Inequalities in birth before arrival at hospital in South West England: a multimethods study of neonatal hypothermia and emergency medical services call-handler advice.

OBJECTIVES: To examine inequalities in birth before arrival (BBA) at hospitals in South West England, understand which groups are most likely to experience BBA and how this relates to hypothermia and outcomes (phase A). To investigate opportunities to improve temperature management advice given by emergency medical services (EMS) call-handlers during emergency calls regarding BBA in the UK (phase B). DESIGN: A two-phase multimethod study. Phase A analysed anonymised data from hospital neonatal records between January 2018 and January 2021. Phase B analysed anonymised EMS call transcripts, followed by focus groups with National Health Service (NHS) staff and patients. SETTING: Six Hospital Trusts in South West England and two EMS providers (ambulance services) in South West and North East England. PARTICIPANTS: 18 multidisciplinary NHS staff and 22 members of the public who had experienced BBA in the UK. RESULTS: 35% (64/184) of babies conveyed to hospital were hypothermic on arrival. When compared with national data on all births in the South West, we found higher percentages of women with documented safeguarding concerns at booking, previous live births and 'late bookers' (booking their pregnancy >13 weeks gestation). These women may, therefore, be more likely to experience BBA. Preterm babies, babies to first-time mothers and babies born to mothers with disability or safeguarding concerns at booking were more likely to be hypothermic following BBA. Five main themes emerged from qualitative data on call-handler advice: (1) importance placed on neonatal temperature; (2) advice on where the baby should be placed following birth; (3) advice on how to keep the baby warm; (4) timing of temperature management advice and (5) clarity and priority of instructions. CONCLUSIONS: Findings identified factors associated with BBA and neonatal hypothermia following BBA. Improvements to EMS call-handler advice could reduce the number of babies arriving at hospital hypothermic.

Assessment of home hazards for non-fatal childhood injuries in rural Nepal: a community survey.

BACKGROUND: Unintentional injuries in and around the home are important causes of preventable death and disability among young children globally. In Nepal, there is a lack of data regarding home injuries and home hazards to guide the development of effective interventions for preventing childhood home injuries. This study aimed to determine the burden of unintentional home injuries in children <5 years in rural Nepal and quantify the injury hazards in their homes. METHODS: A survey was conducted in 740 households in rural areas of the Makwanpur district during February and March 2015. The primary carer reported home injuries which occurred in the previous 3 months and data collector observation identified the injury hazards. Injury incidence, mechanism and the proportion of households with different hazards were described. Multivariable logistic regression explored associations between the number and type of home hazards and injuries. RESULTS: Injuries severe enough to need treatment, or resulting in non-participation in usual activities for at least a day, were reported in 242/1042 (23.2%) children <5 years. The mean number of injury hazards per household was 14.98 (SD=4.48), range of 3-31. Regression analysis found an estimated increase of 31% in the odds of injury occurrence associated with each additional injury hazard found in the home (adjusted OR 1.31; 95% CI 1.20 to 1.42). CONCLUSIONS: A high proportion of young children in rural Nepal sustained injuries severe enough to miss a day of usual activities. Increased frequency of hazards was associated with an increased injury risk.

Exploring perceptions of common practices immediately following burn injuries in rural communities of Bangladesh.

BACKGROUND: Burns can be the most devastating injuries in the world, they constitute a global public health problem and cause widespread public health concern. Every year in Bangladesh more than 365,000 people are injured by electrical, thermal and other causes of burn injuries. Among them 27,000 need hospital admission and over 5600 people die. Immediate treatment and medication has been found to be significant in the success of recovering from a burn. However, common practices used in the treatment of burn injuries in the community is not well documented in Bangladesh. This study was designed to explore the perception of local communities in Bangladesh the common practices used and health-seeking behaviors sought immediately after a burn injury has occurred. METHODS: A qualitative study was conducted using Focus Group Discussions (FGD) as the data collection method. Six unions of three districts in rural Bangladesh were randomly selected and FGDs were conducted in these districts with six burn survivors and their relatives and neighbours. Data were analyzed manually, codes were identified and the grouped into themes. RESULTS: The participants stated that burn injuries are common during the winter in Bangladesh. Inhabitants in the rural areas said that it was common practice, and correct, to apply the following to the injured area immediately after a burn: egg albumin, salty water, toothpaste, kerosene, coconut oil, cow dung or soil. Some also believed that applying water is harmful to a burn injury. Most participants did not know about any referral system for burn patients. They expressed their dissatisfaction about the lack of available health service facilities at the recommended health care centers at both the district level and above. CONCLUSIONS: In rural Bangladesh, the current first-aid practices for burn injuries are incorrect; there is a widely held belief that using water on burns is harmful.

