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Effects of Improved Access to Safety Counseling, Products, and Home Visits on Parents' Safety Practices
Results of a Randomized Trial
Andrea Carlson Gielen, ScD, ScM;
Eileen M. McDonald, MS;
Modena E. H. Wilson, MD, MPH;
Wei-Ting Hwang, PhD;
Janet R. Serwint, MD;
John S. Andrews, MD;
Mei-Cheng Wang, PhD
Arch Pediatr Adolesc Med. 2002;156:33-40.
ABSTRACT
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Objective To present the results of an intervention trial to enhance parents'
home-safety practices through pediatric safety counseling, home visits, and
an on-site children's safety center where parents receive personalized education
and can purchase reduced-cost products.
Design Pediatricians were randomized to a standard- or an enhanced-intervention
group. Parents of their patients were enrolled when the patient was 6 months
or younger and observed until 12 to 18 months of age.
Setting A hospital-based pediatric resident continuity clinic that serves families
living in low-income, inner-city neighborhoods.
Participants First- and second-year pediatric residents and their patient-parent
dyads.
Interventions Parents in the standard-intervention group received safety counseling
and referral to the children's safety center from their pediatrician. Parents
in the enhanced-intervention group received the standard services plus a home-safety
visit by a community health worker.
Outcomes Home observers assessed the following safety practices: reduction of
hot-water temperature, poison storage, and presence of smoke alarms, safety
gates for stairs, and ipecac syrup.
Results The prevalence of safety practices ranged from 11% of parents who stored
poisons safely to 82% who had a working smoke alarm. No significant differences
in safety practices were found between study groups. However, families who
visited the children's safety center compared with those who did not had a
significantly greater number of safety practices (34% vs 17% had  3).
Conclusions Home visiting was not effective in improving parents' safety practices.
Counseling coupled with convenient access to reduced-cost products appears
to be an effective strategy for promoting children's home safety.
INTRODUCTION
HOME INJURIES are a substantial health problem for young children. An
estimated 1 in 4 children experiences a medically attended injury every year.1-2 Children at increased risk for injuries
include those who are younger than 4 years, members of a minority ethnic group,
and those living in poverty.3-5
An estimated one half of all unintentional, nonfatal injuries occur in the
home environment.2
Home safety can be enhanced by a number of modifications that are supported
by scientific research and professional practice guidelines. Mallonee et al6 demonstrated that distributing smoke alarms in high-risk
neighborhoods significantly reduced the fire-related deaths and injuries.
Erdmann and colleagues7 found that lowering
the temperature on hot-water heaters was associated with a reduction in hospital
admission rates for children due to tap-water scald burns. For other safety
practices, policy-making organizations such as the American Academy of Pediatrics8 and other experts9
have made specific recommendations about what safety practices should be included
in anticipatory guidance. The Injury Prevention Program of the American Academy
of Pediatrics recommends that anticipatory guidance promote the safe storage
of poisonous substances and the use of smoke alarms, ipecac syrup, safety
gates for stairs, and safe tap-water temperatures.
Many families are not adopting these recommended practices. LeBailey
and colleagues10 found more hazards in inner-city
homes compared with suburban homes. In a study of low-income, urban mothers
of children younger than 3 years, many reported not using safety gates for
stairs (59%) or smoke alarms (27%).11 A national
survey found that having smoke alarms, the local Poison Control telephone
number, and ipecac syrup and checking hot-water temperatures varied by ethnicity,
education, and income.3 Families with fewer
economic resources tend to be least likely to adopt these safety practices.3, 11
Given the importance of increasing safety practices, the question of
how best to accomplish this task needs to be answered, especially for low-income
families. A systematic review of home-visit interventions by Roberts et al12 found support for their effectiveness overall, but
not for those conducted in the first year of life. Health care workers who
provided home-visiting services in Glasgow, Scotland, reported that it was
difficult and probably ineffective to deliver safety education to families
in their homes.13 In the United States, Schwarz
et al14 demonstrated that an in-home intervention
delivered by community outreach workers was effective in improving safety
knowledge and reducing some hazards in an urban, African American community.
