Richard Reading

Do interventions that improve immunisation uptake also reduce social inequalities in uptake

Abstract Objective: To investigate whether an intervention designed to improve overall immunisation uptake affected social inequalities in uptake. Design: Cross-sectional small area analyses measuring immunisation uptake in cohorts of children before and after intervention. Small areas classified into five groups, from most deprived to most affluent, with Townsend deprivation score of census enumeration districts. Setting: County of Northumberland. Subjects--All children born in county in four birth cohorts (1981-2, 1985-6, 1987-8, and 1990-1) and still resident at time of analysis. Main outcome measures: Overall uptake in each cohort of pertussis, diphtheria, and measles immunisation, difference in uptake between most deprived and most affluent areas, and odds ratio of uptake between deprived and affluent areas. Results: Coverage for pertussis immunisation rose from 53.4% in first cohort to 91.1% in final cohort. Coverage in the most deprived areas was lower than in the most affluent areas by 4.7%, 8.7%, 10.2%, and 7.0% respectively in successive cohorts, corresponding to an increase in odds ratio of uptake between deprived and affluent areas from 1.2 to 1.6 to 1.9 to 2.3. Coverage for diphtheria immunisation rose from 70.0% to 93.8%; differences between deprived and affluent areas changed from 8.6% to 8.3% to 9.0% to 5.5%, corresponding to odds ratios of 1.5, 2.0, 2.5, and 2.6. Coverage for measles immunisation rose from 52.5% to 91.4%; differences between deprived and affluent areas changed from 9.1% to 5.7% to 8.2% to 3.6%, corresponding to odds ratios of 1.4, 1.4, 1.7, and 1.5. Conclusion--Despite substantial increase in immunisation uptake, inequalities between deprived and affluent areas persisted or became wider. Any reduction in inequality occurred only after uptake in affluent areas approached 95%. Interventions that improve overall uptake of preventive measures are unlikely to reduce social inequalities in uptake.

Deprivation, low birth weight, and children's height: a comparison between rural and urban areas.

OBJECTIVE--To compare proportions of low birthweight babies and mean heights of schoolchildren between rural and urban areas at different levels of social deprivation. DESIGN--Cross sectional population based study classifying cases by Townsend material deprivation index of enumeration district of residence and by rural areas, small towns, and large towns. SETTING--Northumberland Health District. SUBJECTS--18,930 singleton infants delivered alive during January 1985 to September 1990 and resident in Northumberland in October 1990; 9055 children aged 5 to 8 1/2 years attending Northumberland schools in the winter of 1989-90. MAIN OUTCOME MEASURES--Odds ratios for birth weight less than 2800 g; difference in mean height measured by standard deviation (SD) score. RESULTS--Between the most deprived and most affluent 20% of enumeration districts the odds ratio for low birth weight adjusted for rural or urban setting was 1.71 (95% confidence interval 1.51 to 1.93) and the difference in mean height -0.232 SD score (-0.290 to -0.174). Between large towns and rural areas the odds ratio for low birth weight adjusted for deprivation was 1.37 (1.23 to 1.53) and the difference in mean height -0.162 SD score (-0.214 to -0.110). Results for small towns were intermediate between large towns and rural areas. CONCLUSIONS--Inequalities in birth weight and height exist in all rural and urban settings between deprived and affluent areas. In addition, there is substantial disadvantage to living in urban areas compared with rural areas which results from social or environmental factors unrelated to current levels of deprivation.

Keeping children safe at home: protocol for three matched case–control studies of modifiable risk factors for falls

Background Childhood falls result in considerable morbidity, mortality and health service use. Despite this, little evidence exists on protective factors or effective falls prevention interventions in young children. Objectives To estimate ORs for three types of medically attended fall injuries in young children in relation to safety equipment, safety behaviours and hazard reduction and explore differential effects by child and family factors and injury severity. Design Three multicentre case–control studies in UK hospitals with validation of parental reported exposures using home observations. Cases are aged 0–4u2005years with a medically attended fall injury occurring at home, matched on age and sex with community controls. Children attending hospital for other types of injury will serve as unmatched hospital controls. Matched analyses will use conditional logistic regression to adjust for potential confounding variables. Unmatched analyses will use unconditional logistic regression, adjusted for age, sex, deprivation and distance from hospital in addition to other confounders. Each study requires 496 cases and 1984 controls to detect an OR of 0.7, with 80% power, 5% significance level, a correlation between cases and controls of 0.1 and a range of exposure prevalences. Main outcome measures Falls on stairs, on one level and from furniture. Discussion As the largest in the field to date, these case control studies will adjust for potential confounders, validate measures of exposure and investigate modifiable risk factors for specific falls injury mechanisms. Findings should enhance the evidence base for falls prevention for young children.

