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Alexandra Slemaker, Hannah C. Espeleta, Zohal Heidari, Som B. Bohora, Jane F. Silovsky, Childhood Injury Prevention: Predictors of Home Hazards in Latino Families Enrolled in SafeCare®+, Journal of Pediatric Psychology, Volume 42, Issue 7, August 2017, Pages 738–747, https://doi.org/10.1093/jpepsy/jsx045
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Abstract
This archival project (a) examined potential risk and protective factors for hazards in the homes of Spanish-speaking immigrant Latino families and (b) provided an independent examination of the SafeCare®+ Home Safety module adapted for Latino families at high risk for child neglect.
The sample comprised 92 Latina caregivers of young children enrolled in SafeCare®+.
Results of the negative binomial regression model of predictors of home hazards before the Home Safety module found none of the factors were significant. The longitudinal analysis with a negative binomial model found significant effects both during (b = −0.905, p < .001) and after (b = −2.118, p < .001) the intervention. Depression was negatively associated with the number of hazards (b = −0.026, p < .05, β = −.1858).
Support for application of SafeCare®+ Home Safety module to prevent access to hazards for Latino children was found.
Objectives
Unintentional injuries result from physically harmful events that are often preventable with safety precautions (e.g., installation of safety devices) and proper education (Centers for Disease Control and Prevention [CDC], 2012; Patel & Sandell, 2013; Watson & Errington, 2016). Young children are particularly vulnerable to these injuries. These injuries represent the leading cause of child deaths in the United States and the fifth leading cause of death for newborns and infants <1 years of age (CDC, 2014). Most injuries in children <6 years of age are unintentional (Mowry, Spyker, Cantilena, Bailey, & Ford, 2013) and occur in their homes (DiGuiseppi & Roberts, 2000; Evans & Kohli, 1997).
Investigations of risk and protective factors for unintentional injuries can improve implementation and impact of prevention efforts. For example, understanding how multiple factors impact children’s access to hazards in the home can address who and how to target prevention strategies. Risks of poverty and depression can hinder supervision, while having a partner to help supervise the children may reduce risk of child access to hazards. Previous research has suggested that children from single-parent families (Nicolais, 2014) and families with low income are at higher risk for unintentional injuries (Damashek & Kuhn, 2014); the latter are five times more likely to die from injury than their affluent counterparts (Evans & Kohli, 1997). Lower income may increase exposure to hazards and reduce accessibility to home safety devices (Deal, Gomby, Zippiroli, & Behrman, 2000; Patel & Sandell, 2013). In terms of maternal depression increasing the risk for injury in young children (Orton, Kendrick, West, & Tata, 2012), severely and chronically depressed mothers may not be able to properly secure the physical environment in which their children engage (e.g., inattention, poor concentration, fatigue), which may reduce their ability to adequately supervise and enforce rules (Schwebel & Brezausek, 2008). Overall, low parental supervision is related to increased injury risk in young children (Morrongiello, Corbett, & Brison, 2009).
Limited understanding of potential child hazards can also lead to unintentional injuries, as parents may be unacquainted with potential causes of injuries and how to alleviate risk of exposure (Mayes, Roberts, & Stough, 2014). Parents often do not judge their own child as being vulnerable to many types of home injuries (Mayes et al., 2014). They underestimate their infants’ motor abilities and curiosity, or overestimate their children’s ability to maintain their own safety (Azar & Weinzierl, 2005). Further, Lewis, DiLillo, and Peterson (2004) found that fathers in particular believe that minor injuries serve a developmental benefit by providing opportunities to “learn a lesson” or “toughen up”. Previous studies have found that parents are more likely to take precautions to reduce environmental hazards if they understand the potential harm to their children (Mayes et al., 2014). Thus, education on hazards could help reduce child injuries in the home (Lao, Gifford, & Dalal, 2012).
Limited direct education about potential hazards in the home may help explain U.S. ethnic disparities in early childhood injuries (Pressley et al., 2009). Children who are Latino remain at a significantly greater risk for unintentional injuries than those who are White (Agran, Winn, Anderson, & Del Valle, 1998; Flores et al., 2002). Rates of unintentional injuries in Latino children may be even higher than reported, as Latino mothers are less likely to report their children’s injuries owing to fear of removal of the child from their home (Hendrickson, 2008; Mull, Agran, Winn, & Anderson, 2001). They may also be less likely to seek medical attention owing to lack of insurance, limited understanding of the health care system, and anxiety about the possible responses. Parents who are racial minorities have been found to be less likely than White parents to purchase and install stair gates, cabinet locks, and other safety devices, or to turn down hot water settings (Pressley et al., 2009). For immigrant families, limited exposure to these devices in their home country may reduce the likelihood of their use of safety devices (Mull et al., 2001).
