Effects of fully-established Sure Start Local Programmes on 3-year-old children and their families living in England: a quasi-experimental observational study

Health and development of children born after assisted reproductive technology and sub-fertility compared to naturally conceived children: data from a national study

In a non-matched case-control study using data from two large national cohort studies, we investigated whether indicators of child health and development up to 7 years of age differ between children conceived using assisted reproductive technology (ART), children born after sub-fertility (more than 24 months of trying for conception) and other children. Information on ART use/sub-fertility was available for 23,649 children. There were 227 cases (children conceived through ART) and two control groups: 783 children born to sub-fertile couples, and 22,639 children born to couples with no fertility issues. In models adjusted for social and demographic factors there were significant differences between groups in rate of hospital admissions before the children were 9 months old (P=0.029), with the ART group showing higher rates of hospital admission than the no fertility issues control group, the sub-fertile control group being intermediate between the two. Children born after ART had comparable health and development beyond 9 months of age to their naturally conceived peers. This applied to the whole sample and to a sub-sample of children from deprived neighborhoods.

Explaining ecological clusters of maternal depression in South Western Sydney

BACKGROUND

The aim of the qualitative study reported here was to: 1) explain the observed clustering of postnatal depressive symptoms in South Western Sydney; and 2) identify group-level mechanisms that would add to our understanding of the social determinants of maternal depression.

METHODS

Critical realism provided the methodological underpinning for the study. The setting was four local government areas in South Western Sydney, Australia. Child and Family practitioners and mothers in naturally occurring mothers groups were interviewed.

RESULTS

Using an open coding approach to maximise emergence of patterns and relationships we have identified seven theoretical concepts that might explain the observed spatial clustering of maternal depression. The theoretical concepts identified were: Community-level social networks; Social Capital and Social Cohesion; "Depressed community"; Access to services at the group level; Ethnic segregation and diversity; Supportive social policy; and Big business.

CONCLUSIONS

We postulate that these regional structural, economic, social and cultural mechanisms partially explain the pattern of maternal depression observed in families and communities within South Western Sydney. We further observe that powerful global economic and political forces are having an impact on the local situation. The challenge for policy and practice is to support mothers and their families within this adverse regional and global-economic context.

National survey of the injury prevention activities of children's centres

Children's centres were established across England to provide a range of services including early education, social care and health to pre-school children and their families. We surveyed children's centres to ascertain the activities they were undertaking to prevent unintentional injuries in the under fives. A postal questionnaire was sent to a sample of children's centre managers (n = 694). It included questions on current activities, knowledge and attitudes to injury prevention, health priorities and partnership working. Responses were received from 384 (56%) children's centres. Overall, 58% considered unintentional injury prevention to be one of the three main child health priorities for their centre. Over half the respondents (59%) did not know if there was an injury prevention group in their area, and 21% did not know if there was a home safety equipment scheme. Knowledge of how child injury deaths occur in the home was poor. Only 11% knew the major cause of injury deaths in children under five. Lack of both staff time and funding were seen as important barriers by children's centre staff to undertake injury prevention activities. Nearly all stated that training (97%) and assistance with planning injury prevention (94%) would be helpful to their centres. Children's centres need further support if they are to effectively tackle this important public health area.

Neighborhood socioeconomic circumstances and the co-occurrence of unhealthy lifestyles: evidence from 206,457 Australians in the 45 and up study

BACKGROUND

Research on the co-occurrence of unhealthy lifestyles has tended to focus mainly upon the demographic and socioeconomic characteristics of individuals. This study investigated the relevance of neighborhood socioeconomic circumstance for multiple unhealthy lifestyles.

METHOD

An unhealthy lifestyle index was constructed for 206,457 participants in the 45 and Up Study (2006-2009) by summing binary responses on smoking, alcohol, physical activity and five diet-related variables. Higher scores indicated the co-occurrence of unhealthy lifestyles. Association with self-rated health, quality of life; and risk of psychological distress was investigated using multilevel logistic regression. Association between the unhealthy lifestyle index with neighborhood characteristics (local affluence and geographic remoteness) were assessed using multilevel linear regression, adjusting for individual-level characteristics.

RESULTS

Nearly 50% of the sample reported 3 or 4 unhealthy lifestyles. Only 1.5% reported zero unhealthy lifestyles and 0.2% had all eight. Compared to people who scored zero, those who scored 8 (the 'unhealthiest' group) were 7 times more likely to rate their health as poor (95%CI 3.6, 13.7), 5 times more likely to report poor quality of life (95%CI 2.6, 10.1), and had a 2.6 times greater risk of psychological distress (95%CI 1.8, 3.7). Higher scores among men decreased with age, whereas a parabolic distribution was observed among women. Neighborhood affluence was independently associated with lower scores on the unhealthy lifestyle index. People on high incomes scored higher on the unhealthy lifestyle index if they were in poorer neighborhoods, while those on low incomes had fewer unhealthy lifestyles if living in more affluent areas.

INTERPRETATION

Residents of deprived neighborhoods tend to report more unhealthy lifestyles than their peers in affluent areas, regardless of their individual demographic and socioeconomic characteristics. Future research should investigate the trade-offs of population-level versus geographically targeted multiple lifestyle interventions.

