Fire departments in the United States respond to approximately 374,000 residential fires each year.¹ There are more than 2,000 deaths due to residential fires every year, and in 2009, fire and other burns led to 381,012 medical visits.^2,3 The lifetime costs generated in a single year by hospitalizations due to fires and burns is an estimated $1.2 billion.⁴ Injuries due to fire disproportionately affect those with lower incomes and living in poor urban environments.^5,6

Smoke alarms substantially reduce the risk of death in the event of a fire, and increasing their use is a national health objective in the United States.⁷ Almost two-thirds (63%) of all residential fire deaths occur in homes without working smoke alarms.⁸ Rates of working smoke alarms on every level of a home, the recommended standard, range between 22%-40% in high risk urban communities.^8,9,10

The CDC-sponsored Smoke Alarm Installation and Fire Safety Education (SAIFE) program has been found to increase smoke alarm coverage in high-risk communities.¹¹ The program recommends installing 10-year lithium battery smoke alarms on each level of a home, educating the resident about smoke alarm maintenance and fire safety, and community promotion. How to implement such a program to maximize community participation remains uncertain.

Community health workers (CHWs) are often turned to for community promotion. However, a recent systematic review found mixed evidence of their effectiveness,¹² and only two studies involving home injury prevention.^13,14 Almost two decades ago, Schwartz et al¹³ found that a CHW intervention addressing multiple home safety behaviors increased smoke alarm coverage by 14%. Gielen et al¹⁴ found that a single CHW home visit after a pediatric health care visit had no effect on smoke alarm use. Thus, the contribution of CHWs to promoting smoke alarm canvassing programs is unclear.

To date, there have been no studies comparing different methods of accessing homes to provide smoke alarms at the community level. With strong evidence supporting their effectiveness and community wide installation programs, and the availability of 10-year lithium battery alarms, it is timely to explore how to maximize participation in these programs.

The Johns Hopkins Center for Injury Research and Policy (JHCIRP) addressed this question in partnership with the Baltimore City Fire Department (BCFD), the Maryland Department of Health and Mental Hygiene’s (DHMH) SAIFE program, the Environmental Justice Partnership’s (EJP) community outreach program, and the Urban Health Institute’s (UHI) community health worker program. Together, we conducted the Johns Hopkins Home Safety Study to evaluate strategies to maximize participation in the BCFD’s smoke alarm home visiting program.

The primary aim of this paper is to evaluate the impact of an enhanced BCFD home visiting program on community participation and installation of smoke alarms when compared to their standard program. We hypothesized that enhancing the BCFD’s standard home visiting program with a community promotion component would increase the number of residents who participated in the program and thus an increase in the number of homes properly protected.

To determine comparability of the communities that were to receive the home visiting programs, we conducted baseline household surveys. Thus, a secondary aim of this paper is to describe the rates of fire and burn hazards in a large urban area. The study was approved by the Johns Hopkins Institutional Review Board.

The overall aim of this community based intervention trial was to evaluate the impact of an enhanced fire department home visiting program on community participation and installation of smoke alarms. Our baseline survey demonstrated a high need for the program in that the majority of the residents surveyed had been visited previously by the fire department, and yet, 60% of homes did not have working smoke alarms on every level, 72% had unsafe water temperatures, and 44% did not have CO alarms.

The enhanced home visiting program increased access to homes by 21%, from 62% of residents in the standard to 75% in the enhanced area who let the fire department into their homes. Once inside the home, the majority of home visits were successfully completed, and those in the enhanced community relative to those in the standard were significantly more likely to result in having smoke alarms on all levels (84% vs 78%). All of the installed alarms were the 10-year lithium battery alarms with a hush feature. These new alarms offer longer term protection because the batteries do not have to be changed every six months, and the hush feature allows residents to turn off nuisance alarms without removing the batteries or otherwise disabling the smoke alarm. ¹⁸

A recent review of fire and life safety activities in US fire departments revealed that although the vast majority (86%) report conducting prevention education, fewer than 20% report conducting community canvassing programs such as the one evaluated here.¹⁹ Our work shows that such programs are feasible and result in increased protection. Prior smoke alarm distribution programs that have evaluated their impact on fire deaths have had mixed results,^20,21 but programs with 10 year batteries are only just now being evaluated, and we fully expect that increased coverage with these longer lasting batteries will result in fewer fire deaths.

To our knowledge, this is the first time CHWs have joined with a fire department to provide community education and promotion in advance of a canvassing program. Previously reported smoke alarm distribution programs have used various combinations of community volunteers, paid staff, and fire personnel with mixed results^13,14,21,22 Our study is most similar to the earlier work by Schwarz et al,¹³ who hired community liaisons to engage community members at the block level in advance of having safety inspectors go door-to-door. Like Schwarz’s work, we too found that advance notice provided by a recognized community representative resulted in increased access to homes. We were surprised, however, that the advance notice did not result in more residents being home on the day of the event; how to address the 60% of residents who were not home remains a challenge.

We were also surprised that more smoke alarms were installed per home in the enhanced community relative to the standard because the fire department protocol was the same in both. It is possible that residents were more receptive in the enhanced community, which encouraged the fire personnel in their efforts to install alarms on all levels. Perhaps the fire personnel were influenced by knowing they were in the enhanced community and by having a health educator with them. It was not possible to “blind” the fire personnel to study condition given the added intervention components in the enhanced area. Because canvassing was assigned based on the firehouse’s designated inspection area that did not align with our study areas, some firefighters provided home visits in both areas in which case they may have been more diligent in the standard community, suggesting our results may underestimate the benefit of the enhanced program.

There are limitations to this study. Our findings, while significant, were likely muted by our decision to define the geographic areas using census tracts rather than natural borders that define neighborhoods. Using census tracts allowed us to access existing data to select a comparable set of households. However, we were limited in our ability to create a robust community level campaign because our enhanced community was made up of pieces of several neighborhoods. It was difficult for community partners to fully engage in promoting the program when their organizations encompassed areas that were part of the intervention and other areas that were not. Researchers designing community interventions will need to consider how best to define community in light of the implications for fully engaging community partners. Finally, something other than our intervention may have produced the observed effect. However, we know of no competing ongoing fire safety events in our study areas, and because both study areas were in Baltimore City, any major fire event or fire safety campaign would probably have affected both study areas equally. To maximize the lessons learned from this intervention trial will require follow up of the homes in which alarms were installed to determine their maintenance, and a careful cost-benefit analysis of the interventions would be useful.

Despite these limitations, our large sample size and demonstrated success in gaining access to homes and installing smoke alarms warrants consideration of the implications for fire department canvassing programs more broadly. First, fire departments serving communities such as ours need to take an “all hazards” approach to public education, given the high prevalence of unsafe water temperatures and lack of CO alarms we observed. Second, fire departments should consider ways to better utilize CHWs and other community partners to promote their fire and life safety goals. Although fire department budgets may preclude hiring CHWs, there are likely a number of opportunities for fire departments to partner with other local agencies and organizations that could provide the same function as the CHWs did in this study. Finally, the partnership between the fire service and a public health academic center was important for being able to systematically collect evidence on program effectiveness that can be used to inform decision making about resource allocation for fire and life safety education.