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The Effectiveness of Interventions to Address Health Inequalities in the Early Years: A Review of Relevant Literature

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CHAPTER FOUR: BIRTH ONWARDS - HOME VISITING PROGRAMMES

4.1 Introduction

Health professionals such as midwives and health visitors have been using home visiting over a century. Health visiting is a universal service provided to children and families from a few days after birth. It has undergone major changes in recent times as the service has moved from a solely medical model towards a holistic approach, with an emphasis on health promotion, prevention and intervention for children at risk. Social services and voluntary services also have an established history of providing flexible services within the home.

Home visiting has been identified as an important intervention for tackling health inequalities from an intergenerational perspective, and is capable of producing improvements in parenting, child behavioural problems, cognitive developments in high-risk groups, a reduction in accidental injuries to children and improved detection and management of postnatal depression (Bull et al, 2004). However, there is also a significant problem of non-use, meaning that many families fall through the statutory-voluntary sector gap (Oakley et al, 1998) and not all evaluations are positive.

Sutton et al (2004) report that a number of studies in the UK have shown that the provision of individual, home-based support, conducted weekly over the first few months after birth, and typically totalling around 8-10 sessions, is effective in speeding up the mother's recovery from post-natal depression. It appears that this kind of support can be just as effective when delivered by trained health visitors as by experienced psychotherapists (Cooper and Murray, 2003), making it a practicable intervention. One trial showed the provision of such psychological support to be as effective, in the majority of cases, as antidepressant medication (Appleby et al, 1997). Moreover, the provision of psychological support appeared to be highly acceptable to the mothers concerned. It is not known whether initiatives specifically targeted mothers in low socio-economic groups, or whether outcomes were better or worse for women in these groups.

Home visitation programmes targeting high risk families have also been found to be effective in reducing antisocial outcomes for children. Most involve a multi-dimensional approach. The Elmira Prenatal/Early Infancy Project ( PEIP; Olds et al, 1997), for example, provided parent education and enhanced family support and access to services via nurse home visits for the first two years of the child's life. Outcomes included reduced neglect and abuse, and fewer arrests of children by the age of 15 years (see Nurse-Family Partnership, Chapter Two, section 2.5. Elmira was one of the three sites where the programme was evaluated).

Programmes which use trained volunteers, rather than professionals, to provide home based support to vulnerable mothers have shown promise when evaluated, and have the additional advantages of being acceptable to families and benefiting families, the volunteers themselves and the wider community (Barker et al, 1992). However, as discussed in Chapter Two, using paraprofessionals in the Nurse-Family Partnership programme was not so promising.

The evidence summarised above includes a number of different approaches. This chapter will attempt to investigate the individual models operating in Scotland and elsewhere to highlight the known strengths and weaknesses of each approach.

The Scottish Government currently funds a range of projects which promote positive parenting skills and support to parents. Evidence relating to the following major initiatives is considered below:

  • Sure Start Scotland
  • Starting Well (and Parents and Children Together)
  • Home-Start
  • Child Development Programme and Community Mothers Programme

4.2 Sure Start Scotland

4.2.1 Introduction to Sure Start

Sure Start is a UK Government programme which aims to deliver the best start in life for every child. A review of services for young children, carried out 1997-98 ( http://www.archive.official-documents.co.uk/document/cm40/4011/401122.htm)

concluded that there was no single blueprint for the ideal set of effective early interventions, but that they should share the following characteristics:

  • two generational: involve parents as well as children
  • non-stigmatising: avoid labelling 'problem families'
  • multifaceted: target a number of factors, not just ( e.g.) education or health or 'parenting'
  • locally driven: based on consultation and involvement of parents and local communities
  • culturally appropriate and sensitive to the needs of children and parents

Accordingly, Sure Start was developed in 1999 to bring together early education, childcare, health and family support, with an emphasis on outreach and community development. Sure Start covers a wide range of programmes, both universal and those targeted on particular local areas. In England, where national and local evaluations have taken place, local programmes are concentrated in neighbourhoods where a high proportion of children are living in poverty, although programmes are not necessarily targeted at families experiencing disadvantage. Rather than providing a specific service, the Sure Start initiative represents an effort to change existing services by 'reshaping, enhancing, adding value an by increasing co-ordination' ( http://www.ness.bbk.ac.uk/documents/Methodology.pdf).

Although services are designed to meet the needs of families with children under four within each catchment area, and offered to those families first, many of the services developed are available to those living outside the catchment areas. Local authorities are responsible for Sure Start settings and children's centres, and the services on offer may vary from area to area.

Sure Start Scotland is the main programme in Scotland which supports vulnerable families with very young children. The programme brings together early education, childcare, health and family support, with an emphasis on outreach and community development. The broad objectives of the initiative are to:

  • improve children's social and emotional development
  • improve children's health
  • improve children's ability to learn
  • strengthen families and communities

The initiative represents an effort to change, expand and enhance existing services, rather than providing a specific service. Funding has been allocated to local authorities to spend on Sure Start Scotland since 1999, distributed on a weighted basis to reflect population, deprivation and rurality. The target is for 15,000 vulnerable children aged 0-3 to receive an integrated package of care involving a range of services.