The feasibility of community mobilisation for child injury prevention in rural Nepal: a programme for female community health volunteers.

BACKGROUND: Injuries accounted for 23% of all deaths in children and adolescents in Nepal during 2010 (n = 3,700). Despite this, there is no national death registration or injury surveillance system. Non-fatal injuries are many times more common than fatal injuries and may leave the injured person with lifelong consequences. Children in low-income settings are exposed to widespread risks of injuries but there is little awareness of how they can be prevented. Community mobilisation has been shown to be effective to reduce maternal and neonatal morbidity. This study aimed to develop a child safety programme and assess the feasibility of delivering the programme through a community mobilisation approach. METHODS: We developed a culturally appropriate, educational programme for Female Community Health Volunteers that included both primary and secondary prevention materials for unintentional child injuries. We determined the feasibility of evaluating its effectiveness through the mobilisation of women's groups in rural Nepal. Ten women's groups across 9 wards in one village development committee area completed the programme during 6 monthly meetings. Parent-reported injuries were collected through a notification system established for this study. Experience of the programme by women's group participants and leaders was assessed through a structured questionnaire and process measures assessed the delivery and reach of the programme. RESULTS: Programme resources were developed for this setting and adapted following feedback from users. Nine FCHVs received first-aid training and shown how to use the facilitation manual and injury prevention resources. The FCHVs convened 10 women's groups to run over 6 months with 24-29 mothers attending each meeting (290 mothers participated in total). Each group presented their views on child injury risks and proposed prevention activities at local public meetings. Women reported 155 injuries to children under 18 years during 7 months of follow up using the notification system. CONCLUSIONS: It is feasible to develop and implement a community mobilisation intervention where women's groups work together with local FCHVs to prevent injuries in children. The intervention was well received by the women's groups and by community members. The effectiveness and cost effectiveness of the intervention should now be evaluated through an experimental study.

Recruitment and retention strategies and the examination of attrition bias in a randomised controlled trial in children's centres serving families in disadvantaged areas of England.

BACKGROUND: Failure to retain participants in randomised controlled trials and longitudinal studies can cause significant methodological problems. We report the recruitment and retention strategies of a randomised controlled trial to promote fire-related injury prevention in families with pre-school children attending children's centres in disadvantaged areas in England. METHODS: Thirty-six children's centres were cluster randomised into one of three arms of a 12-month fire-related injury prevention trial. Two arms delivered safety interventions and there was one control arm. Retention rates compared the numbers of participants responding to the 12-month questionnaire to the number recruited to the trial. Multivariable random effects logistic regression was used to explore factors independently associated with participant retention. RESULTS: The trial exceeded its required sample size through the use of multiple recruitment strategies. All children's centres remained in the study, despite increased reorganisation. Parent retention was 68% at 12 months, ranging from 65% to 70% across trial arms and from 62% to 74% across trial sites. There was no significant difference in the rates of retention between trial arms (p = 0.58) or between trial sites (p = 0.16). Retention was significantly lower amongst mothers aged 16-25 years than older mothers [adjusted odds ratio (AOR) 0.57, 95% CI 0.41, 0.78], those living in non-owner occupied accommodation than in owner occupied accommodation (AOR 0.53, 95% CI 0.38, 0.73) and those living in more disadvantaged areas (most versus least disadvantaged quintiles AOR 0.50, 95% CI 0.30, 0.82). CONCLUSIONS: Studies recruiting disadvantaged populations should measure and report attrition by socioeconomic factors to enable determination of the extent of attrition bias and estimation of its potential impact on findings. Where differential attrition is anticipated, consideration should be given to over-sampling during recruitment and targeted and more intensive strategies of participant retention in these sub-groups. In transient populations collection of multiple sources of contact information at recruitment and throughout the study may aid retention. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01452191 ; Date of registration: 10 October 2011, ISRCTN65067450.