Using natural experiments to evaluate population health interventions: new Medical Research Council guidance

Natural experimental studies are often recommended as a way of understanding the health impact of policies and other large scale interventions. Although they have certain advantages over planned experiments, and may be the only option when it is impossible to manipulate exposure to the intervention, natural experimental studies are more susceptible to bias. This paper introduces new guidance from the Medical Research Council to help researchers and users, funders and publishers of research evidence make the best use of natural experimental approaches to evaluating population health interventions. The guidance emphasises that natural experiments can provide convincing evidence of impact even when effects are small or take time to appear. However, a good understanding is needed of the process determining exposure to the intervention, and careful choice and combination of methods, testing of assumptions and transparent reporting is vital. More could be learnt from natural experiments in future as experience of promising but lesser used methods accumulates.

Home safety education and provision of safety equipment for injury prevention

BACKGROUND

In industrialised countries injuries (including burns, poisoning or drowning) are the leading cause of childhood death and steep social gradients exist in child injury mortality and morbidity. The majority of injuries in pre-school children occur at home but there is little meta-analytic evidence that child home safety interventions reduce injury rates or improve a range of safety practices, and little evidence on their effect by social group.

OBJECTIVES

We evaluated the effectiveness of home safety education, with or without the provision of low cost, discounted or free equipment (hereafter referred to as home safety interventions), in reducing child injury rates or increasing home safety practices and whether the effect varied by social group.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2009, Issue 2) in The Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Social Sciences Citation Index (SSCI), ISI Web of Science: Conference Proceedings Citation Index- Science (CPCI-S), CINAHL (EBSCO) and DARE (2009, Issue 2) in The Cochrane Library. We also searched websites and conference proceedings and searched the bibliographies of relevant studies and previously published reviews. We contacted authors of included studies as well as relevant organisations. The most recent search for trials was May 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs), non-randomised controlled trials and controlled before and after (CBA) studies where home safety education with or without the provision of safety equipment was provided to those aged 19 years and under, and which reported injury, safety practices or possession of safety equipment.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. We attempted to obtain individual participant level data (IPD) for all included studies and summary data and IPD were simultaneously combined in meta-regressions by social and demographic variables. Pooled incidence rate ratios (IRR) were calculated for injuries which occurred during the studies, and pooled odds ratios were calculated for the uptake of safety equipment or safety practices, with 95% confidence intervals.

MAIN RESULTS

Ninety-eight studies, involving 2,605,044 people, are included in this review. Fifty-four studies involving 812,705 people were comparable enough to be included in at least one meta-analysis. Thirty-five (65%) studies were RCTs. Nineteen (35%) of the studies included in the meta-analysis provided IPD.There was a lack of evidence that home safety interventions reduced rates of thermal injuries or poisoning. There was some evidence that interventions may reduce injury rates after adjusting CBA studies for baseline injury rates (IRR 0.89, 95% CI 0.78 to 1.01). Greater reductions in injury rates were found for interventions delivered in the home (IRR 0.75, 95% CI 0.62 to 0.91), and for those interventions not providing safety equipment (IRR 0.78, 95% CI 0.66 to 0.92).Home safety interventions were effective in increasing the proportion of families with safe hot tap water temperatures (OR 1.41, 95% CI 1.07 to 1.86), functional smoke alarms (OR 1.81, 95% CI 1.30 to 2.52), a fire escape plan (OR 2.01, 95% CI 1.45 to 2.77), storing medicines (OR 1.53, 95% CI 1.27 to 1.84) and cleaning products (OR 1.55, 95% CI 1.22 to 1.96) out of reach, having syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.44) or poison control centre numbers accessible (OR 3.30, 95% CI 1.70 to 6.39), having fitted stair gates (OR 1.61, 95% CI 1.19 to 2.17), and having socket covers on unused sockets (OR 2.69, 95% CI 1.46 to 4.96).Interventions providing free, low cost or discounted safety equipment appeared to be more effective in improving some safety practices than those interventions not doing so. There was no consistent evidence that interventions were less effective in families whose children were at greater risk of injury.

AUTHORS' CONCLUSIONS

Home safety interventions most commonly provided as one-to-one, face-to-face education, especially with the provision of safety equipment, are effective in increasing a range of safety practices. There is some evidence that such interventions may reduce injury rates, particularly where interventions are provided at home. Conflicting findings regarding interventions providing safety equipment on safety practices and injury outcomes are likely to be explained by two large studies; one clinic-based study provided equipment but did not reduce injury rates and one school-based study did not provide equipment but did demonstrate a significant reduction in injury rates. There was no consistent evidence that home safety education, with or without the provision of safety equipment, was less effective in those participants at greater risk of injury. Further studies are still required to confirm these findings with respect to injury rates.

The health and development of children born to older mothers in the United Kingdom: observational study using longitudinal cohort data

OBJECTIVE

To assess relations between children's health and development and maternal age.

DESIGN

Observational study of longitudinal cohorts.

SETTING

Millennium Cohort Study (a random sample of UK children) and the National Evaluation of Sure Start study (a random sample of children in deprived areas in England), 2001 to 2007.

PARTICIPANTS

31,257 children at age 9 months, 24,781 children at age 3 years, and 22,504 at age 5 years.