A programme of evaluation activity has been carried out in relation to Sure Start in England (see below) but in Scotland there has been less research to date. However, two mapping exercises have been carried out and findings from these are reported here.

4.2.2 First Sure Start Scotland mapping exercise, carried out 2001

This exercise used information supplied to the Scottish Government by local authorities, summaries of Sure Start Scotland spending, service provision and service use. Information was also collected about systems for monitoring and evaluating services.

Service providers recognised the need for monitoring and evaluation, although not all claimed this was being done in relation to their own service. Guidance on how services were to be measured would have been appreciated at the outset, along with the specific evaluation criteria to be used.

The following benefits of Sure Start funding were acknowledged:

  • Capacity building - investment in staff training and development
  • Building of new and extended premises
  • Developments may not have increased the number of children attending centres, but have improved the children's environment and quality of daily experience
  • Additional staffing ratios have allowed more preventive and developmental work to be done
  • Staff have been given the capacity and support to work with harder to reach families
  • The benefits of recruiting local people as volunteers for services may be seen in increased self-confidence, improved quality of parent-child relationships and the adoption of training and employment opportunities which might previously not have been taken.

Weblink to final report: http://www.scotland.gov.uk/Resource/Doc/46922/0024036.pdf

4.2.3 Second Sure Start Scotland mapping exercise, carried out 2004-05

The exercise aimed to assess the impact of Sure Start Scotland services and funding on children and families, as well as updating the quantitative data obtained from local authorities in 2001. Data were collected via a range of quantitative and qualitative methods.

Five thousand and seventy five children were found to be in receipt of an integrated package of care, but numerical information was only received from 7 out of 32 local authorities, and it was not clear that all children being supported were necessarily from disadvantaged families. The Scottish Executive target of 15,000 vulnerable children receiving an integrated package of care may have been met, but this is not known for certain, as less than a third of returns had data on this. Sure Start Services were found to be reaching pre-birth services as well as children in the 0-3 age group.

Key findings relating to Sure Start Scotland services:

  • Sure Start contributes to extending and enhancing services rather than replacing existing services with new services
  • Services for which data were collected were meeting the range of Sure Start Scotland objectives. Fewer claimed to be meeting the objective 'to improve children's health' although data suggest that it is in the area of health that some of the most innovative developments were taking place
  • Improvements in joint working between professional groups (health, social work and education) although progress still needs to be made on this
  • Services aiming to serve the hardest to reach groups reported success (individual examples are noted in the report)
  • Some services had formal evaluations in place and the majority of local authorities carried out formal consultations
  • Impacts of services related to improved child behaviour and development, increased self-esteem of the parent, preventing more intensive social work involvement as well improving health. Evidence from the case examples showed the impact of single, short term interventions as well as longer term, integrated interventions

Areas of concern highlighted re Sure Start Scotland:

  • Demand for services outweighs supply
  • Expectations may be raised that cannot be delivered in terms of support beyond age 3 and, in particular, across the transition to primary school
  • Balancing needs of highest priority families with preventative work with other vulnerable families
  • Services need to be well coordinated to ensure that support does not become intrusive

The mapping exercise made a number of recommendations, including:

  • the further development and expansion of Sure Start in order to provide adequate support to vulnerable families
  • assessment of longer term impacts, especially at key transition points ( e.g. into nursery or primary school)
  • issues of rurality need to be addressed, especially in relation to transport needs and reach of services
  • review, and development, of arrangements for monitoring and evaluation.

Weblink to final report: http://www.scottishexecutive.gov.uk/Resource/Doc/47121/0020894.pdf

4.3 Sure Start in England

A comprehensive programme of evaluation activities has been in progress in relation to Sure Start in England for several years and many of the findings are likely to be transferable to Scotland. The overall evaluation of Sure Start in England focused on three core questions:

  • Do existing services change?
  • Are delivered services improved?
  • Do children, families and communities benefit?

If changes/improvements/benefits were found to occur, the evaluation would assess how they happened, for which populations and under what conditions.

A number of reports from the evaluation have been published. The following are the most recent and appear to be the most important.

4.3.1 Early impacts of Sure Start Local Programmes on Children and Families (published 2005)

Sure Start Local Programmes ( SSLPs) do not have a prescribed 'curriculum' or set of services. However, SSLPs were advised that services should be 'evidence-based' and were directed to sources of information on evidence-based interventions. A great diversity of interventions has been employed in SSLPs, and this poses challenges to evaluating their impact.

As a first step in assessing the impact of SSLPs on child and family functioning, the cross-sectional phase of the Impact Study of the National Evaluation of Sure Start ( NESS) gathered information on 9- and 36-month old children and their families living in SSLP areas and in comparison communities. These data were obtained after SSLPs had been in existence for at least 3 years: i.e. it was possible to pick up early indications, but too soon to draw definitive conclusions (9-month olds are to be followed up at 36 months, after exposure to SSLPs for a longer period of time).