Ethnic and racial disparities with childhood injuries are complex, as first-generation immigrants and non-English-speaking families appear to be at lower risk for childhood injuries than English-speaking and nonimmigrant families (Schwebel & Brezausek, 2009; Schwebel, Brezausek, Ramey, & Ramey, 2005). Levels of acculturation and enculturation are important factors to consider. Acculturation has been linked to stress, depression, and other health-related issues (Yoon et al., 2013). Acculturation is the process of adopting the cultural beliefs of the dominant, surrounding culture (Thomson & Hoffman-Goetz, 2009), whereas enculturation is the process of retaining one’s traditional culture and values while living within a dominant culture (Yoon et al., 2013). Latina mothers may be unfamiliar with environmental hazards, such as apartment staircases or balconies and hot water faucets because these may not have been common in their country of origin (Flores et al., 2002, Mull et al., 2001). Despite this risk, young children of immigrant families appear to be at lower risk. Specific cultural practices, beliefs, or traditions may serve as protective factors. For example, keeping connections to one’s cultural beliefs could serve as a protective factor when moving to an unfamiliar location because it allows people to keep their sense of identity. To our knowledge, no research examining enculturation association with childhood exposure to hazards has been conducted.
Owing to the high frequency of unintentional injuries and potential for fatality, development and evaluation of interventions to prevent injuries has become a sharp focus of this study. Targeting home hazards with behavioral parent training programs has been one of the responses. SafeCare® (SC) is an in-home, skills-based parenting program with demonstrated support for child maltreatment prevention, along with parent behavior change across a series of studies (Chaffin, Hecht, Bard, Silovsky, & Beasley, 2012; Gershater-Molko, Lutzker, & Wesch, 2003; Lutzker & Bigelow, 2002; Silovsky et al., 2011). This structured, behavioral skills training program focuses on teaching, modeling, and practicing objective parenting skills to the point of mastery. Parent–child bonding, child health, and home safety are the core modules. The family meets weekly with a trained, typically bachelor’s level, provider. SafeCare® augmented (SC+) meets the U.S. Department of Health and Human Services criteria for Home Visiting Evidence of Effectiveness (homvee.acf.hhs.gov/document.aspx?sid = 18&rid = 1&mid = 1).
SC’s Home Safety module is aimed at increasing parental skills in identifying, reducing, and eliminating accessible hazards. The Home Safety module begins with an assessment of hazards present in the home using the Home Accident Prevention Inventory—Revised (HAPI-R; Lutzker & Bigelow, 2002). Next, didactic training on types of hazards, prevalence of injury associated with hazards, and strategies to reduce access to hazards is provided. Finally, the parent and provider actively identify hazards in the home and reduce accessibility, such as through the installation of safety devices. This continues each week until the parent demonstrates mastery of the knowledge and skills.
Previous studies conducted by the developer of SC examined the Home Safety module with the HAPI-R to assess home hazards. Multiple baseline studies demonstrated a decrease in home hazards after receiving the Home Safety module of SC (Barone, Greene, & Lutzker, 1986; Mandel, Bigelow, & Lutzker, 1998; Metchikian, Mink, Bigelow, Lutzker, & Doctor, 1999; Tertinger, Greene, & Lutzker, 1984). In terms of research with Latino families, a case study examined the Home Safety module with a Spanish-speaking Latina mother (Cordon, Lutzker, Bigelow, & Doctor, 1998). Similar to other studies of SC (Metchikian et al., 1999), this participant reported no child accidents, and believed that her home was safer and she was better prepared after receiving the training (Cordon et al., 1998).
SC+ has recently been culturally adapted for Spanish-speaking Latino families. Beyond translation, SC+ was adapted in the areas of (1) language, (2) extended family, (3) acculturation, (4) traditional beliefs of the Latino culture, and (5) relationship development among the family and provider. In a mixed-methods feasibility study, Latina mothers reported benefits of the program on all targeted areas as well as cultural congruency of program (Beasley et al., 2014).
The current project was designed to (a) examine potential risk (i.e., depression, low income, number of vulnerable children) and protective factors (i.e., acculturation, enculturation, social support, partner in home) for accessible hazards in the homes of Spanish-speaking immigrant Latino families with young children and (b) provide an independent (outside of the program developer) examination of the Home Safety module adapted for Latino families at high risk for child neglect. Archived data from the SC+ arm of a randomized clinical trial was used. This analysis systematically examined socioeconomic, cultural, family structure, family composition, parental factors, and the effect of the Home Safety intervention on presence of and reduction in home hazards accessible to young children. Based on previous research with non-Latino populations, it was hypothesized that stressors, such as low income, low social support, depression, and high number of vulnerable children, would be identified as risk factors associated with higher numbers of accessible household hazards. Further, it was hypothesized that acculturation would demonstrate a protective role, meaning higher acculturation would be associated with lower hazards, as it may reflect exposure to safety education and guidelines reflecting the practices and beliefs of the dominant host society. The role of enculturation as a protective factor was also examined. Finally, it was hypothesized that with the provision of the culturally adapted Home Safety intervention, there would be a negative effect on home hazards, demonstrated by decreasing home hazards across time points of the intervention.
