Ethnic Minority Families Research Articles

Title- exploring the experiences of black, asian, and minority ethnic family members living with black, asian, and minority health care workers in the uk during the covid-19 pandemic: an interpretative phenomenological analysis

Title- exploring the experiences of black, asian, and minority ethnic family members living with black, asian, and minority health care workers in the uk during the covid-19 pandemic: an interpretative phenomenological analysis

Prevalence and mean number of teeth with amalgam and nonamalgam restorations, United States, 2015 through 2018

BackgroundAmalgam has been used for more than 150 years as a safe and reliable restorative material. The authors described the occurrence of amalgam and nonamalgam restorations in the United States in primary and permanent teeth across age groups and according to sociodemographic characteristics. MethodsThe authors used clinical examination data from the National Health and Nutrition Examination Survey 2015-2018 for participants 2 years and older (n = 17,040). The authors estimated the prevalence and mean number of amalgam and nonamalgam restorations in primary and permanent teeth according to age groups (2-5 years, 6-11 years, 12-15 years, 16-19 years, 20-39 years, 40-59 years, 60-79 years, and ≥ 80 years), race and ethnicity, federal poverty guideline, education, and pregnancy status. ResultsThe prevalence of amalgam restorations ranged from 4% through 69%. Overall, amalgam restorations were more prevalent in children and adolescents from racial and ethnic minority groups and families at lower poverty levels and with lower education. The mean number of teeth with nonamalgam restorations was higher than those with amalgam restorations in primary teeth of children aged 6 through 11 years, permanent teeth of those 12 through 15 years and 20 through 39 years, and women aged 20 through 49 years, regardless of pregnancy status. The mean number of amalgam restorations was higher than that for nonamalgam restorations in older age groups. ConclusionsNonamalgam restorations were the most common in the primary teeth of children older than 5 years and in the permanent teeth of adults younger than 40 years. Amalgam restorations were more common in older adults. Amalgam and nonamalgam restorations were equally common in children younger than 5 years. Practical ImplicationsThe study findings suggest a shift from amalgam to alternative restorative materials in the United States.

Effect of household toilet accessibility on physical health of ethnic minority adolescents: a longitudinal study from the China Education Panel Survey 2013 and 2014

BackgroundAccessing household toilets is vital for adolescent health during crucial stages of growth and development; however, some ethnic minority families in China lack toilets. The relationship between household toilet accessibility and the physical health of adolescents in China’s ethnic minority areas has been underexamined.MethodsUsing two waves of data from the China Education Panel Survey (2013 and 2014), this study explored the effect of household toilet accessibility on Chinese ethnic minority adolescents’ physical health. The sample consisted of 576 ethnic minority adolescents with an average age of approximately 13 years. To test the health effect of household toilet accessibility on ethnic minority adolescents, a fixed effects ordinary least squares model and difference-in-differences combined with propensity score matching method were used.ResultsThe results of the fixed effects model and difference-in-differences combined with propensity score matching showed a significant and positive effect of household toilet accessibility on adolescents’ physical health. The heterogeneity analysis indicated that among the toilet types of soil cesspits, cement cesspits, squat toilets, and flush toilets, the flush toilets were proven to be the most efficient in improving adolescents’ physical health. Moreover, the family living arrangement was proven to play a moderating role in the effect of household toilet accessibility on the physical health of ethnic minority adolescents. The average marginal effects of household toilet accessibility on the physical health of ethnic minority adolescents who lived without parents were more evident and significant than those who lived with their parents.ConclusionPromoting household toilet accessibility in China’s ethnic minority areas is essential for improving adolescents’ health. Moreover, having a household toilet is not sufficient, the quality and dignity of household toilets are also important.

Multigenerational living and children’s risk of living in unaffordable housing: differences by ethnicity and parents’ marital status

ABSTRACT A growing share of Canadian households are living in unaffordable housing (i.e. spending 30% or more of their pre-tax income on housing costs). During this time, the prevalence of multigenerational living has also increased. Ethnic minority families are more likely than White families to live in multigenerational households. These trends raise the questions: (a) is multigenerational living a strategy for families to navigate the housing affordability crisis? (b) do ethnic minority children benefit more from multigenerational living than their White peers? Using confidential data from the 2016 Canadian Census, we examine how multigenerational living shapes the housing experiences of children under the age of 16. Multigenerational living is associated with consistent reductions in children’s odds of living in unaffordable housing. Yet, for those in single-parent families, this protective association is largest among White children. For those in dual-parent families, this protective association is largest among Black children. Socioeconomic disadvantage and a greater propensity for three-generation families to reside in metropolitan areas with expensive housing appear to suppress the benefits emerging from multigenerational living.

