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Disability and home hazards and safety practices in US households
Disability and Health Journal 5 (2012) 49e54 www.disabilityandhealthjnl.com
Disability and home hazards and safety practices in US households Catherine J. Vladutiu, M.P.H.a,b,*, Carri Casteel, Ph.D.a,b, Stephen W. Marshall, Ph.D.a,b, Kara S. McGee, M.S.P.H.c,d, Carol W. Runyan, Ph.D.a,b,e,f, and Tamera Coyne-Beasley, M.D.e,f,g a University of North Carolina Injury Prevention Research Center, Chapel Hill, NC 27599-7505, USA Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7435, USA c Division of Infectious Diseases, Duke University Medical Center, Durham, NC 27710, USA d Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7445, USA e Department of Health Behavior and Health Education, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7440, USA f Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7220, USA g Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7005, USA b
Abstract Background: Individuals with disabilities have an elevated risk of residential injury. However, the prevalence of home hazards and safety practices among households where an individual with a disability resides is unknown. Methods: This study examined patterns of home hazards and safety practices among 1003 households across the United States in 2002. Results: Households with at least 1 resident with a disability had a lower prevalence of household hazards than those without a resident with a disability, including living in a 2-story dwelling (34.6% vs 50.7%) and having stairs inside the home (48.1% vs 58.4%). They were more likely to implement fall prevention strategies, such as handrails or grab bars in the bathroom (40.4% vs 21.8%) and mats or nonskid strips in the tub or shower (71.7% vs 61.5%). Conclusion: There is room for improvement in safety practices among households where an individual with a disability resides. Ó 2012 Elsevier Inc. All rights reserved. Keywords: Disability; Injury; Home; Safety
Each year, approximately 12 million unintentional, nonfatal residential injuries and at least 18,000 fatal residential injuries occur in households across the United States [1,2]. The leading causes of nonfatal residential injuries include falls, sharp objects, being struck by/against a person or object, and poisonings [1], while falls, poisonings, and fires/burns account for the majority of fatal residential injuries [2]. Children and older adults are at particularly high risk of unintentional residential injury, with estimated rates of fatal injuries ranging from 6.4% for children aged !4 years to 47.9% for adults 80 years and older [2]. This study was funded by a contract from the Home Safety Council to the University of North Carolina Injury Prevention Research Center, with additional support from the National Center for Injury Prevention and Control (R49/CCR402444). Dr. Vladutiu received partial support from grant T32HD052468-03, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD. The authors have no conflicts of interest, financial, or otherwise. * Corresponding author: 137 East Franklin Street, CB #7505. E-mail address: [email protected] (C.J. Vladutiu). 1936-6574/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.dhjo.2011.10.003
Several studies have found that the presence of a disability increases the risk of injury for children [3-5] and adults [6-8], particularly in the home environment [9]. Vladutiu et al. (2008) [9] estimated the residential injury risk for individuals with 1 or more disabilities. This study found that the risk of residential injury increased O3-fold with increasing numbers of disabilities while there was little change in the risk of nonresidential injury as the number of disabilities increased. Little is understood about factors in the home environment that may increase the risk of injury among individuals with disabilities. In addition, while safety practices that reduce the risk of residential injury, such as installing fire alarms, hand rails, and nonskid strips in tubs and showers, have been identified for children and older adults [10-13], the prevalence of these practices in households where an individual with a disability resides is unknown. This study examined patterns of hazards and safety practices among households with at least 1 resident with a disability compared to households without a resident with a disability.
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C.J. Vladutiu et al. / Disability and Health Journal 5 (2012) 49e54
Table 1 Household characteristics of the study population, by household disability status (N 5 1,003), 2002* Homes with a resident All respondents reporting a disability (n 5 190)
Structure of home House Apartment Duplex/townhouse Modular/manufactured Other Annual household incomez !$50,000 >$50,000 Residential tenure Owner-occupied Rental Household compositionx Child <6 years old Adult >70 years old No children <6, no adult >70 Region of residencek Northeast South Midwest West
Homes without a resident reporting a disability (n 5 833)
Unweighted No. of respondents
Weighted percentage (95% CI)
Unweighted No. of respondents
Weighted percentage (95% CI)
Unweighted No. of respondents
Weighted percentage (95% CI)
698 162 74 67 2
65.4 20.3 7.6 6.5 0.2
(62.2-68.5) (17.5-23.1) (5.9-9.4) (5.0-8.0) (0.0-0.5)
120 42 10 17 1
58.1 27.3 5.5 8.6 0.6
(50.7-65.5) (20.3-34.3) (2.1-8.9) (4.5-12.6) (0.0-1.8)
578 120 64 50 1
67.1 18.6 8.2 6.0 0.1
(63.6-70.5) (15.6-21.6) (6.2-10.1) (4.4-7.6) (0.0-0.4)
.02
428 438
45.5 (42.0-48.9) 54.5 (51.1-58.0)
110 59
67.6 (60.4-74.7) 32.4 (25.3-39.6)
328 369
51.3 (47.5-55.2) 48.7 (44.8-52.5)
!.01
747 243
68.9 (65.8-72.1) 31.1 (27.9-34.2)
133 54
64.9 (57.5-72.3) 35.1 (27.7-42.5)
614 189
69.9 (66.4-73.4) 30.1 (26.6-33.6)
.23
194 145 648
16.3 (14.1-18.5) 17.0 (14.4-19.5) 66.8 (63.7-69.8)
31 53 102
13.7 (9.0-18.5) 31.1 (24.0-38.2) 55.2 (47.8-62.6)
163 92 546
16.9 (14.4-19.4) 13.6 (11.0-16.2) 69.5 (66.2-72.8)
!.01
211 348 247 197
21.0 34.3 24.4 20.4
20.0 35.1 22.4 22.4
171 275 208 159
21.2 34.1 24.8 19.9
(18.4-23.6) (31.3-37.3) (21.6-27.1) (17.8-23.0)
40 73 39 38
(14.2-25.8) (28.2-42.1) (16.2-28.7) (16.1-28.8)
(18.3-24.1) (30.7-37.5) (21.8-27.9) (17.0-22.7)
p Valuey
.82
* Percentages and 95% confidence intervals (CI) were weighted by the presence of multiple telephone lines, any person <6 years old, any person >70 years old, and tenure (owner-occupied vs rental) in the overall US population of households, excluding Alaska and Hawaii. y The p Value for the chi-square statistics testing the association between homes with a resident reporting a disability and homes without a resident reporting a disability for each household characteristic. z 86% of respondents reported their annual household income. x Categories are mutually exclusive. k Northeast (CT, MA, ME, NH, NJ, NY, PA, RI, VT); Midwest (IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, WI); South (AL, AR, DC, DE, FL, FA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV); West (AZ, CA, CO, ID, MT, NM, NV, OR, UT, WA, WY).