Methods
Participants
The present analysis used an archived data set from the SC+ arm of a clinical trial evaluating the effectiveness of a culturally adapted model of SC+ for a Midwestern Latino community (see Beasley et al., 2014 for feasibility results of the culturally adapted model). Participants were primarily self-referred or referred by friends or family. Participants were included in the study if they were the primary caregiver of at least one child ≤5 years of age and at risk for child maltreatment owing to poverty, depression, intimate partner violence, and/or substance abuse. Exclusion criteria for the larger study comprised (1) current or more than two prior child welfare referrals, (2) a substantiated report of perpetrating child sexual abuse, (3) caregiver <16 years of age, (4) conditions that would prevent valid self-report data (e.g., severe mental retardation), and (5) caregiver did not wish to receive services in Spanish. For the current analysis, the participant must have been (1) assigned to the SC+ condition, (2) completed at least two safety assessments, and (3) a female primary caregiver.
Participants comprised 92 female Spanish-speaking caregivers enrolled in a SC+ program. The caregivers were between 16 and 42 years of age (M = 26.7, SD = 6.1) and all identified as Latina (100%). Almost half of the participants were married (45.7%) with an average monthly income of $1,320 (SD = 703.7). The number of children <5 years of age ranged from one to three children per family (M = 1.4, SD = 0.6); the mean number of children considered particularly vulnerable to hazards (ages 6 months to 3 years) was 0.83 (SD = 0.57). Participants in our sample had resided in the United States between 0 and 19 years (M = 8.9, SD = 4.5), and 96% were immigrants with the majority of participants born in Mexico (83.7%). Of 145 participants assigned to the SC+ condition, 92 met inclusion criteria for the present analysis. Reasons the 52 participants assigned to SC+ were not included were they (a) did not receive treatment because participant dropped out of services (N = 40, 76% of those excluded from the analysis), (b) did not receive/complete treatment because participant moved out of service area (N = 6, 12%), (c) received partial training for another reason (N = 2, 4%), (d) participant was male (N = 2, 4%), and (e) participant completed the services, but HAPI-R scores were missing (N = 4, 8%). Owing to nonnormality and ties in the data, the nonparametric Wilcox test with an exact distribution was used to compare major continuous factors included in this model for participants who were included in the present analysis with those who did not (coin package in R; Hothorn, Hornik, van de Wiel, & Zeileis, 2006, 2008). Categorical variables were compared in these two groups using the chi-square test. Only social support (p < 0.01) was statistically different between these two groups. Those participants included in the analysis had higher median social support as compared with the participants who were not.
Measures
Demographic Questionnaire
A demographic questionnaire assessed basic demographic information. An early version of this questionnaire was pilot tested on 100 parents, and items answered inconsistently or indicated to be confusing were corrected. The current analysis used gender, marital status, education level, number of children within the home, country of origin, primary language, and years in the United States.
Home Hazards
The HAPI-R (Mandel, Bigelow, & Lutzker, 1998) is a measure of the number of accessible home hazards in the following categories: fire and electrical, suffocation, guns or firearms, poisonings by solids and liquids, choking, drowning, falling, the presence of sharp objects, crushing hazards (i.e., objects over 10 pounds with the potential to fall), and organic or allergen hazards (i.e., decaying food, excess dirt/dust, and insect infestation; Lutzker & Bigelow, 2002). The HAPI-R is an observational assessment in which hazards in rooms are identified, counted, and classified in the previously listed categories. For the present study, the HAPI-R was administered in multiple rooms within one home before, during, and after intervention. The total number of hazards at each time point was divided by the number of rooms for an average hazard count per room.
Acculturation and Enculturation
The Stephenson Multigroup Acculturation Scale (Stephenson, 2000) is composed of 32 items and 2 subscales. The Dominant Society Immersion (DSI) subscale consists of 15 items and assesses acculturation to the dominant cultural group of the United States (acculturation). The Ethnic Society Immersion (ESI) subscale consists of 17 items and assesses enculturation to the participants’ own cultural group (enculturation). For the current analysis, the scale was reverse scored, so that higher scores indicate more acculturation/enculturation. This measure has demonstrated acceptable to high internal consistency and reliability (Huynh, Howell, & Benet-Martinez, 2009; Stephenson, 2000) including the current study (α = .86 for the DSI subscale and α =.74 for the ESI subscale).
Depression
The 12-item Center for Epidemiology Studies Depression-Short Form (CESD-SF; Radloff, 1977) assesses depressive symptomology, with higher scores indicating higher depressive symptomology. The CESD-SF has shown strong psychometrics overall (Clark, Mahoney, Clark, & Eriksen, 2002; Van Dam & Earleywin, 2010), with Latino samples (Grzywacz et al., 2009), and in the current study (α = .90).