A recent Canadian study found that a home-visit intervention (including education
and discount coupons for products) was effective in reducing the number of
reported child injuries and their associated costs, although few home-safety
modifications were observed.15 When low-cost
safety equipment was provided for families who received state benefits in
a study based in Nottingham, England, no differences in injury outcomes were
observed between families who received and did not receive the safety supplies.16 However, significant improvements in safety practices
were found when access to low-cost safety products was coupled with advice
from general practitioners.17
In the first phase of the present study, we demonstrated that pediatricians
who were trained in an Enhanced Anticipatory Guidance (EAG) program provided
more safety counseling than did pediatricians in a control group.18 Parents whose children were treated by EAG-trained
physicians were more satisfied with the safety information they received than
were parents whose children were treated by control-group physicians, but
their safety practices were no different. We concluded that families needed
additional interventions to enable them to follow their pediatricians' advice.
Our objective in the second phase of the study, presented herein, was to supplement
the pediatric counseling with improved access to safety supplies through product
distribution and home visits. In addition to the EAG safety counseling routinely
provided in the clinic, an on-site children's safety center (CSC) was established
where parents could purchase safety supplies at reduced cost. A randomized,
controlled trial was undertaken to compare home safety between families who
were referred to the CSC only and those who were also offered a home visit.
The safety topics and practices covered in this trial were fall prevention
(use of safety gates), poison prevention (use of ipecac syrup and safe storage
of poisons), and fire and burn prevention (use of smoke alarms and safe hot-water
temperatures). These topics were selected because they represent leading injury
hazards to low-income, urban children, and because the recommended safety
practices are feasible. The conceptual framework for the interventions and
their implementation are described in detail elsewhere.19
We tested the following hypotheses: (1) Families offered the CSC and a home
visit will have safer homes than families offered only the CSC; and (2) families
who visit the CSC will have safer homes than families who do not, adjusting
for any differences that distinguish CSC visitors from nonvisitors.
SUBJECTS AND METHODS
STUDY DESIGN
This study was undertaken in a pediatric resident continuity clinic
in a large, urban teaching hospital. A randomized design was used in which
pediatric residents were randomly assigned to a standard- or an enhanced-intervention
group (Figure 1). Parents (or guardians)
of infants no older than 6 months who agreed to be in the study were assigned
to the same study group as their pediatrician. Outcomes were assessed by means
of a home observation when the patient was 12 to 18 months of age. Written
informed consent was obtained from the pediatricians and the parents or guardians
in accordance with the hospital's institutional review board, which approved
the study. Families in the standard-intervention group received safety counseling
and a referral to the CSC from their pediatrician. Families in the enhanced-intervention
group received the same services as the standard-intervention group and the
offer of a home-safety visit by a community health worker.
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Study design and sample sizes. Standard intervention indicates safety
counseling plus referral to the children's safety center (CSC); enhanced intervention,
standard intervention plus home-safety visit (HSV).
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INTERVENTION CONTENT AND DELIVERY
Safety Counseling
Both groups of pediatric residents were invited to attend a 1-hour seminar
on the problem of injuries that was offered annually by the director of general
pediatrics, at which the American Academy of Pediatrics Injury Prevention
Program materials were distributed. Both groups then received the 5-hour EAG
training program. The EAG training was provided by pediatric and health education
faculty for 2 sessions and included didactic material on childhood injuries
and the role of pediatric counseling; hands-on training at safety-skills stations
where products were demonstrated; and role-playing to learn the SAFE Communication
Framework (Solicit Information, Advise, Focus on Risks and Barriers, Encourage
Compliance) developed for this project.18 Residents
who could not attend both sessions received the material they missed via videotaped
sessions and hands-on experience at the CSC. Residents were then expected
to provide the appropriate safety counseling to their patients' families at
all well-infant and -child visits, which were monitored by means of audiotaping.