Implementing an Injury Prevention Briefing to aid delivery of key fire safety messages in UK children's centres: qualitative study nested within a multi-centre randomised controlled trial.

BACKGROUND: To improve the translation of public health evidence into practice, there is a need to increase practitioner involvement in initiative development, to place greater emphasis on contextual knowledge, and to address intervention processes and outcomes. Evidence that demonstrates the need to reduce childhood fire-related injuries is compelling but its translation into practice is inconsistent and limited. With this knowledge the Keeping Children Safe programme developed an "Injury Prevention Briefing (IPB)" using a 7 step process to combine scientific evidence with practitioner contextual knowledge. The IPB was designed specifically for children's centres (CCs) to support delivery of key fire safety messages to parents. This paper reports the findings of a nested qualitative study within a clustered randomised controlled trial of the IPB, in which staff described their experiences of IPB implementation to aid understanding of why or how the intervention worked. METHODS: Interviews were conducted with key staff at 24 CCs participating in the two intervention arms: 1) IPB supplemented by initial training and regular facilitation; 2) IPB sent by post with no facilitation. Framework Analysis was applied to these interview data to explore intervention adherence including; exposure or dose; quality of delivery; participant responsiveness; programme differentiation; and staff experience of IPB implementation. This included barriers, facilitators and suggested improvements. RESULTS: 83% of CCs regarded the IPB as a simple, accessible tool which raised awareness, and stimulated discussion and behaviour change. 15 CCs suggested minor modifications to format and content. Four levels of implementation were identified according to content, frequency, duration and coverage. Most CCs (75%) achieved 'extended' or 'essential' IPB implementation. Three universal factors affected all CCs: organisational change and resourcing; working with hard to engage groups; additional demands of participating in a research study. Six specific factors were associated with the implementation level achieved: staff engagement and training; staff continuity; adaptability and flexibility; other agency support; conflicting priorities; facilitation. CCs achieving high implementation levels increased from 58% (no facilitation) to 92% with facilitation. CONCLUSION: Incorporating service provider perspectives and scientific evidence into health education initiatives enhances potential for successful implementation, particularly when supplemented by ongoing training and facilitation.

The feasibility of using a parenting programme for the prevention of unintentional home injuries in the under-fives: a cluster randomised controlled trial.

BACKGROUND: Unintentional injury is the leading cause of preventable death of children over the age of 1 year in the UK and a major cause of attendance at emergency departments. Children having one injury are at increased risk of further injuries. Parenting programmes can reduce injuries in preschool children if delivered in the home and on a one-to-one basis. It is not known if group-based programmes delivered outside the home are effective. OBJECTIVES: To develop (1) a parenting programme to prevent recurrent unintentional home injuries in preschool children and (2) a tool for parents to report unintentional home injuries occurring to their preschool children. To assess the feasibility of delivering and evaluating the parenting programme through a cluster randomised controlled trial, specifically to (1) assess methods for the recruitment and retention of parents; (2) determine the training, equipment and facilities needed for the delivery of the programme; (3) establish appropriate primary and secondary outcome measures and methods for their collection; (4) determine how 'normal care' in a comparison arm should be defined; and (5) determine the resource utilisation and costing data that would need to be collected for the cost-effectiveness component of a future trial; and (6) produce estimates of effect sizes to inform sample size estimation for a main trial. DESIGN: Feasibility multicentre, cluster, randomised, unblinded trial. SETTING: Eight children's centres in Bristol and Nottingham, UK. PARTICIPANTS: Ninety-six parents of preschool children who had sustained an unintentional injury requiring medical attention in the previous 12 months. INTERVENTIONS: The First-aid Advice and Safety Training (FAST) parent programme, comprising parenting support and skills combined with first aid and home safety advice. MAIN OUTCOME MEASURES: Parent-reported medically attended injuries in the index child and any preschool siblings sustained during a 6-month period of observation. RESULTS: An 8-week parenting programme was produced, designed with participant-friendly, incrementally progressive content. A slimline, month-to-a-view injury calendar, spiral bound and suitable for hanging on a wall, was designed for parents to record injuries occurring to their preschool children during the 6-month period of observed time. Fifty-one parents were recruited (40 meeting eligibility criteria plus 11 following 'open invite' to participate); 15 parents completed the FAST parent programme and 49 provided data at baseline and during follow-up. Completion of the programme was significantly greater for participants using the 'open invite' approach (85%) than for those recruited using the original eligibility criteria (31%). Prototype resource use checklists, unit costs and total costs were developed for phases 0, 1 and 2 of the study for use in a future trial. CONCLUSIONS: This feasibility study has developed an innovative injury prevention intervention and a tool to record parent-reported injuries in preschool children. It was not feasible to recruit parents of children who had sustained a recent injury, or to ask health visitor teams to identify potential participants and to deliver the programme. A trial should target all families attending children's centres in disadvantaged areas. The intervention could be delivered by a health professional supported by a member of the children's centre team in a community setting. TRIAL REGISTRATION: Current Controlled Trials ISRCTN03605270. SOURCE OF FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 3. See the NIHR Journals Library website for further project information.