Social Support
The Social Provision Scale-short form (SPS; Russell & Cutrona, 1984) is a 12-item questionnaire in which participants rate their overall perceived social support. Higher scores indicate greater levels of perceived support. The SPS has demonstrated good reliability and internal consistency across various samples and cultures (Cutrona, Hessling, Bacon, & Russell, 1998; Mancini & Blieszner, 1990) and in the current study (α = .79).
SafeCare Satisfaction
Social validity and satisfaction surveys were created by the National SafeCare Training and Research Center. The Home Safety satisfaction form was used in the current study. This survey consisted of eight items on the impact of the module and services received, and nine questions on the provider. Items about impact of module and providers were rated on a 5-point scale ranging from strongly agree (1) to strongly disagree (5); service questions were rated on a 5-point scale ranging from useful (1) to useless (2).
Procedures
Approval from the appropriate institutional review board was obtained before study implementation and approved procedures were followed. Consenting and measurement collection were conducted with bilingual data collectors at baseline. Consent, all measures, and all SC+ materials were available in both Spanish and English, though no participants chose to use English forms. All demographic information, acculturation, enculturation, depression, and social support measures examined for this project were collected via Tablet-PC’s running ACASI software with touch-screen responses. For the larger study, participants were assigned to either a SC+ treatment group or “Service as Usual” group after baseline data collection dependent on assessed risk level, and those at the moderate risk were randomized (i.e., hybrid regression discontinuity/randomized clinical trial design; Bard, Silovsky, Owora, & Beasley, 2012). The larger study evaluated program effectiveness from 2010 to 2015. The present analysis was exclusive to families assigned to the SC+ condition. The HAPI-R was not administered to the comparison condition in the larger clinical trial. See Supplementary Figure S1 for flow diagram.
SC+ was provided in the home on a weekly basis for 9–15 months by fully certified SC providers (completed project-specific training, national SC training certification, observation of implementation of all modules to fidelity, and continuous consultation). The skills-based approach of the curriculum allows the provider to continuously assess comprehension of the material through direct observation and feedback. Each module is provided sequentially, and the Home Hazard module was administered for an average of 7.6 (SD = 2.7) sessions.
To evaluate the number of accessible hazards, providers conducted observations to complete the HAPI-R before, during, and after the implementation of the Home Safety module. At each time point, the HAPI-R was administered in at least three home locations. After the initial assessment (before training), the home provider implemented the Home Safety module of SC+. The HAPI-R was readministered during the module’s training and posttraining. The HAPI-R was readministered approximately at the 3-week point (during training) and 6-week point (after training). The goal is to reduce the number of hazards to zero at the end of training. However, the number of sessions focused on Home Safety was limited because it was one of five SC+ modules to be addressed. The provider, with guidance of the supervisor, could determine the family has reached maximum benefit and move to the next module. On conclusion of the Home Safety module, the parent was provided the Satisfaction form, which was completed, sealed in an envelope, and returned to the research team.
Analytic Plan
The goals of these analyses were to examine potential risk and protective factors in predicting rates of accessible hazards in Latino Spanish-speaking families and to examine the relationship of these factors and time on the rate of home hazards during the Home Safety module of SC+.
Initial Examination of Data
There were few missing values (0.08%) in predictor variables; they were imputed using an R package MICE version 2.22 with the assumption that data were missing at random (MAR; van Buuren & Groothuis-Oudshoorn, 2011). The MICE function uses an approach of chained equations to impute incomplete multivariate data. Multicollinearity was not present (r ranged from .001 to .34). Owing to the multiple assessments conducted, the first Home Safety assessment before intervention was considered as the first time point, and the last HAPI-R was the postintervention assessment (third time point). All other HAPI-Rs collected were during intervention (second time point). HAPI-R scores for multiple rooms per home and multiple assessments were summarized by averages. Before conducting analyses, the HAPI-R data were examined for normality and completeness. Analysis of skewness and kurtosis of the HAPI-R fell outside of the acceptable range of ± 2 (Cameron, 2004). Additionally, examination of the means and variances at each time point suggest that the HAPI-R data were overdispersed, meaning our sample means are smaller than the sample variances.
Predictors of Home Hazards
To better understand predictors of home hazards at each stage of intervention, a longitudinal negative binomial model was used. That is, a negative binomial model was used to model count HAPI-R outcome in a repeated-measures setting. The interactions of predictors with time were assessed to test if the relation between predictors and outcome changed over time. This analysis was determined to be the best fit for our data’s properties including the discrete outcome variable (i.e., number of home hazards), the positive skewness, and overdispersion. This model with random intercept for all participants was analyzed with the glmmadmb function within the glmmADMB package in R 3.2.4 (R Core Team, 2016; Fournier et al. 2012; Skaug et al. 2016). To be able to compare effect sizes, the same analyses were repeated with the inclusion of z-scored continuous predictors plus all other factor variables. This model examined the following variables as predictors of the magnitude of home hazards: number of vulnerable children (between the ages of 6 months and 3 years), years in the United States, marital status, income, social support, acculturation, enculturation, and depression. Marital status had four categories combined into two (married/cohabitating vs. separated/single).