MAIN OUTCOME MEASURES

Childhood unintentional injuries and hospital admissions (aged 9 months, 3 years, and 5 years), immunisations (aged 9 months and 3 years), body mass index, language development, and difficulties with social development (aged 3 and 5 years).

RESULTS

Associations were independent of personal and family characteristics and parity. The risk of children having unintentional injuries requiring medical attention or being admitted to hospital both declined with increasing maternal age. For example, at three years the risk of unintentional injuries declined from 36.6% for mothers aged 20 to 28.6% for mothers aged 40 and hospital admissions declined, respectively, from 27.1% to 21.6%. Immunisation rates at nine months increased with maternal age from 94.6% for mothers aged 20 to 98.1% for mothers aged 40. At three years, immunisation rates reached a maximum, at 81.3% for mothers aged 27, being lower for younger and older mothers. This was linked to rates for the combined measles, mumps, and rubella immunisation because excluding these resulted in no significant relation with maternal age. An increase in overweight children at ages 3 and 5 years associated with increasing maternal age was eliminated once maternal body mass index was included as a covariate. Language development was associated with improvements with increasing maternal age, with scores for children of mothers aged 20 being lower than those of children of mothers aged 40 by 0.21 to 0.22 standard deviations at ages 3 and 4 years. There were fewer social and emotional difficulties associated with increasing maternal age. Children of teenage mothers had more difficulties than children of mothers aged 40 (difference 0.28 SD at age 3 and 0.16 SD at age 5).

CONCLUSION

Increasing maternal age was associated with improved health and development for children up to 5 years of age.

The Well London program--a cluster randomized trial of community engagement for improving health behaviors and mental wellbeing: baseline survey results

BACKGROUND

The Well London program used community engagement, complemented by changes to the physical and social neighborhood environment, to improve physical activity levels, healthy eating, and mental wellbeing in the most deprived communities in London. The effectiveness of Well London is being evaluated in a pair-matched cluster randomized trial (CRT). The baseline survey data are reported here.

METHODS

The CRT involved 20 matched pairs of intervention and control communities (defined as UK census lower super output areas (LSOAs); ranked in the 11% most deprived LSOAs in London by the English Indices of Multiple Deprivation) across 20 London boroughs. The primary trial outcomes, sociodemographic information, and environmental neighbourhood characteristics were assessed in three quantitative components within the Well London CRT at baseline: a cross-sectional, interviewer-administered adult household survey; a self-completed, school-based adolescent questionnaire; a fieldworker completed neighborhood environmental audit. Baseline data collection occurred in 2008. Physical activity, healthy eating, and mental wellbeing were assessed using standardized, validated questionnaire tools. Multiple imputation was used to account for missing data in the outcomes and other variables in the adult and adolescent surveys.

RESULTS

There were 4,107 adults and 1,214 adolescent respondents in the baseline surveys. The intervention and control areas were broadly comparable with respect to the primary outcomes and key sociodemographic characteristics. The environmental characteristics of the intervention and control neighborhoods were broadly similar. There was greater between-cluster variation in the primary outcomes in the adult population compared to the adolescent population. Levels of healthy eating, smoking, and self-reported anxiety/depression were similar in the Well London adult population and the national Health Survey for England. Levels of physical activity were higher in the Well London adult population but this is likely to be due to the different measurement tools used in the two surveys.

CONCLUSIONS

Randomization of social interventions such as Well London is acceptable and feasible and in this study the intervention and control arms are well-balanced with respect to the primary outcomes and key sociodemographic characteristics. The matched design has improved the statistical efficiency of the study amongst adults but less so amongst adolescents. Follow-up data collection will be completed 2012.

Implementation of new Healthy Conversation Skills to support lifestyle changes - what helps and what hinders? Experiences of Sure Start Children's Centre staff

Effective communication is necessary for good relationships between healthcare practitioners and clients. This study examined barriers and facilitators to implementing new communication skills. One hundred and ten Sure Start Children's Centre staff attended one of 13 follow-up workshops in Southampton, UK between May 2009 and February 2011 to reflect on the use of new skills following a training course in communication, reflection and problem-solving. Barriers and facilitators were assessed with an adapted Problematic Experiences of Therapy scale (PETS). Staff reported frequency of skill use, and described what made it more difficult or easier to use the skills. Complete data were available for 101 trainees. The PETS indicated that staff had confidence in using the skills, but felt that there were practical barriers to using them, such as lack of time. Skills were used less often when staff perceived parents not to be engaging with them (Spearman's correlation r(s) = -0.42, P < 0.001), when staff felt less confident to use the skills (r(s) = -0.37, P < 0.001) and when there were more practical barriers (r(s) = -0.37, P < 0.001). In support of findings from the PETS, content analysis of free text responses suggested that the main barrier was a perceived lack of time to implement new skills. Facilitators included seeing the benefits of using the skills, finding opportunities and having good relationships with parents. Understanding the range of barriers and facilitators to implementation is essential when developing training to facilitate ongoing support and sustain skill use. Special attention should be given to exploring trainees' perceptions of time, to be able to address this significant barrier to skill implementation. Staff training requires a multi-faceted approach to address the range of perceived barriers.

