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 interventions to the needs of families and stage of development of the child, focusing on specific injury 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.
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.19,218–220,236–244 More recently, in 2010, NICE produced two guidelines on preventing unintentional injuries in children and young people (PH2925 and 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.245 Barriers 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.247 These 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,218,219 lack of strategic planning,218,219 lack of capacity and resources, in particular injury prevention co-ordinator posts,218 lack of useful local data,218 inadequately developed multiagency working219 and 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.248 At 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 (see Chapter 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 (see Chapter 7). The methods and results for studies E–G are reported in this chapter along with an overarching discussion covering all three studies.
Systematic review using quantitative and qualitative studies of barriers to, and facilitators of, implementing home safety interventions among families with young children (study E)
Methods
The objective was to systematically review quantitative [RCTs, non-RCTs (including quasi-randomised studies) and controlled before-and-after studies (CBAs)] and qualitative (all designs) studies on barriers to, and facilitators of, implementing home safety interventions to prevent unintentional injuries in children aged 0–4 years. The systematic review was conducted in parallel with an update of a Cochrane systematic review of the effectiveness of home safety interventions,49 undertaken as part of the KCS programme of research and reported in Chapter 6 (work stream 5). We used the quantitative papers identified from the Cochrane systematic review and supplemented these with a systematic review of qualitative evidence. Full details of the methods used are reported elsewhere.49,252
Studies were eligible if they included children aged ≤ 5 years and their families, provided home safety education with or without the provision of safety equipment for the prevention of falls, poisonings or thermal injuries and reported barriers to, or facilitators of, success of the intervention. Community injury prevention programmes (e.g. World Health Organization Safe Community-type interventions) were included only if it was clear that they provided home safety education for the prevention of falls, poisonings or thermal injuries to individual parents or groups of parents. Studies reporting fire setting were excluded because of the difficulty of attributing intent. The sources searched and search strategies for the Cochrane review are described in work stream 5 (see Chapter 6). Searches were conducted from the date of inception of the bibliographic databases up to 31 May 2009. We searched MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Applied Social Sciences Index and Abstracts (ASSIA), PsycINFO and Web of Science for qualitative evidence from the date of database inception to March 2010 as well as a range of other electronic sources. The search strategy for qualitative papers is provided in Appendix 4, Search strategy for identification of qualitative studies for the systematic review of barriers to, and facilitators of, injury prevention (study E).
All papers included in the Cochrane review were assessed for inclusion by two reviewers searching the full-text articles for mention of reported barriers and facilitators. Assessment of risk of bias was undertaken as described in work stream 5. Titles and abstracts of qualitative papers were assessed for inclusion independently by two reviewers. We did not appraise qualitative papers for quality because there is considerable debate about (1) whether qualitative studies should be appraised for quality, (2) which methods should be used and (3) the degree of agreement between different appraisers and different methods.253–255 Data were extracted from eligible articles by two reviewers independently using a standard data extraction form. Disagreements between reviewers in study selection or data extraction were handled by consensus-forming discussions. Data were synthesised using an iterative process to develop themes, which were explored using framework analysis.256
Results
The process of the selection of studies is shown in . Sixty-four studies were included in the review, 57 sourced from the Cochrane review72,257–312 and seven from the searches for qualitative studies.92,313–318 Tables of excluded studies are available from the authors on request. The risk of bias in the included quantitative studies is shown later in Table 72, which demonstrates that many studies were at risk of bias, most commonly from inadequate allocation concealment or lack of blinding of outcome assessment.
Process of the selection of quantitative and qualitative studies for the review. Reproduced from Ingram JC, Deave T, Towner E, Errington G, Kay B, Kendrick D. Identifying facilitators and barriers for home injury prevention interventions for pre-school (more...)
Seven key facilitators and six key barriers were identified from the included studies. shows the key facilitators and shows the key barriers. These key facilitators and barriers are summarised in the following sections.