Results
Descriptive Statistics
Home hazard count via the HAPI-R before intervention ranged from 0 to 80 (Median = 11.5, SD = 12.18), during the intervention ranged from 0 to 39 (Median = 4, SD = 8.12), and at postintervention ranged from 0 to 27 (Median = 1, SD = 3.49). The summary of the demographic factors is provided in the participant section of the Methods. The level of depression for the sample was high (M = 12.30, SD = 7.48). Scores on the protective and cultural measures were M = 29.90, SD = 4.32 for the SPS, M = 2.39, SD = 0.27 for the ESI, and M = 1.23, SD = 0.63 for the DSI. The correlation among the demographic, risk, and protective factor variables ranged from r = .001 to r = .34, with no evidence of multicollinearity. See supplementary tables for details.
Before Intervention
The first negative binomial regression model examined predictors of home hazards before the intervention. None of the factors were significant predictors of HAPI-R scores at the alpha level of .05. However, the effects of the social provisions on HAPI-R was marginally significant (b = −0.551, p < .10, β = −.1,299), suggesting fewer hazards among those participants with higher levels of social provisions (see Table I).
| Variable . | Estimate (b) . | SE (b) . | βa . | SE (β) . | p-value . |
|---|---|---|---|---|---|
| Number of childrenb | −0.025 | 0.143 | −.0144 | 0.0821 | .861 |
| Years in the United States | 0.016 | 0.018 | .0687 | 0.0777 | .376 |
| Marital status (married/cohabitating)c | 0.144 | 0.209 | .1436 | 0.2089 | .492 |
| Income | 0.0001 | 0.00012 | .1254 | 0.0812 | .122 |
| Social support (SPS) | −0.030 | 0.018 | −.1299 | 0.0778 | .095 |
| Enculturation (ESI) | 0.415 | 0.286 | .1127 | 0.0776 | .147 |
| Acculturation (DSI) | 0.074 | 0.129 | .0458 | 0.0796 | .565 |
| Depression (CESD) | −0.007 | 0.011 | −.0509 | 0.0781 | .514 |
| Variable . | Estimate (b) . | SE (b) . | βa . | SE (β) . | p-value . |
|---|---|---|---|---|---|
| Number of childrenb | −0.025 | 0.143 | −.0144 | 0.0821 | .861 |
| Years in the United States | 0.016 | 0.018 | .0687 | 0.0777 | .376 |
| Marital status (married/cohabitating)c | 0.144 | 0.209 | .1436 | 0.2089 | .492 |
| Income | 0.0001 | 0.00012 | .1254 | 0.0812 | .122 |
| Social support (SPS) | −0.030 | 0.018 | −.1299 | 0.0778 | .095 |
| Enculturation (ESI) | 0.415 | 0.286 | .1127 | 0.0776 | .147 |
| Acculturation (DSI) | 0.074 | 0.129 | .0458 | 0.0796 | .565 |
| Depression (CESD) | −0.007 | 0.011 | −.0509 | 0.0781 | .514 |
Standardized regression coefficients.
Vulnerable children are the number of children between the ages of 6 months and 3 years.
Marital status was coded that separated/single category (no partner in the home) was the reference group.
| Variable . | Estimate (b) . | SE (b) . | βa . | SE (β) . | p-value . |
|---|---|---|---|---|---|
| Number of childrenb | −0.025 | 0.143 | −.0144 | 0.0821 | .861 |
| Years in the United States | 0.016 | 0.018 | .0687 | 0.0777 | .376 |
| Marital status (married/cohabitating)c | 0.144 | 0.209 | .1436 | 0.2089 | .492 |
| Income | 0.0001 | 0.00012 | .1254 | 0.0812 | .122 |
| Social support (SPS) | −0.030 | 0.018 | −.1299 | 0.0778 | .095 |
| Enculturation (ESI) | 0.415 | 0.286 | .1127 | 0.0776 | .147 |
| Acculturation (DSI) | 0.074 | 0.129 | .0458 | 0.0796 | .565 |
| Depression (CESD) | −0.007 | 0.011 | −.0509 | 0.0781 | .514 |
| Variable . | Estimate (b) . | SE (b) . | βa . | SE (β) . | p-value . |
|---|---|---|---|---|---|
| Number of childrenb | −0.025 | 0.143 | −.0144 | 0.0821 | .861 |
| Years in the United States | 0.016 | 0.018 | .0687 | 0.0777 | .376 |
| Marital status (married/cohabitating)c | 0.144 | 0.209 | .1436 | 0.2089 | .492 |
| Income | 0.0001 | 0.00012 | .1254 | 0.0812 | .122 |
| Social support (SPS) | −0.030 | 0.018 | −.1299 | 0.0778 | .095 |
| Enculturation (ESI) | 0.415 | 0.286 | .1127 | 0.0776 | .147 |
| Acculturation (DSI) | 0.074 | 0.129 | .0458 | 0.0796 | .565 |
| Depression (CESD) | −0.007 | 0.011 | −.0509 | 0.0781 | .514 |
Standardized regression coefficients.