Risk and protective factors for falls from furniture in young children: multicenter case-control study.

IMPORTANCEnFalls from furniture are common in young children but there is little evidence on protective factors for these falls.nnnOBJECTIVEnTo estimate associations for risk and protective factors for falls from furniture in children aged 0 to 4 years.nnnDESIGN, SETTING, AND PARTICIPANTSnMulticenter case-control study at hospitals, minor injury units, and general practices in and around 4 UK study centers. Recruitment commenced June 14, 2010, and ended April 27, 2012. Participants included 672 children with falls from furniture and 2648 control participants matched on age, sex, calendar time, and study center. Thirty-five percent of cases and 33% of control individuals agreed to participate. The mean age was 1.74 years for cases and 1.91 years for control participants. Fifty-four percent of cases and 56% of control participants were male. Exposures included safety practices, safety equipment use, and home hazards.nnnMAIN OUTCOMES AND MEASURESnFalls from furniture occurring at the childs home resulting in attendance at an emergency department, minor injury unit, or hospital admission.nnnRESULTSnCompared with parents of control participants, parents of cases were significantly more likely not to use safety gates in the home (adjusted odds ratio [AOR], 1.65; 95% CI, 1.29-2.12) and not to have taught their children rules about climbing on kitchen objects (AOR, 1.58; 95% CI, 1.16-2.15). Cases aged 0 to 12 months were significantly more likely to have been left on raised surfaces (AOR, 5.62; 95% CI, 3.62-8.72), had their diapers changed on raised surfaces (AOR, 1.89; 95% CI, 1.24-2.88), and been put in car/bouncing seats on raised surfaces (AOR, 2.05; 95% CI, 1.29-3.27). Cases 3 years and older were significantly more likely to have played or climbed on furniture (AOR, 9.25; 95% CI, 1.22-70.07). Cases were significantly less likely to have played or climbed on garden furniture (AOR, 0.74; 95% CI, 0.56-0.97).nnnCONCLUSIONS AND RELEVANCEnIf estimated associations are causal, some falls from furniture may be prevented by incorporating advice into child health contacts, personal child health records, and home safety assessments about use of safety gates; not leaving children, changing diapers, or putting children in car/bouncing seats on raised surfaces; allowing children to play or climb on furniture; and teaching children safety rules about climbing on objects.

Keeping children safe at home: protocol for a case–control study of modifiable risk factors for scalds

Background Scalds are one of the most common forms of thermal injury in young children worldwide. Childhood scald injuries, which mostly occur in the home, result in substantial health service use and considerable morbidity and mortality. There is little research on effective interventions to prevent scald injuries in young children. Objectives To determine the relationship between a range of modifiable risk factors for medically attended scalds in children under the age of 5u2005years. Design A multicentre case-control study in UK hospitals and minor injury units with parallel home observation to validate parental reported exposures. Cases will be 0–4u2005years old with a medically attended scald injury which occurred in their home or garden, matched on gender and age with community controls. An additional control group will comprise unmatched hospital controls drawn from children aged 0–4 years attending the same hospitals and minor injury units for other types of injury. Conditional logistic regression will be used for the analysis of cases and matched controls, and unconditional logistic regression for the analysis of cases and unmatched controls to estimate ORs and 95% CI, adjusted and unadjusted for confounding variables. Main exposure measures Use of safety equipment and safety practices for scald prevention and scald hazards. Discussion This large case-control study will investigate modifiable risk factors for scalds injuries, adjust for potential confounders and validate measures of exposure. Its findings will enhance the evidence base for prevention of scalds injuries in young children.

