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How the science of injury prevention contributes to advancing home fire safety in the USA: successes and opportunities
  1. Andrea C Gielen1,
  2. Shannon Frattaroli2,
  3. Keshia M Pollack2,
  4. Corinne Peek-Asa3,
  5. Jingzhen G Yang4
  1. 1 Department of Health, Behavior and Society, Johns Hopkins Center for Injury Research and Policy, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
  2. 2 Department of Health Policy and Management, Johns Hopkins Center for Injury Research and Policy, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  3. 3 Injury Prevention Research Center, University of Iowa, Iowa city, Iowa, USA
  4. 4 Center for Injury Research and Policy, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, Ohio, USA
  1. Correspondence to Dr Andrea C Gielen, Johns Hopkins Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; agielen1{at}jhu.edu

Abstract

Background In the decades since the landmark report-America Burning-was published in 1973, the number of home fire deaths has shrunk from >5500 per year to 2650 in 2015. This paper: (1) describes how science and practice in injury prevention and fire and life safety contributed to successful interventions, and (2) identifies emerging strategies and future opportunities to prevent home fire-related deaths.

Methods The aims are addressed through the lens of population health research, with a focus on the work of selected Centers for Disease Control and Prevention-funded Injury Control Research Centers. Results are organised using the Haddon Matrix and an ecological model.

Results We found evidence to support interventions that address all components of both the matrix and the model, including: reduced ignition propensity cigarettes, stop smoking campaigns, housing codes, residential sprinkler systems, smoke alarms, community risk reduction, school-based educational programmes, and fire and burn response systems. Future reductions are likely to come from enhancing residential sprinkler and smoke alarm technology, and increasing their utilisation; expanding the use of community risk reduction methods; and implementing new technological solutions. Despite the successes, substantial disparities in home fire death rates remain, reflecting underlying social determinants of health.

Conclusion Most of the evidence-supported interventions were focused on changing the policy and community environments to prevent home fires and reduce injury when a fire occurs. Future prevention efforts should give high priority to addressing the continued disparities in home fire deaths.

  • burn
  • haddon matrix
  • mortality

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Introduction

Between 1979 and 2007, the US fire death rate was reduced by two-thirds.1 For home fires, the number reported dropped from 696 500 in 1979 to 399 000 in 2007; the number of home fire deaths in this period fell from 5500 to 2865; and in 2015, the number dropped to 2650.2 In an analysis of home fires from 1980 to 2015, Ahrens found fire deaths from smoking materials declined 67%; those associated with upholstered furniture fell by 64% and those associated with mattresses or bedding fell by more than half (56%).3 These data supported an evidence-driven approach to identifying and prioritising prevention needs and targets.

The 1973 report, America Burning, produced by the Presidentially-appointed National Commission on Fire Prevention and Control, called for more emphasis on fire prevention and research to inform prevention strategies.4 The 1987 update, America Burning Revisited, documented substantial reductions in fires and fire injuries since the initial report, which were attributed to improved fire prevention and public education; improved building and fire codes; better building plan checks and inspection programmes; increased use of smoke detectors and sprinkler systems; changes in the population distribution of at-risk age groups; and economic prosperity.5 Many of these explanations for the improvements in overall rates apply to home fires, which accounted for 80% of the fire deaths at the time of the report, and today account for 75% of all fire deaths in the USA.6

While the reductions in home fire deaths are the main focus of this paper, and should be celebrated, there are still challenges. The death rate per home fire has remained unchanged from 7.1/1000 fires in 1980 to 7.0/1000 fires in 2015.3 Using 2015 data, Ahrens3 found that 60% of home fire deaths occurred in homes with no working smoke alarms. Only an estimated 2% of one-family and two-family homes in the USA are sprinkler-equipped, providing another opportunity for technological innovation to reduce the risk and severity of home fire injuries.7 Finally, disparities in home fire death rates continue to exist and are reflective of social determinants of health. Those living in neighbourhoods with high poverty, poor building maintenance or in southern US states, along with men, African American and American Indian/Alaska Natives, and people ≥ 50 years of age have the greatest relative risk of dying in a fire when compared with other groups.8 9

A review of some of the most notable contributions leading to the declines in home fire deaths can illuminate important lessons for addressing these and other disparities and challenges. Thus, the aims of this paper are to: (1) describe how science and practice in injury prevention and fire and life safety contributed to successful interventions, and (2) identify emerging strategies and future opportunities to prevent home fire-related deaths.