Parental characteristics associated with childcare use during the first 4 years of life: results from a representative cohort of Québec families

OBJECTIVE

Studies have shown that children growing up in socio-economically disadvantaged families have poorer cognitive scores than children growing up in more advantaged families, and that high-quality childcare services can reduce this gap. This effect may be attenuated, however, if disadvantaged families are less likely than better-off families to use childcare and if they use childcare of lower quality. The aim of this study was to identify factors related to parental decisions to use formal and informal childcare.

METHODS

Data were obtained from the Quebec Longitudinal Study of Child Development, a birth cohort of children born in 1997/1998 in the Canadian province of Quebec (n=1,504). Children receiving formal (e.g., family and centre) and informal (e.g., grandparents, aunt, nanny) childcare from 5 months to 4 years of age were compared to those receiving exclusively parental care on key psycho-socio-economic family factors.

RESULTS

Maternal unemployment during pregnancy, younger maternal age (at initiation of childbearing) and higher number of siblings (e.g., > or = 2) were related to a lower probability of a child receiving either formal or informal childcare (compared to parental care). In addition, low levels of maternal education, higher levels of overprotection, and lower levels of home stimulation were related to a lower probability of a child receiving formal childcare, but not informal childcare. Insufficient income was not associated with childcare use.

CONCLUSION

Maternal education and maternal employment were the main socio-economic barriers to childcare participation in a province offering low-cost childcare services. Future initiatives may consider prioritizing childcare access to underserved children and other (e.g., literacy-based) interventions to facilitate access.

Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years

BACKGROUND

Early-onset child conduct problems are common and costly. A large number of studies and some previous reviews have focused on behavioural and cognitive-behavioural group-based parenting interventions, but methodological limitations are commonplace and evidence for the effectiveness and cost-effectiveness of these programmes has been unclear.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of behavioural and cognitive-behavioural group-based parenting programmes for improving child conduct problems, parental mental health and parenting skills.

SEARCH METHODS

We searched the following databases between 23 and 31 January 2011: CENTRAL (2011, Issue 1), MEDLINE (1950 to current), EMBASE (1980 to current), CINAHL (1982 to current), PsycINFO (1872 to current), Social Science Citation Index (1956 to current), ASSIA (1987 to current), ERIC (1966 to current), Sociological Abstracts (1963 to current), Academic Search Premier (1970 to current), Econlit (1969 to current), PEDE (1980 to current), Dissertations and Theses Abstracts (1980 to present), NHS EED (searched 31 January 2011), HEED (searched 31 January 2011), DARE (searched 31 January 2011), HTA (searched 31 January 2011), mRCT (searched 29 January 2011). We searched the following parent training websites on 31 January 2011: Triple P Library, Incredible Years Library and Parent Management Training. We also searched the reference lists of studies and reviews.

SELECTION CRITERIA

We included studies if: (1) they involved randomised controlled trials (RCTs) or quasi-randomised controlled trials of behavioural and cognitive-behavioural group-based parenting interventions for parents of children aged 3 to 12 years with conduct problems, and (2) incorporated an intervention group versus a waiting list, no treatment or standard treatment control group. We only included studies that used at least one standardised instrument to measure child conduct problems.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias in the trials and the methodological quality of health economic studies. Two authors also independently extracted data. We contacted study authors for additional information.

MAIN RESULTS

This review includes 13 trials (10 RCTs and three quasi-randomised trials), as well as two economic evaluations based on two of the trials. Overall, there were 1078 participants (646 in the intervention group; 432 in the control group). The results indicate that parent training produced a statistically significant reduction in child conduct problems, whether assessed by parents (standardised mean difference (SMD) -0.53; 95% confidence interval (CI) -0.72 to -0.34) or independently assessed (SMD -0.44; 95% CI -0.77 to -0.11). The intervention led to statistically significant improvements in parental mental health (SMD -0.36; 95% CI -0.52 to -0.20) and positive parenting skills, based on both parent reports (SMD -0.53; 95% CI -0.90 to -0.16) and independent reports (SMD -0.47; 95% CI -0.65 to -0.29). Parent training also produced a statistically significant reduction in negative or harsh parenting practices according to both parent reports (SMD -0.77; 95% CI -0.96 to -0.59) and independent assessments (SMD -0.42; 95% CI -0.67 to -0.16). Moreover, the intervention demonstrated evidence of cost-effectiveness. When compared to a waiting list control group, there was a cost of approximately $2500 (GBP 1712; EUR 2217) per family to bring the average child with clinical levels of conduct problems into the non-clinical range. These costs of programme delivery are modest when compared with the long-term health, social, educational and legal costs associated with childhood conduct problems.

AUTHORS' CONCLUSIONS

Behavioural and cognitive-behavioural group-based parenting interventions are effective and cost-effective for improving child conduct problems, parental mental health and parenting skills in the short term. The cost of programme delivery was modest when compared with the long-term health, social, educational and legal costs associated with childhood conduct problems. Further research is needed on the long-term assessment of outcomes.

Parenting practices and intergenerational associations in cognitive ability

BACKGROUND

Cognitive ability is an important contributor to life chances, with implications for cycles of advantage or disadvantage across generations. Parenting practices are known to influence offspring cognitive development, but the extent to which these mediate intergenerational continuities and discontinuities in cognitive ability has not been adequately studied.