The work set out to answer 4 key questions, listed below with summary findings:

1. Do children/families in SSLPs receive more services or experience their communities differently than children/families in comparison communities?

  • There is little evidence that SSLPs have achieved the goals of increasing service use and/or usefulness, or of enhancing families' impressions of their communities. Among families with 36-month old children, mothers in SSLP areas rated their communities less favourably than those in comparison communities

2. Do families function differently in SSLP areas than in comparison communities?

  • SSLPs seem to enhance growth-promoting family processes to some extent, though many family outcomes appear to be unaffected by SSLPs.

3. Do the effects of SSLPs extend to children themselves?

  • Relatively less disadvantaged children/families seem to benefit, while relatively more disadvantaged children/families seem to be adversely affected.

4. Are some SSLPs more effective than other SSLPs?

  • There is some evidence that programmes led by health agencies have certain advantages. This may be because such SSLPs have immediate access to birth records; also their health visitors, who visit every infant, are likely to be better integrated with SSLP services and can direct needy families to relevant SSLP services.

In the short term, the intervention appears to have produced greater benefits for the moderately disadvantaged than for the more severely disadvantaged. It is suggested in the paper that the utilisation of services by those with greater human capital left others with less access to services than would have been the case if they had not lived in SSLP areas. Special efforts may need to be made to ensure that those most in need are not inadvertently deprived of assistance, due to the way in which SSLPs operate. Less disadvantaged families are likely to find it easier to access services and information about services, whereas the most disadvantaged families remain, at least in the shorter term, harder to reach and to engage.

Weblink to report: http://www.ness.bbk.ac.uk/documents/activities/impact/1183.pdf

4.3.2 Variation in Sure Start Local Programmes' Effectiveness: Early Preliminary Findings (published 2005)

SSLPs differ from other interventions undertaken to enhance the life prospects of young children in that they are area based, with all children and their families living in a prescribed area serving as the 'targets' of intervention. This has the advantage that services within a SSLP area are universally available, thus avoiding any stigma that could result from the targeting of individuals. However, as noted above, it may also mean that families in greatest need are not accessing or engaging with services.

The Programme Variability Study ( PVS) considered links between aspects of SSLP implementation and the level of effectiveness on child and parenting outcomes for the SSLPs included in the Impact Study. The PVS study developed ratings of 18 dimensions of implementation relating to:

  • what was implemented ( e.g. service quantity, identification of users, reach strategies)
  • the processes underpinning proficient implementation of services ( e.g. partnership functioning, leadership, staff turnover)
  • holistic aspects of implementation (vision, communications, empowerment, ethos)

SSLPs tended to score consistently across the three domains, indicating that proficiency in one domain usually goes with proficiency in other domains. Results indicated that these 18 dimensions are able to collectively differentiate between the most and least effective SSLPs on parenting and child outcomes, and that the proficiency with which the whole model is implemented has a direct bearing on effectiveness.

The study was more successful in relating aspects of SSLPs to improvement of parenting than to improvement of child outcomes.

Where programmes scored highly on 'identification of users,' 3 year old children's scores for non-verbal ability tended to be better in the programme catchment area. This finding is likely to be relevant to identifying and supporting the most vulnerable and hard-to-reach members of the community.

There are indications that improved child-focussed services and a higher proportion of health-related staff in SSLP areas are both independently associated with higher maternal acceptance.

The paper suggests that findings indicate a link between the processes by which SSLPs were implemented and the variation in child and parenting outcomes. Where SSLPs are implementing their programme in a manner that reflects the basic principles of the Sure Start initiative, they are more likely to achieve better outcomes for both parents and children.

Weblink to report: http://www.ness.bbk.ac.uk/documents/activities/impact/1184.pdf

4.3.3 Understanding variations in effectiveness among Sure Start Local Programmes: Lessons for Sure Start Children's Centres (Anning et al, 2007)

The study aimed to investigate:

  • Why some SSLPs were more effective than others
  • To characterise and explain variations between high, medium and low levels of programme proficiency in the delivery of services
  • To characterise and give examples of proficient and effective services for families with young children in programmes which were becoming Sure Start children's centres

Evidence was collected from 150 SSLPs. 18 dimensions were used, as in the earlier work, described above. Unlike the earlier work, this was a longitudinal study, looking at child and parent outcomes when the children were aged 9 months and 3 years.

