Home modifications: important for fall injury prevention for Māori in New Zealand
Authors: Keith D Hill
Journal: The Lancet Public Health (2021)

The Article by Michael Keall and colleagues1Keall MD Tupara H Pierse N et al.Home modifications to prevent home fall injuries in houses with Māori occupants (MHIPI): a single-blind randomised controlled trial.Lancet Public Health. 2021; (published online August 6.)https://doi.org/10.1016/S2468-2667(21)00135-3Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar in The Lancet Public Health addresses the important area of health inequality for Indigenous populations, in this case Māori in New Zealand. Despite strong advances in the research evidence base for prevention of falls in the community setting,2Hopewell S Adedire O Copsey BJ et al.Multifactorial and multiple component interventions for preventing falls in older people living in the community.Cochrane Database Syst Rev. 2018; 7CD012221PubMed Google Scholar, 3Sherrington C Fairhall NJ Wallbank GK et al.Exercise for preventing falls in older people living in the community.Cochrane Database Syst Rev. 2019; 1CD012424PubMed Google Scholar some important knowledge gaps remain. One of these gaps relates to the scarcity of culturally relevant falls prevention interventions for older First Nations people (commonly reported as age >55 years), in whom falls and high falls risk are common, and falls and fall-related injuries occur at higher rates than in other older populations (commonly reported as age >65 years) in general, and at younger ages.4Hill KD Flicker L LoGiudice D et al.Falls risk assessment outcomes and factors associated with falls for older Indigenous Australians.Aust N Z J Public Health. 2016; 40: 553-558Crossref PubMed Scopus (8) Google Scholar, 5Finès P Bougie E Oliver LN Kohen DE Hospitalizations for unintentional injuries among Canadian adults in areas with a high percentage of Aboriginal-identity residents.Chronic Dis Inj Can. 2013; 33: 204-217Crossref PubMed Google Scholar, 6Jin A Lalonde CE Brussoni M McCormick R George MA Injury hospitalizations due to unintentional falls among the Aboriginal population of British Columbia, Canada: incidence, changes over time, and ecological analysis of risk markers, 1991–2010.PLoS One. 2015; 10e0121694PubMed Google Scholar The particular public health focus of the paper by Keall and colleagues relates to reducing injuries from falls, with an intervention targeting home environment (indoor and outdoor) modifications. Environmental hazards are an important contributor to falls in older people, both at home, as well as away from home. For younger, healthier, more active older people, a higher proportion of falls occur away from home, whereas for older, frailer, less active older people, the majority of falls occur within the home environment.7Bath PA Morgan K Differential risk factor profiles for indoor and outdoor falls in older people living at home in Nottingham, UK.Eur J Epidemiol. 1999; 15: 65-73Crossref PubMed Scopus (142) Google Scholar, 8Boyé ND Mattace-Raso FU Van der Velde N et al.Circumstances leading to injurious falls in older men and women in the Netherlands.Injury. 2014; 45: 1224-1230Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar As such, interventions targeting falls prevention through home modification are likely to have greater effect on frailer older people, who spend most of their time within the home environment. Keall and colleagues also acknowledge that Māori homes can have greater home environmental hazards that might contribute to increased risk of injuries, including from falls.1Keall MD Tupara H Pierse N et al.Home modifications to prevent home fall injuries in houses with Māori occupants (MHIPI): a single-blind randomised controlled trial.Lancet Public Health. 2021; (published online August 6.)https://doi.org/10.1016/S2468-2667(21)00135-3Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar It is important to note that most falls are multifactorial, often involve an environmental hazard, and that intrinsic factors (such as poor vision, impaired balance, or cognitive impairment) can also be important; as such comprehensive falls prevention assessment and intervention are crucial. Home environment safety interventions only address part of the falls risk for people at risk. However, the approach reported by Keall and colleagues was relatively low cost, was able to be applied widely, and substantially reduced falls injuries at home. The study by Keall and colleagues is a well designed single-blind randomised trial of households with Māori occupants in two regions of New Zealand, with stratification by region. The study built on a previous successful trial,9Keall MD Pierse N Howden-Chapman P et al.Home modifications to reduce injuries from falls in the home injury prevention intervention (HIPI) study: a cluster-randomised controlled trial.Lancet. 2015; 385: 231-238Summary Full Text Full Text PDF PubMed Scopus (108) Google Scholar but included some refinements to the home modifications provided and their implementation. A strength of the study was the use of injury data from a national no-fault insurer, the Accident Compensation Corporation, although there were limitations in some aspects of data accuracy (eg, classification of the injury as fall-related required analysis of free text describing injury circumstances, which could have introduced bias). The intervention involved provision of a range of home modifications, based on a checklist developed by the authors. The average cost of modifications per house was $460 (NZ$, 2017 values), and the most common modifications were combinations of step modifications (eg, rails, slip-resistant edging) and bathroom modifications (eg, grab rails, non-slip bath mats). The intervention group had a 31% reduction in the rate of fall injuries at home per year exposed to the intervention compared with households in the control group, after adjustment for previous falls and geographical region (adjusted relative rate 0·69 [95% CI 0·47–1·00]). The focus on fall injuries is important (injurious falls are associated with substantial health-care costs, often including emergency department presentation, hospitalisation, rehabilitation, and ongoing medical and allied health professional treatments). However, it is important to note that most falls do not cause injury, and are not reported to health professionals. Non-injurious falls can also have a substantial impact, by leading to loss of confidence in mobility (fear of falling), and curtailment of activities. These factors can over time result in reduced balance and strength, and subsequently increase the risk of further falls and injuries, and lead to long-term costs for the health and care systems. Therefore, from a system perspective, it is important to minimise the risk of all falls, including non-injurious falls. This study has several limitations. Determination of suitable home safety modifications using a checklist applied by builders might have limited the selection of the most appropriate modifications to suit the needs and function of individual residents. The most recent Cochrane review that included home safety modifications, published in 2012, indicated that home hazard assessment and tailored interventions delivered by occupational therapists to maximise safety of the home environment were more effective than those delivered by non-occupational therapists.10Gillespie LD Robertson MC Gillespie WJ et al.Interventions for preventing falls in older people living in the community.Cochrane Database Syst Rev. 2012; 2012CD007146Google Scholar Only households occupied by the owner (any age) were included in the study by Keall and colleagues,1Keall MD Tupara H Pierse N et al.Home modifications to prevent home fall injuries in houses with Māori occupants (MHIPI): a single-blind randomised controlled trial.Lancet Public Health. 2021; (published online August 6.)https://doi.org/10.1016/S2468-2667(21)00135-3Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar although this was justified with the rationale that household owners were more likely to remain at the same address for the study duration than those in rental accommodation. The trial adds to the falls prevention evidence relating to home modifications to reduce fall injuries generally, but also makes a key contribution in highlighting that a relatively low-cost targeted interventional approach can be effective in reducing injuries from home falls in Māori people, who have high rates of injury and health inequality. There is a need for greater focus on culturally relevant approaches to other falls and interventions to prevent fall injuries for Māori and other First Nations people globally. I declare no competing interests. Home modifications to prevent home fall injuries in houses with Māori occupants (MHIPI): a randomised controlled trialLow-cost home modiﬁcations and repairs can be an effective means to reduce injury disparities. The high prevalence of modifiable safety issues in Māori homes merits considerable policy and community effort. Full-Text PDF Open Access