Methods Sampling A nationally representative telephone survey was conducted in 2002 to assess home safety practices among private residences in the United States. GENESYS Sampling Systems (Fort Washington, PA) provided the sampling frame, which included published and unpublished telephone numbers. Households were sampled using random digit dialing of active residential numbers. Two-stage sample weights were calculated to facilitate valid projections to US households (ie, the number of telephone lines per household, the presence of children aged <6 years, the presence of older adults, home ownership status) and to account for nonresponse. More detailed information on the sampling methods is described in previous publications [13-15]. Eligibility Eligible households contained an English-speaking adult, aged 18 or older, and excluded institutions (ie, not a prison, nursing home, assisted living facility, barrack or dormitory). Respondents were required to reside in the
household and have a role in making safety decisions. Only households in the 48 contiguous states were included. Data collection instrument Investigators at the University of North Carolina Injury Prevention Research Center, with input from the Home Safety Council, developed and reviewed the 92-item instrument. (This survey is available from the authors upon request.) The instrument was developed to identify the presence of household hazards and safety devices specific to the leading causes of residential injury death (ie, falls, fires/burns, poisonings). Sociodemographics, household composition, home features, and geographic region were also collected. To identify the presence of fall hazards in the home, interviewers asked the respondents about the presence of outside steps, O1 story or level (including the basement and attic), indoor stairs (including those leading to the basement or attic), and stairs without handrails or banisters. Respondents were also asked about their safety practices pertaining to fall prevention (ie, handrails or grab bars in the bathroom and mats or nonskid strips in the tub or
C.J. Vladutiu et al. / Disability and Health Journal 5 (2012) 49e54
51
Table 2 Prevalence of home hazards and safety practices in US households, by household disability status and residential tenure (N 5 1,003), 2002* Residential tenure All households
Rental
Owner-occupied
Disability, No disability, Disability, No disability, Disability, No disability, n (%) p Valuey n (%) n (%) p Valuey n (%) n (%) p Valuey n (%) Household hazards At least one outside step into home Yes No At least two stories/levels inside home Yes No Stairs inside the homez Yes No Stairs without handrails or banisters Yes No Safety practices Handrails or grab bars in any bathroom Yes No Mat or nonskid strips in any tubs or showers Yes No Fire escape planx Yes No Fire extinguisher Yes No Smoke alarm Yes No Aware of setting on hot water heater Yes No
145 (74.8) 663 (81.3) 45 (25.2) 148 (18.7)
.06
40 (71.0) 14 (29.0)
143 (75.8) 45 (24.2)
.49
104 (77.7) 512 (83.8) 29 (22.3) 101 (16.2)
.10
72 (34.6) 442 (50.7) 118 (65.4) 371 (49.3)
!.01
5 (7.7) 49 (92.3)
54 (27.8) 135 (72.2)
!.01
66 (49.0) 385 (61.0) 67 (51.0) 229 (39.0)
.01
97 (48.1) 501 (58.4) 93 (51.9) 312 (41.6)
.01
12 (19.8) 42 (80.2)
73 (37.7) 116 (62.3)
.01
83 (62.6) 425 (67.8) 50 (37.4) 189 (32.2)
.26
52 (33.3) 260 (33.7) 105 (66.7) 489 (66.3)
.92
11 (26.0) 29 (74.0)
47 (29.6) 113 (70.4)
.66
40 (36.2) 210 (35.4) 75 (63.8) 370 (64.6)
.87
78 (40.4) 179 (21.8) 112 (59.6) 634 (78.2)
!.01
14 (28.1) 40 (71.9)
29 (16.1) 160 (83.9)
.06
61 (45.6) 147 (24.1) 72 (54.4) 467 (75.9)
!.01
138 (71.7) 508 (61.5) 52 (28.3) 304 (38.5)
.01
31 (56.8) 23 (43.2)
105 (54.7) 84 (45.3)
.79
104 (79.1) 396 (64.3) 29 (20.9) 217 (35.7)
!.01
80 (45.9) 377 (50.2) 84 (54.1) 344 (49.8)
.34
18 (36.1) 26 (63.9)
57 (35.0) 102 (65.0)
.90
62 (52.0) 316 (56.2) 55 (48.0) 238 (43.8)
.41
135 (69.1) 577 (68.5) 55 (30.9) 234 (31.5)
.88
25 (47.4) 29 (52.6)
91 (47.1) 98 (52.9)
.97
107 (80.0) 480 (77.9) 26 (20.0) 132 (22.1)
.60
180 (95.8) 788 (96.9) 10 (4.2) 25 (3.1)
.44
49 (94.5) 5 (5.5)
180 (95.4) 9 (4.6)
.75
128 (96.4) 599 (97.6) 5 (3.6) 15 (2.4)
.41
55 (28.6) 197 (23.7) 135 (71.4) 616 (76.3)
.17
13 (23.0) 41 (77.0)
27 (14.2) 162 (85.8)
.13
42 (32.3) 169 (28.0) 91 (67.7) 445 (72.0)
.34
* Percentages were weighted by the presence of multiple telephone lines, any person <6 years old, any person >70 years old, and tenure (owneroccupied vs rental) in the overall US population of households, excluding Alaska and Hawaii. y The p Value for the chi-square statistics testing the association between homes with a resident reporting a disability and homes without a resident reporting a disability for each household hazard and safety practice. z Stairs inside the home include those to the basement or attic. x Restricted to those with O 1 person living in their home.