METHODS

We used factor analysis to derive summary measures of parenting practices, and regression analyses and path modelling to test associations between these and cognitive function at age 8 years in 1690 first offspring of the British 1946 birth cohort. Analyses allowed for direct and indirect effects of parental original and achieved social circumstances, educational attainment and own childhood cognitive ability. Additional covariates were provided by indicators of parental physical and mental health.

RESULTS

Regression analyses revealed that three aspects of parenting, intellectual home environment, parental aspiration and cognitive stimulation, were positively and independently associated with offspring childhood cognitive ability, whereas coercive discipline was negatively and independently associated. Path modelling was appropriate for intellectual environment, which also revealed direct and indirect effects of parental cognitive ability and educational and occupational attainment on offspring cognitive ability.

CONCLUSION

Parenting practices, particularly provision of an intellectual environment, were directly associated with offspring cognitive development. These data add to the relatively few studies that examine intergenerational continuity and discontinuity in cognitive ability.

The characteristics of mobile families with young children in England and the impact of their moves on neighbourhood inequalities in maternal and child health

This study compares the health and socio-demographic characteristics of residentially mobile families with young children in England to families that do not move and assesses the impact of their moves upon inequalities in health between neighbourhoods. The analysis uses data from the first two waves of the Millennium Cohort Study describing 9022 cohort members, born in 2000-2002, and their families. A third of the families moved between the waves of the survey when the children were aged nine months and three years. Mobile families moved disproportionately toward less deprived areas but had disadvantaged socio-economic characteristics and poor outcomes for infant's birth weight and accidents and mother's self-rated health, limiting longstanding illness and mental health. Health outcomes were worst among the minority moving to more deprived neighbourhoods. Families' moves moderately increased health inequalities between neighbourhoods with high and low deprivation.

Home visitors and child health in England: advances and challenges

There is increasing interest in the early years as a focus for reducing health inequalities as well as one that is important for the children themselves. This paper describes the introduction in England of Sure Start Local Programmes, which included home visiting within a community development approach, and an intensive home visiting programme, the Nurse-Family partnership, for disadvantaged teenage mothers. It reflects on changes and challenges in service provision to mothers and their pre-school children in England, explaining that a long tradition of home visiting was, paradoxically, reduced as attention focused on the newer initiatives. This is now being addressed, with attention to a range of evidence based programmes and a specific focus on heath visitor provision.

Neighborhood characteristics and mental health: the relevance for mothers of infants in deprived English neighborhoods

PURPOSE

Neighborhood features have been linked with adult mental-health problems, particularly depression. A recent comprehensive review indicated structural neighborhood features derived from data sources such as the census may be less important predictors of mental health problems than social processes but that most studies lack multiple neighborhood measures. The aim of the study is to investigate relations between multiple neighborhood factors (observations, interviewer ratings, UK Census data) and maternal mental-health problems.

METHODS

14,700 mothers with 9-month-old infants living in 195 deprived neighborhoods in England were interviewed, neighborhoods were observed and census data on employment, ethnic background and housing tenancy utilized.

RESULTS

Lower (interviewer-rated) neighborhood quality and lower neighborhood prosperity predicted more mother-reported mental-health problems net of family-level predictors. Contrary to expectations detailed observations did not contribute additionally.

CONCLUSIONS

Neighborhood conditions, though not as important as family factors and maternal characteristics, are sufficiently important to consider when planning mental health services; they can be assessed at relatively low cost by census data or professionals' ratings.

A mixed-methods investigation to explore how women living in disadvantaged areas might be supported to improve their diets

Mixed-methods explored the potential for using Sure Start Children's Centres (SSCCs) to deliver an intervention to improve the diets of disadvantaged women and their children. In an 'expert' discussion, SSCC staff described gaining women's trust, meeting needs and bringing about change as key to engaging women successfully. Structured observations in SSCCs showed they host activities in an environment conducive to building relationships and meeting women's needs. However, staff often missed opportunities to support women to make dietary changes. These data suggest that an intervention to help staff make the most of these opportunities would have the best chance of success.

Using matched areas to explore international differences in population health

In this paper, we develop and test a method for examining the influence of national level contextual influences on population health. Acknowledging calls for the use of experimental study designs to explore contextual influences on health, we develop a study design in which sets of local areas from Britain and Belgium became akin to two 'treatment' groups; one exposed to British society and culture and the other exposed to Belgian society and culture. The areas are matched on the basis of showing very strong similarities in economic, demographic and historical characteristics. Data describing these characteristics are obtained from national census data. A principal component analysis of these variables permits areas in Britain and Belgium with similar scores on the resulting components to be matched into pairs. A sequence of logistic regression models identifies between-country difference in the risk of reporting poor health. Our final model compares the risk of reporting poor health among Belgians and people from Britain living in similar local contexts, adjusting for any residual differences in individual level characteristics. We compare results from this new method with those from more conventional approaches. All approaches show that residence in Britain is associated with a substantial and significantly higher risk of reporting poor health for both men and women, after adjustment for both individual and local contextual influences. We then critically reflect on our method and on the context-composition framework for research into area variation in health. We conclude that whilst our approach succeeded in applying the idea of comparable groups with different exposures to an observational, international comparison, it also brought associated questions about external validity and the extent to which a sample of matched areas captures a 'national' context.