Women’s experiences of accessing vaccines during pregnancy and for their babies during COVID-19

Abstract Background COVID-19 changed access to healthcare, including vaccinations, in the United Kingdom (UK). This study explored UK women’s experiences of accessing pertussis vaccination during pregnancy and infant vaccinations during COVID-19. Methods An online cross-sectional survey was completed, between 3rd August-11th October 2020, by 1404 women aged 16+ years who were pregnant at some point after the first UK lockdown from March 23rd 2020. Ten follow-up semi-structured interviews were conducted. Results Most women surveyed were pregnant (65.7%) and a third postnatal (34.3%). Almost all women (95.6%) were aware that pertussis vaccination is recommended in pregnancy. Most pregnant (72.1%) and postnatal women (84.0%) had received pertussis vaccination however, access issues were reported. Over a third (39.6%) of women had a pregnancy vaccination appointment changed. COVID-19 made it physically difficult to access pregnancy vaccinations for one fifth (21.5%) of women and physically difficult to access infant vaccinations for almost half of women (45.8%). Nearly half of women (45.2%) reported feeling less safe attending pregnancy vaccinations and over three quarters (76.3%) less safe attending infant vaccinations due to COVID-19. The majority (94.2%) felt it was important to get their baby vaccinated during COVID-19. Pregnant women from ethnic-minorities and lower-income households were less likely to have been vaccinated. Minority-ethnicity women were more likely to report access problems and feeling less safe attending vaccinations for both themselves and their babies. Qualitative analysis found women experienced difficulties accessing antenatal care and relied on knowledge from previous pregnancies to access vaccine appointments. Conclusions COVID-19 disrupted access to vaccinations in the UK. Vaccine services must ensure equitable access to vaccine appointments during ongoing and future pandemics including tailoring services for lower income and ethnic minority families. Key messages • Pregnancy and infant vaccines was disrupted by COVID-19 with women feeling less safe and having difficulties accessing vaccinations with ethnic minority women more likely to report access issues. • Equitable access to routine pregnancy and infant vaccine appointments must be prioritised during future pandemics, including considering tailoring services for different population groups.

Family language policy in multi-ethnic and multilingual villages in Yunnan, China: a comparative case study of Kena village and Anmin village

ABSTRACT Based on Spolsky’s (2004) tripartite framework for language policy, this study explores language practices, language ideology, and language management in relation to minority languages, Putonghua, and English in ethnic minority families in Yunnan, China. Through observations of and interviews with nine interethnic marriage families in Kena Village and Anmin Village, we found that although people in both villages recognise the value of their native languages in ethnic identification and cultural inheritance, people in Anmin Village make efforts to teach the children Mosuo, while children in Kena Village usually acquire Malimasa naturally. Such differences are associated with sociolinguistic environment and child agency. Meanwhile, Putonghua is widely used in television programmes and smartphone applications and acquired by the young generation due to national policy and the spread of smartphones and television. Families in both villages demonstrated similar aspirations for their children’s English learning, but low socioeconomic status affected their ability to invest in foreign language learning. The results suggest that in the special context of multi-ethnic and multilingual villages in Yunnan the agency of rural parents and grandparents is relatively weak, and family language policies are mainly influenced by meso – (e.g. school) and macro- (e.g. socioeconomic environment, national policy) level factors.

Home-Visiting in a Shared Reading Intervention: Effects on Children from Low SES and Ethnic Minority Families

ABSTRACT Research Findings: In this study, we examined the short- and long-term effects of Reading Express, a home-visiting intervention in which volunteers encourage low socio-economic status and ethnic minority parents to engage in interactive shared reading with their child. Outcomes of a quasi-experiment involving 176 children in the Netherlands (mean age 72 months; nexperimental = 95; ncontrol = 81) revealed favorable outcomes of Reading Express for children’s home literacy environments (i.e., children’s book exposure and parents’ reported shared reading frequency), which were maintained over time. Reading Express also had a positive short-term effect on story comprehension. However, the positive trend in story comprehension leveled off 20 weeks after program termination and there were neither short-term nor long-term effects on receptive vocabulary. Practice or Policy: Our results show that longer-term changes can be made in children’s home literacy environments by means of home visiting programs such as Reading Express, but they also suggest the relevance of better adapting programs to the characteristics and needs of participating families.

