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Original research
Cost-effectiveness of the ‘Stay One Step Ahead’ Home Safety programme for the prevention of injuries among children under 5 years
  1. Matthew Jones1,
  2. Elizabeth Orton1,
  3. Michael James Taylor1,
  4. Clare Timblin1,
  5. Rachel Clarke1,
  6. Michael Craig Watson2,
  7. Mike Hayes3,
  8. Tina Patel1,
  9. Carol Coupland1,
  10. Denise Kendrick1
  1. 1 Centre for Academic Primary Care, Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
  2. 2 Institute of Health Promotion and Education, Altrincham, UK
  3. 3 Child Accident Prevention Trust, London, UK
  1. Correspondence to Dr Matthew Jones, University of Nottingham, Nottingham, UK; matthew.jones3{at}nottingham.ac.uk

Abstract

Background Unintentional injuries are a common cause of morbidity and mortality in the under-5s, but undertaking home safety practices can reduce injury risk. Stay One Step Ahead (SOSA) is an evidence-based standardised home safety programme. This study evaluates the cost-effectiveness of SOSA versus usual care in Nottingham, UK.

Methods Cost-effectiveness analysis from a National Health Service and personal social services perspective. SOSA activity data, injury occurrence and associated short-term healthcare costs were collected within a controlled before-and-after study from 2017 to 2020. The primary outcome was the incremental cost-effectiveness ratio (ICER) per additional home adopting three key safety practices (working smoke alarm, safe poisons storage and fitted stair gate). Secondary outcomes were ICERs per injury avoided and quality-adjusted life-years (QALYs) gained.

Results SOSA costs £30 per child but reduces short-term healthcare expenditure by £42. SOSA increased the number of homes with three key safety practices by 0.02 per child, reduced injuries per child by 0.15 and gained 0.0036 QALYs per child. SOSA was dominant as it was cheaper and more effective than current practice. ICERs were −£590 per additional home deemed safe, −£77 per injury avoided and −£3225 per QALY gained. Focusing on healthcare expenditure alone, SOSA saved £1.39 for every pound spent.

Conclusions SOSA is a cost-saving intervention. Commissioners should consider implementing SOSA.

  • Quality Of Life
  • Costs
  • Injury Diagnosis
  • Interventions
  • Economic Analysis

Data availability statement

No data are available.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/ip-2024-045236

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Unintentional injuries among children under 5 years old are a common cause of morbidity and mortality. Multicomponent interventions to reduce injuries have been shown to be effective but not cost-effective.

    WHAT THIS STUDY ADDS

    • The multicomponent intervention was found to be more effective at making homes safer, reducing injuries and increasing health. The intervention cost was smaller than healthcare savings resulting from the intervention. The intervention was cost saving.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • Funders should commission evidence-based multicomponent interventions for preschool children as they are cost saving.

    Introduction

    Unintentional injuries are a common cause of morbidity and mortality in 0–5 years.1 Most of these injuries occur in the home environment and are preventable.2 3 The most frequently occurring avoidable causes are falls, unintentional poisonings and scalds.1 Injuries from these causes are associated with considerable costs, both to the affected families and to health services.4

    Injury risks can be reduced by safety practices which may involve modifying homes or undertaking certain safety behaviours. Many of these safety practices can be improved through educational interventions.5 Examples of these that have the strongest evidence for effectiveness include having a fitted and working smoke alarm; storing household poisons (cleaning products and medications) out of children’s reach; and having a stair gate (also known as a safety gate) on stairs.5–11 Though some types of intervention are effective in improving home safety or reducing the risk of injury,5 their cost-effectiveness may vary.12–14 Providing robust economic evaluations, therefore, is crucial in informing child injury prevention strategies, policies and funding decisions.15 16 Current guidance in England and Wales recommends that health and social care services provide safety advice, home safety assessments or safety equipment to families whose children are at increased risk of injury,17 but there is a lack of consistent implementation.6