Children's Safety Center
The CSC was built in renovated space near the pediatric clinic. The
goals of the CSC are (1) to increase the accessibility and affordability of
home-safety supplies for low-income families; (2) to provide personalized
education that reinforces and supplements pediatric advice; and (3) to elevate
the priority given to injury prevention in medical care settings. The CSC
is staffed by a professional health educator with special training in injury
prevention. Safety products (eg, ipecac syrup, cabinet latches, safety gates,
smoke alarms, batteries, and hot-water thermometers) are sold at 10% to 15%
below retail cost in a homelike environment where their use can be demonstrated.
Educational pamphlets produced specifically for low-literacy groups are also
distributed. Pediatricians in both study-intervention groups received prescription
forms to make referrals to the CSC for all patients, although the CSC is open
to anyone, with or without a referral.
Home-Safety Visit
Community health workers received specific training from the investigators
to conduct home visits with families in the enhanced-intervention group. The
community health workers assessed injury hazards for falls, burns, and poisonings
with the parent; made recommendations about the appropriate safety products
and practices; and referred families to the CSC. The home-safety visit occurred
between the patient's 6- and 9-month well-infant visits.
Sample Eligibility and Random Assignment.
All first- and second-year pediatric residents (n = 43) were eligible
to participate and received a letter of invitation from the study investigators;
39 (91%) agreed and provided signed consent. The project director (E.M.M.)
used a table of random numbers to assign participating residents to the standard
(n = 20) or the enhanced-intervention group (n = 19). Parent-patient dyads
of participating residents were then approached in the clinic waiting room
by the study interviewer, who was in the clinic on a daily basis. The study
interviewer obtained signed consent and enrolled participants into the same
study group as their physician.
Based on sample size calculations for moderate-effect sizes, using 
= .05 and ß = .20, we sought to enroll 100 families in each study group.
Eligibility criteria included infants 6 months or younger, free of serious
medical problems, whose caretakers were English speaking and lived with the
child. Of 305 families approached, 40 were ineligible (13 were non–English
speakers, 12 were not the child's parent or guardian or did not live with
the child, 8 had a sibling already enrolled, 3 had infants of the wrong age
or were assigned to a nonparticipating physician, and 4 infants had medical
problems). Of the remaining 265 eligible families, 78 (29%) refused and 187
(71%) were enrolled (93 in the standard- and 94 in the enhanced-intervention
group). Participating families were similar to those who refused in level
of education, age, relationship to the infant, the infant's age, and the infant's
previous injuries. A smaller proportion of those who refused were African
American (64/78 [82%] vs 176/187 [94%]; P = .003).
Data Collection Protocol.
A baseline interview was administered at the time of study enrollment
to obtain sociodemographic characteristics and reported safety practices.
Audiotapes of scheduled clinic visits were obtained throughout the study to
measure exposure to the pediatric counseling. Intake surveys completed by
parents at each visit asked whether the parent had been to the CSC since their
previous visit. A follow-up interview was completed at the child's 12-month
visit (or the 15- or 18-month visit if the 12-month visit was missed), and
the home observation to assess safety practices was scheduled for a convenient
time within 2 weeks. Families received $10 for each completed interview and
for the home observation.
MEASURES
Safety Counseling
Two research assistants listened to the audiotapes and coded every mention
of any of the 5 safety practices under study and whether the physician made
a specific referral to the CSC. We then tallied the number of mentions across
all visits for each parent and for each safety practice. Binary variables
were used to indicate receipt of any counseling for each safety practice and
any referral to the CSC.
CSC Use
At each clinic visit and at the home observation, parents were asked
whether they had visited the CSC since last contact, and if so, what they
received or purchased. The number of visits ranged from 0 to 3, with only
10 families having made more than 1 visit during the study period; therefore,
a binary variable was created to indicate any use (vs no use) of the CSC.
Safety Practices
Safety practices at baseline were analyzed as dichotomous (yes or no)
variables based on parents' responses to interview questions about (1) having
a working smoke detector, (2) maintaining hot-water temperatures of less than
48.9°C, (3) planning to use a safety gate for stairs, (4) keeping poisons
locked or latched, and (5) having ipecac syrup. Safety practices at the home
observation were observed by research assistants specifically trained for
this study who tested smoke alarms and tap-water temperatures and conducted
detailed observations of the other safety practices and products. For analysis,
each safety practice was treated as a dichotomous variable (safe or unsafe).
