The KCS programme addressed the issue of childhood injuries occurring in the home through 13 interlinked studies, involving both quantitative and qualitative methods and including the perspectives of families, children’s centre staff, health professionals and other stakeholders with an injury prevention role. The studies took place in four sites throughout England, including both urban and rural locations and a diverse range of social areas. PPI has underpinned this research.
The research undertaken within the KCS programme generated new evidence about what works to prevent home injuries in children and the cost of such injuries, explored injury prevention practices by parents and children’s centres, reviewed and narratively synthesised and meta-analysed existing data, assessed the cost-effectiveness of a range of interventions and developed and tested an injury prevention intervention (an IPB for the prevention of fire-related injuries and training and support to implement the IPB) using a RCT. Finally, the findings from all work streams were used to develop a further IPB covering the prevention of fire-related injuries, scalds, falls and poisonings.
The KCS programme also advanced methodological approaches in the field of child home injury prevention, which will have applications in evaluating other public health interventions. This included a range of developments to NMA to simultaneously incorporate aggregate and individual participant data, adjust for baseline risk, explore effect modifiers and evaluate evidence on multiple outcomes across different networks. The IPB was developed using innovative methods to bring together evidence of effectiveness with practitioner experience of implementing interventions. The RCT evaluating the IPB incorporated a comprehensive assessment of implementation of the intervention rarely seen in child injury research, adding to our understanding of factors aiding successful implementation.
Patient and public involvement
Throughout the programme, from its design and original funding application to producing the final report and undertaking dissemination activities, we have worked collaboratively with an experienced lay research adviser (see Chapter 8). Her role developed over the course of the programme, with increasing involvement in developing and piloting study documentation and tools, undertaking data collection, participation in analysis, presenting her work at conferences, writing for publication, producing written feedback and website information for families who participated in the programme, drafting the lay summary of the final report and participating in dissemination events. We also had additional input from other lay advisers on the development and piloting of study tools.
Synergies
The KCS programme was much more than the sum of its parts. The synergies between the 13 component studies, with all studies informing at least one and often many other studies within the programme, allowed a very large body of work to be produced more quickly than would have been possible with individually funded research projects. It enabled the use of consistent approaches and the sharing of skills, resources and data between component projects. There are many examples of this within the programme and several are given here to illustrate this point. Conducting multiple overviews of reviews and systematic reviews simultaneously (studies E, H and I) allowed, when appropriate, studies identified in one review to be included in other reviews and simultaneous data extraction and risk-of-bias assessment. The collection of individual participant data for PMAs (study I) allowed the development of methods to incorporate individual participant data into NMAs (study J). Conducting five large case–control studies (study A) allowed the sharing of analysis plans and syntax files between studies, enabling consistency of analyses and reducing duplication of work. In addition, the KCS programme used simultaneous identification of participants for multiple studies (studies A–C and G), enhancing research efficiency and reducing costs. Importantly, the programme enabled learning from earlier parts to be efficiently incorporated into later parts. For example, the experiences of developing and evaluating the implementation of the IPB for the prevention of fire-related injuries (study M) allowed for the rapid development of a more comprehensive IPB, which also addressed the limitations of the first IPB.
Conclusions
The KCS programme aimed to increase evidence-based NHS thermal injury, falls and poisoning prevention by assessing risk and protective factors for these injuries, evaluating the effectiveness and cost-effectiveness of interventions to prevent these injuries, developing IPBs for effective and cost-effective interventions and evaluating the implementation of one IPB in children’s centres.
Work stream 1 found that a range of risk factors were significantly associated with secondary care-attended falls from furniture, falls on stairs or steps, poisonings and scalds in children aged 0–4 years. Only two modifiable risk factors were significantly associated with secondary care-attended falls on one level in children aged 0–4 years.
Work stream 2 found that the PedsQL was a feasible and acceptable measure of HRQL in young children following injury, with adequate internal consistency reliability, the ability to discriminate between varying levels of injury severity and sequelae and evidence of responsiveness to change. Findings in respect of construct validity were equivocal. In terms of the health-care costs of injury, scalds had the highest mean total cost for ED attendances and admissions for observation. Poisonings had the lowest mean total cost for ED attendances and falls on one level had the lowest mean total cost for admissions for observation. The number of admissions requiring at least one overnight stay was too small to reliably estimate health-care costs. In terms of non-health-care costs, informal child care and time off work were the major contributors and could be considerable. Scalds had the highest mean non-health-care costs and falls on one level had the lowest mean non-health-care costs.
Work stream 3 found that most children’s centres did not use an evidence-based strategic approach and child injury prevention appeared to be a neglected area within children’s centres given the scale of the problem. To ensure effective injury prevention children’s centres need support to plan, deliver and evaluate their activities, and centres would welcome such support.
Work stream 4 found a range of barriers to and facilitators of parents preventing child injuries in the home and those delivering injury prevention programmes. Many of these barriers and facilitators are addressable during the design of injury prevention interventions. The effect of addressing these barriers and facilitators on the degree of implementation of injury prevention programmes and on the outcomes of such programmes requires evaluation.
Work stream 5 found that some interventions were effective and some were both effective and cost-effective in promoting home safety and preventing fire-related injuries, scalds, falls and poisonings. More intensive interventions (e.g. those providing education and free or low-cost safety equipment and in some cases fitting equipment and providing home safety inspections) were more likely to be effective than less intensive interventions for promoting functional smoke alarms, having a safe hot water temperature, use of safety gates on stairs and the safe storage of medicines and household products. The most effective interventions were not necessarily the most cost-effective. Decision analyses were conducted from a public sector perspective and included costs incurred by different stakeholders including NHS and non-NHS organisations. However, analyses were limited to HRQL outcomes expressed in terms of QALYs and future studies may want to consider both welfare and quality of life more broadly (e.g. a cost–consequence analysis or a multicriteria decision-making approach), but thresholds would need careful consideration as it is unclear whether or not a threshold of £30,000 per QALY gained is relevant to different sectors of the economy beyond health care.