    The Stay One Step Ahead (‘SOSA’) programme is a multicomponent intervention that was implemented in Nottingham City in electoral wards with high levels of health, social and educational needs.18 The purpose of SOSA was to increase home safety practices and reduce child injuries within these electoral wards. The aim of this study was to estimate the cost-effectiveness of the SOSA programme compared with usual care in increasing the number of homes with the three key safety practices (having at least one fitted and working smoke alarm, a safety gate on stairs and storing poisons out of reach) and reducing the number of child injuries. The effectiveness of the programme is reported elsewhere.19

    Materials and methods

    Objectives

    The objectives of this study were to:

    • Estimate the cost of the SOSA programme as delivered.

    • Estimate the number of injuries in children aged under 5 years over the 24-month follow-up for SOSA and usual care wards, and their associated healthcare cost and health-related quality of life.

    • Estimate the number of homes with the three key safety practices for both SOSA and usual care wards.

    • Demonstrate the cost-effectiveness of the SOSA programme for increasing the number of homes with the three key safety practices, avoiding injuries among children and increasing quality-adjusted life-years (QALYs).

    Study design

    The economic evaluation was done alongside a non-randomised controlled before-and-after study.18 19 The key components of the economic evaluation including population, intervention, comparator, perspectives outcomes and analytical strategy can be found in table 1. The SOSA programme was delivered in four electoral wards in Nottingham City, UK. SOSA wards were chosen due to high levels of health, education and social needs, with four matched control wards, matched on the basis of rate of emergency department injury presentation by 0–5 years,20 income deprivation affecting children, similar child population sizes of children aged 0–5 and minimising health visitor service caseload overlap.

    View this table:
    Table 1

    Key components of the economic evaluation of the SOSA programme

    Patient and public involvement

    The SOSA intervention was coproduced with parents from Nottingham City. These ‘Parent Champions’ were parents of young children, residents of the intervention wards and part of the SSBC programme. They contributed to developing parent recruitment and retention strategies, designing data collection tools, study oversight and dissemination.

    Microcosting of the SOSA programme

    A detailed description and breakdown of the microcosting of the SOSA programme can be found in online supplemental information S1. In summary, costs were split into two categories: programme development and day-to-day running. Development costs represented the resources required to create and refine the materials and resources required for the SOSA programme through consultations with stakeholders (parents, health visiting teams, family mentors, children’s centre staff, the Fire and Rescue service and an injury prevention expert from the Child Accident Prevention Trust) as part of a series of workshops.

    Supplemental material

    For day-to-day running costs, activity was split into six categories: children’s centre activity, family mentor activity, health visiting team activity, provision of interpreters, provider training and central administration. Information regarding activity related to children’s centres, family mentors, health visiting teams and interpreters was estimated where possible on a per ward basis, to allow for any variation of SOSA delivery that might occur across wards. This was done by direct contact with each team (if possible) with requests for a summary of their SOSA programme-related activity and the length of time spent on each activity. Details of reported activity can be found in online supplemental file SI1. Costs were estimated on a per each occurrence basis (eg, cost per safety week, costs per monthly safety message), at a ward level where possible. If a ward was missing information on activity, then an average cost across the other wards was used as an estimate. For each provider training session, the total cost was estimated by multiplying the length of time at the session by the number of attendees by their salary, as well as the number and level of instructors at the session. Costs of central administration were collected directly by the study team. These included staff time for printing resources for monthly safety messages, safety weeks and home safety checklists, the costs of printing materials and the postage required to send materials to relevant teams.

    Total SOSA programme costs were estimated for each financial quarter over the full duration of the programme. For each cohort of children, we then estimated the cost per child of the SOSA programme by dividing the total SOSA programme cost per financial quarter by the number of children aged 0–5 years on health visitor caseloads within SOSA programme wards. Next, we summed the cost per quarter over the 2-year follow-up to estimate the total cost per child for each cohort. Finally, we took the average total cost per child across the three cohorts. A detailed description is given in online supplemental file SI1.