Minority and low-SES families’ experiences during the early phases of the COVID-19 pandemic crisis: A qualitative study

ObjectivesTo explore minority and low-SES families’ general experiences with the stay-at-home mandate initiated by the COVID-19 pandemic crisis. MethodsSemi-structured qualitative interviews (n = 31) were conducted in May 2020 – six to nine weeks after the stay-at-home mandate was initiated in Chicago Heights, Illinois. Participants were randomly selected from the parent Chicago Heights Early Childhood Center (CHECC) study (N = 2,185). Thematic content analysis of transcribed semi-structured interviews were employed. ResultsDuring the early phases of the COVID-19 pandemic crisis, ethnic minority and low-SES families were generally comfortable in their homes, but both children and their parents experienced poor wellbeing, such as elevated stress. Families reportedly avoided social resources, despite low-SES. Upon reflection, parents expressed that the pandemic had changed them and, in some ways, the changes were positive. ConclusionReadily available crisis-oriented resources, for both children and parents, are needed to help families maintain or rebuild their sense of control over their lives during the early phases of a collective crisis (e.g., pandemic). Although early observations help to contextual families’ initial experiences, examining long-term trends can inform meaningful policies and practices that both support how low-SES families buffer against COVID-19-related negative impacts and mitigate ethnic and SES inequities and disparities.

Women's views and experiences of accessing pertussis vaccination in pregnancy and infant vaccinations during the COVID-19 pandemic: A multi-methods study in the UK

BackgroundCOVID-19 changed access to healthcare, including vaccinations, in the United Kingdom (UK). This study explored UK women’s experiences of accessing pertussis vaccination during pregnancy and infant vaccinations during COVID-19. MethodsAn online cross-sectional survey was completed, between 3rd August-11th October 2020, by 1404 women aged 16+ years who were pregnant at some point after the first UK lockdown from March 23rd, 2020. Ten follow-up semi-structured interviews were conducted. ResultsMost women surveyed were pregnant (65.7%) and a third postnatal (34.3%). Almost all women (95.6%) were aware that pertussis vaccination is recommended in pregnancy. Most pregnant (72.1%) and postnatal women (84.0%) had received pertussis vaccination; however, access issues were reported.Over a third (39.6%) of women had a pregnancy vaccination appointment changed. COVID-19 made it physically difficult to access pregnancy vaccinations for one fifth (21.5%) of women and physically difficult to access infant vaccinations for almost half of women (45.8%). Nearly half of women (45.2%) reported feeling less safe attending pregnancy vaccinations and over three quarters (76.3%) less safe attending infant vaccinations due to COVID-19. The majority (94.2%) felt it was important to get their baby vaccinated during COVID-19.Pregnant women from ethnic-minorities and lower-income households were less likely to have been vaccinated. Minority-ethnicity women were more likely to report access problems and feeling less safe attending vaccinations for both themselves and their babies.Qualitative analysis found women experienced difficulties accessing antenatal care and relied on knowledge from previous pregnancies to access vaccines in pregnancy. ConclusionDuring the ongoing and future pandemics, healthcare services should prioritise equitable access to routine vaccinations, including tailoring services for ethnic-minority families who experience greater barriers to vaccination.

Mothers’ School Readiness Beliefs and Literacy Involvement and Children’s Academic Outcomes in Ethnic Minority Families

ABSTRACT This research tested a mediation model, examining whether individual differences in mothers’ school readiness beliefs influenced home literacy practices and children’s later academic achievement among African American (n = 114) and primarily Mexican origin Latina mothers (n = 164) and their children. Mothers of children ages 3–4 years reported school readiness beliefs and home literacy practices. Later (ages 6–7 years), reading and math achievement scores were measured using the Woodcock-Johnson Revised (WJR) or the Batería Woodcock-Muñoz, as appropriate, depending upon the child’s primary language. Research Findings: Results showed that African American and Latina mothers differed in their beliefs about school readiness skills, with African American mothers more likely to emphasize general pre-academic knowledge and Latina mothers more likely to emphasize social-focused readiness skills. Academic-focused readiness beliefs predicted mothers’ engagement in home literacy practices, social-focused readiness beliefs predicted math achievement, and home literacy practices mediated the association between academic-focused readiness beliefs and math achievement. Policy or Practice: Findings suggest that interventions to enhance school readiness should consider ethnic minority parents’ expectations and at-home practices, particularly during children’s early childhood.