The use and reporting of multiple imputation in medical research - a review

BACKGROUND

Multiple imputation (MI) is an advanced, principled method of dealing with missing data in statistical analyses, a common problem in medical research. This paper sought to document the use of MI in general medical journals and to evaluate the information provided to readers about the application of the procedure in studies.

METHODS

Research articles using MI in analyses published in JAMA, New England Journal of Medicine, BMJ and the Lancet were identified using full text searches from the earliest date each journal offered such searches until the end of 2008. Ninety-nine articles were found. Studies were classified according to their design.

RESULTS

Multiple imputation was used in 49 RCTs and 50 other types of studies. A third of the articles (n = 33) reported no details of the procedure used. In a third of these (n = 11), it was not possible to infer the approach used from references cited or software used. The nature of the imputation model was rarely reported. MI was frequently used as a secondary analysis (n = 40) either to justify reporting a simpler approach or as a form of sensitivity analysis.

CONCLUSIONS

Whilst still relatively uncommon, the use of MI has risen substantially, particularly in trials. MI is rarely adequately reported, leading to doubt about its appropriateness in some cases. This gives rise to uncertainty about conclusions reached and poses a barrier to attempts to replicate analyses. Guidelines for the reporting of MI should be developed.

[Social inequalities in child health. SESPAS report 2010]

There is considerable evidence of the impact of poverty and social exclusion on child health. In the last few years, interest has grown in the concept of social gradients in health, according to social position, family educational level, gender, and ethnic background. Several cohort studies have demonstrated an association between maternal socioeconomic position during the prenatal period and adult health. The Commission on Social Determinants of Health of the World Health Organization proposed closing the health gap in a generation by giving a major role to early child development. Family educational level and academic achievement are fundamental determinants of health inequalities. There is scarce empirical evidence on the effectiveness of interventions to reduce child health inequalities. Most of the interventions in children and adolescents aim to change individual behavior, and very few have been critically evaluated. The present manuscript provides a review of initiatives and recent interventions aimed at reducing social inequalities, as well as a checklist to be taken into account in interventions on health promotion and disease prevention in schools from the perspective of social and gender inequalities. Strategies for data collection, research and health and educational policies are proposed.

A rapid review of key strategies to improve the cognitive and social development of children in Scotland

OBJECTIVES

Inequalities in health and educational outcomes in Scotland show a strong and persistent socioeconomic status gradient. Our aims were to provide policy-makers with a synthesis of international research evidence that assesses the effectiveness of early childhood interventions aimed at equitably promoting cognitive and social development and suggest potential areas for action in Scotland.

METHODS

A rapid review was conducted of review level studies of early childhood interventions with outcome measures relating to child cognitive-language or social-emotional development, subsequent academic and life achievement. Websites were searched and interviews were conducted to identify relevant interventions, policies and programmes delivered in Scotland.

RESULTS

: Early childhood intervention programmes can reduce disadvantage due to social and environmental factors. Scottish health policy demonstrates a clear commitment to early childhood development but much work remains in terms of detail of policy implementation, identification of high risk children and families, and early childhood monitoring systems.

CONCLUSIONS

Programmes should provide a universal seamless continuum of care and support from pregnancy through to school entry with the intensity of support graded according to need. The current information systems in Scotland would be inadequate for monitoring the effects of early childhood interventions especially in relation to cognitive-language and social-emotional development.

Child Health Partnerships: a review of program characteristics, outcomes and their relationship

Background

Novel approaches are increasingly employed to address the social determinants of health of children world-wide. Such approaches have included complex social programs involving multiple stakeholders from different sectors jointly working together (hereafter Child Health Partnerships). Previous reviews have questioned whether these programs have led to significant improvements in child health and related outcomes. We aim to provide definitive answers to this question as well as identifying the characteristics of successful partnerships.

Methods

A comprehensive literature search identified 11 major Child Health Partnerships in four comparable developed countries. A critical review is focused on various aspects of these including their target groups, program mechanics and outcomes.

Results and Conclusions

There was evidence of success in several major areas from the formation of effective joint operations of partners in different partnership models to improvement in both child wellbeing and parenting. There is emerging evidence that Child Health Partnerships are cost-effective. Population characteristics and local contexts need to be taken into account in the introduction and implementation of these programs.

Evaluating health impacts: Results from the neighbourhood renewal strategy [corrected] in Victoria, Australia

AIMS

Neighbourhood Renewal [NR] Strategy is currently underway in the Victoria's most disadvantaged neighbourhoods. Neighbourhood Renewal utilises an 'area-based' approach to reducing inequalities between NR sites and the Victorian state average across a range of social, educational and health outcomes. We examine the impact of this intervention on health and life satisfaction in the five metropolitan sites involved in first phase of the project.

DESIGN

We employed a before-and-after study design using two cross sectional community surveys to assess changes in health and life satisfaction. The study sample includes people living in NR areas and people living in other areas of the same Local Government Area (LGA). Survey responses from the five metropolitan NR and their surrounding were used in this analysis.