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

BACKGROUND: The UK has one of the highest fatality rates for deaths from fire-related injuries in children aged 0-14 years; 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/DESIGN: Pragmatic, 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. DISCUSSION: This 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 REGISTRATION: http://NCT01452191 (date of registration: 13/10/2011).

The role of community centre-based arts, leisure and social activities in promoting adult well-being and healthy lifestyles.

Developed countries are experiencing high levels of mental and physical illness associated with long term health conditions, unhealthy lifestyles and an ageing population. Given the limited capacity of the formal health care sector to address these public health issues, attention is turning to the role of agencies active in civil society. This paper sought to evaluate the associations between participation in community centre activities, the psycho-social wellbeing and health related behaviours. This was based on an evaluation of the South West Well-being programme involving ten organisations delivering leisure, exercise, cooking, befriending, arts and crafts activities. The evaluation consisted of a before-and-after study with 687 adults. The results showed positive changes in self-reported general health, mental health, personal and social well-being. Positive changes were associated with diet and physical activity. Some activities were different in their outcomes-especially in cases where group activities were combined with one-to-one support. The results suggest that community centre activities of this nature offer benefits that are generically supportive of health behaviour changes. Such initiatives can perform an important role in supporting the health improvement objectives of formal health care services. For commissioners and partner agencies, accessibility and participation are attractive features that are particularly pertinent to the current public health context.

Obesity in Hong Kong Chinese preschool children: where are all the nurses?

We report an ethnographic study of 10 preschool children aged 2-6 years recruited from kindergartens in Hong Kong, 6 of whom were overweight or obese. Each was followed for 12-18 months. We confirmed previously described risk factors and showed how these interacted to produce obesity in some but not all at-risk children. Despite much rhetoric in the literature about holistic care of the preschool child, we were struck by the lack of coordinated professional input to the needs of children at risk of obesity and by the absence of nursing input in particular. We argue that a "whole-systems" nursing role, based in the community and with remit that includes clinical care, education, and policy, is urgently needed, as well as review examples of such roles from other countries.

Transition to parenthood: the needs of parents in pregnancy and early parenthood.