    Costing healthcare consultations

    Data on injury occurrence and associated healthcare consultations were obtained from 3-monthly administered parent self-reported questionnaires. A recall period of 3 months was used to assess injury occurrence as previous research suggests parents recall over 80% of minor injuries to their children which resulted in attendance at an urgent care provider or emergency department or major injuries regardless of place of treatment.21 They included the number of injuries and healthcare provided for each injury (general practitioner consultation, emergency department visit, urgent care/walk-in centre consultation, hospital admission and outpatient follow-up). For each child, the number of health service consultations was totalled for year 1 and year 2 of follow-up. Prices for each type of National Health Service (NHS) consultation can be found in online supplemental file SI2. All prices were inflated to 2019/2020 prices using the NHS Cost Inflation Index.22 The unit prices of an emergency department visit and an outpatient visit were taken as the average weighted price across all emergency department visits and all outpatient visits reported in NHS Reference Costs, as per standard approaches.23 For the cost of hospital admission, as data on length of stay were not recorded, we used a weighted average for the total cost of admission for an injury as reported in Cooper et al.4 Parental self-reported injury data were validated against injuries recorded in medical records for 22 participants whose parents gave consent for injury data to be extracted from their child’s medical records.

    Primary outcome measure

    Data on the three key safety practices (having at least one fitted and working smoke alarm, a safety gate on stairs and storing poisons out of reach) were obtained by parent-completed questionnaires at recruitment, 12-month and 24-month follow-up. Further information can be found elsewhere.19

    Estimating QALYs

    Utilities for children were taken from published literature,24 and further details as to how utility weights were applied to estimate QALYs can be found in online supplemental file SI3.

    Secondary analysis

    Two secondary analyses were conducted:

    1. Inclusion of development costs attributed in the first financial quarter.

    2. Using per family as the denominator in estimating incremental costs and outcomes rather than per child as some families had more than one child aged under 5 years, based on health visitor caseloads.

    Results

    Cost of SOSA programme

    The total discounted total cost of the SOSA programme was £216 805. A breakdown of costs by activity can be found in table 2. The average cost per child of the SOSA programme across the three cohorts was £30.

    View this table:
    Table 2

    Total discounted (3.5% per annum) cost for SOSA programme by activity, excluding development costs

    Number of injuries and their associated cost

    Data from 764 children across all wards were collected over 2 years. 110 had missing outcome data for both first-year and second-year follow-up while a further 58 children had missing data on prespecified independent variables, leaving 596 children with complete data in the analysis (278 children in SOSA wards and 318 in usual care wards). 154 children reported having one or more injuries, with a total of 235 injuries over the 2-year follow-up requiring 291 healthcare consultations. The total discounted healthcare cost was £45 497 for both usual care and SOSA wards (see table 3). Validation of self-reported injuries on 22 participants found that parents reported 29 medically attended injuries in the 2-year follow-up period while medical records reported 28 medically attended injuries.

    View this table:
    Table 3

    Discounted costs (3.5% per annum) for healthcare by consultation type and ward

    Home safety practices

    At recruitment, 103 homes in the usual care wards and 94 homes in SOSA wards had the three key safety practices, increasing to 141 and 129 homes in usual care and SOSA wards respectively at 24 months follow-up.

    Base case analysis

    SOSA wards were associated with a saving of £42 per child in healthcare costs while increasing the number of homes with the three key safety practices by 0.02 per child, reducing injuries by 0.15 per child and gaining 0.0036 QALYs per child. Incremental total cost was −£12, suggesting that the SOSA programme was dominant as it was more effective than usual care and saved money. The respective incremental cost-effectiveness ratios (ICERs) were −£590 per additional home deemed safe, −£77 per injury avoided and £3225 per QALY gained. The Stay One Step Ahead (ROI) was £1.39, suggesting that for every pound spent on the SOSA programme there was a return of £1.39 in healthcare savings.

