Julie Mytton

Effect of intervention aimed at increasing physical activity, reducing sedentary behaviour, and increasing fruit and vegetable consumption in children: Active for Life Year 5 (AFLY5) school based cluster randomised controlled trial

Objective To investigate the effectiveness of a school based intervention to increase physical activity, reduce sedentary behaviour, and increase fruit and vegetable consumption in children. Design Cluster randomised controlled trial. Setting 60 primary schools in the south west of England. Participants Primary school children who were in school year 4 (age 8-9 years) at recruitment and baseline assessment, in year 5 during the intervention, and at the end of year 5 (age 9-10) at follow-up assessment. Intervention The Active for Life Year 5 (AFLY5) intervention consisted of teacher training, provision of lesson and child-parent interactive homework plans, all materials required for lessons and homework, and written materials for school newsletters and parents. The intervention was delivered when children were in school year 5 (age 9-10 years). Schools allocated to control received standard teaching. Main outcome measures The pre-specified primary outcomes were accelerometer assessed minutes of moderate to vigorous physical activity per day, accelerometer assessed minutes of sedentary behaviour per day, and reported daily consumption of servings of fruit and vegetables. Results 60 schools with more than 2221 children were recruited; valid data were available for fruit and vegetable consumption for 2121 children, for accelerometer assessed physical activity and sedentary behaviour for 1252 children, and for secondary outcomes for between 1825 and 2212 children for the main analyses. None of the three primary outcomes differed between children in schools allocated to the AFLY5 intervention and those allocated to the control group. The difference in means comparing the intervention group with the control group was –1.35 (95% confidence interval –5.29 to 2.59) minutes per day for moderate to vigorous physical activity, –0.11 (–9.71 to 9.49) minutes per day for sedentary behaviour, and 0.08 (–0.12 to 0.28) servings per day for fruit and vegetable consumption. The intervention was effective for three out of nine of the secondary outcomes after multiple testing was taken into account: self reported time spent in screen viewing at the weekend (–21 (–37 to –4) minutes per day), self reported servings of snacks per day (–0.22 (–0.38 to –0.05)), and servings of high energy drinks per day (–0.26 (–0.43 to –0.10)) were all reduced. Results from a series of sensitivity analyses testing different assumptions about missing data and from per protocol analyses produced similar results. Conclusion The findings suggest that the AFLY5 school based intervention is not effective at increasing levels of physical activity, decreasing sedentary behaviour, and increasing fruit and vegetable consumption in primary school children. Change in these activities may require more intensive behavioural interventions with children or upstream interventions at the family and societal level, as well as at the school environment level. These findings have relevance for researchers, policy makers, public health practitioners, and doctors who are involved in health promotion, policy making, and commissioning services. Trial registration Current Controlled Trials ISRCTN50133740.

Examining inequalities in the uptake of the school-based HPV vaccination programme in England: a retrospective cohort study

BACKGROUND Although uptake of Human Papillomavirus (HPV) vaccine is high in the United Kingdom, it is unknown whether the programme has been delivered equitably by ethnicity or deprivation. This study aimed to investigate factors associated with HPV vaccine initiation and completion within the routine HPV vaccination programme in the South West of England. METHODS Data were retrieved for young women eligible for routine vaccination from 2008/09 to 2010/11 from three Primary Care Trusts (PCTs)/local authorities. Multivariable logistic regression models were developed to examine factors associated with uptake of HPV vaccination. RESULTS Of 14 282 eligible young women, 12 658 (88.6%) initiated, of whom 11 725 (92.6%) completed the course. Initiation varied by programme year (86.5-89.6%) and PCTs/local authorities (84.8-91.6%). There was strong evidence for an overall difference of initiation by ethnicity (P < 0.001), but not deprivation quintile (P = 0.48). Young women educated in non-mainstream educational settings were less likely to initiate and, if initiated, less likely to complete (both P < 0.001). CONCLUSIONS HPV vaccination uptake did not vary markedly by social deprivation. However, associations with ethnicity and substantially lower uptake in non-mainstream educational settings were observed. Research to identify reasons for low vaccine uptake in these population groups is required.

Unintentional injuries in school-aged children and adolescents: lessons from a systematic review of cohort studies

Objectives: To critically synthesise current knowledge of the patterns of injuries and risk factors for injury in school-aged children, to summarise the evidence and support effective child injury prevention initiatives. Design: Systematic review. Selection criteria and methods: Prospective cohort studies reporting unintentional injuries in healthy children aged 5–18 years were identified by searching 15 electronic databases and additional grey literature sources. A narrative synthesis was conducted of papers meeting quality criteria, with risk factors analysed at individual, family and environmental levels. Limitations of existing evidence were considered. Results: 44 papers from 18 different cohort studies met the inclusion criteria. There were broad and consistent patterns of injury across time and place. Male sex, psychological, behavioural and risk-taking behaviour problems, having a large number of siblings, and a young mother were all associated with increased injury occurrence across more than one cohort and setting. Conclusions: Descriptive epidemiology and risk factors for injury were derived from prospective cohort studies, but few studies used the full potential of their design. Opportunities to use repeated measures to assess temporal changes in injury occurrence, and the exploration of risk factors, particularly those related to the child’s environment, have rarely been undertaken. Few studies were conducted in low/middle-income countries where the burden of injury is greatest. These findings should be considered when planning future research and prevention initiatives.

