Missed opportunities to keep children safe? National survey of injury prevention activities of children’s centres

Objective: To ascertain the activities undertaken by children’s centres to prevent unintentional injuries in the under-fives and, in particular, the prevention of falls, poisoning and scalds. Design: A questionnaire was posted to managers of 851 children’s centres, using stratified cluster sampling. The questionnaire included questions on injury prevention activities undertaken by the centre, knowledge and attitudes to injury prevention, partnership working, and barriers and facilitators to injury prevention. Setting: England. Results: A response rate of 61% was achieved. Most respondents (98%) agreed that children’s centres can be effective in preventing accidents. Over half of the respondents (59%) did not know whether there was an injury prevention group in their area, and 22% did not know whether there was a home safety equipment scheme. Only 12% knew the major cause of injury deaths in children under five. A variety of activities were being undertaken including one to one advice and issuing leaflets. However, for some important topics such as baby walkers and disposal of unwanted medicines, no advice was being provided in some areas. Lack of funding (52%) and lack of capacity (39%) were the most common reasons cited as barriers to injury prevention activities. Conclusion: Injury prevention is an important activity undertaken by children’s centres. Given their position in the heart of the community, their potential as an agency to prevent injuries has been highlighted and recommended. Further support and resource will be needed if they are to fully develop their potential in preventing unintentional injuries in the home.


Introduction
Child unintentional injuries are an important global public health problem and are a major cause of mortality and disability in the under-fives (Peden et al., 2008). Although the burden of childhood injuries is greatest in low-income countries, it is important to note that within each country, injuries disproportionately affect children from low-income families (Peden et al., 2008). In the United Kingdom, there are steep social gradients in injury mortality and morbidity for a range of injury mechanisms (Edwards et al., 2006;Hippisley-Cox et al., 2002;Lyons et al., 2003;Roberts, 1997;Roberts and Power, 1996). The majority of injuries in the under-fives occur at home and falls are the most common injury (British Medical Association [BMA], 2001;Morrison et al., 1999;Public Health England, 2014).
To address this challenge, the Department of Health's Healthy Child Programme provides guidance on a range of health topics including injury prevention and identifies children's centres as key to supporting the programme (Department of Health, 2009). Additionally, the National Institute for Health and Care Excellence (NICE) has published guidance on the prevention of unintentional injuries among children and recommendations include prioritising households at greatest risk with home safety assessments, advice and referral to safety equipment schemes, and partnership approaches (National Institute for Health and Clinical Excellence, 2010a, 2010b. The guidance is targeted at a wide range of groups and organisations including health services, local authorities, health and wellbeing boards and children's centres. More recently, Public Health England has highlighted both the key child injury areas that they think should be prioritised and the researchbased interventions that are available (Public Health England, 2014).
Children's centres were established across England starting in 2004 to improve health and educational outcomes for children (Children Schools and Families Committee, 2010). They are now managed by or on behalf of, or under arrangements with, local authorities. In 2013, a new 'core purpose' for children's centres was developed: 'to improve outcomes for young children and their families and reduce inequalities between families …' (Department for Education, 2013). One analysis suggests that every year over 1 million families are being supported by children's centres (4Children, 2013). Children's centres thus have the remit and potential to make significant contributions to this important public health issue, particularly among the most disadvantaged.
There are now numerous publications reporting the development and impact of children's centres (Avis et al., 2007;Baggott, 2011;Children Schools and Families Committee, 2010;Department for Education, 2010;Goff et al., 2013;House of Commons Education Committee, 2014;Hutchings et al., 2007;MacNeill, 2009;Melhuish et al., 2008Melhuish et al., , 2010The National Evaluation of Sure Start Research Team, 2008). However, their role in injury prevention has received little attention in the literature. Our research seeks to address this gap, consisting of national injury prevention surveys at two points in time. Our first survey had a fire prevention focus (Watson et al., 2014), while this second study aims to describe and quantify the injury prevention activities focussing on the prevention of falls, poisoning and scalds being undertaken by children's centres across England.

Methods
The survey comprised questions taken from previous injury prevention surveys targeting professional groups (Kendrick et al., 2003;Watson et al., 2007;Watson and White, 2001), accompanied by questions designed by the research study team. Content validity was assessed by experts within the research study team (Litwin, 1995) and face validity was assessed by members of staff at the University of Nottingham who had no injury prevention training. Questions were structured according to standard principles of questionnaire design, together with advice from experts and piloting (Oppenheim, 1992;Salant and Dillman, 1994). The survey was piloted with managers from 10 children's centres that were not included in the sample, with minor modifications made after piloting.
The questionnaire consisted of 10 open-ended and closed questions to gather information about characteristics of the children's centres, health priority areas, injury prevention activities, knowledge and attitudes towards injuries and their prevention, barriers and facilitators to injury prevention activity and partnership working. The questionnaire was developed for individuals responsible for the day-to-day management and running of children's centres.