    Sensitivity analyses

    ICERs were most sensitive to changes in the overall incremental SOSA programme cost and incremental healthcare savings while changes in the incremental number of homes with the three key safety practices safe and injuries avoided had little impact on the ICERs (see online supplemental file SI4).

    The probabilistic sensitivity analysis suggested considerable uncertainty in the base case findings with wide 95% CIs (see table 4), with the possibility that the SOSA programme did not reduce healthcare costs, increase homes with the three key safety practices, reduce injuries or increase QALYs. Mean ICERs were £350 (95% CI −£1621 to £1490) per additional home with the three key safety practices, −£206 (95% CI −£1161 to £983) per injury avoided and £6600 (95% CI −£42 876 to £64 771) per QALY gained. There was a 62% chance that SOSA was cost saving (ie, greater reductions in healthcare expenditure than the increase in programme cost per child), a 52% chance that the SOSA programme led to an improvement in homes with the three key safety practices, a 75% chance that there was a reduction in injuries, and a 95% chance that there was an increase in QALYs (see figure 1 and online supplemental file SI5). The ROI for the SOSA programme was £1.28 (95% CI −£0.33 to £3.08), suggesting on average there was a £1.28 return in healthcare savings for every £1 spent on the SOSA programme.

    Figure 1
    Figure 1

    Cost-effectiveness acceptability curves for the SOSA programme per additional home with the three key safety practices and per injury avoided. QALY, quality-adjusted life-year; SOSA, Stay One Step Ahead.

    View this table:
    Table 4

    Results of probabilistic sensitivity analyses

    Secondary analyses

    The total cost of developing the SOSA programme was £12 275, increasing the cost of the SOSA programme to £229 080 and the average cost per child to £33. This reduced incremental cost to −£9 per child. Therefore, the SOSA programme remained dominant. ICERs were now −£468 per additional home with the three key safety practices, −£61 per injury avoided and −£2559 per QALY gained. The ROI was reduced to £1.29, suggesting that for every pound spent on the SOSA intervention returned £1.29 in healthcare savings.

    The SOSA programme cost was £39 per household. Data on households registered to health visitors per financial quarter indicated there were on average 1.31 children per household in SOSA wards, therefore, we multiplied the base case incremental healthcare savings, incremental injuries avoided, incremental homes with the three key safety practices and incremental QALYs by 1.31, giving £55, 0.20, 0.03 and 0.0047, respectively, per household. The incremental cost per household was −£16, hence the SOSA programme was still estimated to be dominant. ICERs were now −£613 per additional household with the three key safety practices, −£82 per injury avoided and −£3405 per QALY gained. The SOSA programme had an ROI of £1.41, which meant a return of £1.41 was made per household for every pound spent on the programme.

    Discussion

    The SOSA programme was found to increase the number of homes with the three key safety practices and gain QALYs while decreasing the number of injuries among children as well as reducing healthcare expenditure. Meanwhile, the SOSA programme cost was smaller than the healthcare savings, suggesting that the SOSA programme was a dominant intervention in that it saved money and was more effective. However, sensitivity analyses demonstrated considerable uncertainty regarding the result, with a 52% chance that the SOSA programme led to an improvement in homes with the three key safety practices, a 75% chance that there was a reduction in injuries and a 95% chance of increasing QALYs.

    Strengths and limitations

    We have investigated the cost-effectiveness of the SOSA programme in a real-world setting, using a combination of routinely collected data as well as data collected directly from families. The microcosting approach used provided an accurate picture of the costs of providing the SOSA programme.

    Although we have captured most healthcare expenditure, we originally intended to capture more detailed healthcare data from the medical records of a sample (n=100) of study participants but only recruited 22 parents, so our analysis is based on self-reported data. This meant that we did not capture prescription data for any injuries that occurred in the 2-year follow-up, and our analyses may, therefore, slightly underestimate healthcare expenditure. However, Cooper et al found that prescriptions costs were only a small amount of the total cost of an injury,4 with £0.16 being for prescriptions out of a total of £194.11 for a child who has a fall. Therefore, although we are missing this data, it is unlikely that this would change the main findings of our study.

