An evaluation of thermostatic mixer valves to reduce bath water temperature in homes of families with young children living in social housing Denise Kendrick Professor of Primary Care Research University of Nottingham Jane Stewart Senior Research Fellow Nottinghamshire Healthcare Trust (NHS Nottinghamshire County) And co- authors

The problem – bath hot tap water scalds in young children Each year 2,000 ED attendances, 500 admissions Most admissions children < 5years Steep social gradient –most deprived most vulnerable Domestic hot water temperatures can scald in about a second Cost of severe scald ~ £

What is a Thermostatic Mixer Valve (TMV)? Engineering solution to reduce the temperature of hot bath tap water temperature No active participation by parents required Mixes hot and cold bath tap water to pre-set temperature - 46 ºC Takes 6 hours for a scald at this temperature

Aims of the study To assess TMVs for their: Effectiveness and cost effectiveness in reducing bath hot water temperature Acceptability to families Impact on bath time safety practices –In families with children under the age of 5 years living in social housing

Methods Randomised controlled trial –Questionnaire at baseline Delivered the intervention –TMV –Educational leaflet –Laminated leaflet on how to use TMV –Water temperature checks at baseline, 3 and 12 months –Questionnaire at 12 months follow up Fieldwork in Glasgow

Participants 124 families completed baseline questionnaire Intervention arm 62 (46 TMVs fitted) Water temps: baseline n=23 3 months n=15 12 months n=16 12 month questionnaire 44 still tenants/participating 40 returned (91.9%) Control arm 62 Water temps: baseline n=27 3 months n=15 12 months n=15 12 month questionnaire 49 still tenants/participating 40 returned (81.6%)

Characteristics of participants CharacteristicsIntervention arm n=62 Control arm n=62 Mother completed questionnaire57 (91.9)58 (93.6) Single adult household40 (64.5)47 (75.8) Number of children in the home (46.8) 21 (33.9) 25 (40.3) 26 (41.9) Age respondent left full time education 1638 (73.1) [10]43 (72.9) [3] Number of adults in paid employment (65.0) [2] 16 (26.7) 40 (65.6) [1] 17 (27.9) Family receives state benefits50 (82.0) [1]56 (90.3) Ethnic group of respondent White Scottish Black African 54 (88.5) [1] 6 (9.8) 54 (88.5) [1] 3 (4.9) [ ] missing values

Acceptability of bath hot tap water (baseline) [ ] missing values Intervention arm Control arm Satisfaction (number (%)) n=62 Very happy or happy with bath hot tap water temperature 39 (62.9)37 (59.7) Bath water is: Very hot – need to add a lot of cold water to the bath Hot – need to add some cold water to the bath 41 (67.2) [1] 19 (31.2) 38 (61.3) 24 (38.7)

Bath time safety practices (baseline) [ ] missing values Safety practicesIntervention arm n=62 Control arm N=62 Runs bath using cold water first 2 (3.2)9 (14.8) [1] Bath water temperature checked for every bath 54 (88.5) [1] Child has been left alone in the bath 27 (43.6)13 (21.0) Child has been left alone in bathroom whilst bath is running 19 (30.7)12 (19.4)

Hot bath tap water temperatures at baseline, 3 and 12 months

Were parents satisfied with the TMV? Intervention arm responders with TMV fitted (n=34) Very happy or happy with TMV 30 (88.2) Would recommend TMV to a friend 28 (87.5) [2] Would not be happy if kitchen and bath hot tap water were same temperature 23 (69.7) [1] Since having TMV… Child less likely to be scalded 32 (94.1) Doesnt take longer to run bath 22 (68.8) [2] Easier to control bath water temperature 29 (90.6) [2] Bath water isnt hot enough 12 (36.4) [1] Can no longer top up bath with hot water whilst in the bath 9 (27.3) [1]

Acceptability of bath hot tap water (follow up) Intervention arm Responders n=40 (%) Control arm Responders n=40 (%) Relative Risk (95% CI) Very happy or happy with bath hot tap water temperature 32 (82.1) [1] 23 (57.5) 1.43 (1.05, 1.93) Bath water is: Very hot – need to add a lot of cold water to the bath Hot – need to add some cold water to the bath Warm enough - dont need to add any cold water to the bath 7 (18.0) [1] 16 (41.0) 14 (35.9) 22 (55.0) 18 (45.0) 0 (0.0) 0.33 (0.16, 0.68)

Bath time safety practices (follow up) Intervention arm responders n=40(%) Control arm responde rs n=40(%) Relative Risk (95% CI) Runs bath using cold water first* 5 (12.5)11 (27.5) 0.55 (0.22, 1.39) Bath water temperature checked for every bath 32 (84.2) [2]40 (100.0) 0.84 (0.73, 0.97) Child has been left alone in the bath* 13 (32.5)8 (20.5) [1] 1.11 (0.51, 2.41) Child has been left alone in bathroom whilst bath is running* 12 (30.8) [1]9 (22.5) 1.28 (0.62, 2.68)

Health economic analysis Professor Ceri Phillips - Swansea University NHS costs to treat a scald – range from £25, £71, 902 Cost-effectiveness analysis indicated a potential saving to the NHS of £3, 229, 008 £1.41 saved for every £1 spent

Summary TMVs are effective in reducing bath hot tap water temperature Majority of parents satisfied with the TMV and the temperature Would recommend a TMV to a friend Feel child less likely to be scalded However, parents checking temperature of bath water less often A third of people reported bath water not hot enough

Implications Suggests that parents are willing to trade some inconvenience for increased safety TMVs should be considered as a scald prevention intervention for families with children Important to reinforce bath time safety messages about checking the water temperature and leaving children alone in the bath Cost effective solution – requires interagency working – spend money in one sector to save money in another

Funding Policy Research Programme (PRP) at the Department of Health -Accidental Injury Prevention Research Initiative (001/0009) The final study design, data collection, analysis, interpretation of results, and paper writing was the sole responsibility of the authors. The views and opinions expressed in this paper do not necessarily reflect those of the funding body. This is an independent report commissioned and funded by the Policy Research Program in the Department of Health. The views expressed are not necessarily those of the Department.

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