Methods

This article presents findings from a scoping review in which we mapped key concepts, evidence, and gaps in research by systematically searching and selecting research to ‘provide a descriptive overview’ of what has been done to prevent home fire-related deaths.10 At the beginning of this work, the authors collectively discussed articles that would be included, and identified articles using the following key words and search terms in PubMed: residential, home, fire, burn, fatality, death, and prevention. We also examined reports from federal government websites and national professional associations concerned with home fire deaths. We included risk factors and interventions that have been most rigorously addressed in this literature and in the authors’ experiences, with a focus on the work of the National Centre for Injury Prevention and Control (NCIPC)/Centers for Disease Control and Prevention (CDC)-funded Injury Control Research Centers (ICRCs) with which the authors have been affiliated. The ICRC programme is a national network of comprehensive academic research centres that focus on three core functions—research, training, and outreach. The ICRCs were established in 1987 to "study ways to prevent injuries and violence and to work with community partners to put research findings into action.11 As such, their mission and activities focus on population health, and over their 30-year history have demonstrated notable successes12 including in home fire safety. Consistent with the ICRC programme’s emphasis on community partnerships, we highlight contributions that the authors’ ICRCs have made when collaborating with professional fire services who are equally interested in home fire safety and reducing deaths and injury, but who may not have the resources to conduct population health research.

We address the aims of this paper through the overarching lens of population health research, which is an interdisciplinary field that considers health outcomes, how they are distributed within and across populations, how they result from the interplay of genetics, behaviour, society and the environment, and how cross-sector collaborations are used to improve outcomes and reduce disparities.13 Consistent with this population health focus, we present the results using two organising frameworks that demonstrate the value of integrating cross-sector collaborations: the Haddon Matrix and an adaptation of the ecological model. The Haddon Matrix identifies injury risk and prevention as a function of injury phases and influencing factors.14 Injury phases represent different stages in which risk and protective factors and their associated interventions can impact injury, and include pre-event, event and postevent phases. The pre-event phase is concerned with preventing a fire from starting. The event phase focuses on reducing the likelihood of an injury in the event of a fire and the postevent phase considers recovering from a fire injury. The influencing factors that operate at each of these phases are characteristics of the host or individual at risk, the vehicle or vector of injury and the environment (both physical and social). Once the phases and factors are understood, an ecological model is used to focus on the targets for intervention; these can operate at the individual level (both inter and intrapersonal), community (including organizations), and policy or societal levels.15

Results

Haddon Matrix and ecological model applied to home fire safety

The Haddon Matrix analysis  of  what is known about home fire safety risk and protective factors is depicted in figure 1, which we have adapted and expanded on from Runyan’s work at the University of North Carolina ICRC in 1998.14 The cells of the Haddon Matrix elucidate causal factors and interventions to achieve population-level reduction in fire deaths that were identified in our review of evidence-based strategies. Examples of these interventions that operate at different levels of the ecological model as shown in (figure 2) are also indicated as bold text in figure 1. In the sections that follow, we describe these interventions, classifying them as to where they fit into the Haddon Matrix.

Figure 1

Haddon matrix: risk and protective factors for home fires.

Figure 2

Adapted ecololgical model for reductions in home fire deaths in the USA: primary levels targeted by interventions.

