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Unintentional Injury) and the Second a Policy (Childcare)

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Unintentional Injury) and the Second a Policy (Childcare) Will policies in the early years reduce inequalities in health? A synthesis to inform policy A thesis presented for the degree of Doctor of Philosophy University College London Anna Pearce UCL Institute of Child Health I, Anna Pearce, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. 2 Abstract This thesis aims to examine whether government policies in the early years are likely to influence health inequalities, using information derived from a range of sources to contribute to the „jigsaw of evidence‟, and focussing on two case studies featuring high on the Labour government agenda: the first a measure of health (unintentional injury) and the second a policy (childcare). Scoping reviews were used to map areas requiring further research for each case study. A review of policy documents helped set the policy context, and secondary datasets were utilised to describe prevalence, trends and inequalities. Following this some of the less researched associations identified in the scoping reviews were explored, using data from the Millennium Cohort Study (MCS). An analysis investigating whether the home environment lay on the causal pathway between socio-economic circumstances (SECs) and unintentional injuries found that controlling for a number of proxy measures for housing quality and safety equipment use did not alter the social gradient in injuries occurring in the home. A second analysis exploring a measure of main childcare use in relation to injuries found that infants (aged 9 months) from more advantaged SECs were less likely to have been unintentionally injured (anywhere) since birth if they were looked after in formal childcare (compared to those looked after only by a parent). In contrast, those from less advantaged SECs appeared to be at greater risk of injury. Informal childcare was associated with an increased risk of injury between 9 months and 3 years, overall and in less advantaged SECs. Two further analyses explored breastfeeding and overweight in relation to childcare use. Informal and formal childcare were both associated with a reduced likelihood of breastfeeding, and whilst this remained the case for informal childcare across all social groups, for formal childcare the reduced likelihood of breastfeeding was only observed in those from more advantaged groups. Children who were looked after in informal childcare appeared to be more likely to be overweight at 3 years than those only looked after by a parent, particularly if they were from more advantaged SECs. These results were then synthesised in light of current and potential policy. The analyses were conducted with observational data and using proxy measures for the home environment and main childcare use, therefore further research is required. Findings imply that improvements to the home environment may not necessarily influence inequalities in injuries (although are likely to benefit other areas of health and wellbeing). Main childcare type appeared to be associated with better health outcomes 3 for some social groups but not for others; further research is required to ascertain how these benefits can be recognised for all groups, for example through improved training and guidance for childcare professionals. This thesis demonstrates the use of epidemiological information for contributing to the „jigsaw of evidence‟, but also the complexities of considering policy impacts on health inequalities. 4 Acknowledgements I would like to thank my two supervisors, Professor Catherine Law and Dr Leah Li, for their unwavering help and support, and for making this such an enjoyable experience. I would also like to thank the co-applicants on the Public Health Research Consortium (PHRC) project team Hilary Graham, Brian Ferguson, and Jake Abbas for their advice and enthusiasm. Thanks also to Helen Duncan, Kate Canning, Simon Orange and Stephen Chaplin from ChiMat at Yorkshire and Humber Public Health Observatory and colleagues in the management team at the Centre for Longitudinal Studies, at the Institute of Education, University of London. I would also like to thank the members of the ICH Millennium Cohort Study child health group at the Centre for Paediatric Epidemiology and Biostatistics, UCL Institute of Child Health and in particular Lucy Griffiths, Summer Hawkins, and the late Richard Jenkins. Thanks to Louca-Mai Brady at the National Children‟s Bureau and the PEAR group for working with us, and to my friends and colleagues at the Centre for Paediatric Epidemiology and Biostatistics for helping me to stay positive, and in particular to Chloe Parkin for her proof reading and reassuring words of wisdom. And finally my thanks go out to my wonderful friends and family, and especially Bhurut, without whom this would not have been possible. The work presented in this thesis was undertaken as part of the Public Health Research Consortium. The Public Health Research Consortium is funded by the Department of Health Policy Research Programme. The views expressed in this thesis are those of the author and not necessarily those of the Department of Health. Information about the wider programme of the PHRC is available from www.york.ac.uk/phrc. The Centre for Paediatric Epidemiology and Biostatistics was supported in part by the Medical Research Council in its capacity as the MRC Centre of Epidemiology for Child Health. Research at the UCL Institute of Child Health and Great Ormond Street Hospital for Children receives a proportion of its funding from the Department of Health's National Institute for Health Research Biomedical Research Centres funding scheme. 5 Abbreviations A&E Accident and emergency department AD Absolute difference ALSPAC Avon Longitudinal Study of Parents and Children CHPP Child Health Promotion Programme CI Confidence interval CMO Chief Medical Officer CLS Centre for Longitudinal Studies, Institute of Education CRB Criminal Records Bureau DH Department of Health DCSF Department of Children, Schools and Families DfES Department for Education and Skills EHCS English House Conditions Survey EPPE Effective Provision of Pre-School Education EYPS Early Years Professional Status GB Great Britain GCSE General Certificate of Secondary Education GHS General Household Survey GP General Practitioner HES Hospital Episode Statistics HCP Healthy Child Programme HSE Health Survey for England ICD International Classification of Diseases IFS Infant Feeding Survey IMD Index of Multiple Deprivations IOTF International Obesity Task Force LEA Local Education Authority MCS Millennium Cohort Study NCB National Children‟s Bureau NCMP National Child Measurement Programme NICE National Institute for Health and Clinical Excellence NS-SEC National Statistics Socio-Economic Classification OECD Organisation for Economic Cooperation and Development ONS Office for National Statistics PEAR Public Health, Education, Awareness, Research (young person‟s reference group) PHO Public Health Observatory PHRC Public Health Research Consortium PSA Public Service Agreement RCT Randomised controlled trial RoSPA Royal Society for the Prevention of Accidents RD Relative difference RR Risk ratio SECs Socio-economic circumstances SOA Super Output Area UK United Kingdom UNICEF United Nations Children‟s Fund US United States of America WHO World Health Organisation NSF National Service Framework YHPHO Yorkshire and Humber Public Health Observatory 6 Table of contents 1 Chapter 1 – Aims and objectives ......................................................................... 15 1.1 Background ................................................................................................. 15 1.1.1 Policy context for children‟s health, during the Labour administration . ............................................................................................................. 15 1.1.2 Approaches for evaluating the health impacts of policies .................. 18 1.2 Aims ............................................................................................................ 19 1.2.1 Phase 1 ................................................................................................ 20 1.2.2 Phase 2 ................................................................................................ 20 1.2.3 Involving young people in research .................................................... 21 1.2.4 Phase 3 ................................................................................................ 22 1.3 Structure of the thesis .................................................................................. 22 1.4 Role of the researcher.................................................................................. 23 1.5 Ethics approval ............................................................................................ 24 2 Chapter 2 – Methods ............................................................................................. 26 Development of Phase 1 .............................................................................................. 26 2.1 Objectives .................................................................................................... 26 2.2 Selecting the two case studies ..................................................................... 26 2.2.1 Producing menus of potential health outcomes and policies .............. 26 2.2.2 Assessing the health outcomes and policies in the menus .................. 27 2.2.3 Final selection
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