shower) and fire/burn prevention (ie, smoke alarms, fire extinguishers, fire escape plans, and awareness of the water heater setting). The disability portion of the survey consisted of 2 questions based on those used in the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System: (1) ‘‘Are you, or is anyone in your household, limited in any way in any activities because of physical, mental or emotional problems?’’ and (2) ‘‘Do you, or does anyone in your household, have a health problem that requires the use of special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?’’ We classified a household as having at least 1 resident with a disability if a ‘‘yes’’ was recorded for either or both of the questions.
Survey administration The University of North Carolina Survey Research Unit administered the survey using computer-assisted telephone interview (CATI) methodology between March and June 2002. The Institutional Review Board at the University of North Carolina at Chapel Hill approved this study. Statistical analysis We used c2 statistics to examine whether distributions of household hazards and safety practices varied by disability status and conducted stratified analyses by residential tenure and household composition. All analyses used sample weights to account for the complex sampling design.
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Table 3 Prevalence of home hazards and safety practices in US households, by household disability status and household composition (N 5 1,003), 2002* Household composition Child < 6 years old
Household hazards At least one outside step into home Yes No At least two stories/levels inside home Yes No Stairs inside the homez Yes No Stairs without handrails or banisters Yes No Safety practices Handrails or grab bars in any bathroom Yes No Mat or nonskid strips in any tubs or showers Yes No Fire escape planx Yes No Fire extinguisher Yes No Smoke alarm Yes No Aware of setting on hot water heater Yes No
Adult > 70 years old
No person < 6 or > 70 years old
Disability, No disability, Disability, Disability, No disability, n (%) p Valuey n (%) n (%) n (%) p Valuey n (%)
No disability, n (%)
27 (86.8) 4 (13.2)
134 (81.4) 29 (18.6)
.49
40 (74.1) 13 (25.9)
74 (80.1) 17 (19.9)
.43
75 (72.4) 27 (27.6)
444 (81.3) 101 (18.7)
.05
11 (31.1) 20 (68.9)
96 (54.7) 67 (45.3)
.02
27 (47.5) 26 (52.5)
35 (35.7) 57 (64.3)
.17
32 (27.1) 70 (72.9)
305 (52.9) 241 (47.1)
!.01
15 (47.0) 16 (53.0)
105 (60.8) 58 (39.2)
.17
32 (57.3) 21 (42.7)
44 (44.7) 48 (55.3)
.16
48 (42.7) 54 (57.3)
345 (60.6) 201 (39.2)
!.01
10 (38.9) 18 (61.1)
64 (42.0) 84 (58.0)
.77
15 (36.0) 27 (64.0)
20 (24.9) 61 (75.1)
.21
27 (31.5) 57 (68.5)
174 (33.9) 334 (66.1)
.68
9 (25.0) 22 (75.0)
33 (19.5) 130 (80.5)
.49
33 (60.5) 20 (39.5)
32 (36.2) 60 (63.8)
.01
34 (32.9) 68 (67.1)
108 (18.9) 438 (81.1)
!.01
21 (60.9) 10 (39.1)
106 (63.8) 57 (36.2)
.78
45 (84.4) 8 (15.6)
71 (76.6) 21 (23.4)
.28
68 (66.1) 34 (33.9)
325 (58.2) 220 (41.8)
.15
17 (54.8) 14 (45.2)
92 (54.3) 71 (45.7)
.96
13 (30.6) 27 (69.4)
26 (37.6) 42 (62.4)
.47
48 (50.8) 41 (49.2)
256 (51.6) 225 (48.4)
.89
23 (68.2) 8 (31.8)
116 (69.4) 47 (30.6)
.90
39 (72.6) 14 (27.4)
61 (63.3) 31 (36.7)
.27
70 (67.3) 32 (32.7)
392 (69.4) 152 (30.6)
.69
29 (93.5) 2 (6.5)
156 (94.7) 7 (5.3)
.81
52 (98.5) 1 (1.5)
89 (96.8) 3 (3.2)
.48
95 (94.6) 7 (5.4)
531 (97.3) 15 (2.7)
.13
11 (37.2) 20 (62.8)
24 (14.0) 139 (86.0)
!.01
20 (35.3) 33 (64.7)
15 (16.0) 77 (84.0)
.01
24 (23.9) 78 (76.1)
155 (27.7) 391 (72.3)
.45
p Valuey
* Percentages were weighted by the presence of multiple telephone lines, any person <6 years old, any person >70 years old, and tenure (owneroccupied vs rental) in the overall US population of households, excluding Alaska and Hawaii. y The p Value for the chi-square statistics testing the association between homes with a resident reporting a disability and homes without a resident reporting a disability for each household hazard and safety practice. z Stairs inside the home include those to the basement or attic. x Restricted to those with O 1 person living in their home.