Facilitators for implementing home safety interventions identified from included studies
Barriers to implementing home safety interventions identified from included studies
Facilitators
Features of successful interventions were prearranged home safety visits, at which free safety equipment was provided and fitted with easy-to-use instructions, particularly for low-income families; tailoring methods for different groups or individuals and combining with environmental measures (active and passive interventions); community involvement and awareness raising to understand community perceptions and values and address these and to reduce stigma, normalise safety practices and reach high-risk groups; and partnership working with a range of organisations. For some types of injury (e.g. scald prevention through reducing hot tap water temperature), focusing on a single type of injury was helpful, as was providing short and simple home safety messages. Simple methods for reinforcing advice, such as continued contact with health professionals, group sessions in clinics, poster displays, mailed reminders and stickers to display in the home, were described as helpful. Interventions requiring minimal, simple, non-repetitive action to implement (such as lowering the hot water temperature) were more likely to be successful than those requiring more complex or repeated actions. Interventions providing and fitting safety equipment had greater effects than those providing discount vouchers for equipment purchase or those providing advice about equipment and local suppliers or facilitating access to equipment in other ways. Studies using behaviour change models for influencing parental safety behaviour and techniques to increase self-efficacy found these to be beneficial. The use of techniques to achieve organisational change in terms of delivering home safety interventions was also considered important. A range of incentives was used successfully to encourage participation in studies and uptake of interventions such as providing free interventions (safety equipment or first aid training), small monetary incentives for completing outcome measurement tools or crèche facilities for group sessions.
Using professionals who had established a relationship with families to deliver safety messages had many benefits, as they were trusted familiar figures and were accepted in the home. Trained lay community volunteers were more acceptable to some communities, and it was appreciated when they were able to deliver messages in the primary language of participants or were of the same ethnic origin. The credibility of home safety messages was enhanced in some studies by being delivered in clinical settings, such as child health clinics or EDs. Those delivering the interventions gained both home safety knowledge and skills in delivering home safety interventions, and this helped to sustain interventions.
Barriers
Parents in some studies, particularly in disadvantaged areas, were suspicious of unannounced home visits because of mistrust of the health system, child protection fears, immigration issues and/or fear of strangers in the home. Transient populations, with frequent house moves, were difficult to deliver interventions to and those moving house sometimes removed safety equipment. Living in rented accommodation prevented equipment being fitted because families worried that landlords might object or equipment might inconvenience other tenants (e.g. smoke alarms going off) or families could not afford to make changes to a property they did not own. Language barriers and low literacy hampered the delivery of interventions in some studies and using interpreting services and translators proved difficult. Families living with economic constraints would often choose food and daily living items over the purchase of safety equipment. In addition, installing equipment required time, tools and skills. When safety equipment broke, was faulty or was perceived as inconvenient or annoying by families (e.g. smoke alarms), this contributed to poor compliance.
Families’ beliefs, traditions and supervisory behaviours influenced whether or not they were likely to take part in studies and the extent to which they were willing to change their home safety and supervisory practices. Short intervention periods and brief educational interventions including single home visits or well-child contacts or awareness raising campaigns were viewed as insufficient to change beliefs and behaviours.
Complex interventions were not always successful if they addressed too many home safety topics in one intervention or used multiple methods that required several concurrent behaviour changes. Often they also required more highly skilled practitioners, which made them less sustainable. Interventions that needed large numbers of staff or volunteer training or large amounts of time to deliver were sometimes unsuccessful because of time constraints, and were often unsustainable.
Identifying barriers to, and facilitators of, injury prevention among children’s centre managers and staff (study F)
Methods
The objective of this study was to explore perceptions of barriers to, and facilitators of, implementing health promotion and injury prevention interventions among children’s centre staff.
Semistructured interviews were conducted with staff members from children’s centres, which were sampled purposively to include a range of characteristics: phase of establishment of children’s centre, PCT area, lead agency and catchment population size. For each study site we identified phase 1 and phase 2 centres in the most deprived 30% of super output areas, as assessed by 2007 Indices of Multiple Deprivation for each region,319,320 and located in the two PCT areas closest to each study site. Children’s centre managers were approached by researchers by letter, followed by a telephone call to discuss the study and answer any questions managers might have.
