CHAPTER 6: CONCLUSIONS
This chapter summarises the main findings of the study, highlighting the main risk factors for disengagement with formal services, and draws out some of the key reasons explaining reluctance amongst some parents to engage with support services. Drawing on these findings, the discussion points towards the areas on which policy may need to focus in order to encourage engagement with formal services for families with children.
The main objectives of this study were to measure formal service use among families with young children in Scotland, to investigate the risk factors associated with disengagement, and to explore some of the reasons and attitudes behind this disengagement.
6.1 Summary of main findings
Forty-one per cent of mothers were deemed 'low service users' when their child was aged 10 months, and 43% were defined as being 'low service users' when the child was aged 4. Respondents with lower maternal educational qualifications and those with lower household income were more likely to be low service users at 10 months. At age 4, low service usage was also related to having lower maternal educational qualifications and further associated with being in a lower socio-economic classification. Mothers who had other children before the cohort child were, perhaps unsurprisingly, more likely to be lower service users (at least in relation to this child).
Low service use when the child was aged 10 months did not appear to be a strong predictor of later low service use, suggesting respondents levels of usage were not that stable. The group of repeatedly low service users is likely to be of most concern to policymakers and service providers. Representing 18% of respondents, this group had particular characteristics: they were more likely to have lower educational qualifications and were more likely to be of lower socio-economic status.
Unexpectedly, parents of children with a long-term illness or disability were more likely to be in the low service group use groups at age 4 and in terms of repeated use. This may be due to the social patterning of such illness - being more prevalent amongst more disadvantaged groups who are less likely to use services - or because the service use scale incorporates information on use of a range of services unconnected to child health.
Mothers who did not attend ante-natal classes and/or mother and baby/toddler groups were asked the reason(s) why they did not attend. For ante-natal classes, being a first-time mother or not was important; the majority of women with other children who did not attend said it was because they had attended for a previous pregnancy or that they knew it all already. First-time mothers reasons for non-attendance included not liking the group format, not knowing where classes were held and simply for 'no reason'. Logistical reasons such as time, cost and travel were barriers for very few women. Reasons for not going to mother and baby/toddler groups followed similar patterns, with common reasons being that they didn't like groups or were shy/awkward about attending, or because there were no groups available or accessible. For a large proportion though, lack of time was also a key factor, particularly for mothers who had returned to work.
Reasons for using and not using childcare were also explored. Almost three-quarters of parents who used childcare when their child was 10 months old did so to allow them to work, although other common reasons included giving the main carer a break, so that the carer could go shopping or attend an appointment, and because the child liked spending time at the provider. The primary reasons for not using childcare at both 10 months and 4 years old were that the respondent would rather look after the cohort child themselves or because the respondent rarely needed to be away from the child. In addition, at 10 months, many respondents did not use childcare simply because they didn't need it. Cost was an issue for a small proportion of families at both years, as was lack of availability or choice at 10 months. Not surprisingly, cost was more of an issue for lower income households.
Attitudes towards seeking help or advice from formal services were also explored. Using a scale constructed from respondent attitudes, just over a quarter of respondents were found to be 'reluctant' service users. Multivariate analysis was then used to investigate the predominant characteristics of parents in this group. Reluctant service users at 10 months were found to have lower household incomes, lower employment and lower educational qualifications. They were also likely to have less confidence in themselves as a parent and to have low actual service use, though the direction of causality is difficult to establish in the latter case. Analysis of the age 4 data found similar associations with reluctant service users being more likely have a lower household income, to have lower educational qualifications, to have less confidence in their abilities as a parent and to have low service use. In addition, at age 4, living in a more urbanised area was related to reluctance to engage with formal services.
The final stage of the analysis investigated the relationship between levels of formal and informal support. At 10 months, respondents who had lower levels of service use also had lower levels of informal support, though differences in use of informal support between those with different levels of service use were small and, on a positive note, the data indicate that almost two-thirds of respondents who had lower formal service use had medium or high informal support. Patterns at age 4 were found to be almost identical.