Pre-event intervention strategies addressing the vector and host: reduced ignition propensity cigarettes and stop smoking campaigns

Smoking is one of the leading causes of fatal home fires, and that risk is greatly increased with alcohol and other substance use.16–18 Reduced ignition propensity cigarettes (also known as ‘fire safer cigarettes’) are cigarettes that have a lower likelihood of burning when left unattended relative to traditional cigarettes. Intervening with the fire-causing product is responsive to the pre-event vector cell of the Haddon Matrix. All 50 states enacted laws between 2004 and 2011 requiring that all cigarettes sold within their borders self-extinguish if they are not being smoked,19–21 reflecting a policy-level intervention to affect the types of cigarettes available for individuals to smoke. Results from studies evaluating the effect of these laws on home fire mortality rates are mixed. One study concluded that the laws are associated with a 19% reduction in overall home fire mortality rates,20 while another found the laws had no significant effect on all-cause fire mortality, home fire mortality or cigarette-caused fire rates.19 Confounding factors such as higher cigarette prices and lower smoking rates may influence the observed trends; when smoking rates decrease, fewer cigarette-related fires are a likely result.22

Stop smoking/tobacco control campaigns can also address smoking’s contribution to the home fire problem, and are focused on the pre-event, host cell of the Haddon Matrix. Such campaigns are often developed for and disseminated through the media, a strategy that operates at the community level of an ecological model and targets individual smokers, while at the same time seeking to achieve population-level changes in smoking rates.23 Stop smoking campaigns could also be used to educate the public about the association between smoking and dying in a home fire; a 1% decrease in the percent of smokers corresponds to a 7% decrease in the home fire mortality rate.24 The available evidence suggests that comprehensive tobacco control programmes (education, cessation options, and policy changes) are likely to be the most effective and sustainable option for increasing the prevalence of smoke-free homes,25 which will contribute to reducing home fire deaths and injuries.

Pre-event, event and post-event intervention strategies addressing the physical environment: housing codes, residential sprinkler systems, and smoke alarms

Housing characteristics such as building materials used and where homes are built can affect the likelihood of a fire and of injuries. Risk is increased through poorly constructed and maintained building structures and absent or non-functioning systems such as residential sprinkler systems (RSS) and smoke alarms.17 18 26 27 Research conducted at the Johns Hopkins ICRC demonstrated significant increased risk for residents living adjacent to abandoned housing.28 Finally, risks for home fires has increased as homes are increasingly built in fire-prone areas.29 Such risk factors span the host, vector/vehicle and environment cells of the Haddon Matrix.

Housing codes are  a policy-level intervention strategy that addresses the physical environment and sets minimum standards required for all types of residential housing. Organisations such as the National Fire Protection Association (NFPA) and the International Code Council have developed and published hundreds of consensus codes and standards designed to reduce the occurrence of home fires and ameliorate the consequences when fire does occur.30 31 These codes provide guidance for states and localities when setting standards for safety with regard to new and existing buildings. Policies that require high-quality construction and that establish high-quality fire prevention-oriented building codes are protective, and are an example of interventions at the policy level that address the physical environment in which injury risk can be mitigated across all injury event phases.

Residential Sprinkler Systems (RSS), another example of a policy-level intervention strategy, protect occupants with quick delivery of water to an ignition site before the fire spreads. RSS are currently mandated in new one-family and two-family homes in over 400 jurisdictions, including at the state level in California, Maryland and Washington, DC.32–34 Evidence suggests that RSS significantly reduce fire-related injury, contain fire spread, reduce the demand on fire department resources, and likely reduce injury risk to first responders as well as to residents.34–36 RSS could reduce fire-related deaths by an estimated 69% alone and 82% in combination with smoke alarms, and 37 38 they have also been shown to be cost effective.39 40 The main impetus for RSS uptake appears to be state and local policies, efforts that have been met by organised opposition.41 This example illustrates a policy-level intervention with elements of community-level involvement that enables or hinders success across jurisdictions.