RESULTS

NR residents involved in the program had worse health than people living in the LGA in all analyses. There was no evidence of an NR effect at a whole of area level. However, the health (OR=2.15, 95%CI 1.23-3.74) and life satisfaction (OR=1.79 95%CI 1.38-1.52) of people living in NR areas who participated in the intervention improved relative to people in the LGA.

CONCLUSIONS

The results suggest that area-based health interventions are an important tool in the portfolio of strategies to reduce health inequalities.

Can preschool improve child health outcomes? A systematic review

Early childhood development interventions (ECDIs) have the potential to bring about wide ranging human capital benefits for children through to adulthood. Less is known, however, about the potential for such interventions to improve population health. The aim of this study was to examine the evidence for child health effects of centre-based preschool intervention programs for healthy 4 year olds, beyond the preschool years. Medline, Embase, ERIC, Psych Info, Sociological Abstracts, the Cochrane Library, C2-SPECTR and the Head Start database were searched using terms relating to preschool and health from 1980 to July 2008, limited to English language publications. Reference lists and the journal Child Development were hand searched for eligible articles missed by the electronic search. There were 37 eligible studies identified. The reviewed studies examined a range of interventions from centre-based preschool alone, to interventions also including parenting programs and/or health services. The study populations were mostly sampled from populations at risk of school failure (76%). Only eight of the 37 studies had a strong methodological rating, 15 were evaluated as at moderate potential risk of bias and 14 as at high potential risk of bias. The review found generally null effects of preschool interventions across a range of health outcomes, however there was some evidence for obesity reduction, greater social competence, improved mental health and crime prevention. We conclude that the great potential for early childhood interventions to improve population health across a range of health outcomes, as anticipated by policy makers worldwide, currently rests on a rather flimsy evidence base. Given the potential and the increasingly large public investment in these interventions, it is imperative that population health researchers, practitioners and policy makers worldwide collaborate to advance this research agenda.

Randomised controlled trial of parent groups for child antisocial behaviour targeting multiple risk factors: the SPOKES project

BACKGROUND

There is a pressing need for cost-effective population-based interventions to tackle early-onset antisocial behaviour. As this is determined by many factors, it would seem logical to devise interventions that address several influences while using an efficient means of delivery. The aim of this trial was to change four risk factors that predict poor outcome: ineffective parenting, conduct problems, attention deficit/hyperactivity disorder (ADHD) symptoms, and low reading ability.

METHODS

A randomised controlled trial was carried out in eight schools in London, England. Nine hundred and thirty-six (936) 6-year-old children were screened for antisocial behaviour, then parents of 112 high scorers were randomised to parenting groups held in schools or control; 109 were followed up a year later. The intervention lasted 28 weeks and was novel as it had components to address both child behaviour (through the Incredible Years programme) and child literacy (through a new 'SPOKES' programme to help parents read with their children). Fidelity of implementation was emphasised by careful training of therapists and weekly supervision. Controls received an information helpline. Assessment of conduct problems was by parent interview, parenting by direct observation and child reading by psychometric testing.

RESULTS

At follow-up parents allocated to the intervention used play, praise and rewards, and time out more often than controls, and harsh discipline less; effect sizes ranged from .31 to .59 sd (p-values .046 to .005). Compared to control children, whose behaviour didn't change, intervention children's conduct problems reduced by .52sd, (p < .001), dropping from the 80th to the 61st percentile; oppositional-defiant disorder (ODD) halved from 60% to 31% (p = .003). ADHD symptoms reduced by .44sd (p = .002), and reading age improved by six months (.36sd, p = .027). Teacher-rated behaviour didn't change. The programme cost pound2,380 ($3,800) per child.

CONCLUSIONS

Effective population-based early intervention to improve the functioning of with antisocial behaviour is practically feasible by targeting multiple risk factors and emphasising implementation fidelity.

National dissemination of effective parenting programmes to improve child outcomes

Although living standards have increased in the past 40 years, children's behaviour problems have become worse. Good parenting can help by maximising children's potential and promoting resilience. Effective programmes are available that improve parenting, but unfortunately ineffective approaches are still used widely. A new National Academy for Parenting Practitioners has been set up in England, which offers free training in evidence-based interventions and conducts research to increase their effectiveness.

Using practice development methodology to develop children's centre teams: ideas for the future

The Children's Centre Programme is a recent development in the UK and brings together multi-agency teams to work with disadvantaged families. Practice development methods enable teams to work together in new ways. Although the term practice development remains relatively poorly defined, its key properties suggest that it embraces engagement, empowerment, evaluation and evolution. This paper introduces the Children's Centre Programme and practice development methods and aims to discuss the relevance of using this method to develop teams in children's centres through considering the findings from an evaluation of a two-year project to develop inter-agency public health teams. The evaluation showed that practice development methods can enable successful team development and showed that through effective facilitation, teams can change their practice to focus on areas of local need. The team came up with their own process to develop a strategy for their locality.

The paediatrician--past, present and future--a conversation with Nils Rosén von Rosenstein

An imagined conversation takes place with the author of the first textbook of Paediatrics, Nils Rosén von Rosenstein. Enormous progress in the prevention and treatment of diseases of children is demonstrated. But a different spectrum of diseases has replaced the old one. And in spite of unprecedented material well-being a substantial minority of our children cannot make full use of their capabilities.