Main findings:

  • Programmes that scored well across all 18 dimensions of proficiency showed better results in some parenting outcomes and, to a lesser extent, in child development outcomes
  • High scores in empowering users and providers of services were related to:
    • Higher levels of maternal acceptance when child was 9 months old
    • A more stimulating home learning environment when the child was aged 3
  • A stronger ethos and better overall scores on the 18 dimensions were related to higher levels of maternal acceptance for families with 3 year olds
  • Better identification of users by programmes was related to higher non-verbal ability in 3 year olds
  • Having a greater number of inherited parent-focused services was related to less negative parenting
  • Having a greater number of improved child focused services was related to higher maternal acceptance
  • Having a greater proportion of staff that was health related was associated with higher maternal acceptance
  • Reach figures were disappointing. Those who used services often used several, and reported satisfaction. But services offered at traditional times and in conventional formats did not reach many fathers, BME families, working parents. Providers found barriers to attracting 'hard to reach' families difficult to overcome
  • Few programmes demonstrated proficiency in systematically monitoring, analysing and responding to patterns of service use or rigour in measuring the impact of treatments
  • Multi-agency teamwork, including effective ways of sharing information, and clarity about the cost effectiveness of deploying specialist and generalist workers strategically, proved difficult to manage and operate.

Weblink to summary report: http://www.ness.bbk.ac.uk/documents/activities/impact/10.pdf

4.3.4 Cost-effectiveness in Sure Start Local Programmes: a synthesis of local evaluation findings (no publication date, references go up to 2006)

SSLPs were required to undertake local evaluation examining the process of service delivery and impacts and outcomes that have resulted from their activities. This report acknowledges the difficulties of assessing cost-effectiveness, and the impossibility of making comparisons when costs data are not always accurate, presentation of the calculations made not transparent and expertise on the part of the analysts not always reliable. However, the requirement to calculate the unit costs of services was alleged to be helpful and some services managed to restructure their arrangements in order to reduce costs. The main messages from the report focus on spend:

  • It takes time for SSLPs to develop and it is not until the third financial year of operation that most SSLPs are spending allocated funds an extent indicating widespread effects on services
  • Health-led SSLPs appear to get services up and running sooner, as indicated by their quicker rate of spend.

Weblink to report: http://www.ness.bbk.ac.uk/documents/synthesisReports/1287.pdf

Summary: what do we know about the effectiveness of Sure Start Scotland?

  • The impact of Sure Start has yet to be evaluated in Scotland, but a mapping exercise carried out in 2004/05 found that some Sure Start services had formal evaluations in place and the majority of local authorities carried out formal consultations. Benefits of Sure Start funding include:
    • capacity building (in terms of staff and premises) has helped staff to work with harder to reach families as well as improving service quality
    • recruitment of local people as volunteers for services
    • improvements in joint working between professional groups
    • services aiming to serve the hardest to reach groups reported some success (self report only)
    • improved child behaviour and development and increased self-esteem of the parent
  • The following concerns have been raised:
    • demand for Sure Start services outweighs supply
    • how to ensure provision of support beyond age three?
    • how to balance the needs of the highest priority families with preventative work with other vulnerable families
    • support may become intrusive
  • In England, a programme of evaluation has found that, where Sure Start is implemented as intended, there is some evidence of effectiveness, but that it is too early to see the expected long-term benefits. To date, the initiative has experienced difficulties reaching and engaging the most disadvantaged families.

4.4 Starting Well

Starting Well began in 2000 as a national health demonstration project serving as a 'test-bed' for innovative practice. It aimed to demonstrate that child health in Glasgow could be improved by a programme of activities that supported families and provided them with access to enhanced community-based resources. There is no indication of how/if work was integrated with Sure Start.

4.4.1 Phase One

Phase One (2002-04) focused on intensive home-visiting support to all families with new-born babies in two communities in Glasgow. This was implemented through health visitor-led skill mix teams. Areas were selected on the basis of a range of criteria:

  • levels of socio-economic deprivation
  • cultural mix
  • evidence of significant child health and parental support needs
  • presence of appropriate organisational community infrastructures

There were two essential components in the project: intensive home-based support and the provision of a strengthened network of community-based services for children and their families.

The project provided this intensive home visiting service as standard provision for families with a newborn baby. The level and type of support offered was based on a comprehensive assessment of family need. The project also aimed to develop enhanced local community supports and structures within these areas and to develop integrated organisational services to respond to the needs of children and their families both within the local areas and across Glasgow as a whole.

4.4.2 Independent evaluation of Starting Well

An independent evaluation of Phase One reported in June 2004 (Mackenzie et al, 2004). The evaluation aimed to assess impact by comparing the two intervention areas with socio-demographically similar areas in the north of the city. It compared the health and development of intervention children over the first 18 months of life with a group of families receiving statutory health visiting. The evaluation aimed to assess each child on 3 occasions (at birth, at six months, at 18 months).

The evaluation investigated 3 key process issues:

  • extent to which intensive home visiting led to the development of therapeutic relationships between families and their home visitors
  • implementation issues involved in developing a skill mix approach to home visiting
  • degree to which intensive home visiting at an individual family level led to improved community and strategic responses to child and family health problems

Findings were complex and difficult to interpret, but indicated that more time and direct contact with mothers encouraged the formation of trust, an individualised care package and the provision of better quality information on needs and life circumstances. Variation in process and outcomes was explained by mothers' receptivity to the service and health visitor caseload pressures.

