency department (ED) visit. This constituted 29% of all injury-related ED visits and 11% of all ED visits overall. Many factors and events contribute to injuries in the home and community. For the purposes of the Injury Center’s research agenda, home and community safety research includes fires, falls, dog bites, poisonings, consumer product–related injuries, choking (including strangulation and suffocation), and scalds and other nonfire burns. Other injuries such as playground, pedestrian, and bicycling injuries are included in the agenda’s chapters about sports, recreation, and exercise and transportation.
Two major sources of
injuries at home and in the community are fires and falls. In 1999, fires
were the third leading cause of injury-related deaths among children 1 to
9 years old and the fifth leading cause among people 65 and older. Falls
were the third leading cause of injury-related deaths among Americans of
all ages and were the leading cause of injury-related deaths among people
ages 65 and older. Of older adults who fall, 20% to 30% suffer moderate to
severe injuries that reduce mobility and independence and increase the
risk of premature death. The total direct cost of fall injuries for people
65 and older in 1994 was $20.2 billion. Falls are the leading cause of ED
visits among children, accounting for an estimated 3 million visits
annually. Infants and children who fall from low heights are at
substantial risk for head injuries, while those falling from heights of 10
feet or more may also sustain other, multiple, serious injuries.
The Injury Center’s Niche in Home and Community Injury Prevention
Injuries occurring in the home and in the community represent a significant public health burden in health care costs, injuries, and deaths. CDC’s Injury Center can lessen this burden by developing, evaluating, and promoting effective interventions in the home and in the community. Public perception that injuries are "accidents" that cannot be prevented hinders prevention efforts. Using the public health approach to injuries, CDC’s Injury Center conducts surveillance and research and translates science into effective public health practice.
Residential and community injuries derive from many sources and involve many products, environments, and risk groups. Addressing this complexity requires varied approaches and multiple partners. One of the Injury Center’s key partners is the U.S. Consumer Product Safety Commission (CPSC), which conducts research to protect the public from unreasonable risks of injury or death caused by consumer products. CPSC and the Injury Center jointly conduct nationally representative ED surveillance of injured persons.
The National Institute for Child Health and Human Development (NICHD) conducts research about home and community safety, including pilot work about child supervision. The Injury Center intends to conduct applied research about supervision using results from NICHD foundational research. The Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration provides training and technical assistance in injury prevention. The Injury Center complements MCHB work in state health departments by funding prevention programs in states with active MCHB programs.
Several nonprofit organizations conduct programs to promote safety in the home and community, particularly the National SAFE KIDS Campaign, the National Fire Protection Association, and the National Safety Council. The Injury Center has collaborated with these as well as other federal and nonprofit partners to build more effective interventions at the community level. Examples include research about smoke alarm technology; analysis of residential fires, including their causes and risk factors; prevention of older adult falls; and promotion of effective childhood injury prevention strategies. The U.S. Fire Administration (USFA) has authority in fire suppression and responsibility for primary data collection on causes and consequences of fires. The Injury Center works with USFA to support improved fire and burn surveillance. Other federal agencies also address older adult falls, including the Centers for Medicare and Medicaid Services (quality-of-care and cost/benefit issues), the National Institute on Aging (biology of aging, older adult fall prevention trials), and the Administration on Aging (programs). The Injury Center pursues many opportunities for collaboration with these agencies to support science and public health practice promoting home and community safety.
Every research priority
in this agenda is important. After considering input from experts in the
field, Injury Center staff identified the five most important priorities,
those that warrant the greatest attention and intramural and extramural
resources from the Injury Center over the next three to five years. They
are designated with asterisks.
A.* Evaluate strategies for widespread dissemination and implementation of effective interventions to reduce injuries at home and in the community.
Research has demonstrated that many interventions at home and in the community work: smoke alarms and sprinklers, bicycle helmets, stair gates and window bars, secured storage for poisons, child-proof cigarette lighters, and others. However, many of these strategies have not gained wide acceptance in some areas and among particular racial, ethnic, and socioeconomic groups for economic and other reasons. Encouraging widespread adoption of these efficacious interventions calls for dissemination research.