Functional smoke alarms reduce the risk of a fire fatality by at least one-half,42–44 and are an example of an event phase change to the physical environment. According to population-level data from the University of Iowa ICRC, photoelectric alarms, which use a light beam to help detect the presence of smoke and are more effective in detecting smouldering fires, have the longest functional life across various battery types when operated with lithium batteries.45 Many homes do not have a smoke alarm on every level and in every sleeping area in accordance with national recommendations, and in home visiting research many alarms have been found to be non-working .46 47 In a recent collaboration, ICRC researchers and national fire safety organisations compiled and disseminated the best available evidence on smoke alarms and identified significant research gaps and opportunities for technological improvements.48

Smoke alarm public information and distribution programmes are the most commonly used interventions to modify the host behaviour and increase the number of working smoke alarms in homes; they rely on a variety of individual-level and community-level strategies.49–51 These strategies most often include educating residents about home fires and home fire safety, and distributing and/or installing alarms, or referring residents to sources for alarms.50 51 The ‘Oklahoma Smoke Alarm Project’ documented, through a 6-year follow-up, an 81% decrease in fire–related injury among the target population where alarms were distributed.52 A community-based smoke alarm installation programme in Dallas, Texas concluded that fire-related deaths and injuries decreased 68% in programme homes 5 years after installation compared with non-program homes.53 The Smoke Alarm Installation and Fire Safety Education programme, a CDC-funded programme for high-risk homes in 16 states, installed over 212 000 smoke alarms in over 126 000 high-risk homes resulting in approximately 610 potentially saved lives.54 The recent 5-year nationwide, Red Cross Home Fire Campaign engaged >40 national and 1900 local partners, reached more than 63 000 homes with fire safety information, installed 125 000 smoke alarms and saved 26 lives during its first year.55 Existing evidence indicates a greater effect on smoke alarm uptake with free alarm installation compared with providing alarm vouchers.56 Researchers have documented the extent to which installation programmes can be cost-effective and have identified the need for better data on population impacts.57–60

ICRC research also highlights important implementation issues for installation programmes. Alarm type and location can have a significant impact on the alarm’s effectiveness.61 62 More homes can be served by programmes when community health workers provide advance notice of the visit and accompany the firefighters.63 Firefighters’ interactions with residents affect families’ satisfaction with installation programmes, which may be important for long-term maintenance of alarms.47 Smoke alarm installation programmes must incorporate such evidence into programme delivery to enhance their impact.45 64

Pre-event, event and post-event intervention strategies that address the social environment: community risk reduction, school-based educational programmes, and fire and burn response

Fire and life safety education through community risk reduction efforts, school-based educational programmes, and support for first responders and trauma and burn care professionals represent the type of progress envisioned in America Burning more than a quarter century ago. These examples use a combination of individual, community and policy-level intervention strategies.

Community risk reduction (CRR) has been adopted by many fire service agencies in the USA, and resources to support these efforts through technical assistance and materials are increasingly available.65 CRR grew out of traditional fire and life safety education (FLSE) that originally was fire departments’ prevention programming. With the exception of smoke alarm canvassing programmes, little scholarly work has been done to understand FLSE initiatives within the US fire service. A case study of prevention in the Delaware fire service66 found that most prevention efforts were directed at individual safety behaviours in families and communities. Due to fire departments’ limited funding for prevention, and the fact that 72% of firefighters in the USA are volunteers, there are barriers to conducting FLSE activities and evaluating their impacts.66 CRR involves a series of community-based, fire prevention interventions built on a data-based assessment of a community’s health and injury issues and their resources to address needs. It is focused on individual and community fire safety knowledge and practices, as well as on policy engagement for safer communities through such actions as code enhancements.65 Nevertheless, most of the examples we identified were focused on the former—for example, an in-home visit to educate parents on escape planning coupled with the installation of smoke alarms,67 a hands-on smoke alarm operability practice68 and the NFPA’s Keeping Your Community Safe and Sound,69 a free educational resource in an online tool kit to help communities raise awareness about the benefits of smoke alarms.