BACKGROUND: Pregnancy and the transition to parenthood are major adjustment periods within a family. Existing studies have asked parents, retrospectively, about their experience of antenatal education, mainly focusing on women. We sought to address this gap by asking first-time mothers and their partners about how they could be better supported during the antenatal period, particularly in relation to the transition to parenthood and parenting skills. METHODS: Purposive sampling was used to recruit 24 nulliparous women with a range of ages from two healthcare organisations in South-West England, 20 of whom had partners. Recruitment took place antenatally at around 28 weeks gestation. Semi-structured interviews were undertaken at home in the last trimester of pregnancy and between 3-4 months postpartum. Content analysis of the interview data was undertaken. RESULTS: Several common themes emerged from both the ante- and postnatal data, including support mechanisms, information and antenatal education, breastfeeding, practical baby-care and relationship changes. Knowledge about the transition to parenthood was poor. Women generally felt well supported, especially by female relatives and, for those who attended them, postnatal groups. This was in contrast to the men who often only had health professionals and work colleagues to turn to. The men felt very involved with their partners' pregnancy but excluded from antenatal appointments, antenatal classes and by the literature that was available. Parents had been unaware of, and surprised at, the changes in the relationship with their partners. They would have liked more information on elements of parenting and baby care, relationship changes and partners' perspectives prior to becoming parents. CONCLUSION: Many studies and policy documents have highlighted the paucity of parents' preparation for parenthood. This study has indicated the need for an improvement in parents' preparation for parenthood, the importance of including fathers in antenatal education and that inadequate preparation remains a concern to both women and their partners. This paper identifies several avenues for action and further research to improve both new parents' experience of antenatal education and their preparation for parenthood.

Can primary care identify an 'at risk' group in the older population.

The promotion of health and independence for older people through preventative strategies is rising up the public health agenda in many countries and has been made a government policy objective in the UK. Despite forty years of experimentation, community nursing and general practice involvement in this field has been characterized by a lack of evidence to support broad screening and surveillance programmes and a failure to reach consensus on the most effective approaches to health promotion in later life. One initiative brought together community nursing, general practice and the voluntary social welfare sector in an inner urban setting to proactively identify and address unmet need and promote health through short term case management in an older population. This paper reports on the ability of the primary care teams to identify 'at risk' groups in the older population, which can then be targeted for comprehensive assessment.

The feasibility and acceptability of a specialist health and social care team for the promotion of health and independence in 'at risk' older adults.

Population ageing, escalating costs in pensions, health-care and long-term care have prompted a new policy agenda for active ageing and quality of life in old age across the European Union and other developed countries. In England, the National Service Framework for Older People (NSF OP) explicitly demands for the first time that the NHS and local authorities, in partnership, agree programmes to promote health ageing and to prevent disease in older people. These programmes are expected to improve access for older people to mainstream health promotion services and also to develop multiagency initiatives to promote health, independence and well-being in old age. This paper describes the evaluation of one interagency project team established to test out mechanisms for addressing health promotion for older people through primary care. A mixed methodology was used to understand the processes of service development, the impact of the team's intervention, and the primary and secondary outcomes for older people. The project demonstrated that multi-agency partnerships have the potential to improve the quality of the lives of older people deemed 'at risk' by their general practitioners, particularly through income generation but also in the identification of medical problems such as unrecognised hypertension, hearing loss and visual loss. It also offered some key learning points for other multi-agency groups developing similar services.

Older people's services. A picture of health.

A scheme offering joint health and social care assessments to people aged over 75 in inner London identified more than a quarter in need of services. The older people were accessed via general practice, but this proved an inefficient way of identifying the target population. In some practices, almost half of those contacted were no longer at the same address. The assessments, conducted by a community nurse and social welfare officer, often involved two visits. The mobility of the elderly population needs to be taken into account when planning joint assessments. Organisations involved had different aspirations for the scheme and management proved problematic.

Patient group directions for antibiotic supply in Walk-in Centres: how legal are they?

Until recently antibiotics were only available on prescription. Nurses in NHS Walk-in Centres (WiCs) now supply and administer antibiotics in accordance with patient group directions (PGDs). The aim of this study was to investigate the process of antibiotic supply from WiCs. Antibiotic PGDs from ten WiCs were selected and medical notes of 50 patients who received an antibiotic at these WiCs were examined to determine compliance with PGD specifications. No consistency of approach in format and content of PGDs was found. PGDs from six WiCs complied with 15/20 or fewer PGD requirements. In the examination of patients' records, 65% of all relevant PGD requirements were explicitly recorded. The breadth and variability of PGDs demonstrates local needs and priorities; however, low compliance levels with PGD requirements provide cause for concern. This article discusses the legality of PGDs, equity in both service provision and advice offered, compliance of medical notes with PGD requirements, implications for patients and WiC nurses, and training implications. Incomplete documentation makes it impossible to verify the quality of care provided across and within WiCs. It also suggests that uncertainty remains around the supply of medicines under PGDs.