Research should focus on effective home- and community-based interventions, especially large-scale community injury prevention programs and policies. Demonstration programs should be developed and evaluated to determine the effectiveness of various persuasive communications techniques, audience segmentation, various dissemination strategies and communication channels, tailored messaging, and collaboration models to speed diffusion and widen adoption. Research that builds on the strengths of a community and encourages the community to participate in the research process and develop the capacity to sustain the benefits of interventions will be of additional value.
B.* Identify modifiable behavioral responses to residential fires and evaluate interventions to prevent fire-related injuries in mass trauma events.
Almost three-quarters of all fire and burn deaths occur in the home. Residential fires killed nearly 2,900 people and injured 16,000 in 1999. Researchers have identified the major causes of most fires: cooking, heating equipment, and smoking. They have also identified the groups at highest risk of injuries from fires: very young children, older adults, people with disabilities, and people who live in poverty. Additionally, research has shown that residential smoke alarms, when functional, can prevent 50% to 80% of deaths by providing early warning of fires, which often occur at night when people are sleeping.
Research should identify behavioral responses—what people do—when a residential fire breaks out. Researchers need a better understanding of the social, environmental, and behavioral circumstances that affect an individual’s ability to escape safely once a fire starts. These circumstances include the development, practice, use, and effectiveness of fire escape plans and other aspects of evacuation; the presence and use of appropriate fire extinguishers; the existence of functioning smoke alarms in appropriate areas of the home; and fear of and maladaptive responses to uncontrolled fire and smoke. Further, research is needed to identify strategies that improve the abilities of high-risk persons to detect and escape from a fire, including older adults, who may not hear commercially available smoke alarms; young children, who may not know how to respond effectively; and people with physical and mental disabilities. Rural residents are 1.5 to 3.5 times more likely to die in a fire than urban dwellers. Interventions to reduce this disparity are needed.
Research is also needed to address evacuation strategies in mass trauma events, such as large office and school building fires. Such findings can also be applied to events related to bioterrorism, terrorist attacks, bombings, and building collapses. Although the 2001 World Trade Center fire was the most dramatic, recent example of fire-related mass trauma, fires killed more than 100 people in commercial buildings in 1999. Strategies such as fire safety policies, disaster planning, education programs, and other methods of preventing and escaping fires in emergencies should be evaluated. Examples of this type of research include evaluating the effectiveness of environmental modifications that facilitate egress, such as architectural design, exit signs, construction specifications, and building codes; improving residential and building safety inspections; and adding or modifying home and commercial sprinklers and other fire extinguishing systems, floor and stair designs, electrical systems, and hard-wired smoke alarms. To integrate human factor issues into performance-based fire safety designs and regulations, researchers will need a better understanding of human reaction to fire and of fire risk perception. Such research will necessitate a broad, interdisciplinary approach involving many professionals in fire prevention, safety science, engineering, psychology, design, and environmental and policy science.
C.* Develop and evaluate community-based interventions to prevent falls among older, community-dwelling adults and study the dissemination of those programs.
Approximately 30% of older adults and 40% of those over age 80 report having fallen in the past year. Falls account for 29% of injury deaths among adults ages 65 and older and result in 300,000 hip fractures annually at a cost of more than $10 billion. Individual factors known to increase the risk of a fall include low muscle tone and balance problems, vision problems, polydrug and psychotropic medication use, and sedentary lifestyles. Less conclusively, research suggests that some home hazards and lifestyle behaviors may also contribute to the risk of falling.
Research about fall prevention is needed for three phases: dissemination, efficacy and effectiveness, and developmental. For proven interventions such as strength and balance training and medication review and adjustment (especially for psychotropic drugs), research is needed to identify barriers to widespread adoption by public health and health care professionals. Researchers have already identified some barriers. For example, some health professionals do not have adequate information about effective interventions; others may have the information but do not use it in their work with patients and the public. Once researchers have identified the barriers to widespread adoption, they should develop and test strategies for overcoming them.
Research is needed to develop and evaluate approaches to implementing and disseminating effective fall prevention programs in the community, especially programs involving multiple strategies. This includes research to identify the best formats and channels for delivering interventions to ensure that older adults adopt them. Health services and operations research is necessary to develop model infrastructures for service delivery that include partnerships between public health agencies and networks that serve the aging community. Research is also needed to identify people most in need of falls prevention programs and to discern whether different programs work for different subgroups (e.g., frail older adults, people who have fallen previously, and people with a fear of falling).