Of particular interest to policymakers and service providers are those families who are unsupported, both formally and informally. Just 15% of parents fell into this group at 10 months, the proportion was similar - 14% - at age 4 and only 3% were in this group at both years. Unsupported parents were more likely to have lower educational qualifications, to live in a household with no-one in employment and to live in urban areas, all known risk factors in terms of isolation.
6.2 Implications for policy and practice
It is apparent that Hart's Inverse Care law is still very much at work in relation to parental service use in the early years, with those parents who service providers and policymakers most want to reach, and those most in need, being reluctant to engage. In addition, it is clear that policymakers and service providers cannot presume that those parents who do not engage with formal services instead have high levels of informal support because, particularly when the child is in infancy, this is not always the case. Respondents who were reluctant to engage with services, and/or who had poor informal support, were generally more disadvantaged in a range of ways, from having lower incomes and no-one in employment in the household, to having a mother with lower educational qualifications. Lower confidence as a parent was also a common theme, presenting a particular problem for those service providers whose aim is to build that confidence.
Reasons for non-attendence at ante-natal classes and parent and baby groups suggests that the group format of some of these supports is off-putting for some women. This appears to stem, at least in part and for some of these mothers, from a lack of confidence in their ability as a parent. In the group format, some mothers may believe their parenting skills are being assessed and discussed by other mothers. Thus, rather than a source of support, such groups are considered a source of scrutiny and stress which they would prefer to avoid. The existence of such scrutiny, and the stress it can create, is widely acknowledged and has resulted in a campaign, led by NetMums, which looks for a move away from conceptions of the 'perfect parent', and calls for more honesty amongst parents and a "societal understanding and acknowledgement of the challenges of being a parent" 17.
For others, simply providing more information, and possibly more appropriate information, on how to access such groups may be enough to encourage engagement. A three-tiered approach to ante-natal and post-natal care may therefore be the most appropriate and cost-sensitive way of engaging these women (and their partners). For each tier, the importance of establishing personal relationships with children and families and referring them to other services is key, as emphasised through the Scottish Government's Getting it right for every child approach.
As we have seen, for the majority of women, the current system of care and support through ante-natal groups and baby and toddler groups, alongside limited individual midwife and health visitor appointments, is deemed appropriate and accessible, though further qualitative research is warranted on the quality and usefulness of this care. These services and supports may, however, benefit from further sign-posting, for example from health professionals or in the communities in which they are run.
The second tier of support suggested is a non-professional intervention such as the Community Mothers programme. This may overcome the stigma associated with professional help, whilst still providing dedicated support and information to some of the more vulnerable families who otherwise may fall into the low support group. In an era of economic restraint, this 'middle ground' solution is also an attractive option to support this group, although it should not be regarded as the only reason for implementing this approach. As Susan Deacon recently noted: "we have known for a very long time, long before the spending cuts, that encouraging community and parental involvement and wider volunteer effort is a good thing to do, for children and for the whole family and the wider community" (Deacon, 2011).
The most vulnerable families are likely to need a more targeted professional support, such as the Family Nurse Partnership 18, which is currently being piloted amongst young mothers in Scotland. One of the keys to the success of this project is the fact that contact takes place regularly in the client's home - thus avoiding the group-based reluctance - and involves building up a relationship with one nurse over a sustained period. Uptake rates are extremely high, particularly given the vulnerability of this normally disengaged group.
Both evidence from GUS and the recent Deacon report make it clear that formal services and supports provided for families are only one of a handful of ways that parents can be supported. Rather, parents need to be supported by professionals, volunteers, the local community and other mothers. Not all of these approaches will work for all families, as the data has shown. The key appears to be targeting appropriate interventions for different groups of parents, using the characteristics highlighted in this report, so that all families should be able to access help and support that is right for them - whether that be through formal or informal groups, volunteer schemes or intensive professional support.