Results Study sample A total of 1539 eligible respondents were invited to participate in the study, of which 498 refused to participate and 38 did not complete the interview. The final study sample included 1003 respondents. A high proportion of these respondents lived in houses (65%), had household incomes of at least $50,000 (55%), lived in owneroccupied residences (69%), did not have children younger than 6 years or adults older than 70 years living in the home (67%), and lived in the southern region of the United States (34%) (Table 1). Approximately 20% of the households (n 5 190) reported at least 1 resident with a disability. Among these
households, 162 reported at least 1 person who was limited in activities because of a physical, mental, or emotional problem; 93 reported at least 1 person who had a medical condition that required use of special equipment. Household characteristics Households with at least 1 resident with a disability were more likely than households without a resident with a disability to live in an apartment (27.3% vs 18.6%), report a lower annual household income (67.6% vs 51.3%), and have a resident 70þ years of age (31.1% vs 13.6%) (Table 1). The distributions of residential tenure and region of residence were similar for households with and without a resident with a disability.
C.J. Vladutiu et al. / Disability and Health Journal 5 (2012) 49e54
Prevalence of household hazards and safety practices Households where an individual with a disability resided were less likely to live in a 2-story dwelling (34.6% vs 50.7%) and have stairs inside the home (48.1% vs 58.4%) (Table 2). These households were also more likely to implement fall prevention practices (ie, have handrails or grab bars in the bathroom and mats or nonskid strips in the tub or shower) (40.4% vs 21.8% and 71.7% vs 61.5%, respectively). There were differences in the prevalence of household hazards and safety practices by residential tenure. In rental households, those with a resident with a disability were less likely than those without a resident with a disability to have 2 stories (7.7% vs 27.8%) or indoor stairs (19.8% vs 37.7%) (Table 2). In owner-occupied households, those with a resident with a disability were more likely to implement fall prevention practices (45.6% vs 24.1% had handrails or grab bars in the bathroom and 79.1% vs 64.3% had mats or nonskid strips in the tub or shower). No differences in the prevalence of safety practices by disability status were found among rental households. Among households with no young children or older adults, those with a resident with a disability were less likely to have at least 1 step to get into their home (72.4% vs 81.3%), 2 stories (27.1% vs 52.9%), or indoor stairs (42.7% vs 60.6%) (Table 3). These households were also more likely to have handrails or grab bars in the bathroom (32.9% vs 18.9%). Among households with an older adult, those with a resident with a disability were more likely to have handrails or grab bars in the bathroom (60.5% vs 36.2%) and be aware of the water heater setting (35.3% vs 16.0%).
Discussion Households with at least 1 resident with a disability appear to be safer than households without a resident with a disability with respect to fall prevention practices (ie, presence of handrails or grab bars in the bathroom and mats or nonskid strips in the tub or shower). These homes are also less likely to have fall hazards, including multiple stories and indoor stairs. However, the prevalence of fire safety practices in households with at least 1 resident with a disability did not differ from those in households without a resident with a disability. Many homes in the United States, regardless of whether the household has a resident with a disability, lack home safety practices that can reduce the risk of residential injury. In this study, the overall prevalence of several safety practices was low. For example, less than half of the households had handrails or grab bars in the bathroom, a fire escape plan, or knowledge of the water heater setting. Given that falls and fire/burns are leading causes of residential injury in the United States [1,2], it is important to improve safety practices
53
to prevent their occurrence. Interventions that address this, however, may differ in households with and without a resident with a disability and by the type and severity of the disability. For example, fire escape plans may be ineffective in households where an individual with a mobility limitation resides depending on which exits are able to be used. This study has limitations. This research does not represent all households in the United States, particularly noneEnglish-speaking households and those outside the contiguous United States. The disability measure did not assess the type (eg, physical, emotional), domain (eg, seeing, hearing), or severity of disability. In addition, the data were collected in 2002 and may not reflect current household hazards and safety practices in homes where an individual with a disability resides. However, to our knowledge, there is no reason to believe they have changed significantly over time. The findings from this study suggest that there are opportunities for improving safety in households where individuals with disabilities reside. Future research should focus on describing home hazards and safety practices among persons with specific types of disabilities to develop and evaluate interventions that are tailored to the ability of household members to effectively implement and benefit from them.
References [1] Runyan CW, Perkis D, Marshall SW, Johnson RM, et al. Unintentional injuries in the home in the United States, part II: morbidity. Am J Prev Med. 2005;28(1):80-87. [2] Runyan CW, Casteel C, Perkis D, et al. Unintentional injuries in the home in the United States, part I: mortality. Am J Prev Med. 2005;28(1):73-79. [3] Petridou E, Kedikoglou S, Andrie E, et al. Injuries among disabled children: a study from Greece. Inj Prev. 2003;9:226-230. [4] Xiang H, Zhu M, Sinclair SA, et al. Risk of vehicle-pedestrian and vehicle-bicyclist collisions among children with disabilities. Accid Anal Prev. 2006;38:1064-1070. [5] Xiang H, Stallones L, Chen G, et al. Nonfatal injuries among US children with disabling conditions. Am J Public Health. 2005;95: 1970-1975. [6] Hsieh K, Heller T, Miller AB. Risk factors for injuries and falls among adults with developmental disabilities. J Intellect Disabil Res. 2001;45:76-82. [7] Xiang H, Leff M, Stallones L. Non-fatal injuries among adults with activity limitations and participation restrictions. Inj Prev. 2005;11: 157-162. [8] Brophy M, Zhang X, Xiang H. Injuries among US adults with disabilities. Epidemiology. 2008;19:465-471. [9] Vladutiu CJ, Casteel C, Runyan CW. Disability and risk of non-fatal residential injuries among adults. Inj Prev. 2008; 14(5):302-305. [10] Plautz B, Deck DE, Selmar C, et al. Modifying the environment: a community-based injury-reduction program for elderly residents. Am J Prev Med. 1996;12(4 Suppl):33-38. [11] DiGuiseppi C, Roberts I, Li L. Smoke alarm ownership and house fire death rates in children. J Epidemiol Community Health. 1998;52(11): 760-761.