    Recall bias may have occurred in parents’ self-reported injury data as this data was collected at 3-monthly intervals, a time period previously shown to have injury recall rates of between 58% for clinic visits and 86% for emergency department visits or hospital admissions.21 But the small amount of data we extracted from medical records found parents were accurately reporting their child’s medically attended injuries, though numbers are too small to assess accuracy of reporting between the two arms.

    Our analysis was only able to take account of short-term healthcare costs. This will underestimate the true cost of injuries to health services, education, social care, parents, children, and wider society and hence our estimate of the cost-effectiveness of the SOSA programme is likely to be an underestimate.

    The COVID-19 pandemic also impacted our study, with many of the SOSA programme activities becoming remote as face-to-face activities were suspended during periods of social restrictions, decreasing the provision of materials. This impacted the SOSA programme cost (see table 2 where the last two financial quarters are below the previous quarter’s cost) and potentially the effectiveness of the SOSA programme.

    The considerable uncertainty within the evaluation results may be of concern. However, the probabilistic sensitivity analysis demonstrates a 62% chance that the SOSA programme saved money even though the evaluation excludes longer-term health and social costs for more severe injuries, educational costs and productivity losses. This means that SOSA is more likely to be cost-effective than our evaluation finds.

    In context with the literature

    Findings of the economic evaluation of SOSA are consistent with studies indicating cost-effectiveness of interventions that improve home safety through home visiting,25 and educational interventions promoting safe poison storage26 and fire escape planning.14 Family mentors were a new type of role, and therefore, an economic evaluation of their inclusion in a child home safety intervention has not previously been performed. There is evidence, however, that interventions provided by trained laypersons to reduce child maltreatment (and therefore injuries) are cost-effective.27 Previous research shows that promotion of safe poison storage is more cost-effective when provided in disadvantaged as opposed to more affluent areas, and the disadvantaged areas in which SOSA was delivered may partly explain its cost-effectiveness.26

    Implications for policy and research

    Policy-makers and health and social care commissioners should note that SOSA is cost saving, returning £1.39 for every one pound spent on the SOSA programme, even when only short-term healthcare costs are included in the evaluation. Using costs associated with longer-term health, social care, education and productivity losses is only likely to make SOSA more cost saving. Commissioners should, therefore, consider commissioning the SOSA programme for families in disadvantaged areas. Further research, perhaps as part of larger studies and incorporating longer-term costs of injuries, would be helpful to produce more precise estimates of cost-effectiveness.

    Conclusions

    The SOSA programme was associated with an increase in the number of homes with the three key safety practices and a reduction in associated injuries. Despite the SOSA programme including only short-term healthcare costs, it returned £1.39 for every £1 spent on SOSA, with a 62% chance of SOSA producing cost savings. SOSA is a cost-saving intervention, and as such commissioners should consider implementing the SOSA programme. Further larger studies, particularly including the longer-term costs of injuries would provide more precise estimates of cost-effectiveness.

    Data availability statement

    No data are available.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by the East Midlands Leicester Central Research Ethics Committee (reference: 17/EM/0240). Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    We would like to thank the Small Steps Big Changes Parent Champions (a team of parent volunteers) for their invaluable input into this project and the parents and practitioners who participated in the project.

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    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • Contributors EO, DK, MCW, MH, MJ and CC obtained funding for the study and designed the main study methods and data collection tools. MJ, EO, MJT and DK planned and conducted the data analysis. CT prepared documentation for the ethics committee. CT, TP and RC collected the data. MJ, MJT, EO and DK drafted the manuscript with revisions additionally from CC, MH, MCW, RC, CT and TP. EO is the guarantor for the study.

    • Funding This project was supported by funding from Small Steps Big Changes, part of The National Lottery Community Fund A Better Start Programme.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.