School-based educational programmes on fire safety are often taught by professionals external to school staff, such as safety organisation and fire service personnel. These programmes implemented at community level have been found to be beneficial in teaching children injury prevention and critical protective thinking skills.70 One example is the ‘Risk Watch’ programme in the USA and Canada. Evidence shows that the Risk Watch programme delivered by a fire service public educator effectively increased short-term knowledge in early elementary students70 and improved safety skills and behaviours in school-age children.71

Addressing recovery from a fire injury (post-event in the Haddon Matrix) depends heavily on community-level and policy-level interventions to support fire and burn response. Government policies and community support for them have been essential to having fire services that quickly respond to fires, provide on-site emergency care and transport injured individuals to medical facilities, and to having specialised burn centres, all of which has contributed to increased survival.72 73 Psychological distress among burn survivors has been shown to be very high,74 and recovery is enhanced when there is good access to services following a fire, such as mental health services and financial aid. Peck reports that patients’ adjustment following injury is more heavily influenced by the patient’s preinjury characteristics related to coping skills, family and community support, and general mental health than by the physical characteristics of the burn.75 While these services focus on the individual at risk or injured, the availability and quality of the services (a social environmental factor in the Haddon Matrix) are largely determined by state and local policies that finance and support them, which in turn can be informed by communities. The extent to which disenfranchised communities have access to adequate services after a fire event has not been described in the literature, although many of the social determinants that put such communities at risk of having fires in the first place probably apply to the post-event phase as well.

Discussion

As a result of a comprehensive understanding of the risk and protective factors (Haddon Matrix, figure 1) and the application of multiple intervention strategies at multiple levels of influence (ecological model, figure 2), population death rates from home fires have been significantly reduced. Future success in reducing fire-related death and injury is likely to come from enhancing residential sprinkler and smoke alarm technology and increasing their utilisation; expanding the use of CRR methods and practices; and implementing new technological solutions to reduce risk. Each of these is discussed in more detail below.

The future for RSS

There is clear promise in the expanded use of RSS as a tool for preventing fire injury and death. In addition to the long-standing efforts to incorporate sprinkler systems into new homes,32 retrofitting existing homes with RSS is an opportunity for future growth. In one survey of owners of sprinkler-equipped homes, 20% of respondents reported retrofitting their homes, suggesting a market for retrofit options.7 Advances in residential sprinkler technology, such as mist systems and flexible tubing, offer promising alternatives to traditional sprinkler systems in that they can be retrofitted into existing homes with less physical disruption to the home and often at a lower cost. Research to assess the effectiveness of these systems in suppressing fire and preventing injury and death is needed to inform legislative, regulatory and code decisions, as well as public education efforts.

The future for smoke alarms

Smoke alarms have long been at the core of residential fire injury prevention efforts because of their demonstrated life-saving value. However, the literature also documents the challenges associated with reaching highly vulnerable families and assuring smoke alarms are maintained. Partnerships with a nurse home visiting programme are a promising strategy for reaching low-income new mothers who are at elevated risk of dying in a fire. [Omaki, unpublished data] Studies are also needed to better understand how to maintain smoke alarms in good working order through improved technologies and/or better-educated consumers. Developing best practices for smoke alarm distribution that speak to identifying target populations, engaging those populations, installing the smoke alarms, educating residents and using particular technologies (such as long-life batteries in tamper-resistant alarms) are needed, along with disseminating this information to practitioners to foster widespread use of the best available technologies and practices. One model for engaging in an action-oriented consensus process suggests that progress can be realised through such efforts.48

The future for CRR

There is a need to evaluate CRR efforts that are being adopted by many communities to document the process of implementing the approach and to identify which strategies or combination of strategies are most effective in which contexts. By tailoring interventions to address community risks and respond with interventions that consider community context, CRR expands fire prevention interventions to address community threats beyond fire. It may also offer an important opportunity for communities to address larger social determinants of health that are an inseparable part of the context in which fire risk exists. Moreover, CRR approaches can facilitate policy-level and community-level solutions through activities such as: enactment and enforcement of housing codes that reduce risk and partnerships with government agencies and community housing organisations to promote and ensure smoke alarm and RSS installation and maintenance. Assuring that such efforts are informed by evidence is important to realising a reduction in residential fire injuries and deaths.