CONCLUSION

We must resume the full responsibility for our children and act as their advocates in society.

The effects of an area-based intervention on the uptake of maternal and child health assessments in Australia: a community trial

BACKGROUND

Recognition of the importance of the early years in determining health and educational attainment and promotion of the World Health Organization Health for All (HFA) principles has led to an international trend towards community-based initiatives to improve developmental outcomes among socio-economically disadvantaged children. In this study we examine whether, Best Start, an Australian area-based initiative to improve child health was effective in improving access to Maternal and Child Health (MCH) services.

METHODS

The study compares access to information, parental confidence and annual 3.5 year Ages and Stages visiting rates before (2001/02) and after (2004/05) the introduction of Best Start. Access to information and parental confidence were measured in surveys of parents with 3 year old children. There were 1666 surveys in the first wave and 1838 surveys in the second wave. The analysis of visiting rates for the 3.5 year Ages and Stages visit included all eligible Victorian children. Best Start sites included 1,739 eligible children in 2001/02 and 1437 eligible children in 2004/05. The comparable figures in the rest of the state were and 45, 497 and 45, 953 respectively.

RESULTS

There was a significant increase in attendance at the 3.5 year Ages and Stages visit in 2004/05 compared to 2001/02 in all areas. However the increase in attendance was significantly greater at Best Start sites than the rest of the state. Access to information and parental confidence improved over the course of the intervention in Best Start sites with MCH projects compared to other Best Start sites.

CONCLUSION

These results suggest that community-based initiatives in disadvantaged areas may improve parents' access to child health information, improve their confidence and increase MCH service use. These outcomes suggest such programmes could potentially contribute to strategies to reduce child health inequalities.

Educational attainment, perceived control and the quality of women's diets

OBJECTIVE

Data from the Southampton Women's Survey have established that women of lower educational attainment have poorer quality diets than those of higher educational attainment. This relationship is strong and graded such that for every increase in level of educational qualification, there is an increase in the likelihood that a woman will have a better quality diet. It is not wholly explained by socio-economic status. Qualitative research carried out in Southampton suggests that women of lower educational attainment may have a poorer diet because they feel they lack control over the food choices they make for themselves and their families. We set out to investigate the relationship between educational attainment, perceived control and quality of diet in a sample of women from Southampton.

DESIGN

Cross-sectional study using structured interviews in which women's diet, educational attainment and perceived control were assessed.

SETTING

19 Children's Centres and baby clinics in Southampton, UK.

PARTICIPANTS

372 women, median age 28 years.

MAIN OUTCOME MEASURES

Quality of diet assessed by prudent diet score produced from principal components analysis of 20-item food frequency questionnaire, and perceived control assessed by a validated questionnaire.

RESULTS

Women of lower educational attainment tended to have lower prudent diet scores and lower perceived control scores than women of higher educational attainment. Having a lower prudent diet score was associated with consuming fewer vegetables and vegetable dishes, less wholemeal bread and vegetarian food, and more chips and roast potatoes, meat pies, Yorkshire puddings and pancakes, crisps and snacks, white bread and added sugar. In a regression model both lower educational attainment and lower perceived control were associated with lower prudent diet scores, independent of the effects of confounding factors. However there was an interaction effect such that lower perceived control was only related to prudent diet score in the group of women of lower educational attainment.

CONCLUSION

Women of lower educational attainment perceive themselves to have less control over their lives than women of higher educational attainment, and this perceived lack of control is reflected in their diets being of poorer quality. Our findings suggest that level of perceived control over life is a more important predictor of quality of diet in women of lower educational attainment than in those of higher educational attainment. It may be that psychological and social difficulties disproportionately affect the diets of women of lower educational attainment. We are currently exploring variations in quality of diet among women of lower educational attainment in relation to a range of psychological and social factors.

Understanding the effectiveness of partnership-based early childhood interventions

In this paper, we seek to understand the relationship between partnership effectiveness and preschool enrolment in Best Start, an early childhood intervention for children living in disadvantaged areas in Victoria, an Australian State. We will examine the application of theories of partnership effectiveness at a whole of intervention level and in the context of local evaluation initiatives at the Broadmeadows Early Years Partnership. For the statewide intervention, partnership effectiveness was measured using the VicHealth Partnership Analysis Tool at 11 Best Start Sites. The dependent variable was preschool enrolment in Best Start local government area. For the Broadmeadows Early Years Partnership case study, partnership is conceptualised in terms of the Lasker and Weiss (2003) model of collaborative decision making. Scores rose significantly between the two applications of the VicHealth Partnership Analysis Tool at the beginning and end of the Best Start funding period on almost all of the dimensions of the VicHealth Tool. Support for ‘making partnerships work’, ‘minimising barriers to partnerships’ and the ‘total’ partnership scores were associated with increased preschool enrolments. The results of the case study supported the model for collaborative decision making with particular emphasis on the role of shared leadership, synergy and bridging social ties as crucial processes in improving service integration. The results of the statewide intervention and the case study both provide evidence of the value of partnership approaches in improving service uptake and integration for children living in disadvantaged areas. The study also supports current conceptualisations of partnership value and effectiveness.