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[12] Kendrick D, Watson M, Mulvaney C, et al. How useful are home safety behaviours for predicting childhood injury? A cohort study. Health Educ Res. 2005;20(6):709-718. [13] Marshall SW, Runyan CW, Yang JZ, et al. Prevalence of selected risk and protective factors for falls in the home. Am J Prev Med. 2005;28(1):95-101.
[14] Runyan CW, Johnson RM, Yang JZ, et al. Risk and protective factors for fires, burns, and carbon monoxide poisoning in US households. Am J Prev Med. 2005;28(1):102-108. [15] Coyne-Beasley T, Runyan CW, Baccaglini L, et al. Storage of poisonous substances and firearms in homes with young children visitors and older adults. Am J Prev Med. 2005;28(1):109-115.
Disability and home hazards and safety practices in US households Catherine J. Vladutiu, M.P.H.a,b,*, Carri Casteel, Ph.D.a,b, Stephen W. Marshall, Ph.D.a,b, Kara S. McGee, M.S.P.H.c,d, Carol W. Runyan, Ph.D.a,b,e,f, and Tamera Coyne-Beasley, M.D.e,f,g a University of North Carolina Injury Prevention Research Center, Chapel Hill, NC 27599-7505, USA Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7435, USA c Division of Infectious Diseases, Duke University Medical Center, Durham, NC 27710, USA d Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7445, USA e Department of Health Behavior and Health Education, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7440, USA f Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7220, USA g Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7005, USA b
Abstract Background: Individuals with disabilities have an elevated risk of residential injury. However, the prevalence of home hazards and safety practices among households where an individual with a disability resides is unknown. Methods: This study examined patterns of home hazards and safety practices among 1003 households across the United States in 2002. Results: Households with at least 1 resident with a disability had a lower prevalence of household hazards than those without a resident with a disability, including living in a 2-story dwelling (34.6% vs 50.7%) and having stairs inside the home (48.1% vs 58.4%). They were more likely to implement fall prevention strategies, such as handrails or grab bars in the bathroom (40.4% vs 21.8%) and mats or nonskid strips in the tub or shower (71.7% vs 61.5%). Conclusion: There is room for improvement in safety practices among households where an individual with a disability resides. Ó 2012 Elsevier Inc. All rights reserved. Keywords: Disability; Injury; Home; Safety
Each year, approximately 12 million unintentional, nonfatal residential injuries and at least 18,000 fatal residential injuries occur in households across the United States [1,2]. The leading causes of nonfatal residential injuries include falls, sharp objects, being struck by/against a person or object, and poisonings [1], while falls, poisonings, and fires/burns account for the majority of fatal residential injuries [2]. Children and older adults are at particularly high risk of unintentional residential injury, with estimated rates of fatal injuries ranging from 6.4% for children aged !4 years to 47.9% for adults 80 years and older [2]. This study was funded by a contract from the Home Safety Council to the University of North Carolina Injury Prevention Research Center, with additional support from the National Center for Injury Prevention and Control (R49/CCR402444). Dr. Vladutiu received partial support from grant T32HD052468-03, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD. The authors have no conflicts of interest, financial, or otherwise. * Corresponding author: 137 East Franklin Street, CB #7505. E-mail address: [email protected] (C.J. Vladutiu). 1936-6574/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.dhjo.2011.10.003
Several studies have found that the presence of a disability increases the risk of injury for children [3-5] and adults [6-8], particularly in the home environment [9]. Vladutiu et al. (2008) [9] estimated the residential injury risk for individuals with 1 or more disabilities. This study found that the risk of residential injury increased O3-fold with increasing numbers of disabilities while there was little change in the risk of nonresidential injury as the number of disabilities increased. Little is understood about factors in the home environment that may increase the risk of injury among individuals with disabilities. In addition, while safety practices that reduce the risk of residential injury, such as installing fire alarms, hand rails, and nonskid strips in tubs and showers, have been identified for children and older adults [10-13], the prevalence of these practices in households where an individual with a disability resides is unknown. This study examined patterns of hazards and safety practices among households with at least 1 resident with a disability compared to households without a resident with a disability.