Mothers in the intervention group were more satisfied with levels of health visitor support at both 6 month and 18 month assessments and were also less likely to be at risk of postnatal depression at 6 months (though not at 18 months). More 'Starting Well' children were registered with a dentist at 6 and 18 months.

The project teams developed very differently in the two intervention areas and differed in the degree to which they advocated integration within GP practices and in the dilution of the 'Starting Well' approach. Although much good practice was identified in bringing together health visitors and nursery nurses, issues of role clarity caused problems. The employment of health support workers through a voluntary organisation allowed a supportive model of engaging individuals with knowledge of the local area, who might not previously have been engaged in the labour market. However, the dual management structure led to difficulties around the day to day deployment and supervision of health support workers.

Findings indicated that intensive contact with families, better communication within the project teams and working with other agencies helped health visitors to understand health needs at a community level, although the process of sharing perceptions of community level need was haphazard. Increased burden on health visitor caseloads and early lack of clarity about roles led to less emphasis on advocating for community change.

Weblink to full evaluation report: http://www.scotland.gov.uk/Resource/Doc/37432/0009543.pdf

After Phase One a series of roadshow events was held across Scotland (spring and summer 2004). Key themes arising included the following:

  • Interagency and partnership working should be improved, to include joint training and pooling of resources
  • There was support for the model of skill mix adopted within Phase One (innovative roles assigned to Health Support Workers and Community Nursery Nurses). It was felt that including professionals from social work and education would have been helpful
  • Interest and support was expressed for the use of a comprehensive and evidence-based parenting programme, but there was not universal agreement on the most appropriate programme to use
  • Establishing relationships and conducting assessments during the antenatal period was felt to have received inadequate attention to date
  • Strong support was expressed for health visitors working within a defined geographical patch, rather than being attached to specific GP surgeries. However, it was felt that GPs would be resistant to this way of working.

Weblink to report: http://www.healthscotland.com/documents/1205.aspx

4.4.3 Phase Two

In Phase Two (2005-06) the universal service provided in the two geographic areas moved to a targeted approach to those most likely to gain from the interventions..

During this period the project aimed to demonstrate that the wellbeing of vulnerable and disadvantaged children (aged 0-5) and their families could be enhanced through an integrated, multi-disciplinary and multi-agency approach to the provision of care. This involved creating multi-agency teams across Glasgow to provide short-term, intensive support for highly vulnerable children.

Weblink to Phase Two plan: http://www.scotland.gov.uk/Resource/Doc/54357/0012598.pdf

A team of researchers from the University of Strathclyde Graduate Business School was contracted by Starting Well to evaluate Phase Two. They focused on the development of the integrated team approach and the input of change management support in this process. The evaluation was significantly delayed due to problems in gaining ethical approval and with the implementation of new teams. As a result the initial evaluation plan was only partially delivered. A report on the change management issues for the multi-agency teams tasked to deliver care to vulnerable families in Glasgow was expected to be published NHS Health Scotland at about the same time that this paper was completed (January 2008).

4.4.4 Parents and Children Together ( PACT)

The approach developed under Starting Well has now been devolved across Glasgow in the form of Parents and Children Together ( PACT) teams. Teams include colleagues from Health and Social Work Services. The seven teams are co-located within either community premises or within local authority buildings (one team is co-located with Jeely Piece Nursery 8.

The most vulnerable families are targeted through a multi-agency referral process. The family should be keen to address parenting support issues which require interagency input, and are required to engage fully with PACT. The multi-disciplinary approach allows for a range of interventions to meet a variety of child and parental needs. For example:

  • Individual work with parents and children to increase self-esteem, reduce isolation, promote play and development etc
  • Parenting work (individually and/or in groups)
  • Practical support (such as money advice, advocacy, accessing relevant services and supports)
  • Group work (such as women specific and men specific groups focusing on building confidence, social skills etc)

The timeframe for completion of the intervention includes a 4-week period of integrated assessment and initial support by the team, following by a planning meeting with agencies involved in supporting the family. This is followed by a 12 week planned intervention. After a final review meeting, the family and services determine whether further support is required.

There is currently no evaluation data relating to PACT in Glasgow, but a case study has been produced [by NHS Health Scotland? - not sure when to be published] to draw out general lessons in managing change and providing a resource for managers involved in planning and implementing complex change.

Learning is being shared across Scotland through the Early Years Learning Network at NHS Health Scotland.

4.4.5 Other reports on Starting Well

Since the project ended in March 2006, there has been extensive analysis of the database that was used in Phase One by the 'Starting Well' staff team. The Starting Well project Phase One Database Analysis - Family Characteristics and Health Visitor Targeting, A Briefing Paper' was published in January 2007 by the PEACH Unit, Glasgow University. Eight risk factors were identified as predictors of contact rates:

  • most deprived decile (Scottish Index of Multiple Deprivation)
  • South Asian
  • multiple birth
  • premature (<37 weeks)
  • family unwaged
  • mother or father in care as child
  • high score on Edinburgh Postnatal Depression Scale
  • involvement with Social Work Services or criminal justice.