The criteria for safe practices included any working smoke alarm, hot-water
temperature of no greater than 48.9°C, all stairs protected by a safety
gate or door, any poisons kept locked or latched, and at least 1 unexpired
bottle of ipecac syrup. A total safety score variable was also constructed,
counting the number of safe practices in each home.
SOCIODEMOGRAPHIC VARIABLES
The baseline interview included items assessing the respondent's age,
ethnicity, education, and employment; the number of children and adults living
in the household; and whether the respondent's child had ever experienced
an injury that required medical attention.
ANALYSIS
Bivariate analyses, including t tests and  2 statistics, were used to compare the sociodemographic characteristics
and baseline safety practices between the standard- and enhanced-intervention
groups at the time of enrollment and home observation to identify potential
sources of bias and adjustment variables. The proportions in each study group
who received any safety counseling and a referral to the CSC from their pediatrician
were also compared to examine the degree to which receipt of the intervention
services was comparable between both intervention groups. We first used 2 analysis to evaluate the impact of the interventions on parents' home-safety
practices by comparing the proportion of families practicing each safety behavior
and the total safety score between the standard- and enhanced-intervention
study groups. We then examined the effect of the CSC by comparing safety practices
between those families who visited the CSC and those who did not, using logistic
regression analysis of individual safety practices and proportional odds analysis
of total safety score. To examine and control for the effects of the other
intervention components (ie, safety counseling and home visits), these variables
were included in the logistic regression and proportional odds models. We
also examined the models for potential confounding by the sociodemographic
variables and for interaction between the intervention components; no significant
confounders or interactions were found. Therefore, these variables were not
included in the final models.
RESULTS
SAMPLE
A total of 122 families completed the trial (ie, completed the home
observation). Reasons for noncompletion are provided in Figure 1. Among the total sample, 11 families became ineligible
(eg, moved or changed guardianship), 15 families refused further contact,
and 39 could not be contacted in time (ie, before the study ended or the child
was too old), most often because of problems with telephone numbers or scheduling.
Families who did not complete the study were compared with completers on sociodemographic
characteristics and safety practices reported at baseline (Table 1). The 2 groups differed only in terms of marital status
(Table 1). When these same analyses
were conducted for the enhanced- and standard-intervention groups separately,
only the following 2 statistically significant differences (P<.05) were found: in the enhanced-intervention group, noncompleters
were more likely to be married (11 parents [34%] vs 9 [15%]; P = .03), and in the standard-intervention group, noncompleters were
more likely to be employed (13 parents [41%] vs 10 [17%]; P = .01).
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Table 1. Characteristics of Families by Study Completion*
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Participants were almost always the infant's mother (98%) and most were
African American (94%). Mothers' mean age was 24 years and infants' mean age
was 3 months at the time of study enrollment. A small proportion of participants
were married (13%), had more than a high school education (12%), and were
employed (23%) (Table 1). The
sample was generally low income, with 39% reporting household incomes of less
than $5000 per year. Self-reported safety practices at baseline ranged from
a low of 12% who said they had ipecac syrup to a high of 92% who reported
having a working smoke alarm. None of the sociodemographic characteristics
or baseline safety practices differed between the enhanced- and standard-intervention
groups (data not shown). Both study groups made an average of 3.7 scheduled
medical visits during the course of the study. A total of 451 medical visits
were captured on the study intake forms and 205 (45%) of these visits were
also audiotaped.
Rates of pediatrician counseling differed between the study-intervention
groups only for receiving counseling about poison storage, ie, 46 families
(76%) in the standard-intervention group vs 35 those in the enhanced-intervention
group (57%) (P = .04). Rates of counseling about
the other safety topics were 62% for smoke alarms, 58% for safety gates, and
42% for ipecac syrup. Rates of referral to the CSC did not differ by study
group; 78% of the sample received a referral, and 67% of those who received
a referral made a visit to the CSC. The proportion of families in each study
group who visited the CSC did not differ, with 61% of the sample making at
least 1 visit (see Figure 1). The
home-safety visit, offered only in the enhanced intervention, was received
by 98% (n = 61) of the group (see Figure 1).