Facilitators and Barriers to Engagement in Parenting Programs A Qualitative Systematic Review

Parenting programs have the potential to improve the health and well-being of parents and children. A challenge for providers is to recruit and retain parents in programs. Studies researching engagement with programs have largely focused on providers’, policy makers’, or researchers’ reflections of their experience of parents’ participation. We conducted a systematic review of qualitative studies where parents had been asked why they did or did not choose to commence, or complete programs, and compared these perceptions with those of researchers and those delivering programs. We used data-mining techniques to identify relevant studies and summarized findings using framework synthesis methods. Six facilitator and five barrier themes were identified as important influences on participation, with a total of 33 subthemes. Participants focused on the opportunity to learn new skills, working with trusted people, in a setting that was convenient in time and place. Researchers and deliverers focused on tailoring the program to individuals and on the training of staff. Participants and researchers/deliverers therefore differ in their opinions of the most important features of programs that act as facilitators and barriers to engagement and retention. Program developers need to seek the views of both participants and deliverers when evaluating programs.

Taking the long view: a systematic review reporting long-term perspectives on child unintentional injury

Objective The relative significance of child injury as a cause of preventable death has increased as mortality from infectious diseases has declined. Unintentional child injuries are now a major cause of death and disability across the world with the greatest burden falling on those who are most disadvantaged. A review of long-term data on child injury mortality was conducted to explore trends and inequalities and consider how data were used to inform policy, practice and research. Methods The authors systematically collated and quality appraised data from publications and documents reporting unintentional child injury mortality over periods of 20 years or more. A critical narrative synthesis explored trends by country income group, injury type, age, gender, ethnicity and socioeconomic group. Findings 31 studies meeting the inclusion criteria were identified of which 30 were included in the synthesis. Only six were from middle income countries and none were from low income countries. An overall trend in falling child injury mortality masked rising road traffic injury deaths, evidence of increasing vulnerability of adolescents and widening disparities within countries when analysed by ethnic group and socioeconomic status. Conclusions Child injury mortality trend data from high and middle income countries has illustrated inequalities within generally falling trends. There is scope for greater use of existing trend data to inform policy and practice. Similar evidence from low income countries where the burden of injury is greatest is needed.

Epidemiology of unintentional child injuries in the Makwanpur District of Nepal: a household survey

Secondary sources of information indicate that the proportion of child deaths due to injuries is increasing in Nepal. This study aimed to describe the epidemiology of unintentional injuries in children, explore risk factors and estimate the burden faced by families and the community in the Makwanpur district. We conducted a household survey in Makwanpur, covering 3441 households. Injuries that occurred during the 12 months before the survey and required treatment or caused the child to be unable to take part in usual activities for three or more days were included. We identified 193 cases of non-fatal unintentional child injuries from 181 households and estimated an annual rate of non-fatal injuries of 24.6/1000 children; rates for boys were double (32.7/1000) that for girls (16.8/1000). The rates were higher among the children of age groups 1–4 years and 5–9 years. Falls were the most common cause of non-fatal child injuries followed by burns in preschool children and road traffic injuries were the most likely cause in adolescence. Mean period of disability following injury was 25 days. The rates and the mechanisms of injury vary by age and gender. Falls and burns are currently the most common mechanisms of injury amongst young children around rural homes.

The first aid advice and safety training (FAST) parents programme for the prevention of unintentional injuries in preschool children: A protocol

Background Unintentional injury is the leading cause of preventable death in children in the UK, and 0–4-year-olds frequently attend emergency departments following injuries in the home. Parenting programmes designed to support parents, promote behaviour change and enhance parent–child relationships have been shown to improve health outcomes in children. It is not known whether group-based parenting programmes have the potential to prevent unintentional injuries in preschool children. Methods A study to develop a group-based parenting programme to prevent unintentional home injuries in preschool children, and assess the feasibility of evaluation through a cluster-randomised controlled trial. The intervention, designed for parents of children who have sustained a medically attended injury, will be developed with two voluntary sector organisations. The feasibility study will assess ability to recruit parents, deliver the programme and follow-up participants. Participants will complete questionnaires at baseline, 3 months and 6 months, and report injuries in their preschool children using a tool designed and validated for this study. Qualitative methods will assess user and deliverer perceptions of the programme. Discussion This study will develop the first group-based parenting programme to prevent injuries in preschool children, and design tools for parent-reported injury outcomes. A key challenge will be to recruit parents to participate in a manner that is non-stigmatising, and does not result in feelings of guilt or belief that they are perceived to be a bad parent. The findings will be used to prepare a trial to assess the effectiveness and cost-effectiveness of the intervention.