Weblink to briefing paper: http://157.203.43.151/uploads/documents/3496-SW%20Database%20analysis.pdf

Further analysis has been completed by Julie Chambers through the PEACH unit and was awaiting publication by NHS Health Scotland at the time this document was completed (February 2008).

There is a wide range of reports on both phases of Starting Well, including an evaluation of the project's use of the parenting education programme Triple P, that can be accessed on: http://www.healthscotland.com/resources/networks/early-years.aspx (for more information about the evaluation of the Triple P parenting programme, see Chapter Five).

Summary: what do we know about the effectiveness of Starting Well?

  • An independent evaluation of Phase One reported in 2004.
  • Findings are difficult to interpret, not least because Starting Well was implemented differently in the two intervention sites, and the approach was diluted to various extents
  • The intensive visiting programme encouraged mothers to trust services
  • Better quality information on needs and life circumstances helped in putting together individualised care packages
  • Variations in process and outcomes depended on the receptivity of mothers to the service and health visitor caseload pressures.
  • The intervention changed from a universal to a targeted approach within the pilot areas between Phase 1 and Phase 2.
  • Phase 2 information is not yet available

4.5 The Child Development Programme and Community Mothers Programme

Developed in Bristol in the 1980s, the Child Development Programme ( CDP) is used in Britain, the Netherlands and Australia. (A version of the programme, the Comprehensive Child Development Program, is used and has been evaluated in the US, but it is not clear how/whether this differs from the version operating elsewhere in the world.)

The programme offers monthly visits to first time parents by specially trained health visitors, starting antenatally and continuing for the first year of the child's life. Visits are made every four-five weeks and are of 40-60 minutes duration. The programme focuses on six areas: health, language, cognition, socialisation, nutrition and early education. The focus is on developing the potential of the parents, rather than making them dependent on the health visitor. Emphasis is placed on the health and wellbeing of the mother, as a woman with her own needs and interests. The programme also aims to enhance the role of fathers/partners, by building on their existing strengths and giving them a sense of control over their lives and their children's upbringing. A significant factor in this programme is the exploration of issues such as health, development, diet and self-esteem in relation to both children and parents.

Twenty six areas of Britain are covered by the programme, including at least one in Scotland (Lanarkshire).

Evaluation of the initial phase of the programme in the UK (Barker, 1994) concluded that three main factors were attributable to its success:

  • Strong emphasis on the parents learning to take control over the health and development of their children
  • Fostering of parental skills through the use of programme strategies
  • Joint working out, by parents and health visitors, of objectives for the next month's parenting activities

It was not possible to asses whether individual aspects were less successful, or whether the programme worked better for less disadvantaged parents. The author is (or was) also the Director of the Child Development Programme in Bristol, so the objectivity of the evaluation might be questioned (see also the study below).

A detailed study of statistical data, across a sample of more than 30,000 children in 24 health authorities, trusts and boards in England and Wales suggested that those families involved in the CDP have a 41% lower rate of registration on the Child Protection Register, and a 50% lower rate of physical abuse, than adjusted levels for the relevant populations in the same health authorities. The authors emphasised that the success of the intervention comes about because parents have been supported to become better parents and, if the programme should be targeted at specific families, they would be likely to recognise this and refuse the intervention (Barker et al, 1992).

An evaluation which followed 4,000 families across a five year period (Goodson et al, 2000) found no significant difference in either child outcomes or parent outcomes between the intervention and control families. (This evaluation appears to relate to the US intervention only.) However, the evaluation has been criticised for shortcomings in implementation and on methodological grounds, including the reliability of comparison data, poor randomisation and low participation rates (Gilliam et al, 2000).

The First Parent Visitor Programme ( FPVP) evolved from the CDP and comprises a programme of regular home visits by a specially trained health visitor to first-time parents from deprived areas. The mother is visited once antenatally, at the statutory primary birth visit, three weeks postnatally and then every five weeks until the eighth postnatal month (although some families experiencing ongoing difficulties continue to receive the service until the child is two years old). The effectiveness of the programme has been evaluated in the UK using prospective and retrospective data from areas receiving the FPVP and matched comparison sites and a sample of over 2000 families. Findings indicated that:

  • There were no differences between the groups of mothers in self esteem, locus of control or depression rates
  • Women who received the FPVP were more likely to have changed partners, but had a wider support network than the comparison group and consulted their GP less often
  • Breast feeding rates were higher in FPVP mothers, who also gave their infants more fruit juice drinks than the comparison group
  • No differences were apparent in developmental outcomes for children in the study and comparison groups
  • There were no differences between the groups in immunisation rates, uptake of child health surveillance, or use of hospital services
  • Receipt of the FPVP was associated with increased use of electric socket covers and lower accident rates in the second year of life
  • A higher proportion of families who received the FPVP were registered on the local child protection register, compared with comparison families

Although some of the findings are positive, the evaluation could not show a clear advantage for the FPVP over conventional health visiting for families in deprived areas (Emond et al, 2002). It is not clear how/whether the FPVP differs from the CDP.