Finally, for some interventions, researchers and practitioners have little information about the intervention’s effectiveness when it is broadly applied in the community. Examples include vision enhancement (e.g., vision screening and correction, home lighting improvements) and hip pads. Research should evaluate these interventions and determine how best to implement them in community settings with older adults. Further, researchers should use the results of biomechanic and other research to design and test new interventions.
D.* Among young children, determine the immediate causes of the most severe and disabling types of falls and develop and evaluate interventions to prevent them.
Of the nearly 3 million ED visits each year for falls among children and adolescents, more than 40% occur among infants, toddlers, and preschoolers. Annual direct medical costs for falls among young children are estimated at $958 million. Two key determinants of fall-related injuries are characteristics of children at greatest risk and the causal sequence of events leading to the fall. Falls that result in a traumatic brain injury are of particular concern. In the home, such an injury may occur after a fall from a great height (e.g., down a staircase) or from a lesser height (e.g., off a changing table). Research should develop and evaluate interventions in home and community settings to reduce the major risks and most serious consequences of falls among children.
E.* Develop methods to better define and measure aspects of supervision for children and impaired older adults.
Supervision is generally considered one of the strongest yet least understood protective factors against many types of home and community injuries, including playground injuries, drowning deaths, dog bites, and child pedestrian injuries. The developmental ability, temperament, and cognitive and physical abilities of children affect their requirements for supervision and the effectiveness of supervision. These factors also influence the degree of supervision needed for impaired older adults, such as those with Alzheimer’s disease, Parkinson’s disease, or stroke, and for children with special needs.
Research should develop and validate a classification scheme for supervision to capture the variety of supervisory patterns currently used across a spectrum of ages and cultures. Researchers should develop measurement tools to describe and compare various styles of supervision and their relative effectiveness in preventing injuries.
F. Determine the impact of legislation, litigation, and regulation in preventing specific home and community injuries.
Legislation, litigation, and regulation have been used to prevent injuries, but their relative effectiveness has not been established. Legislation addresses motor vehicle traffic and the design, manufacture, sale, possession, or use of a product. Litigation is used to uphold the law. Regulation addresses specific issues, such as building codes or ordinances banning specific dog breeds. Researchers should evaluate each of these approaches to injury prevention.
G. Develop and evaluate interventions to prevent dog bite injuries.
Dog bites accounted for an estimated 4.7 million injuries in 1994; of the nearly 800,000 people who sought medical care for dog bites, approximately half were children. Modifiable risk factors for dog bites include victim behaviors, characteristics of the dog, and behaviors of the dog owner. Modifiable community factors include dog leash laws, neutering norms, and the prevalence of dog ownership training and school-based and educational programs delivered by veterinarians and medical care personnel. Researchers should develop and evaluate programs to modify risk factors to prevent dog bites and related injuries.
H. Develop and evaluate programs to prevent scalds and nonfire burns.
Scalds, contact burns, and electrical and chemical burns are frequent causes of nonfatal, nonfire injuries. Scalds from hot liquids are the most frequent cause of these injuries; 95% of scalds occur among children younger than 5 years old. Research is needed to identify or develop, then evaluate, practical and effective solutions to reduce scalds and nonfire burns. Important factors to investigate include the role of supervision and water tap temperature regulators.
I. Study the relationship between the urban environment and the occurrence of unintentional and violence-related injuries.
Community changes in land use, housing development, and personal transportation may increase or decrease residents’ exposure to harm. For example, changes in exposure can occur by shifting transportation from car to bicycle or foot; by increasing the amount of recreational time spent outdoors near traffic; by isolating homes and schools from traffic; or by other structural changes. These aspects of the community environment and their construction, maintenance, and alteration may have consequences for unintentional injury or interpersonal violence.
Structural changes are rarely studied in a comprehensive manner. Researchers should investigate the relationship between characteristics of the built environment and the occurrence of unintentional and violence-related injuries and assess how changing these characteristics affects these types of injury.
This page last reviewed September 07, 2006.