Researchers from the four study sites, Nottingham, Norwich, Newcastle and Bristol, undertook interviews lasting for 30–45 minutes at the children’s centre, university or local NHS premises, at a time convenient to participants. Participation was voluntary and participants were free to withdraw at any time. Participants completed a consent form prior to interview. Interview topics included details about health and safety promotion programmes, focusing on aspects of the barriers to, and facilitators of, holding health promotion sessions, the best ways to engage with parents and the development of staff capacity and child safety work. An interview topic guide was developed using the findings from study D described in work stream 3 (see Chapter 4) and is shown in Appendix 4, Interview guide for interviews with children’s centre managers and staff (study G). Interviews were digitally recorded and transcribed verbatim. Quotations are presented using a code giving the study centre name, a number for the children’s centre and a letter for the interviewee.
Analysis was undertaken using framework analysis321,322 and completed with software package NVivo 9.2 (QSR International, Warrington, UK). The initial framework was developed by researchers in Nottingham coding six randomly selected transcripts and reviewed by researchers in Bristol who developed the final thematic framework after analysing data from the 33 interviews. Emerging themes were reviewed by researchers from the four study sites and the qualitative consultant to the KCS research programme at each stage of the analysis. Coding consistency was checked by independent coding of two interviews by two researchers during development of the initial framework and of four interviews once coding was complete for all 33 interviews. Disagreements were handled by consensus-forming discussions. The coding frame was reviewed by researchers in all study sites, the qualitative consultant and the lay research adviser. Ethics approval was granted by North Nottinghamshire Research Ethics Committee (reference number 09/H0408/113).
Results
Semistructured interviews were conducted with 33 staff members (17 managers and 16 staff nominated by managers with face-to-face contact with parents and responsibility for organising health promotion activities) from 16 children’s centres across the four study areas. The characteristics of participating children’s centres are shown in . This indicates that a wide range of children’s centres across the four study sites took part in the study in terms of lead agency, rural/urban setting, phase and length of operation.
Characteristics of participating children’s centres
Seven key facilitators and six key barriers were identified. These are shown in Boxes 1 and 2, illustrated by participants’ quotations.
Key facilitators for delivering health promotion and injury prevention interventions in children’s centres
Key barriers to delivering health promotion and injury prevention interventions in children’s centres
Identifying barriers to, and facilitators of, injury prevention among parents and caregivers (study G)
Methods
The objective of this study was to identify key facilitators and barriers for parents in terms of keeping their children safe from unintentional injury within the home. Participants recruited to the case–control studies undertaken in work stream 1 (see Chapter 2) were eligible to participate in this or two other studies nested within the case–control studies (studies B and C). Participants were eligible to participate in only one nested study, so those participating in study B or C were excluded from taking part in this study.
A sampling frame was devised to aid maximum variation sampling. This grouped parents by injury type (falls, poisonings, scalds or no injury) and deprivation, based on the IMD65 (less than the median IMD rank and greater than or equal to the median IMD rank). Before inviting parents to participate, researchers checked the sampling frame to ensure that participants would add to the variation within the sample.323 Sixty-five parents across four centres (Nottingham, Bristol, Norwich and Newcastle) consented to participate and were recruited: 49 parents whose child had attended an ED or a MIU or had been admitted to hospital with an unintentional injury and 16 parents whose child had not experienced an unintentional injury requiring secondary care attendance when recruited to the study (as defined for recruiting controls for the case–control studies in work stream 1).
Data were collected using semistructured interviews. The interview topic guide was developed using findings from the systematic review of barriers to, and facilitators of, injury prevention252 described earlier in this chapter (study E). Four pilot interviews were undertaken across two study centres. Following piloting, the interview guide was adapted with minor word changes and additional prompts. Data from pilot interviews were not included in the analysis. Two versions of the interview guide were developed: one for use when interviewing parents whose child had experienced an injury and one for use with parents with an uninjured child. The guide covered five main topics: parental beliefs about injury prevention, strategies that can help to prevent injuries, parent or carer control over injury prevention actions, barriers to injury prevention actions and facilitators of injury prevention actions (see Appendix 4 for the interview guides).