The Community Mothers Programme ( CMP) evolved from the Child Development Programme and was launched in Dublin in 1983. Currently it appears to be used throughout Ireland and at least some parts of the UK, although the emphasis of the intervention varies slightly (in Lanark, for example, the focus seems to be entirely on supporting mothers to breastfeed their babies) and the length of time support is offered also varies between one and two years.

Recognising that some parents seek social support from other parents, rather than professionals, the programme aims to utilise experienced volunteer mothers ('community mothers') to give support to first-time and some second-time parents in rearing their children. Specifically targeted at disadvantaged areas with large numbers of births, the programme aims to develop the skills of parents of young children and build their self-esteem.

Community mothers live in the same area as the recipients and are recruited to reflect the ethos of the community they will be visiting. They are guided by a Family Development Nurse, who serves as a facilitator. The community mother receives training over a four week period before engaging with families.

Community mothers make structured visits once a month to parents in their own homes, providing empathy and information in a non-directive way to foster parenting skills and build parental self-esteem. Each community mother visits between five and 15 families.

The community mothers' motivation is to help their community with the knowledge and experience each has gained through childrearing. Participation in the programme helps to increase their feelings of self-worth and their status in their own community. It is claimed (in an unpublished thesis by Molloy (2005)) that volunteering in the CMP contributed to lifelong learning.

The parents are empowered to believe in their own capabilities and parenting skills without becoming dependent on professionals.

The programme was evaluated in Dublin, using a randomised controlled approach in 1989-90, when programme children were one year old. Both intervention (n=141) and control (n=121) groups received the standard support from their local public health nurse and invitations to attend for primary immunisations and a development assessment. Eighty-nine percent of the sample completed the study.

The programme was found to have significant beneficial effects: children in the intervention group scored better in terms of immunisation, cognitive development and nutrition, and their mothers scored better in terms of nutrition and self-esteem than those in the control group (Johnson et al, 1993). The children were then followed up seven years later (Johnson et al, 2000). Findings indicated that:

  • Superior parenting skills persisted among the programme families
  • Children whose mothers were in the CMP were more likely to read books, to visit the library regularly, to visit the dentist and to have better nutritional intake
  • Programme mothers had higher levels of self-esteem and were more likely to express positive feelings about motherhood
  • The effects also carried through to subsequent children born to mothers, who were more likely to have received immunisation and to have been breastfed

One-third of the original sample group were followed up (38 in the intervention group and 38 in the control group). It is not clear whether the smaller sample was selected (and if so, how) or whether only one third of the families could be traced. If the latter was the case, it could be argued that those who had benefited most from the programme were the most likely to agree to participate in the follow up, and therefore the full, long-term impact of the programme remains to be evaluated.

Although it is clear that levels of disadvantage were high within the communities targeted by the initiative, the authors do not state whether outcomes were better or worse for particular groups of families within the communities. There is also no mention of negative findings. However, the programme is not intensive (many of the volunteers had just twelve contact hours with each mother), it offers benefits to the volunteers and to the mothers visited (and, ultimately, to the wider community) and it may engage parents who are difficult to reach via traditional services.

Summary: what do we know about the effectiveness of the Child Development Programme and the Community Mothers Programme?

  • Evaluation of the CDP in the UK indicated that empowering parents to take control of the health and development of their children and fostering their parenting skills are fundamental for the success of the programme
  • A longitudinal study of the effectiveness of the First Parent Visitor Programme (a variant of the Child Development Programme) in the UK was unable to demonstrate an overall advantage over conventional health visiting
  • Evaluation of the Comprehensive Child Development Programme in the US found that children's health, ability to concentrate and social behaviour were better, compared with those who received conventional postnatal care, and that they were more likely to have story books at home.
  • A study in the Irish Republic found that visits from community mothers had beneficial effects on parenting skills and maternal self-esteem, which were sustained over time. The effects also carried through to subsequent children born to mothers, who were more likely to have received immunisation and to have been breastfed.
  • In general, it is not clear from the evidence whether outcomes were better or worse for particular groups of families within the communities participating in evaluations of the CDP or CMP and, therefore, it is hard to tell whether the initiatives are effective for the most disadvantaged families
  • The CMP is not a costly or intensive intervention and offers benefits to the community volunteers and, potentially, to the wider community as well as to the mothers visited

4.6 Home-Start

Home-Start is another example of a UK-based volunteer home visiting programme in which trained volunteers offer regular support, friendship and practical help to young families under stress, in their own homes. Established in 1973, it has schemes in Scotland, England, Wales and Northern Ireland. Volunteers are of all ages and backgrounds; the only criterion for inclusion is that the volunteer has had experience of being a parent.