Sample size
We calculated that responses would be required from a total of 314 children's centres from 25 Primary Care Trusts (PCTs) to estimate the proportions of positive responses to a number of questions relating to injury prevention activity to within ±7% (95% confidence interval), based on responses to questions in a previous survey (Kendrick et al., 2003). This calculation accounted for clustering of children's centres within PCTs, assuming an intraclass correlation coefficient (ICC) of 0.05, an average of 20 children's centres per PCT and an estimated 65% response rate such that an average of 13 children's centres per PCT would respond to the questionnaire.

Survey distribution
Stratified cluster sampling was used. A list of children's centres in England was obtained from the Department for Education in November 2011. Three PCTs were selected at random from each Strategic Health Authority (SHA, n = 10) and all children's centres (n = 851) within the sampled PCTs were invited to participate. Questionnaires, together with a covering letter and freepost reply envelope, were posted in January 2012. Questionnaires were addressed to the children's centre manager, rather than a named contact, with the aim of ensuring questionnaires were opened and forwarded if appropriate. To improve the response rate, managers received three further reminder questionnaires at 2-week intervals (Edwards et al., 2002;McColl et al., 2001).

Data entry and analysis
All data were double entered and two separate operators keyed every questionnaire. The two datasets were then compared and one master file created. Discrepancies were manually corrected after referring back to the questionnaire. Data were analysed using Stata SE 11.0. Binary and categorical variables were summarised using frequencies and proportions. Responses to open questions were categorised by generating a coding list and assigning responses to categories.

Ethics
Approval for the study was granted by North Nottinghamshire Research Ethics Committee (study reference number = 09/H0407/44).

Results
A total of 526 questionnaires were returned, of which 9 were blank. Of 851 questionnaires posted, 8 were returned undelivered, giving a response rate of 61.3% (517/843). It should be noted that some children's centre managers manage more than one centre.

Strategies
Just under half of respondents (n = 198, 42.3%) reported that their centre had a written child injury prevention strategy, 47.4% (n = 222) stated that their centre did not and 10.3% (n = 48) did not know.
In addition, 32.8% respondents stated that their local authority had a written strategy and 22.0% said their PCT had a written strategy. The majority of respondents did not know whether their local authority or PCT had a strategy (n = 308, 64.8% and n = 337, 74.1%, respectively).

Knowledge and attitudes
Knowledge of the main cause of child injury deaths in the under-fives in the home was poor, only 11.7% of respondents (n = 51) correctly identified choking and suffocation. One quarter of respondents (24.5%, n = 107) thought falls was the main cause of child injury deaths. Almost half of respondents (47.4%, n = 211) knew that falls were the major cause of non-fatal unintentional injuries to children under five in the home. Table 1 shows responses to questions about attitudes towards injury prevention. While 81.3% of respondents agreed or strongly agreed that injury prevention is predominantly the responsibility of the parent/carer, nearly all respondents (98.2%) agreed or strongly agreed that children's centres can be effective in preventing accidents.

Activities
Overall, 98.0% (n = 499) stated that their centre was involved in some form of injury prevention activity. While nearly all displayed posters on child safety (n = 501, 97.7%) and took part in Child Safety Week (n = 461, 90.4%), fewer were involved in media work (n = 79, 15.8%). Almost a third (n = 157, 31.3%) lobbied or campaigned on local safety issues. However, many centres (n = 403, 79.2%) had invited outside speakers to talk to parents and had collected data on children's accidents (n = 403, 79.2%).
Centre managers were asked how they provided advice in relation to falls, scalds and poisoning prevention: they provided this in various forms (Table 2). Topics they were least likely to provide advice on were as follows: non-slip bath mats (22.2%), disposal of unwanted medicines (22.4%), poisonous plants (25.0%) and thermostatic mixer valves (38.1%).
Centre managers were asked whether there was a home safety equipment scheme in their area and a total of 42.0% (n = 217) reported that a scheme was in operation; however, 21.7% (n = 112) did not know. Just over a quarter of these schemes were reported as being led by the children's centre (28.6%, n = 59) with 10.2% (n = 21) run by the local authorities and 8.3% (n = 17) run by the Royal Society for the Prevention of Accidents (RoSPA), as part of the 'Safe At Home' national scheme. The majority of schemes (59.8%, n = 128) provided equipment free, while 34.1% (n = 73) provided low-cost equipment and 4.7% (n = 10) loaned equipment. In addition, over half of schemes (55.3%, n = 114) fitted equipment.

Working together
Only 13.5% (n = 68) of respondents knew of an organised group specifically for child injury prevention in their area; the majority (58.9%, n = 296) did not know whether there was such a group.
Children's centre managers reported that their centres frequently refer families to organisations for home safety checks (53.1%, 251/473), safety equipment schemes (47.4%, 221/466) and to pharmacists for the safe disposal of unwanted medicines (48.7%, 230/472). Few centres refer families to an organisation for a thermostatic mixer valve (2.8%, 13/461). Most frequently, families were referred to fire and rescue services for a home safety check (61.6%, 122/198).