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Table 1 Household characteristics of the study population, by household disability status (N 5 1,003), 2002* Homes with a resident All respondents reporting a disability (n 5 190)
Structure of home House Apartment Duplex/townhouse Modular/manufactured Other Annual household incomez !$50,000 >$50,000 Residential tenure Owner-occupied Rental Household compositionx Child <6 years old Adult >70 years old No children <6, no adult >70 Region of residencek Northeast South Midwest West
Homes without a resident reporting a disability (n 5 833)
Unweighted No. of respondents
Weighted percentage (95% CI)
Unweighted No. of respondents
Weighted percentage (95% CI)
Unweighted No. of respondents
Weighted percentage (95% CI)
698 162 74 67 2
65.4 20.3 7.6 6.5 0.2
(62.2-68.5) (17.5-23.1) (5.9-9.4) (5.0-8.0) (0.0-0.5)
120 42 10 17 1
58.1 27.3 5.5 8.6 0.6
(50.7-65.5) (20.3-34.3) (2.1-8.9) (4.5-12.6) (0.0-1.8)
578 120 64 50 1
67.1 18.6 8.2 6.0 0.1
(63.6-70.5) (15.6-21.6) (6.2-10.1) (4.4-7.6) (0.0-0.4)
.02
428 438
45.5 (42.0-48.9) 54.5 (51.1-58.0)
110 59
67.6 (60.4-74.7) 32.4 (25.3-39.6)
328 369
51.3 (47.5-55.2) 48.7 (44.8-52.5)
!.01
747 243
68.9 (65.8-72.1) 31.1 (27.9-34.2)
133 54
64.9 (57.5-72.3) 35.1 (27.7-42.5)
614 189
69.9 (66.4-73.4) 30.1 (26.6-33.6)
.23
194 145 648
16.3 (14.1-18.5) 17.0 (14.4-19.5) 66.8 (63.7-69.8)
31 53 102
13.7 (9.0-18.5) 31.1 (24.0-38.2) 55.2 (47.8-62.6)
163 92 546
16.9 (14.4-19.4) 13.6 (11.0-16.2) 69.5 (66.2-72.8)
!.01
211 348 247 197
21.0 34.3 24.4 20.4
20.0 35.1 22.4 22.4
171 275 208 159
21.2 34.1 24.8 19.9
(18.4-23.6) (31.3-37.3) (21.6-27.1) (17.8-23.0)
40 73 39 38
(14.2-25.8) (28.2-42.1) (16.2-28.7) (16.1-28.8)
(18.3-24.1) (30.7-37.5) (21.8-27.9) (17.0-22.7)
p Valuey
.82
* Percentages and 95% confidence intervals (CI) were weighted by the presence of multiple telephone lines, any person <6 years old, any person >70 years old, and tenure (owner-occupied vs rental) in the overall US population of households, excluding Alaska and Hawaii. y The p Value for the chi-square statistics testing the association between homes with a resident reporting a disability and homes without a resident reporting a disability for each household characteristic. z 86% of respondents reported their annual household income. x Categories are mutually exclusive. k Northeast (CT, MA, ME, NH, NJ, NY, PA, RI, VT); Midwest (IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, WI); South (AL, AR, DC, DE, FL, FA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV); West (AZ, CA, CO, ID, MT, NM, NV, OR, UT, WA, WY).
Methods Sampling A nationally representative telephone survey was conducted in 2002 to assess home safety practices among private residences in the United States. GENESYS Sampling Systems (Fort Washington, PA) provided the sampling frame, which included published and unpublished telephone numbers. Households were sampled using random digit dialing of active residential numbers. Two-stage sample weights were calculated to facilitate valid projections to US households (ie, the number of telephone lines per household, the presence of children aged <6 years, the presence of older adults, home ownership status) and to account for nonresponse. More detailed information on the sampling methods is described in previous publications [13-15]. Eligibility Eligible households contained an English-speaking adult, aged 18 or older, and excluded institutions (ie, not a prison, nursing home, assisted living facility, barrack or dormitory). Respondents were required to reside in the
household and have a role in making safety decisions. Only households in the 48 contiguous states were included. Data collection instrument Investigators at the University of North Carolina Injury Prevention Research Center, with input from the Home Safety Council, developed and reviewed the 92-item instrument. (This survey is available from the authors upon request.) The instrument was developed to identify the presence of household hazards and safety devices specific to the leading causes of residential injury death (ie, falls, fires/burns, poisonings). Sociodemographics, household composition, home features, and geographic region were also collected. To identify the presence of fall hazards in the home, interviewers asked the respondents about the presence of outside steps, O1 story or level (including the basement and attic), indoor stairs (including those leading to the basement or attic), and stairs without handrails or banisters. Respondents were also asked about their safety practices pertaining to fall prevention (ie, handrails or grab bars in the bathroom and mats or nonskid strips in the tub or
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51
Table 2 Prevalence of home hazards and safety practices in US households, by household disability status and residential tenure (N 5 1,003), 2002* Residential tenure All households
Rental
Owner-occupied
Disability, No disability, Disability, No disability, Disability, No disability, n (%) p Valuey n (%) n (%) p Valuey n (%) n (%) p Valuey n (%) Household hazards At least one outside step into home Yes No At least two stories/levels inside home Yes No Stairs inside the homez Yes No Stairs without handrails or banisters Yes No Safety practices Handrails or grab bars in any bathroom Yes No Mat or nonskid strips in any tubs or showers Yes No Fire escape planx Yes No Fire extinguisher Yes No Smoke alarm Yes No Aware of setting on hot water heater Yes No
145 (74.8) 663 (81.3) 45 (25.2) 148 (18.7)
.06
40 (71.0) 14 (29.0)
143 (75.8) 45 (24.2)
.49
104 (77.7) 512 (83.8) 29 (22.3) 101 (16.2)
.10
72 (34.6) 442 (50.7) 118 (65.4) 371 (49.3)
!.01
5 (7.7) 49 (92.3)
54 (27.8) 135 (72.2)
!.01
66 (49.0) 385 (61.0) 67 (51.0) 229 (39.0)