Underrepresented Voices: Impacts of Social Determinants of Health on Type 1 Diabetes Family Management in Single-Parent, Black Families

ObjectivesSocial determinants of health (SDOH) impact families’ ability to manage chronic illnesses such as type 1 diabetes (T1D). Black, single parents have unique SDOH-related resource needs and concerns when caring for a child with a chronic illness, yet their voices are underrepresented in the pediatric T1D literature. The aim of this qualitative study was to identify and explore the SDOH that influence T1D management in Black, single-parent families. MethodsIn this 2-phase qualitative study we used content analysis to explore themes derived from 3 nominal group technique sessions and semistructured interviews, with 20 self-identified Black, single parents of a child with T1D. ResultsParents encountered various SDOH-related issues that negatively influenced management of their children’s T1D. Six major themes emerged from the parent-generated list of SDOH-related barriers: 1) lack of parent and child emotional and physical support systems, 2) maintaining parent and child’s physical and mental health, 3) pain management with medication administration, 4) clinical team empathy, 5) provider communication, and 6) economic burden of food costs. ConclusionsThese exploratory findings contribute to the knowledge base required to guide development of culturally relevant, individual- and population-level interventions for racially and compositionally minority families, to increase health equity and address racial health disparities in T1D. Routine assessment of family social support context and resources, better integration of community-level social services into clinical health encounters and clinician bias and communication training are advised starting points to address the specific needs of racial and ethnic minority families experiencing the greatest social and clinical challenges.

Sibling Relationships in Adolescence and Young Adulthood in Multiple Contexts: A Critical Review

In many contexts worldwide, most people grow up with one or more siblings. The current paper reviews research on sibling relationship quality (closeness, communication, and conflict) in adolescence and young adulthood in four different contexts: primarily White North American and European samples (132 articles reviewed); ethnic minority families (26 articles reviewed); China (6 articles reviewed); and when one sibling has a disability (21 articles reviewed). Where the literature was available, within each context we addressed five questions: how does sibling relationship quality change from adolescence through young adulthood, how are demographic and structural characteristics linked to sibling relationship quality, how is sibling relationship quality linked to adjustment and behavior, how are familial relationships and processes linked to sibling relationship quality, and how is sibling relationship quality linked to non-familial relationships. Included articles were published between 2001 and 2021 and included aspects of sibling closeness, communication, or conflict in adolescence or young adulthood. Across all contexts, individual (e.g., gender) and dyadic characteristics (e.g., gender composition, birth order) play a role in siblings’ relationship qualities. In several contexts, the current literature suggests that sibling closeness and communication are linked to positive development, well-being, and healthy relationships with other social partners. In multiple contexts, sibling conflict is linked to poorer well-being and negative relationships with other social partners. These broad patterns, however, are qualified by each context and often multiple moderators.

Revisiting ‘resilience’ in light of racism, ‘othering’ and resistance

In this commentary the authors analyse how the concept of resilience can be and has been applied to Black, Asian and minority ethnic families and communities in ways that are biased, stigmatising and pathologising. They argue that current definitions of resilience need to be redefined and reconceptualised, particularly in settings dominated by White middle-class voices that define what ‘positive emotions’, ‘successful traits’ and ‘coping mechanisms’ entail. Here, through racism and flawed perceptions and interpretations of resilience and ‘othering’, members from ethnic minority communities are defined as in need of resilience support, whilst at the same time their experience of structural racism, e.g., in relation to mental health support, social/health care practices and school exclusions, is being erased. Instead, the authors argue that resilience can also mean ‘resistance’, i.e., resisting bad treatment and racism, as well as reflecting agency, identity and ownership of one’s own life and choices within this. Reframing resilience thus means taking account of multifaceted and interactive effects of personal, material, institutional and political factors that impact on behaviour, wellbeing and resilience, as well as acknowledging that the way in which ‘behaviour’ is received is by default flawed, if this is largely informed by an oppressive White middle-class viewpoint.