COMPARISON OF OUTCOMES BETWEEN STUDY INTERVENTION GROUPS
There were no significant differences between the standard- and enhanced-intervention
groups in the rates at which any of the safety practices were observed at
home observation (Table 2). For
the entire sample, the rates of safety practices were as follows: 47% had
safe hot-water temperatures; 82% had a working smoke alarm; 25% had all of
their stairs protected by a safety gate or door; 11% stored poisonous substances
safely; and 29% had an unexpired bottle of ipecac syrup.
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Table 2. Observed Safety Practices at Follow-up by Study Group*
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COMPARISON OF FAMILIES WHO VISITED AND DID NOT VISIT THE CSC
Families who visited the CSC (n = 75) were compared with those who did
not (n = 47) on sociodemographic characteristics and exposure to safety counseling
and the home visit (Table 3).
Families who visited the CSC were significantly more likely to have fewer
than 5 people living in the home, higher household incomes, more education,
and more well-infant and -child visits to the pediatrician than did families
who did not visit the CSC. There were no differences between these 2 groups
on their receipt of pediatrician safety counseling, referral to the CSC, or
whether they were in the standard- or enhanced-intervention study group. The
rates of pediatrician counseling varied from a low of 34% (n = 23) who received
counseling about hot water to a high of 70% (n = 47) who received counseling
about poison storage; 77% (n = 26) of CSC users and 79% (n = 53) of nonusers
received a specific referral to the CSC.
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Table 3. Characteristics of Families by Use of Children's Safety Center*
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COMPARISON OF OUTCOMES BETWEEN FAMILIES WHO VISITED AND DID NOT VISIT
THE CSC
Families who visited the CSC had higher rates for all safety practices
except for smoke alarms; more than 80% of both groups had at least 1 working
smoke alarm (Table 4). In the
regression analysis, we adjusted these comparisons for exposure to safety
counseling and a home visit, although neither of these variables was statistically
significant in any of the models. The adjusted odds ratios for having at least
1 safety gate for stairs and storing poisons safely were greater than 2 for
CSC visitors compared with families who did not visit the CSC. The adjusted
odds ratio for having ipecac syrup was 11.63 (P =
.002) for CSC visitors compared with those who did not visit the CSC.
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Table 4. Observed Safety Practices at Follow-up by Use of Children's
Safety Center*
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When we summed the total number of safety practices observed, the distributions
were significantly different between the CSC visitors and nonvisitors. Three
or more safety practices were observed for 34% of the CSC visitors compared
with 17% of the nonvisitors, and 2 safety practices were observed by 42% of
CSC visitors compared with 29% of nonvisitors (Table 5).
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Table 5. Total Number of Observed Safety Practices at Follow-up by
Use of Children's Safety Center*
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The proportional odds regression analysis of total safety score indicated
that CSC visitors had a 3.39 times higher likelihood of having more safety
practices observed compared with those who did not visit the CSC (P = .01) (Table 5). Although
the model included variables indicating whether the families had received
safety counseling or a home visit, neither of these differences was statistically
significant.
COMMENT
This intervention trial was designed to evaluate the impact of a combination
of injury prevention services delivered through a pediatric resident clinic.