Needles, Jabs and Jags: a qualitative exploration of barriers and facilitators to child and adult immunisation uptake among Gypsies, Travellers and Roma

BackgroundGypsies, Travellers and Roma (referred to as Travellers) are less likely to access health services including immunisation. To improve immunisation rates, it is necessary to understand what helps and hinders individuals in these communities in taking up immunisations. This study had two aims.1.Investigate the views of Travellers in the UK on the barriers and facilitators to acceptability and uptake of immunisations and explore their ideas for improving immunisation uptake;2.Examine whether and how these responses vary across and within communities, and for different vaccines (childhood and adult).MethodsThis was a qualitative, cross-sectional interview study informed by the Social Ecological Model. Semi-structured interviews were conducted with 174 Travellers from six communities: Romanian Roma, English Gypsy/Irish Travellers (Bristol), English Gypsy (York), Romanian/Slovakian Roma, Scottish Show people (Glasgow) and Irish Traveller (London). The focus was childhood and selected adult vaccines. Data were analysed using the Framework approach.ResultsCommon accounts of barriers and facilitators were identified across all six Traveller communities, similar to those documented for the general population. All Roma communities experienced additional barriers of language and being in a new country. Men and women described similar barriers and facilitators although women spoke more of discrimination and low literacy. There was broad acceptance of childhood and adult immunisation across and within communities, with current parents perceived as more positive than their elders. A minority of English-speaking Travellers worried about multiple/combined childhood vaccines, adult flu and whooping cough and described barriers to booking and attending immunisation. Cultural concerns about antenatal vaccines and HPV vaccination were most evident in the Bristol English Gypsy/Irish Traveller community. Language, literacy, discrimination, poor school attendance, poverty and housing were identified as barriers across different communities. Trustful relationships with health professionals were important and continuity of care valued.ConclusionsThe experience of many Travellers in this study, and the context through which they make health decisions, is changing. This large study identified key issues that should be considered when taking action to improve uptake of immunisations in Traveller families and reduce the persistent inequalities in coverage.Trial registrationCurrent Controlled Trials ISRCTN20019630.

UNderstanding uptake of Immunisations in TravellIng aNd Gypsy communities (UNITING): protocol for an exploratory, qualitative study

Introduction Gypsies, Travellers and Roma (referred to here as Travellers) experience significantly poorer health and have shorter life expectancy than the general population. They are also less likely to access health services including immunisation. To improve immunisation rates, we need to understand what helps and hinders individuals in these communities in taking up immunisations. This study has two aims: (1) Investigate the barriers and facilitators to acceptability and uptake of immunisations among six Traveller communities in the UK; (2) Identify potential interventions to increase uptake in these Traveller communities. Methods and analysis A three-phase qualitative study with six Traveller communities. PHASE 1: In each community, we will explore up to 45 Travellers’ views about the influences on their immunisation behaviours and ideas for improving uptake in their community. PHASE 2: In each community, we will investigate 6–8 service providers’ perspectives on barriers and facilitators to childhood and adult immunisations for Traveller communities with whom they work, and ideas to improve uptake. Interview data will be analysed using the Framework approach. PHASE 3: The findings will be discussed and interventions prioritised in six workshops, each with 10–12 phase 1 and 3–4 phase 2 participants. Ethics and dissemination This research received approval from NRES Committee Yorkshire and The Humber-Leeds East (Ref. 13/YH/02). It will produce (1) findings on the barriers and facilitators to uptake of immunisations in six Traveller communities; (2) a prioritised list of potentially feasible and acceptable interventions for increasing uptake in these communities; and (3) methodological development in undertaking research with diverse Traveller communities. The study has the potential to inform new ways of delivering services to ensure high immunisation uptake. Findings will be disseminated to participants, relevant UK organisations with responsibility for the implementation of immunisation policy and Traveller health/welfare; and submitted for publication in academic journals. Trial registration number ISRCTN20019630.

Preventing unintentional injuries: what does NICE guidance mean for primary care?

Unintentional injuries are the second most common cause of child death, accounting for one in seven deaths between the ages of 1 and 14 years.1 These deaths represent just the tip of the iceberg. Every year, around 100 000 children are admitted to hospital2 and 2 million attend emergency departments.3 How many seek treatment only from their GP is not known. The impact of injuries on children, their families, and society can be considerable. The immediate effect of an injury is pain, followed by the psychological trauma of having to visit hospital, and loss of enjoyment of everyday activities such as play. But children can also be left disabled and disfigured, and lose education, potentially affecting the rest of their lives. Caring for an injured child can cause family breakdown and loss of employment, as well as having immediate economic consequences. Society has to bear the costs of treatment, rehabilitation, and long-term support. Unintentional injuries are often thought of as accidents, but they are not random, unpredictable events as the term accident implies. We can identify children at risk of injuries and the injuries they are likely to suffer. Those from disadvantaged families are at greatest risk.4 Not surprisingly, the types of injuries experienced are strongly related to a childs stage of development. For example, the more active children become, the more likely they are to run and trip, and climb and fall; the exploratory stage of child development results in children putting objects in their mouth leading to choking and poisoning. Copying adult tasks, such as food preparation, can lead to lacerations and burns. GPs and primary health care teams (PHCTs) have multiple opportunities to contribute to injury prevention and these are highlighted in three …