Vulnerable children are the number of children between the ages of 6 months and 3 years.
Marital status was coded that separated/single category (no partner in the home) was the reference group.
Longitudinal Analyses
The results of the longitudinal negative binomial model are presented in Table II. None of the interactions of predictors with time were significant. Therefore, all interaction terms were dropped from the model. The model results revealed a significant effect of intervention stage for both during the intervention (b = −0.905, p < .001) and after the intervention (b = −2.118, p < .001) on the number of hazards when compared with before intervention, adjusting for all other predictors included in the model. These results indicate that these time points are predicting fewer hazards in the home. In fact, there were 60% and 88% decreases in the number of hazards during and after the intervention as compared with the preintervention, respectively. Surprisingly, depression, in general, was significantly negatively associated with the number of hazards at home (b = −0.026, p < .05, β = −.1,858). This indicated that with one unit increase in depression score, there was a 2.57% decrease in the number of hazards overall, adjusting for all other predictors included in the model.
Longitudinal Analysis With Negative Binomial Link Examining the Impact of the Intervention on HAPI-R
| Variable . | Estimate (b) . | SE (b) . | βa . | SE (β) . | p-value . |
|---|---|---|---|---|---|
| Number of vulnerable childrenb | 0.106 | 0.160 | .0609 | 0.092 | .5081 |
| Years in the United States | 0.025 | 0.020 | .1112 | 0.0878 | .2055 |
| Marital status(married/cohabitating)c | −0.184 | 0.233 | −.1842 | 0.2327 | .4285 |
| Income | 0.0001 | 0.00013 | .0906 | 0.0917 | .3228 |
| Social support (SPS) | −0.029 | 0.021 | −.1254 | 0.0902 | .1643 |
| Enculturation (ESI) | 0.266 | 0.325 | .0724 | 0.0884 | .4127 |
| Acculturation (DSI) | −0.068 | 0.141 | −.0421 | 0.0871 | .6291 |
| Depression (CESD) | −0.026 | 0.013 | −.1858 | 0.0941 | .0482* |
| Period | |||||
| During intervention | −0.905 | 0.150 | −.9046 | 0.1502 | <.001** |
| After intervention | −2.118 | 0.169 | −2.118 | 0.1692 | <.001** |
| Variable . | Estimate (b) . | SE (b) . | βa . | SE (β) . | p-value . |
|---|---|---|---|---|---|
| Number of vulnerable childrenb | 0.106 | 0.160 | .0609 | 0.092 | .5081 |
| Years in the United States | 0.025 | 0.020 | .1112 | 0.0878 | .2055 |
| Marital status(married/cohabitating)c | −0.184 | 0.233 | −.1842 | 0.2327 | .4285 |
| Income | 0.0001 | 0.00013 | .0906 | 0.0917 | .3228 |
| Social support (SPS) | −0.029 | 0.021 | −.1254 | 0.0902 | .1643 |
| Enculturation (ESI) | 0.266 | 0.325 | .0724 | 0.0884 | .4127 |
| Acculturation (DSI) | −0.068 | 0.141 | −.0421 | 0.0871 | .6291 |
| Depression (CESD) | −0.026 | 0.013 | −.1858 | 0.0941 | .0482* |
| Period | |||||
| During intervention | −0.905 | 0.150 | −.9046 | 0.1502 | <.001** |
| After intervention | −2.118 | 0.169 | −2.118 | 0.1692 | <.001** |
Note. Results reflect a negative binomial regression with single marital status as the reference group for marital status and before intervention as the reference group for period.
Standardized regression coefficients.
Vulnerable children are the number of children between the ages of 6 months and 3 years.
Marital status was coded that separated/single category (no partner in the home) was the reference group.
Significance at the .05 level.
Significance at the .01 level.
