Abstract
Research question
What are the barriers to, and facilitators of, implementing thermal injury, falls and poisoning prevention interventions among children’s centres, professionals and community members?
Methods
This work stream included three studies exploring barriers to, and facilitators of, injury prevention: a systematic review (study E), a qualitative study of children’s centre managers and staff (study F) and a qualitative study of parents of injured and uninjured children (study G).
Study E
Quantitative papers were identified from a systematic review undertaken in work stream 5 (study I), which was supplemented with a systematic review of qualitative evidence. Bibliographic databases and other sources were searched up to May 2009 for quantitative papers and up to March 2010 for qualitative papers. Data were explored using framework analysis and synthesised narratively.
Study F
Semistructured interviews were conducted with managers and staff from children’s centres across four study sites. Interview topics included health and safety promotion programmes, barriers to, and facilitators of, delivering health promotion, engaging parents and development of staff capacity and child injury prevention. Data were analysed using framework analysis.
Study G
Semistructured interviews were conducted with parents of injured and uninjured children (cases and controls from study A). Maximum variation sampling was used to ensure a range of child ages, injury types and deprivation levels. Interview topics included beliefs about injury prevention, injury prevention
strategies, control over injury prevention actions and barriers to, and facilitators of, injury prevention actions. Data were analysed using thematic analysis.
Results
In total, 64 papers (quantitative,n=57; qualitative,n=7) were included in the systematic review. Thirty-three
interviews were conducted with staff from 16 children’s centres and 64 parents were interviewed, 16 whose children had had a fall, 16 whose children had had a poisoning, 16 whose children had had a scald and 16 whose children had not had an injury. The review found that many studies did not explicitly explore barriers and facilitators and, when they were explored, this was most often from the perspective of those delivering the intervention. A range of barriers and facilitators was found consistently across studies E–G. These included the need for interventions to be delivered by staff with trusted relationships with families, tailoring
prevention topics and providing simple and reinforced messages. Parents identified that‘real-life’stories of how injuries had happened may help to raise awareness.
Conclusions
Facilitators for children’s centres and parents to undertake injury prevention were identified as were modifiable barriers. The effect of addressing these barriers and facilitators within interventions aimed at children’s centres and families requires evaluation.
Chapter summary
This work stream consisted of a systematic review of facilitators of and barriers to home injury prevention interventions for preschool children (study E), a qualitative study exploring the views of children’s centre managers and staff regarding facilitators of and barriers to injury prevention (study F) and a qualitative study exploring parents’views of facilitators of and barriers to implementing injury prevention within the home (study G). Findings from this work stream were used to inform the design of an injury prevention intervention for delivery in children’s centres. The design and evaluation of this intervention is reported in work stream 6 (seeChapter 7).
Introduction
Over the last 20 years, numerous studies of injury prevention activity among front-line health professionals, public health professionals and health-care organisations in the UK have consistently demonstrated that child injury prevention is given a low priority and is inadequately resourced, that professionals have unmet training needs to deliver injury prevention and that systematic implementation of evidence-based practice is lacking.19,218–220,236–244More recently, in 2010, NICE produced two guidelines on preventing unintentional
injuries in children and young people (PH2925and PH3027), which clearly defined the evidence-based
interventions that should be provided and the responsibilities for professionals and organisations in implementing those interventions. The impact of the NICE guidelines on child injury prevention practice awaits assessment.
Among parents, professionals and organisations, a range of barriers to, and facilitators of, injury prevention has been found. A systematic review of qualitative literature undertaken in 2011 reported on barriers to, and facilitators of, interventions that supply or install home safety equipment or provide home safety risk assessments.245Barriers and facilitators covering 15 areas were found. Legal and policy barriers included the
short-term nature of many programmes, lack of co-ordination and weak legislation or regulation. Information provision was a barrier, with parents reporting a lack of information and service providers reporting
difficulties in providing information to families in accommodation with a rapid turnover of tenants. Living in homes that people were not free to modify, homes in which people lacked autonomy to make household decisions or rented homes with high tenant turnover were major barriers to installing safety equipment and childproofing a home, as were equipment costs, poor-quality or malfunctioning equipment and a lack of skills to fit equipment. Difficulty in understanding child development and anticipating injury risk, having fatalistic attitudes towards injuries, being suspicious of strangers entering the home to assess or install equipment, being suspicious of‘free’equipment and parental perceptions of officials blaming or accusing them of neglect or abuse all acted as barriers. A lack of experience of specific risks in a new environment and lack of understanding by health workers of child safety norms and expectations in immigrants’cultures were also cited as barriers.245
Facilitators included legislation that required action when children were resident in the home (e.g. fire and Rescue Services Act 2004246), providing timely information (e.g. safety information provided in the
community after birth was more likely to be retained than that provided in hospital at the time of birth), using‘real-life’incidents, partnerships and collaborations between service providers, having landlords with
the ability and motivation to repair properties, training for landlords, councils and parents in installing, replacing and using equipment and providing ongoing support and maintenance for safety equipment. Parental supervision was acknowledged as a major facilitator but, as this was resource intensive, the need to supplement it with other forms of injury prevention was emphasised.245
At the level of professionals, a systematic review of the global literature identified six barriers to professionals undertaking injury prevention activities.247These were inadequate knowledge and training, lack of time, lack
of resources, lack of confidence in counselling parents about injury prevention or in their ability to influence parents’behaviour, the setting in which professionals worked and personal injury prevention behaviour.247
Surveys of English health organisations, including health authorities and PCTs, identified the low priority given to unintentional injuries,218,219lack of strategic planning,218,219lack of capacity and resources, in
particular injury prevention co-ordinator posts,218lack of useful local data,218inadequately developed
multiagency working219and a lack of knowledge about the burden of injuries and the effectiveness
of interventions.219
At an organisational level, it is vital to understand the context within which interventions are set. Despite this, details on context, methods and implementation of interventions are rarely reported in the literature. Several systematic reviews conclude that the characteristics of innovations, communities, individuals and the delivery of the intervention are all important in determining the effectiveness of implementation.248–251
In terms of providers, recognition of the need for a specific intervention, belief in its beneficial effects, confidence in ability and having the necessary skills to deliver the intervention have consistently been found to be associated with successful implementation.248At an organisational level, important aspects
for achieving implementation are a culture conducive to change, effective leadership and programme champions and providing training that includes active learning delivered in a supportive atmosphere with ongoing technical assistance, resources and support.248
As described in work stream 3 (seeChapter 4), children’s centres have a key role in promoting child and family safety. It is therefore important to understand how home safety interventions can be most effectively implemented within the context of children’s centres. The findings from study D described in work stream 3 demonstrate considerable interest in and motivation for undertaking child injury prevention work within children’s centres. However, this is coupled with a lack of prioritisation of the topic, gaps in knowledge about child injuries, lack of a strategic evidence-based approach to injury prevention and a range of barriers to undertaking injury prevention, most commonly lack of funding and lack of staff capacity. This work stream aimed to gain a greater understanding of the barriers to, and facilitators of, injury prevention for children’s centres and parents. The findings from work stream 4 were used to inform the design of a child injury prevention intervention (an IPB plus a training and facilitation package to support its implementation), which was evaluated as part of work stream 6 (seeChapter 7). The methods and results for studies E–G are reported in this chapter along with an overarching discussion covering all three studies.