Interviews lasted between 30 and 60 minutes and were conducted in the parents’ home. They were digitally recorded, anonymised prior to transcription and transcribed verbatim. Initially, data were explored for emerging themes by one researcher reading and rereading transcripts. Four transcripts were also read by a group of researchers consisting of an independent research consultant, a lay research advisor who was also a parent and two researchers from different study sites and an agreed coding structure was produced. This was applied to subsequent interview transcripts. Other emerging themes were discussed and agreed until a final set of themes was applied to all remaining interview transcripts. The coding process included identifying both confirming and disconfirming cases.324 Data analysis was facilitated using NVivo 9.
Ethics approval was granted by Nottingham Research Ethics Committee 1 (reference number 09/H0407/14).
Results
The process of selection of participants is shown in . The characteristics of the 65 children whose parents participated in the study are shown in . There illustrates wide variation in terms of child age and deprivation and good representation of both male and female children, with roughly equal numbers of children recruited across the four study sites. One interview was inaudible and was excluded from the analyses.
Recruitment to the study identifying barriers to, and facilitators of, injury prevention among parents and caregivers (study G). a, Includes eight cases subsequently found not to be eligible for study A (study C, n = 7; study G, n = 1). (more...)
Characteristics of the children whose parents participated in the study by injury mechanism
Barriers for parents undertaking injury prevention within the home
Five main themes, each with subthemes, emerged relating to barriers to injury prevention. All parents described multiple barriers. The five main themes and related subthemes were:
lack of anticipation by parents of injury-producing events and/or their consequences:
lack of anticipation that injury-producing event would occur because of child’s age and/or stage of development
anticipation of injury-producing event but lack of anticipation of the severity of injury that may occur during the event
anticipation of injury-producing events but no translation into preventative action
fatalism:
inevitable events that were impossible to prevent
falls were more likely to be viewed as inevitable than poisonings or scalds
interrupted supervision:
distractions and multitasking
maternal fatigue
number of children in the household and the presence of older siblings
difficulties of parenting alone
environmental constraints:
safety equipment cannot be relied on to prevent injury
safety equipment was not relevant for the family
cost of safety equipment
difficulties in having or using safety equipment when the property is not owned by parents
timing/targeting of safety information in relation to ages and stages of child development:
information arriving too late in relation to the ages and stages of child development
lack of safety information
feeling bombarded by safety information.
Quotations illustrating these themes and subthemes are provided in Box 3.
Barriers to parents’ injury prevention practices
Facilitators for parents undertaking injury prevention within the home
Five main themes, most of which had subthemes, emerged relating to facilitators of injury prevention. All parents described a combination of these strategies and the way that they combined these strategies altered with child age and development. The five main themes were:
anticipating and responding to injury risk:
anticipating injury risk and reducing risk through supervision
anticipating injury risk and reducing risk through separation of child and hazard
parental supervision:
never leaving the child alone
knowing where the child is and listening for silence as a cue for parental intervention
parents changed from never leaving the child alone to listening as children got older
teaching children about hazards and safety rules:
use of controlled risk as a teaching tool
explaining risk and consequences of injury
creating and adhering to safety rules
adapting the home:
minimising access to rooms perceived as particularly hazardous
placing items perceived as hazardous out of the child’s reach
installing and using safety equipment
learning from other parents’ ‘real-life’ stories:
real-life stories raise awareness and help parents anticipate injury risk.
Quotations illustrating these themes and subthemes are provided in Box 4.