Work stream 6 identified factors associated with successful implementation of health promotion interventions and incorporated this evidence, along with that from earlier work streams, into the development of an IPB for the prevention of fire-related injuries and a package of training and support to facilitate its implementation in children’s centres. Providing children’s centres with the IPB and a training and facilitation package to support its implementation, designed to address barriers to and facilitators of injury prevention, was effective in increasing some safety behaviours. Providing children’s centres with the IPB alone was marginally more effective and cost less than usual care, whereas providing the IPB with support (IPB+) was marginally more effective but more costly than usual care. Findings from all work streams were used to develop a more comprehensive IPB for the prevention of fire-related injuries, scalds, falls and poisonings.
Dissemination and impact
The extensive programme of research undertaken within the KCS programme has synthesised existing evidence and generated new evidence about preventing fire-related injuries, scalds, falls and poisonings. It has developed and tested evidence-based resources for preventing child injury. Evidence generated by the KCS programme has already informed the evidence update for the NICE guidelines on strategies to prevent unintentional injuries in children and young people aged < 15 years,26 Public Health England guidance for local authorities on reducing unintentional injuries in and around the home in children aged < 5 years1 and the CMO’s annual report for 2012.11 In addition, it has informed local injury prevention strategies497 and successful bids for home safety equipment schemes.497,498
We developed a standard operating procedure for communications and publications and a plan for dissemination of the KCS programme findings. These identified target audiences including:
child health policy-makers
child health commissioners
child health and child care practitioners
injury prevention practitioners
voluntary sector, charitable and partner organisations such as the fire and rescue services
study participants and the wider population of families with young children
researchers.
We will use a wide range of methods to reach these audiences including:
targeted audience-specific feedback for strategic bodies (e.g. Department of Health, Department for Education, Public Health England, strategic directors/directors of public health in local authorities, strategic directors in commissioning bodies), professional bodies (e.g. Faculty of Public Health, Royal College of Paediatrics and Child Health, British Association for Community Child Health, British Association for Child and Adolescent Public Health, Community Practitioners and Health Visitors Association) and other organisations (e.g. Local Government Association, Royal Society for Public Health, Association of Directors of Public Health, Association of Public Health Observatories, Injury Observatory for Britain and Ireland)
articles in practitioner publications targeting local authorities, health commissioners and providers, voluntary organisations and the charity sector
presentations at conferences for practitioner audiences
articles for and newsletters to local authorities, health commissioners and providers, injury prevention practitioners and participants
peer-reviewed publications in academic journals in the fields of injury epidemiology and prevention, child health, public health, health promotion and research methods
presentations at academic conferences
existing distribution networks (Child Accident Prevention Trust, RoSPA, Kid Rapt, Injury Prevention News, etc.).
Dissemination activities to date include 37 peer-reviewed papers from the KCS programme, with a further one in press, 42 presentations at national conferences and nine at international conferences. There have been seven press releases about the KCS programme and its publications and 11 newspaper articles. Four dissemination events were held, one in each study centre, for children’s centre staff and other groups with a child health or injury prevention role (e.g. health visiting team staff, fire and rescue service staff, local authority public health staff) to provide information on the findings form the KCS programme. A total of 166 people attended these events.
The IPB for the prevention of fire-related injuries, scalds, falls and poisonings is one of the key outputs of the KCS programme. It has been made freely available on the KCS programme website (see www.nottingham.ac.uk/research/groups/injuryresearch/projects/kcs/index.aspx) and will be widely disseminated to relevant audiences electronically. The IPB has also been provided (with training in how to use it) to the children’s centres that participated in the RCT in the KCS programme. In addition, the KCS programme team secured external funding to provide the IPB (with training) for up to 180 health and child care staff in Nottinghamshire and 190 health and child care staff, fire and rescue service staff, voluntary sector organisations, early years professionals and health visiting students in Bristol. Furthermore, the Nottingham KCS programme team have secured funding for the injury prevention component of Nottingham CityCare Partnership’s successful Big Lottery bid (Small Steps Big Changes programme) (www.nottinghamcitycare.nhs.uk/ssbc/). This project aims to provide systematic evidence-based injury prevention appropriate to the age and stage of development for all families with children aged 0–3 years in the most disadvantaged areas of the city. The IPB will form part of the intervention and will be provided with training to 200 health and child care professionals, voluntary organisations, peer supporters and graduates from the Family Nurse Partnership programme who will deliver the injury prevention programme. The project evaluation will be undertaken by a team of researchers, including some from the KCS programme.
The lay research advisor for the KCS programme has drafted web pages reporting the main findings from the KCS programme for the KCS programme website and leaflets describing the main findings and giving the address for those web pages. Leaflets are being mailed to > 9600 families who participated in the KCS programme. The Nottingham and Bristol KCS programme teams have participated in university open days for the public, providing information on findings from the KCS programme.
A guide for commissioners of child health services on preventing unintentional injuries to the under-fives has been produced in collaboration with the Child Accident Prevention Trust and disseminated to all directors of public health in England. The guide is available online (www.nottingham.ac.uk/research/groups/injuryresearch/documents/kcs-guide-for-commissioners.pdf).