Language Use and Identity in Minority Hungarian and Hungarian-Romanian Deaf Families.

This paper discusses language use and identity patterns in families set up by deaf partners living in Romania, where at least one of the spouses belongs to the ethnic Hungarian minority. Language use and transmission of identity to children in ethnically homogenous (Hungarian) or heterogeneous (Hungarian-Romanian) families of deaf are explored. The research is based on a survey conducted among members of the ethnic Hungarian Deaf community (including ethnic Romanian spouses), life-path interviews with selected deaf persons and interviews with special school educators. The research results denote that in the case of deaf people living in ethnically homogeneous marriages who graduated from Hungarian language special school the transmission of Hungarian identity, Hungarian sign language/oral language knowledge-combined with the components of Deaf culture-tends to be a natural and usually undisturbed process. However, if one of the spouses is Romanian, the language of communication within the family will probably be the Romanian sign language/oral language. On the other hand, in the families where ethnic minority and ethnic majority family members are present, with typical and atypical hearing, complex, multifaceted linguistic communication models might prevail, favoring specific multicultural modes of intrafamilial identity development and transmission.

Does training affect understanding of implicit bias and care of black, Asian and minority ethnic babies?

Background In the UK, there are huge inequities in maternal and neonatal mortality, yet there appears to be very little training to address this for midwives. This quality improvement project aimed to address this by providing training on implicit bias, stereotyping and clinical assessment of babies from black, Asian and minority ethnic families. Methods A training package was created and delivered to 67 midwives and students on placement at the Yeovil District NHS Foundation Trust on implicit bias, structural racism and clinical assessment of babies from black, Asian and minority ethnic groups. Pre- and post-training surveys were completed and descriptive statistical analysis alongside thematic analysis was used to analyse the findings. Results It was evident that midwives benefited from the training, as pre-session surveys noted that many midwives were unaware of the factors influencing the care of women and babies from black, Asian and minority ethnic families. After the training, they identified a wish to change their practice to be more inclusive. Conclusions The training package was well evaluated; however, more training and research is needed to improve the safety of mothers and babies from black, Asian and minority ethnic families.

Resilience and Family Socialization Processes in Ethnic Minority Youth: Illuminating the Achievement-Health Paradox.

Youth in marginalized communities who “strive” to rise above adversity, including systemic racism and poverty, are considered “resilient.” African-American, Latinx, and Asian-American youth often achieve admirable academic success despite limited social capital and high early life stress by adopting a “striving persistent behavioral style” (SPBS). SPBS may be supported by family socialization processes that facilitate reliance on self-regulation processes. Unfortunately, a young person’s resilience in one domain (i.e., academic) can come at a cost in other domains, including physical and mental health morbidities that are under-identified and under-treated. Indeed, research suggests a link between SPBS in the face of adversity and later health morbidities among ethnic minority youth. Herein, we describe SPBS as an adaptation to minority stress that not only promotes social mobility but may also stoke physical and mental health disparities. We review how family processes related to academic, emotional, and ethnic-racial socialization can facilitate the striving persistent behavioral style. We emphasize the double bind that ethnic minority families are caught in and discuss directions for future research and clinical implications for individual and family-level interventions. While needed, we argue that individual and family-level interventions represent a near-term work around. Solutions and factors that shape the need for SPBS and its cost must be addressed structurally.

Mitigating the Impact of the Coronavirus Pandemic on Rural Low-Income Families.

The COVID-19 pandemic has disrupted rural communities and is exacerbating the economic, health, and social inequality for poor Americans in rural areas. Mounting job losses and illness in these communities are also pushing low-income families further into poverty. Based on previous research on rural poverty, this paper highlights the difficulties that marginalized rural families could experience due to the current pandemic. We focus on five major areas that affect the lives of the rural poor: economic security, family well-being, food insecurity, health security, and the challenges of rural living with a special focus on racial and ethnic minority families. We provide tangible recommendations on what can be done in the short term to enable rural families to cope with the consequences of the pandemic. We also discuss long-term policy recommendations that would be necessary for rural communities to thrive after the pandemic and survive future outbreaks.