Keeping children safe at home: protocol for a matched case-control study of modifiable risk factors for poisoning

Background Childhood unintentional and suspected poisonings are a serious public health problem. Evidence from systematic reviews demonstrates that home safety education in combination with safety equipment provision increases the safe storage of medicines and other products. There is lack of evidence that poisoning prevention practices reduce poisoning rates. Objectives To estimate ORs for medically attended poisonings in children aged 0–4u2005years for items of safety equipment, home hazards and parental safety practices aimed at preventing poisoning, and to explore differential effects by child and family factors. Design Multicentre case-control study in UK hospitals with validation of parent-reported exposures using home observations. Cases are aged 0–4u2005years with a medically attended poisoning occurring at home, matched on age and sex with community controls. Children attending hospital for other types of injury will serve as unmatched hospital controls. Matched analyses will use conditional logistic regression; unmatched analyses will use unconditional logistic regression to adjust for confounding variables. The study requires 266 poisoning cases and 1064 matched controls to detect an OR of 0.64 for safe storage of medicinal products and of 0.65 for non-medicinal products, with 80% power, a 5% significance level and a correlation between exposures in cases and controls of 0.1. Main outcome measures Unintentional childhood poisoning. Discussion This will be the largest study to date exploring modifiable risk factors for poisoning in young children. Findings will inform: policy makers developing poison prevention strategies, practitioners delivering poison prevention interventions, parents to reduce the risk of poisoning in their homes.

Multicentre cluster randomised controlled trial evaluating implementation of a fire prevention Injury Prevention Briefing in children’s centres: study protocol

BackgroundThe UK has one of the highest fatality rates for deaths from fire-related injuries in children aged 0–14xa0years; these injuries have the steepest social gradient of all injuries in the UK. Children’s centres provide children under five years old and their families with a range of services and information, including home safety, but their effectiveness in promoting injury prevention has yet to be evaluated. We developed a fire prevention intervention for use in children’s centres comprising an Injury Prevention Briefing (IPB) which provides evidence on what works and best practice from those running injury prevention programmes, and a facilitation package to support implementation of the IPB. This protocol describes the design and methods of a trial evaluating the effectiveness and cost-effectiveness of the IPB and facilitation package in promoting fire prevention.Methods/DesignPragmatic, multicentre cluster randomised controlled trial, with a nested qualitative study, in four study centres in England. Children’s centres in the most disadvantaged areas will be eligible to participate and will be randomised to one of three treatment arms comprising: IPB with facilitation package; IPB with no facilitation package; usual care (control). The primary outcome measure will be the proportion of families who have a fire escape plan at follow-up. Eleven children’s centres per arm are required to detect an absolute difference in the percentage of families with a fire escape plan of 20% in either of the two intervention arms compared with the control arm, with 80% power and a 5% significance level (2-sided), an intraclass correlation coefficient of 0.05 and assuming outcomes are assessed on 20 families per children’s centre. Secondary outcomes include the assessment of the cost-effectiveness of the intervention, other fire safety behaviours and factors associated with degree of implementation of the IPB.DiscussionThis will be the first trial to develop and evaluate a fire prevention intervention for use in children’s centres in the UK. Its findings will be generalisable to children’s centres in the most disadvantaged areas of the UK and may also be generalisable to similar interventions to prevent other types of injury.Trial registrationhttp://www.NCT01452191 (date of registration: 13/10/2011).

Poison prevention practices and medically attended poisoning in young children: multicentre case–control study

Introduction Childhood poisonings are common, placing a substantial burden on health services. Case–control studies have found inconsistent evidence about modifiable risk factors for poisonings among children aged 0–4u2005years. This study quantifies associations between poison prevention practices and medically attended poisonings in children aged 0–4u2005years. Methods Multicentre case–control study conducted at hospitals, minor injury units and family practices from four study centres in England between 2010 and 2013. Participants comprised 567 children presenting with unintentional poisoning occurring at home and 2320 community control participants matched on age, sex, date of event and study centre. Parents/caregivers provided data on safety practices, safety equipment use, home hazards and potential confounders by means of self-completion questionnaires. Data were analysed using conditional logistic regression. Results Compared with community controls, parents of poisoned children were significantly more likely not to store medicines out of reach (adjusted OR (AOR) 1.59; 95% CI 1.21 to 2.09; population attributable fraction (PAF) 15%), not to store medicines safely (locked or out of reach (AOR 1.83; 95% CI 1.38 to 2.42; PAF 16%) and not to have put all medicines (AOR 2.11; 95% CI 1.54 to 2.90; PAF 20%) or household products (AOR 1.79, 95% CI 1.29 to 2.48; PAF 11%) away immediately after use. Conclusions Not storing medicines out of reach or locked away and not putting medicines and household products away immediately after use increased the odds of secondary care attended poisonings in children aged 0–4u2005years. If associations are causal, implementing these poison prevention practices could each prevent between 11% and 20% of poisonings.