Facilitators of parents’ injury prevention practices
Discussion
Main findings
The systematic review and interviews with children’s centre managers, staff and parents have enabled identification of key barriers to, and facilitators of, implementing injury prevention by children’s centres and parents. Many of these were of direct relevance to, the design of, the intervention evaluated in work stream 6 (see Chapter 7). Some were contradictory, for example the provision of high-quality training was seen as an important facilitator by children’s centre managers and staff but the systematic review found that the requirement for a large amount of training for an intervention could also be a barrier. The systematic review also found that interventions needed to have a sufficiently long intervention period and multiple contacts to be successful in changing behaviour, but these interventions were also less likely to be implemented successfully or be sustainable because of resource requirements. It was therefore clear that there were trade-offs between some facilitators and barriers, which required compromises in the design of the intervention in work stream 6.
The key findings from studies E–G relevant for the design of the intervention in work stream 6 and the sources of the findings are shown in . This illustrates the similarities and differences between the findings arising from the different sources and the value of using findings from multiple sources.
Findings relevant to the design of the injury prevention intervention and the sources of the recommendations
Strengths and limitations of these studies
The use of three different studies to explore barriers to, and facilitators of, implementing home safety interventions from the perspectives of parents and professionals has allowed us to identify themes that are important to the deliverers of injury prevention interventions and to those receiving interventions. The use of different methodologies to explore the same phenomenon provided diversity of views and allowed triangulation of data and verification across studies, enhancing the credibility of the findings. Each study also had its strengths. To our knowledge, our systematic review is the first to combine data from quantitative and qualitative studies of barriers to, and facilitators of, child home safety interventions. Likewise, to our knowledge, the study of the views of children’s centre managers and staff is the first qualitative study in its field. The wide range of roles and experiences of participants provided breadth and depth to the interview responses. The children’s centres were situated in rural, suburban and urban settings across wide geographical areas, and barriers and facilitators were broadly similar across all study centres and are likely to be generalisable to other children’s centres in England. The qualitative study of parents’ views about barriers to, and facilitators of, the prevention of children’s injuries at home is the largest to date, adding considerably to the small amount of existing qualitative evidence in this area. It includes parents of children of varying ages and socioeconomic circumstances, including both parents whose children had been injured and parents whose children had not been injured, providing a range of parental perspectives within the data. The size of this study and the inclusion of parents whose children have experienced a variety of injury mechanisms has allowed, for the first time, comparison of barriers and facilitators across injury mechanisms.
Qualitative research is increasingly being used in multicentre research programmes to help answer complex research questions.327 However, little has been written about the potential applications and limitations of the approach. Both interview studies undertaken as part of work stream 4 were conducted by a team of researchers from the four study sites. One of the main advantages of multicentre qualitative research is the additional capacity and expertise to execute the research, allowing a wide range of different perspectives to be captured.328 This can also be advantageous when recruitment is challenging, and we were able to recruit additional participants at two study centres when recruitment was lower than expected at another centre. Sharing of expertise also extended to the data analysis, whereby multiple researchers were involved in the analytical process, helping to improve the rigour of the findings.329 There are also potential limitations to undertaking qualitative research across multiple study sites. As the researcher plays a central role in eliciting information by creating ‘unique conversational spaces’,330 it is important to ensure that consistent methods are used across the research sites.328 This was achieved in the KCS programme by the use of multicentre training, the development of standard operating procedures, sharing and reading the first four transcripts between researchers coding the data and regular teleconferences, face-to-face meetings and e-mail contact.
Our review was limited, as all reviews are, by the quality of the included studies and the quality of their reporting. Our review focused on barriers and facilitators identified by authors of included studies. As these were not the primary outcome measures for most included studies, it is possible that some outcome reporting bias occurred in authors’ reports of these. Details about how authors became aware of barriers to and facilitators of the delivery of the interventions within their studies were sparse, and explicit attempts by authors to study barriers and facilitators were rare. Most studies reported on barriers and facilitators from the perspective of those delivering interventions, not from the perspective of those receiving interventions.
Our interviews with children’s centre managers and staff took place during a time of reorganisation for many children’s centres, making it difficult at times to find staff who were willing and able to participate, and a small number of interviews were curtailed because of other work pressures. Managers nominated staff members to participate in interviews, hence a selection bias may have occurred whereby particular views are under- or over-represented. The wide range of responses provided by participants would suggest that this may not have occurred to an important extent. Nominated staff tended to be more hesitant and unsure about their children’s centre’s role in injury prevention than managers, but they were able to provide information about the practical experience of delivering interventions, which was very valuable.