The future for new technological solutions

Other promising approaches to reducing fire risks include technologies to improve smoke and flame resistant materials coupled with policies and programmes to ensure their use. For example, flame retardant materials have been successfully integrated into child sleepwear, but little progress has been made in reducing the flammability of home textiles such as drapery and upholstery. Smart home systems now on the market are being refined and offer an untapped potential to improve fire safety. These systems monitor the home environment and alert residents (who may be remote) when sensors detect a risk. Continuous monitoring of the home environment offers a quick and automatic response when a fire is detected, providing an early warning for occupants and automatic notification to the local fire department. Future systems may also have the capability to detect the conditions in which a fire is likely to occur and provide an opportunity to intervene before ignition. Assuring that such technology is monitored and evaluated for maximum impact is important; using the data collected through these systems to further inform fire risk and prevention strategies offers another opportunity to advance the field and continue progress on this important injury topic.

Limitations

We did not review all aspects of progress in home fire prevention and response that contribute to declines in the population death rates, nor did the available literature allow us to determine the relative contributions of the evidence-based interventions. We chose to highlight the risk factors and interventions that have been most rigorously addressed in the peer-reviewed public health literature and in the authors’ experiences, and we did not focus on evaluating the quality of the evidence. These limitations are consistent with the intent and scope of the paper, and future systematic reviews would be beneficial.

We excluded fire-related non-fatal injury data because accessing reliable, valid and complete data on non-fatal injuries is far more challenging than data on deaths. We also did not address trends in outcomes to firefighters that occurred during the period when population death rates were declining. Finally, while we touch on disparities that remain in the rates of fire deaths and how interventions address those, we were unable to deeply explore the relationship between social determinants of health and fire deaths in large part due to the lack of scholarly literature on the topic. This gap urgently needs to be addressed in future research because the continued disparities in fire risk and fire deaths can and must be addressed by targeting the underlying inequities and determinants of health that have created them.

Conclusion

Home fire deaths have been dramatically reduced, indicating that this public health problem is largely preventable. Tools such as the Haddon Matrix and an ecological model help to describe risk and protective factors and interventions in a systematic and comprehensive manner. A number of evidence-supported interventions were identified and, while they spanned the multiple phases of injury and levels of influence, most were focused on changing the policy and community environments to prevent home fires and reduce the risk of injury. Despite successes, fire prevention should remain a priority to further reduce deaths and injuries, such as through a ‘Towards Zero Deaths’ campaign similar to traffic safety efforts. Efforts to reduce disparities should be a focus of future efforts.

What is already known on this subject

  • Home fire deaths have been significantly reduced over the past several decades, although substantial disparities remain.

  • Fire service and injury prevention professionals have established effective collaborative research and practice efforts in many communities.

What this study adds

  • Analysing the reductions in home fire deaths from a population health perspective highlights how interdisciplinary research and practice can achieve health outcomes.

  • The Haddon Matrix and an ecological model help to organise our understanding of the advances in fire prevention that have been made and identify future opportunities.

References

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Footnotes

  • Contributors ACG: organised writing team’s work, edited and finalised all sections of the manuscript, writing portions of each section. SF: edited all sections of the manuscript, wrote Discussion. CP-A: edited all sections of the manuscript, wrote Haddon Matrix analysis Results. JGY: edited all sections of the manuscript, wrote Ecological Model analysis Results. KMP: edited all sections of the manuscript, and contributed to the Introduction and Methods.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

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