Cognitive Dependence in Physically Independent Patients at Discharge From Acute Traumatic Brain Injury Rehabilitation

ObjectiveTo determine the incidence of cognitive dependence in adults who are physically independent at discharge from acute traumatic brain injury (TBI) rehabilitation. DesignAnalysis of historical clinical and demographic data obtained from inpatient stay. SettingInpatient rehabilitation unit in a large, metropolitan university hospital. ParticipantsAdult inpatients with moderate to severe TBI (N=226) who were physically independent at discharge from acute rehabilitation. InterventionsNot applicable. Main Outcome MeasuresFIM Motor and Cognitive subscales, discharge destination, and care plan. ResultsApproximately 69% (n=155) of the physically independent inpatients were cognitively dependent at discharge from acute rehabilitation, with the highest proportions of dependence found in the domains of problem solving and memory. Most (82.6%; n=128) of these physically independent, yet cognitively dependent, patients were discharged home. Of those discharged home, 82% (n=105) were discharged to the care of family members, and 11% (n=15) were discharged home alone. Patients from racial and ethnic minority backgrounds were significantly more likely than White patients to be discharged while cognitively dependent. ConclusionsThe majority of physically independent patients with TBI were cognitively dependent at the time of discharge from acute inpatient rehabilitation. Further research is needed to understand the effect of cognitive dependence on caregiver stress and strain and the disproportionate burden on racial and ethnic minority patients and families. Given the potential functional and safety limitations imposed by cognitive deficits, health care policy and practice should facilitate delivery of cognitive rehabilitation services in acute TBI rehabilitation.

Intergenerational Determinants of Weight Status Concordance and Discordance in Parent/Adolescent Dyads from the Family Life, Activity, Sun, Health, and Eating Study.

Background: Studies have shown that obesity (OB) has strong intergenerational linkages and tends to cluster in families, but there is a dearth of research examining the socioecological factors predictive of weight status concordance and discordance among parents and adolescents. Methods: We ran a stepwise multinomial logistic regression to assess for sociodemographic, individual-, and family-level predictors of four dyadic weight status groups using data from 1516 parent/adolescent dyads from the National Cancer Institute's Family Life, Activity, Sun, Health, and Eating Study. We categorized parent/adolescent dyads into one of four groups based on their BMI: (1) Healthy Weight Concordance (i.e., both parent and adolescent in the normal weight range); (2) overweight (OW)/OB Concordance (i.e., both parent and adolescent with OW or OB); (3) Discordance-Parent OW/OB (i.e., parent with OW/OB and adolescent in the normal weight range); or (4) Discordance-Adolescent OW/OB (i.e., adolescent with OW/OB and parent in the normal weight range). Results: There were 475 parent/adolescent dyads (31.3%) in the Healthy Weight Concordance group, 351 (23.2%) in the OW/OB Concordance group, 604 (39.8%) in the Discordance-Parent OW/OB group, and 86 (5.7%) in the Discordance-Adolescent OW/OB group. Being from a low socioeconomic family, identifying as a minority, and identifying as a male parent were associated with an OW/OB dyadic BMI. Higher levels of adolescent and parent emotional eating were significantly associated with parent/adolescent dyads being in the OW/OB Concordance group. Parent emotional eating was also associated with Discordance-Parent OW/OB. In contrast, parents' and adolescents' physical activity self-efficacy was associated with a Healthy Weight dyadic BMI vs. OW/OB Concordance or Discordance-Parent OW/OB. Conclusions: Our findings highlight the strength of OW/OB concordance in families, especially among lower socioeconomic and ethnic minority families and the significance of emotional eating and physical activity self-efficacy in contributing to BMI patterns among parents and adolescents.

A conceptual replication study of a self-affirmation intervention to improve the academic achievement of low-income pupils in England

ABSTRACT This paper describes an independently evaluated randomised controlled trial of a self-affirmation intervention, replicating earlier studies, mostly conducted in the US with ethnic minority students. Self-affirmation theory suggests that some stigmatised groups, such as those from ethnic minority or poor families, face stereotype threats which undermine their academic performance. Engaging in value affirmation writing activities when such threats are most salient can give individuals a positive sense of value, negating harmful feelings, and fostering academic learning. The present study, involving 10,807 pupils aged 14 to 16 in England showed that the intervention can be successfully replicated with children from low socioeconomic backgrounds in England. The analysis showed positive effects for the intervention group. Pupils who completed more exercises also performed better. The findings are worth consideration given that it costs virtually nothing and does no harm.