Our results suggest that coupling pediatric counseling with convenient access
to low-cost safety supplies and personalized information is necessary to meet
the needs of low-income urban families. Families who visited our on-site safety
resource center had more safety practices observed in their homes than families
who did not, even after we controlled for their having received pediatric
safety counseling. We found no support for our hypothesis that home visits
would be a necessary additional intervention. This finding is consistent with
the assessment of the health care workers in the study by Ehiri and Watt13 in Scotland, who reported that as a safety intervention,
home visits were difficult and ineffective. We did not find the home-visit
protocol difficult to implement, and we were successful in gaining access
to 76% of the homes, but it was a very resource-intensive intervention. The
existing literature is inconclusive on the benefits of home visits for behavior
change14-15 and injury reduction.6, 12, 15 Combined with our
results, these studies suggest that the effectiveness of home visits may be
situation specific, ie, working well for certain audiences and injury topics,
but not for others. One caveat to our conclusions is that we were unable to
install the safety products because of concerns about liability, which may
have been responsible for our finding of no effect. Since the time that this
study was in the field, we have learned of other home-safety programs that
address this issue by obtaining liability waivers. Other research studies
have demonstrated success in installing safety products and making home-safety
modifications.6, 15 More than 1
home visit might have had a greater impact, but this was not feasible in the
present study because of resource constraints.
By contrast, the data supported our hypothesis that families who used
the services of the CSC would have safer homes than those who did not use
the CSC. The difference in the total number of safety practices—34%
vs 17% had 3 or more—was statistically significant. Also, the odds ratios
for all but one of the individual safety practices (smoke alarms) were in
the expected direction and were statistically significant for ipecac syrup.
Our final sample size was smaller than anticipated in our original sample-size
calculations, which limited our power to detect statistical significance.
For example, the rate of storing poisons safely was more than doubled among
the CSC visitors compared with the nonvisitors (13% vs 6%), as were the rates
for stair gates (27% vs 13%) and protected stairs (32% vs 15%). The frequency
of visits to the CSC during the study period was too small to allow an analysis
of any dose response. Since the end of the study, CSC use has continued to
increase and families visit multiple times. A qualitative telephone survey
with CSC visitors has also documented instances in which products obtained
at the CSC have prevented potentially life-threatening injuries (A.C.G. E.M.M.,
M.E.H.W., J.R.S., and L. B. Triffiletti, MA, unpublished data, August 2001).
We have also received numerous requests from service providers in clinical
and community settings for information on the costs and procedures for establishing
such a center, and a replication guide is in preparation. Future research
should be directed to establishing the cost-effectiveness of these types of
centers.
One of the goals of this project was to develop interventions that could
be implemented in real-world settings. Applied research to evaluate service-oriented
interventions in a busy urban clinic has inherent challenges that should be
considered when interpreting the findings. For example, our measure of CSC
use relied primarily on self-report. Although a checklist was available for
CSC staff to assess and record whether the visitor was a study participant,
there were many occasions when it could not be completed (eg, multiple visitors
at the same time, fussy infants, and other parent distractions). We are reassured,
however, because 55 of the 75 participants who reported visiting the CSC had
corroborating evidence of a visit (ie, a completed checklist and/or a specific
purchase reported). We were limited in the resources available to support
the interventions and the evaluation, so we restricted the evaluation to English-speaking
families in the clinic, which limits our ability to generalize our results
to other audiences (eg, non–English-speaking, suburban, and rural).
Tracking participants over time was also challenging because of frequent moves
and telephone changes among our families. Although this reduced the size of
our analytic sample, there were no dramatic differences between completers
and noncompleters, which strengthens our conclusions.
Another limitation is that we do not know the impact of the improved
safety practices on injury reduction. We chose to treat each of our safety
practices as if they are of equal value in the analysis of total number of
safety practices observed. We are unaware of any evidence with which to assign
a more precise weighting to each of these practices, so we must be content
to believe that more is better and to know that the selected safety practices
are widely recommended at present by pediatricians and injury professionals.
The pediatrician counseling was an important intervention component,
with more than 50% of the families receiving injury-prevention counseling
on all but one of the topics (ipecac syrup) and 78% receiving a referral to
the CSC from their pediatrician. Audiotaping medical visits to document the
counseling is a strength of the study, although it was not possible to tape
every visit due to logistical constraints. Therefore, these proportions may
actually underestimate the amount of counseling that took place. Our previous
study that evaluated safety counseling before the CSC was built found that
parents who received counseling were more satisfied but no more likely to
have safer homes.18 In the present study, we
found a significant positive effect on home safety when we added on-site access
to low-cost safety products. These results are consistent with those of Clamp
and Kendrick17 in their study in Nottingham.