Longitudinal Analysis With Negative Binomial Link Examining the Impact of the Intervention on HAPI-R
| Variable . | Estimate (b) . | SE (b) . | βa . | SE (β) . | p-value . |
|---|---|---|---|---|---|
| Number of vulnerable childrenb | 0.106 | 0.160 | .0609 | 0.092 | .5081 |
| Years in the United States | 0.025 | 0.020 | .1112 | 0.0878 | .2055 |
| Marital status(married/cohabitating)c | −0.184 | 0.233 | −.1842 | 0.2327 | .4285 |
| Income | 0.0001 | 0.00013 | .0906 | 0.0917 | .3228 |
| Social support (SPS) | −0.029 | 0.021 | −.1254 | 0.0902 | .1643 |
| Enculturation (ESI) | 0.266 | 0.325 | .0724 | 0.0884 | .4127 |
| Acculturation (DSI) | −0.068 | 0.141 | −.0421 | 0.0871 | .6291 |
| Depression (CESD) | −0.026 | 0.013 | −.1858 | 0.0941 | .0482* |
| Period | |||||
| During intervention | −0.905 | 0.150 | −.9046 | 0.1502 | <.001** |
| After intervention | −2.118 | 0.169 | −2.118 | 0.1692 | <.001** |
| Variable . | Estimate (b) . | SE (b) . | βa . | SE (β) . | p-value . |
|---|---|---|---|---|---|
| Number of vulnerable childrenb | 0.106 | 0.160 | .0609 | 0.092 | .5081 |
| Years in the United States | 0.025 | 0.020 | .1112 | 0.0878 | .2055 |
| Marital status(married/cohabitating)c | −0.184 | 0.233 | −.1842 | 0.2327 | .4285 |
| Income | 0.0001 | 0.00013 | .0906 | 0.0917 | .3228 |
| Social support (SPS) | −0.029 | 0.021 | −.1254 | 0.0902 | .1643 |
| Enculturation (ESI) | 0.266 | 0.325 | .0724 | 0.0884 | .4127 |
| Acculturation (DSI) | −0.068 | 0.141 | −.0421 | 0.0871 | .6291 |
| Depression (CESD) | −0.026 | 0.013 | −.1858 | 0.0941 | .0482* |
| Period | |||||
| During intervention | −0.905 | 0.150 | −.9046 | 0.1502 | <.001** |
| After intervention | −2.118 | 0.169 | −2.118 | 0.1692 | <.001** |
Note. Results reflect a negative binomial regression with single marital status as the reference group for marital status and before intervention as the reference group for period.
Standardized regression coefficients.
Vulnerable children are the number of children between the ages of 6 months and 3 years.
Marital status was coded that separated/single category (no partner in the home) was the reference group.
Significance at the .05 level.
Significance at the .01 level.
Consumer Satisfaction
After completion of the Home Safety module, participants strongly agreed or agreed that their home was safer (98%), they were better able to identify (100%) and remove hazards within their home (98%), and that they intend to continue the home safety changes (100%). All the participants reported that the service providers’ demonstrations, practice, feedback, and written materials were useful or somewhat useful.
Discussion
The relationship of ethnicity and childhood unintentional injury is not well understood. While children who are Latino have been found to be at a significantly greater risk for childhood injury than those who are White (Agran, Winn, Anderson, & Del Valle, 1998; Flores et al., 2002); immigrant, non-English speaking families have been found to be at lower risk of childhood injuries that required medical attention (Schwebel et al., 2005; Schwebel & Brezausek, 2009). Investigating accessible hazards that place children at greater risk for injury is an important next step in this research. The current analysis examined proposed risk and protective factors for accessible hazards in homes of Latino immigrant families with considerable adversity (poverty, depression, intimate partner violence, and substance abuse). Before intervention, many hazards were accessible to the young children (Median = 11, range was up to 80 in the home). Of the risk, protective, and cultural factors studied, none were significantly associated with the number of accessible hazards in the home before any intervention. Thus, higher number of accessible hazards within this sample of Latino Spanish-speaking immigrant families was not explained by acculturation, enculturation, time in the United States, monthly income, number of vulnerable children, or depression. There was a trend that the provision of social support was associated with lower hazards in the home, suggesting that the potential for protective factors of support warrants further investigation.
Accessible home hazards were readily addressed in the homes of the participants, with considerable and significant reduction in hazards during and after administration of the SC+ Home Safety module with Latino families in this project. The number of hazards after the pretreatment assessment reduced during (by 60%) and after implementation (by 88%) of the Home Safety module with Spanish-speaking immigrant Latino families. These results mirror previous findings by the program developer with the English versions of the program (Barone et al., 1986). The approach of the SC+ Home Safety module is skills based, educational, and involves installing safety devices as well as removing hazards from the home environment. Reducing home hazards and providing preventive safety devices have been found to decrease child mortality and unintentional injuries leading to emergency room visits (Borse et al., 2008; CDC, 2012) and hospitalizations (Rodriguez, 1990).
The present study of a primarily immigrant sample does not support that there are particular factors related to maintaining traditional culture or adopting the dominant culture that predicts young children’s risk of access to hazards in the home or reduction of hazards with intervention. Provision of education about potential hazards and strategies to reduce exposure of young children to hazards in the home appeared to reduce hazards in a pattern similar to English-speaking caregivers. The parents perceived they had a greater understanding of hazards and strategies to prevent their children’s access. Preintervention level of understanding of hazards was not measured in the current study, and will be an important target of future research. The promising results in the current analyses support next steps in conducting a more rigorous examination of the Home Safety module of SC+.