Evaluating implementation of a fire-prevention Injury Prevention Briefing in children’s centres: cluster randomised controlled trial

Background Many developed countries have high mortality rates for fire-related deaths in children aged 0–14 years with steep social gradients. Evidence-based interventions to promote fire safety practices exist, but the impact of implementing a range of these interventions in children’s services has not been assessed. We developed an Injury Prevention Briefing (IPB), which brought together evidence about effective fire safety interventions and good practice in delivering interventions; plus training and facilitation to support its use and evaluated its implementation. Methods We conducted a cluster randomised controlled trial, with integrated qualitative and cost-effectiveness nested studies, across four study sites in England involving children’s centres in disadvantaged areas; participants were staff and families attending those centres. Centres were stratified by study site and randomised within strata to one of three arms: IPB plus facilitation (IPB+), IPB only, usual care. IPB+ centres received initial training and facilitation at months 1, 3, and 8. Baseline data from children’s centres were collected between August 2011 and January 2012 and follow-up data were collected between June 2012 and June 2013. Parent baseline data were collected between January 2012 and May 2012 and follow-up data between May 2013 and September 2013. Data comprised baseline and 12 month parent- and staff-completed questionnaires, facilitation contact data, activity logs and staff interviews. The primary outcome was whether families had a plan for escaping from a house fire. Treatment arms were compared using multilevel models to account for clustering by children’s centre. Results 1112 parents at 36 children’s centres participated. There was no significant effect of the intervention on families’ possession of plans for escaping from a house fire (adjusted odds ratio (AOR) IPB only vs. usual care: 0.93, 95%CI 0.58, 1.49; AOR IPB+ vs. usual care 1.41, 95%CI 0.91, 2.20). However, significantly more families in the intervention arms reported more behaviours for escaping from house fires (AOR IPB only vs. usual care: 2.56, 95%CI 01.38, 4.76; AOR IPB+ vs. usual care 1.78, 95%CI 1.01, 3.15). Conclusion Our study demonstrated that children’s centres can deliver an injury prevention intervention to families in disadvantaged communities and achieve changes in home safety behaviours.

119 Cluster-randomised controlled trial of a fire safety injury prevention briefing in children’s centres

Background The UK has high mortality rates for fire-related deaths in children aged 0–14 years with steep social gradients. Interventions to promote fire safety practices can be effective in reducing the risk of fire-related injury. We therefore developed an evidence-based fire safety intervention comprising an Injury Prevention Briefing (IPB), training and facilitation for use in children’s centres. Methods A cluster randomised controlled trial, with integrated qualitative study, was conducted across four study sites in England involving children’s centres in disadvantaged areas; participants were staff and families attending those centres. Centres were stratified by study site and randomised within strata to one of three arms: IPB plus facilitation (IPB+), IPB only, usual care. IPB+ centres received initial training and facilitation at months 1, 3, and 8. Data collected comprised baseline and 12 months parent- and staff-completed questionnaires, home safety activity logs and staff interviews. The primary outcome was the proportion of families with a home fire-escape plan. Treatment arms were compared by using multilevel models to account for clustering by centre. Results 1112 parents at 36 CCs participated. There was no significant effect of the intervention on family possession of fire-escape plans (AOR IPB only vs. usual care: 0.93, 95% CI: 0.58, 1.49; AOR IPB+ vs. usual care 1.41, 95% CI: 0.91, 2.20). However, significantly more families in the intervention arms achieved more fire-escape planning behaviours (AOR IPB only vs. usual care: 2.56, 95% CI: 01.38, 4.76; AOR IPB+ vs. usual care 1.78, 95% CI: 1.01, 3.15). Conclusions Our study demonstrated that children’s centres can deliver an injury prevention intervention to families in disadvantaged communities and achieve changes in home safety behaviours.