It is possible that the parents and children’s centre staff who agreed to take part in the interviews had a particular interest in or were motivated by the aims of the study or child safety in general and that their views may reflect this. As for other qualitative research, given its context-specific nature, it is not appropriate to generalise our findings to the wider population of parents or children’s centres. However, the maximum variation sampling, the large number of interviews conducted and the multicentre nature of both of our interview studies will have helped to obtain a wide representation of views and experiences, which should be broadly transferable to parents of young children and children’s centre staff in other disadvantaged areas of the country.
Comparisons with the published literature
Our review extends the findings of the systematic review of qualitative studies by Smithson et al.,245 who explored barriers to, and facilitators of, interventions supplying and/or installing home safety equipment and home safety risk assessments. The key facilitators, in common with those we found, were partnership working, training, policy drivers, providing culturally sensitive information and advice, providing interventions appropriate to the family’s needs and living conditions, having trusting relationships with professionals, providing education relevant to a child’s developmental stage and acknowledging mothers’ ongoing safety efforts.245 In contrast to the Smithson et al. review,245 we found that the use of behaviour change models to guide the design of interventions and focusing on fewer types of injury also acted as facilitators. Both our review and that of Smithson et al.245 identified many similar barriers including socioeconomic, cultural and language barriers, lack of control over housing and poor housing conditions and mistrust of professionals and their motives. Our review also highlighted the difficulty of providing interventions to transient populations and of achieving behavioural change with one-off educational interventions, short-lived interventions or complex interventions that require multiple concurrent behavioural changes in the face of long-held beliefs and practices and the unsustainability of interventions requiring large investments of resources or staff time. In contrast, Smithson et al.245 highlighted social isolation and poor relationships between mothers and their partners or with the household decision makers as barriers to injury prevention. Making physical changes to the home or allowing an outside agency into the home (e.g. to fit safety equipment or undertake a home safety assessment) is likely to need agreement from all adults living in the household. This may have emerged as a barrier in the Smithson et al. review,245 as it included only studies supplying or installing safety equipment or providing home safety assessments, whereas our review included studies with a much broader range of interventions.
The facilitators identified in the interviews with children’s centre managers and staff are consistent with those from our systematic review252 and Smithson et al.’s review245 regarding partnership working and engagement of families. In terms of barriers, our findings are consistent with the review findings245,252 regarding absence of local injury data, low prioritisation of injuries, short-term interventions, low literacy levels, low income levels, problems with communication between professionals and inadequate funding, resources or time. In addition, our findings are consistent with the barriers to, and facilitators of, injury prevention identified by children’s centre mangers in our national survey of children’s centres in England undertaken as part of work stream 3217 (see Chapter 4).
The findings from interviews with parents regarding barriers to injury prevention are also consistent with those from our systematic review252 and Smithson et al.’s review245 in terms of constraints from economics or living conditions, difficulties in understanding child development and anticipating injury risk, fatalistic attitudes towards injuries and mistrust of professionals, and a lack of information on child safety for parents. In terms of facilitators, our findings are consistent with those of the Smithson et al. review245 in terms of the use of ‘real-life’ injury experiences as learning opportunities for parents, the importance of supervision and the importance of timely safety information.
The findings from our review and qualitative studies are also consistent with recommendations from NICE on interventions to support changing health-related behaviours.226 Recommendations include providing interventions based on partnership working that are evidence based, tailored to individuals’ needs and developed with the target population, that enhance self-efficacy and that are based on theories or models of behaviour change.
How these findings inform other research within the Keeping Children Safe programme
The findings from studies E–G were used to inform the development of an injury prevention intervention (an IPB) for delivery by children’s centres, which was evaluated using a RCT (study M in work stream 6; see Chapter 7). Finally, the findings were used to develop a second IPB incorporating the findings from all studies in the KCS programme (see ).