An urgent need to find ways to improve home safety for low-income families
remains, as many of our observed rates were distressingly low. The present
study suggests that home visiting is not the answer, although on-site access
to safety resources and personalized education that reinforces pediatrician
counseling appear promising.
We found that families who visited the CSC were somewhat more advantaged
(eg, higher income, smaller families, better educated) compared with those
who did not, even among this sample of generally low-income families. Although
these variables were not significant in the multivariate analyses of safety
practices, an unavoidable limitation of our analysis is self-selection. Other
unmeasured differences between CSC visitors and nonvisitors might account
for our finding significant positive associations with use of CSC services.
Random assignment to the CSC, which would address the self-selection bias,
was not possible in the present situation. Once the CSC was opened, we could
not restrict access to its services. Future research could examine similar
populations in facilities with and without a resource center, although potential
biases that would be difficult to control remain in such a design.
Substantial strengths of this study also exist. For example, the home-visit
intervention was randomly assigned. All interventions were well-implemented,
with most participants being exposed to the counseling and receiving a referral
to the CSC. Also, the outcome variables were assessed using home observation
rather than self-report.
One appealing element of having a CSC in the medical care setting is
that it communicates to families the importance of child safety as a health
issue. The CSC can be thought of as the equivalent of a pharmacy for injury
prevention. The physician's endorsement of this notion by making referrals
positions the CSC and its staff as partners in the health care team, which
helps boost the credibility of the CSC and its services. The CSC also addresses
a major barrier to preventive counseling by physicians, ie, time. With the
CSC as a resource, pediatricians' anticipatory guidance may be more efficiently
delivered because they can refer parents to the CSC not just for reasonably
priced safety supplies, but for more information as well. The CSC staff can
spend time educating parents about injury risks and prevention strategies,
explaining the variety of safety products, and teaching parents how to use
products correctly. A remaining challenge is to ensure that all families,
regardless of their personal resources, can take advantage of this potentially
lifesaving service.
AUTHOR INFORMATION
Accepted for publication August 17, 2001.
The CSC was made possible through the support of the following founding
funders: Lowe's Home Safety Council, North Wilkesboro, NC; The Marion I. &
Henry J. Knott Foundation, Baltimore, Md; The Chesapeake Health Plan Foundation,
Baltimore; The Wiessner Foundation for Children, Baltimore; and Anshen &
Allen, Baltimore. Funding for this research was provided by grant MCJ-240638
from the Maternal & Child Health Bureau (Title V, Social Security Act),
Health Resources and Services Administration, Department of Health and Human
Services, Washington, DC; and by the Johns Hopkins Center for Injury Research
and Policy, Baltimore, with grant R49/CCR302486 from the National Center for
Injury Prevention and Control, Centers for Disease Control and Prevention,
Atlanta, Ga.
Presented in part at the 5th World Conference on Injury Prevention and
Control, New Delhi, India, March 6, 2000.
We thank the participating physicians and parents for making the study
possible. We also appreciate the advice and technical assistance of David
Bishai, MD; Debra Roter, PhD; Larry Wissow, MD; Susan Larson, and Mary Kay
Oberle.
Corresponding author and reprints: Andrea Gielen, ScD, ScM, Center
for Injury Research and Policy, Johns Hopkins University, Bloomberg School
of Public Health, 624 N Broadway, Baltimore, MD 21205 (e-mail: agielen{at}jhsph.edu).
From the Department of Health Policy and Management and the Center
for Injury Research and Policy, Bloomberg School of Public Health (Dr Gielen
and Ms McDonald), and the Department of Biostatistics (Drs Hwang and Wang),
Johns Hopkins University, and the Department of Pediatrics, Johns Hopkins
University School of Medicine (Drs Wilson, Serwint, and Andrews), Baltimore,
Md. Dr Wilson is now with the American Academy of Pediatrics, Elk Grove Village,
Ill. Dr Andrews is now with Starship Children's Health, Auckland, New Zealand.
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