.01
97 (48.1) 501 (58.4) 93 (51.9) 312 (41.6)
.01
12 (19.8) 42 (80.2)
73 (37.7) 116 (62.3)
.01
83 (62.6) 425 (67.8) 50 (37.4) 189 (32.2)
.26
52 (33.3) 260 (33.7) 105 (66.7) 489 (66.3)
.92
11 (26.0) 29 (74.0)
47 (29.6) 113 (70.4)
.66
40 (36.2) 210 (35.4) 75 (63.8) 370 (64.6)
.87
78 (40.4) 179 (21.8) 112 (59.6) 634 (78.2)
!.01
14 (28.1) 40 (71.9)
29 (16.1) 160 (83.9)
.06
61 (45.6) 147 (24.1) 72 (54.4) 467 (75.9)
!.01
138 (71.7) 508 (61.5) 52 (28.3) 304 (38.5)
.01
31 (56.8) 23 (43.2)
105 (54.7) 84 (45.3)
.79
104 (79.1) 396 (64.3) 29 (20.9) 217 (35.7)
!.01
80 (45.9) 377 (50.2) 84 (54.1) 344 (49.8)
.34
18 (36.1) 26 (63.9)
57 (35.0) 102 (65.0)
.90
62 (52.0) 316 (56.2) 55 (48.0) 238 (43.8)
.41
135 (69.1) 577 (68.5) 55 (30.9) 234 (31.5)
.88
25 (47.4) 29 (52.6)
91 (47.1) 98 (52.9)
.97
107 (80.0) 480 (77.9) 26 (20.0) 132 (22.1)
.60
180 (95.8) 788 (96.9) 10 (4.2) 25 (3.1)
.44
49 (94.5) 5 (5.5)
180 (95.4) 9 (4.6)
.75
128 (96.4) 599 (97.6) 5 (3.6) 15 (2.4)
.41
55 (28.6) 197 (23.7) 135 (71.4) 616 (76.3)
.17
13 (23.0) 41 (77.0)
27 (14.2) 162 (85.8)
.13
42 (32.3) 169 (28.0) 91 (67.7) 445 (72.0)
.34
* Percentages were weighted by the presence of multiple telephone lines, any person <6 years old, any person >70 years old, and tenure (owneroccupied vs rental) in the overall US population of households, excluding Alaska and Hawaii. y The p Value for the chi-square statistics testing the association between homes with a resident reporting a disability and homes without a resident reporting a disability for each household hazard and safety practice. z Stairs inside the home include those to the basement or attic. x Restricted to those with O 1 person living in their home.
shower) and fire/burn prevention (ie, smoke alarms, fire extinguishers, fire escape plans, and awareness of the water heater setting). The disability portion of the survey consisted of 2 questions based on those used in the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System: (1) ‘‘Are you, or is anyone in your household, limited in any way in any activities because of physical, mental or emotional problems?’’ and (2) ‘‘Do you, or does anyone in your household, have a health problem that requires the use of special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?’’ We classified a household as having at least 1 resident with a disability if a ‘‘yes’’ was recorded for either or both of the questions.
Survey administration The University of North Carolina Survey Research Unit administered the survey using computer-assisted telephone interview (CATI) methodology between March and June 2002. The Institutional Review Board at the University of North Carolina at Chapel Hill approved this study. Statistical analysis We used c2 statistics to examine whether distributions of household hazards and safety practices varied by disability status and conducted stratified analyses by residential tenure and household composition. All analyses used sample weights to account for the complex sampling design.
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Table 3 Prevalence of home hazards and safety practices in US households, by household disability status and household composition (N 5 1,003), 2002* Household composition Child < 6 years old
Household hazards At least one outside step into home Yes No At least two stories/levels inside home Yes No Stairs inside the homez Yes No Stairs without handrails or banisters Yes No Safety practices Handrails or grab bars in any bathroom Yes No Mat or nonskid strips in any tubs or showers Yes No Fire escape planx Yes No Fire extinguisher Yes No Smoke alarm Yes No Aware of setting on hot water heater Yes No
Adult > 70 years old
No person < 6 or > 70 years old
Disability, No disability, Disability, Disability, No disability, n (%) p Valuey n (%) n (%) n (%) p Valuey n (%)
No disability, n (%)
27 (86.8) 4 (13.2)
134 (81.4) 29 (18.6)
.49
40 (74.1) 13 (25.9)
74 (80.1) 17 (19.9)
.43
75 (72.4) 27 (27.6)
444 (81.3) 101 (18.7)
.05
11 (31.1) 20 (68.9)
96 (54.7) 67 (45.3)
.02
27 (47.5) 26 (52.5)
35 (35.7) 57 (64.3)
.17
32 (27.1) 70 (72.9)
305 (52.9) 241 (47.1)
!.01
15 (47.0) 16 (53.0)
105 (60.8) 58 (39.2)
.17
32 (57.3) 21 (42.7)
44 (44.7) 48 (55.3)
.16
48 (42.7) 54 (57.3)
345 (60.6) 201 (39.2)
!.01
10 (38.9) 18 (61.1)
64 (42.0) 84 (58.0)
.77
15 (36.0) 27 (64.0)
20 (24.9) 61 (75.1)
.21
27 (31.5) 57 (68.5)
174 (33.9) 334 (66.1)
.68
9 (25.0) 22 (75.0)
33 (19.5) 130 (80.5)
.49
33 (60.5) 20 (39.5)
32 (36.2) 60 (63.8)
.01
34 (32.9) 68 (67.1)
108 (18.9) 438 (81.1)
!.01
21 (60.9) 10 (39.1)
106 (63.8) 57 (36.2)
.78
45 (84.4) 8 (15.6)
71 (76.6) 21 (23.4)
.28
68 (66.1) 34 (33.9)
325 (58.2) 220 (41.8)
.15
17 (54.8) 14 (45.2)
92 (54.3) 71 (45.7)
.96
13 (30.6) 27 (69.4)
26 (37.6) 42 (62.4)
.47
48 (50.8) 41 (49.2)
256 (51.6) 225 (48.4)
.89
23 (68.2) 8 (31.8)
116 (69.4) 47 (30.6)
.90
39 (72.6) 14 (27.4)
61 (63.3) 31 (36.7)
.27
70 (67.3) 32 (32.7)
392 (69.4) 152 (30.6)
.69
29 (93.5) 2 (6.5)
156 (94.7) 7 (5.3)
.81
52 (98.5) 1 (1.5)
89 (96.8) 3 (3.2)
.48
95 (94.6) 7 (5.4)
531 (97.3) 15 (2.7)
.13
11 (37.2) 20 (62.8)
24 (14.0) 139 (86.0)
!.01
20 (35.3) 33 (64.7)
15 (16.0) 77 (84.0)
.01
24 (23.9) 78 (76.1)
155 (27.7) 391 (72.3)
.45
p Valuey
* Percentages were weighted by the presence of multiple telephone lines, any person <6 years old, any person >70 years old, and tenure (owneroccupied vs rental) in the overall US population of households, excluding Alaska and Hawaii. y The p Value for the chi-square statistics testing the association between homes with a resident reporting a disability and homes without a resident reporting a disability for each household hazard and safety practice. z Stairs inside the home include those to the basement or attic. x Restricted to those with O 1 person living in their home.