The strategic plan for 2005-08 stated aims to expand and further develop the service to all four nations of the UK, demonstrate the effectiveness of the programme, and promote better awareness of Home-Start's services: http://www.home-start.org.uk/about/Home-Start_Strategic_Plan_2005-2008.pdf

Evaluation of case study areas in the 1990s indicated that:

  • referrers appreciated the flexible and responsive nature of the service
  • mothers appreciated having someone to befriend them and listen to them as well as a source of support that was neither stigmatising nor threatening
  • families valued the input of Home-Start and more than half saw an improvement in their emotional wellbeing.

However:

  • involvement of fathers was minimal
  • there was a tendency not to refer families where there were concerns about child protection or domestic violence
  • some families were unwilling to accept the service because of perceived stigma
  • 42% of referrals either did not use the service, or did so only briefly
  • low users were more likely to be the most vulnerable (from socially disadvantaged backgrounds, with a history of depression, larger families and children at risk). (Case studies quoted in Asthana and Halliday, page 179).

An evaluation of the 18 Home-Start schemes operating in Scotland in1998 found that the most common reasons for referral were post-natal depression; ill health; pregnancy or new born baby; isolation; children's behaviour. The most common activities undertaken by volunteers were talking/listening; outings; playing with children; respite; shopping. In most cases, responses showed a reduction in loneliness and increase in confidence. General health improvements were reported by 40% of respondents and reduction in depression by 38%; in 21% of cases, anti-depressant medication ceased altogether. Volunteers were valued as undemanding friends who helped in facing 'authority figures.' In 53% of cases, volunteers had accompanied families to appointments, giving them practical support and encouragement.

However, the evaluation appeared to rely entirely on a survey of families, coordinators and referrers so, presumably, the changes in health status were self-reported rather than measured by validated instruments.

Weblink to news of evaluation: http://www.researchweb.org.uk/rip/ripnov.pdf

4.6.1 The outcomes and costs of Home-Start support for young families under stress (McAuley et al, 2004)

More recently a study evaluated the outcomes and costs of Home-Start support to 80 young families under stress, compared with 82 similar families who did not receive this kind of support. Families in Northern Ireland and South England were included in the study, although it is not clear whether the intervention and control groups came from across the two locations.

Main findings:

  • The majority of mothers from both groups were experiencing a high level of parenting stress at the outset, and high levels of depressive symptoms. Problems with the social and emotional development of their children were also evident. The mothers had little available informal support and contact with mental health services, hospital accident and emergency departments and GPs was high for both groups
  • Home-Start volunteers offered a combination of emotional support, practical assistance and help with outings. Mothers in the intervention group valued the service and considered that it had made a positive difference to their lives
  • At the 11 month follow up, mothers in both groups exhibited fewer depressive symptoms, had improved in wellbeing and were experiencing less parenting stress. However, this appeared to be due to changes over time and to experience. For example, mothers had gained confidence as parents, had established routines to manage competing demands and regained control over their lives. Some had returned to work, thus improving their financial situation, and the children were older and more independent (often attending playgroups or schools) so the mothers had more respite
  • The results did not support the view that Home-Start had made a significant difference to the mothers over the period of the research, relative to the experiences of the families in the comparison group.
  • At follow-up, there were no significant differences in formal service costs between the study and comparison groups. However, the receipt of Home-Start services pushed costs for the study group to a higher level relative to the comparison group.
  • Combined with outcome results, the evidence did not point to a cost-effectiveness advantage of Home-Start.

The researchers pointed out that the benefits of a community-based initiative such as Home-Start, which does not aim to provide a structured, intensive programme, might only be apparent after a number of years. They suggested that a follow-up several years later might prove valuable. However, since mothers in both the study and comparison groups showed similar levels of improvement at the 11 month follow up period, it would be difficult to attribute subsequent outcomes to the Home-Start intervention.

Weblink to report: http://www.jrf.org.uk/bookshop//eBooks/1859352189.pdf

Summary: what do we know about the effectiveness of Home-Start?

  • There is little information about the effectiveness of the intervention in Scotland - an evaluation of the 18 schemes operating in 1998 appears to have relied on survey information and self-reported health improvements
  • The volunteers who delivered the scheme were valued as friends who offered practical support
  • An evaluation of the costs and outcomes of Home-Start support in Northern Ireland and the south of England found that mothers valued the service, exhibited fewer depressive symptoms at follow-up and were experiencing less parenting stress. However, much of the change appeared to be due to the passage of time and greater experience of parenthood. At follow-up, there were no significant differences in formal service costs between the study and comparison groups, although the receipt of Home-Start services pushed costs for the study group higher than costs for the comparison group.
  • The researchers who carried out the costs and outcomes study suggested that the benefits of a community-based initiative, which does not aim to provide a structured, intensive programme, might only be apparent after a number of years