Previous research found single parenthood and poverty were associated with higher rates of injury (Damashek & Kuhn, 2014; Nicolais, 2014). In the present study, accessible hazards in the home rather than rate of injuries was examined. Hazards were not found to be associated with monthly income, though notably the income of most families in the study was in the federal poverty guidelines. Thus, the current sample had a more restrictive range of income than previous studies. Future studies should include more economically diverse samples of Latino families with young children to further examine the relationship between income and accessible home hazards.
A greater level of reported social support was emerging as related to lower number of hazards, while having a partner in the home (married or cohabitating) did not significantly predict fewer hazards when compared with single parents. The social support measure administered in this study examines the extent to which other people in their lives are perceived as helpful, providing guidance, trustworthy, and share interests and activities. Observational research capturing not only access to hazards but supervision strategies of all adults with the children may improve our understanding of how the support factors interact to predict unintentional injury.
The current analysis found that higher rates of maternal depression were related to fewer home hazards over the time. It is important to note that depression was only measured before the SC+ intervention being initiated, and change in depression over time was not captured in the current project. Depression was not associated with pretreatment number of hazards, but rather number of hazards across all periods. Change in depression may provide important information for understanding this unexpected finding. Future research should examine types of depression symptoms to elucidate the relationship with hazards in the home environment. For example, depression symptoms associated with lower motivation (psychomotor retardation, loss of energy, hypersomnia) may impact both supervision and environment, increasing risk for injury. In contrast, psychomotor agitation, insomnia, and feelings of guilt may positively reduce hazard exposure, while continuing to hinder supervision. Previous research shows that severe maternal depression is a risk factor for childhood injuries (Orton et al., 2012; Schwebel & Brezausek, 2008), warranting further research on the influence of type and severity of depression symptoms on safety behaviors, home environment, and childhood injuries, as well as on how the factors change over time.
The design of the current study did not allow for examination of sustainability of home hazard reduction over time and rate of injury. This within-subjects design found a strong repeated pattern of reduction of hazards, but it did not contain a control group, as the HAPI-R was not administered in the comparison condition of the larger trial. Caregivers were aware of the content and timing of every visit, such that they could have altered the home immediately before the HAPI-R administered. However, the number of hazards dramatically reduced from before (Median = 11.5) to after (Median = 1) intervention. Thus, there is evidence that the parents were successful in altering the home environment over time during the Home Safety intervention. It is also important to note the dropout rate of participants in the study (33%), which is not unusual for prevention programs. Though results suggest that participants completing services only varied on amount of social support, further research should examine patterns of participant attrition and factors predicting incomplete services. The current results are promising; however, a controlled trial on the culturally adapted SC+, with independent assessments of hazards, knowledge, skills, and injury over time would be an important next step. Further, the results of the larger clinical trial will allow the examination of the SC+ program impact on risk and protective factors on a range of child outcomes.
Clinical Implications
These findings have the potential to inform clinical practice. Professionals (e.g., medical, child care, and social service personnel) can take the opportunity to screen knowledge and educate about home safety devices and hazards for all families with young children. Specifically, these findings suggest that professionals should screen for social provisions or supports because there was some evidence that lower social support for Latina caregivers of young children may be a risk factor for hazard accessibility. Given the high rates of consumer satisfaction reported in this study, families that are vulnerable may particularly benefit from hands-on skills-based approach, such as SC+. It is important to provide these families with skills-based teachings and provide support for installation of safety devices to change the conditions in the home and the behaviors contributing to the hazards. Families with multiple young children may require additional support, which may focus on more permanent means to remove access to hazards and close supervision strategies.
Conclusions
Given the high rates of injuries and ethnic disparities among Latino children (Agran et al., 1998; Flores et al., 2002), this study provides important implications of the risk and protective factors related to vulnerable children and caregivers and impact of safety knowledge and skills training. This study is the first of its kind to specifically examine the impact of the Home Safety module of SC+ adapted for the Latino community outside of the program developer. This analysis provides some support that the Home Safety module of SC+ impacted a reduction in home hazards in first-generation Latino families with young children. It is important that SC+ was adapted not only in terms of language, but also in terms of cultural congruency. This can help establish a stronger connection between the participant and home providers, which may lead to better results. Findings support the need to conduct rigorous controlled designs specifically on home hazards and use of the module in other contexts.
Supplementary Data
Supplementary data can be found at: http://www.jpepsy.oxfordjournals.org/.
Acknowledgement
We thank the families who participated and willingly welcomed the data collectors and providers into their homes and shared their experiences. Further, we appreciate the individuals and agencies involved in our collaborative partnership among University-based intervention scientists and staff, state agencies, legislative staff, clinical consultants, and community-based service agencies. They are too numerous to mention by name but we note their dedication to our state’s efforts to systematically develop, implement, evaluate, and expand effective prevention programs for families in vulnerable situations.
Funding
This work was supported by grants through the Administration of Children, Youth, and Families, USDHHS (grant number 90CA1764); Health Resources and Services Administration (grant number D89MC23154); and the Potts Family Foundation to J.F.S.
Conflicts of interest: None declared.
References