Results Study sample A total of 1539 eligible respondents were invited to participate in the study, of which 498 refused to participate and 38 did not complete the interview. The final study sample included 1003 respondents. A high proportion of these respondents lived in houses (65%), had household incomes of at least $50,000 (55%), lived in owneroccupied residences (69%), did not have children younger than 6 years or adults older than 70 years living in the home (67%), and lived in the southern region of the United States (34%) (Table 1). Approximately 20% of the households (n 5 190) reported at least 1 resident with a disability. Among these
households, 162 reported at least 1 person who was limited in activities because of a physical, mental, or emotional problem; 93 reported at least 1 person who had a medical condition that required use of special equipment. Household characteristics Households with at least 1 resident with a disability were more likely than households without a resident with a disability to live in an apartment (27.3% vs 18.6%), report a lower annual household income (67.6% vs 51.3%), and have a resident 70þ years of age (31.1% vs 13.6%) (Table 1). The distributions of residential tenure and region of residence were similar for households with and without a resident with a disability.
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Prevalence of household hazards and safety practices Households where an individual with a disability resided were less likely to live in a 2-story dwelling (34.6% vs 50.7%) and have stairs inside the home (48.1% vs 58.4%) (Table 2). These households were also more likely to implement fall prevention practices (ie, have handrails or grab bars in the bathroom and mats or nonskid strips in the tub or shower) (40.4% vs 21.8% and 71.7% vs 61.5%, respectively). There were differences in the prevalence of household hazards and safety practices by residential tenure. In rental households, those with a resident with a disability were less likely than those without a resident with a disability to have 2 stories (7.7% vs 27.8%) or indoor stairs (19.8% vs 37.7%) (Table 2). In owner-occupied households, those with a resident with a disability were more likely to implement fall prevention practices (45.6% vs 24.1% had handrails or grab bars in the bathroom and 79.1% vs 64.3% had mats or nonskid strips in the tub or shower). No differences in the prevalence of safety practices by disability status were found among rental households. Among households with no young children or older adults, those with a resident with a disability were less likely to have at least 1 step to get into their home (72.4% vs 81.3%), 2 stories (27.1% vs 52.9%), or indoor stairs (42.7% vs 60.6%) (Table 3). These households were also more likely to have handrails or grab bars in the bathroom (32.9% vs 18.9%). Among households with an older adult, those with a resident with a disability were more likely to have handrails or grab bars in the bathroom (60.5% vs 36.2%) and be aware of the water heater setting (35.3% vs 16.0%).
Discussion Households with at least 1 resident with a disability appear to be safer than households without a resident with a disability with respect to fall prevention practices (ie, presence of handrails or grab bars in the bathroom and mats or nonskid strips in the tub or shower). These homes are also less likely to have fall hazards, including multiple stories and indoor stairs. However, the prevalence of fire safety practices in households with at least 1 resident with a disability did not differ from those in households without a resident with a disability. Many homes in the United States, regardless of whether the household has a resident with a disability, lack home safety practices that can reduce the risk of residential injury. In this study, the overall prevalence of several safety practices was low. For example, less than half of the households had handrails or grab bars in the bathroom, a fire escape plan, or knowledge of the water heater setting. Given that falls and fire/burns are leading causes of residential injury in the United States [1,2], it is important to improve safety practices
53
to prevent their occurrence. Interventions that address this, however, may differ in households with and without a resident with a disability and by the type and severity of the disability. For example, fire escape plans may be ineffective in households where an individual with a mobility limitation resides depending on which exits are able to be used. This study has limitations. This research does not represent all households in the United States, particularly noneEnglish-speaking households and those outside the contiguous United States. The disability measure did not assess the type (eg, physical, emotional), domain (eg, seeing, hearing), or severity of disability. In addition, the data were collected in 2002 and may not reflect current household hazards and safety practices in homes where an individual with a disability resides. However, to our knowledge, there is no reason to believe they have changed significantly over time. The findings from this study suggest that there are opportunities for improving safety in households where individuals with disabilities reside. Future research should focus on describing home hazards and safety practices among persons with specific types of disabilities to develop and evaluate interventions that are tailored to the ability of household members to effectively implement and benefit from them.
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[14] Runyan CW, Johnson RM, Yang JZ, et al. Risk and protective factors for fires, burns, and carbon monoxide poisoning in US households. Am J Prev Med. 2005;28(1):102-108. [15] Coyne-Beasley T, Runyan CW, Baccaglini L, et al. Storage of poisonous substances and firearms in homes with young children visitors and older adults. Am J Prev Med. 2005;28(1):109-115.