Barriers and enabling factors to injury prevention work
The main barriers and enabling factors to injury prevention activities reported by the children's centre managers are shown in Table 3. Among the 417 reporting barriers, lack of funding (51.8%), lack of capacity in terms of staff time (38.8%) and difficult to access certain families (26.1%) were the three most frequently mentioned barriers. In terms of enabling factors, of the 312 reporting enabling factors, the three most frequently mentioned factors were access to families (38.8%), working with other agencies (34.9%) and availability of leaflets to distribute (25.0%).

Main findings of this study
The findings from this second national survey provide data on unintentional injury prevention activities undertaken within children's centres and the knowledge and attitudes of managers towards unintentional injuries and their prevention. Children's centre managers had positive  attitudes towards injury prevention; however, they had many gaps in knowledge both about local initiatives and injury prevention in general. Moreover, for some managers the priority given to this topic and the activities undertaken did not appear to match recent guidance (National Institute for Health and Clinical Excellence, 2010a, 2010bPublic Health England, 2014).

What is already known on this topic
The first national survey of injury prevention activities of children's centres found that the majority of children's centre managers were unaware of injury prevention activities such as organised injury prevention partnerships in their local area, and their knowledge in relation to some areas of injury prevention was poor (Watson et al., 2014). Similarly, the majority of managers in this study were unaware of important injury prevention initiatives and only 12% could correctly identify the main cause of child injury deaths in the under-fives in the home. An important guide for local planning of child unintentional injuries in the home is NICE PH30 (National Institute for Health and Clinical Excellence, 2010a). Its recommendations include working in partnership and ensuring families with children at high risk of injury are provided with home safety assessments and advice and referred to safety equipment schemes. It is of concern that onefifth of managers in this and the earlier survey did not know whether there was a safety equipment scheme in their area.
Although some joint work is occurring with other agencies, the children's centres appear to be collaborating with individual organisations rather than being part of multi-agency partnerships that are recommended in recent and past injury prevention guidance (Audit Commission/Health Care  Commission, 2007;Public Health England, 2014). It should be noted that partnership work has also been recommended for many decades, as a cornerstone of effective health promotion (Green et al., 2015;Scriven, 1998;World Health Organization [WHO], 1986). However, productive partnership work is a complex process and requires a wide range of skills and a great deal of commitment (Department of Health, 1993;Scriven, 1998;Watson, 1994). Children's centres are going to need help in developing and sustaining effective child injury prevention alliances. The Child Accident Prevention Trust (CAPT) and the RoSPA have considerable expertise in this area and have in the past promoted and supported many local alliances. In some areas, public health specialists from local authorities are also involved in actively supporting such alliances. In relation to the priority given to child injury prevention work in the home and the main barriers to working in this area, there were also similarities between this survey and our earlier one (Watson et al., 2014). In the initial survey, only 58% considered injury prevention to be one of the three main priority areas for children's health for their centre, similarly in this survey the figure was 64%. In both surveys, lack of funding and lack of capacity were stated as the two main barriers to work in this area.
The current survey concentrated on falls, poisoning and scald prevention in the home. Although we found evidence of various activities including one to one advice and the issuing of leaflets, in many areas, centres did not appear to be undertaking activities that have been recommended based on the evidence of effectiveness (National Institute for Health and Clinical Excellence, 2010a, 2013). In addition, for some important topics such as baby walkers, disposal of unwanted medicines and thermostatic mixing valves, no advice was being provided in some areas. It is noteworthy that CAPT and RoSPA websites provide accurate information about national guidance and effective interventions for specific child home safety topics.
In recent guidance for local authorities and partnerships, Public Health England has recommended that 'a senior manager is designated lead for child injury prevention, and that the development of a local strategy is directed by an appropriate board such as the health and wellbeing board' (Public Health England, 2014). Such a manager could ensure that staff in children's centres have the right level of knowledge, skills and awareness about specific injury prevention activities and partnerships in their area.

Limitations of this study
One weakness of this study is that the data collected were self-reported. However, considerable care was taken in the design of the questionnaire, including using questions, where possible, that had been published in articles in peer-reviewed journals, undertaking a pilot study, and using the expertise within the research team to critique the data collection tool in terms of relevance and validity.
Although the response rate for this survey is comparable to a previous survey of children's centres (Tanner et al., 2012) and higher than others (4Children, 2012(4Children, , 2013Watson et al., 2014), a response rate of 61% does raise the possibility that non-response bias may have occurred, that is, those responding may have been more interested in this topic and also may have been more likely to undertake injury prevention activities. If this is the case, the findings may overestimate the injury prevention activity being undertaken by children's centres, but this would not alter our conclusions.

Conclusion
This paper presents the findings from the second national survey of unintentional injury prevention activities taking place in children's centres. There appears to have been little progress over the 2 years since the initial survey. Although managers still have positive views about potential injury prevention roles and are currently undertaking a variety of interventions, their activities do not appear to be in line with national guidance. Children's centres in England are going to need considerable support to fully develop their potential in preventing unintentional injuries in the home.

Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.