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Economic Strategy and National Performance Framework
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Background

Baby in hospitalIt is estimated that between 2 and 5% of children in UK experience multiple deprivation and poor outcomes, incurring high cost to the public purse and society.

Recent neuro-scientific evidence shows how negative experiences and poor parenting in pregnancy and very early childhood can do lasting harm to a child's brain development, behaviour, learning and long term health. There is, therefore, a strong case for intervening early with powerful programmes known to make a difference for these vulnerable children.

FNP is a preventive programme for vulnerable young first time mothers. It offers intensive and structured home visiting, delivered by specially trained nurses, from early pregnancy until the child is 2. FNP has 3 aims: to improve pregnancy outcomes; child health and development; and parents' economic self-sufficiency. The methods are based on theories of human ecology, self-efficacy and attachment, with much of the work focused on building strong relationships between the client and Family Nurse to facilitate behaviour change and tackle the emotional problems that prevent some mothers and fathers caring well for their child.

FNP has brought a different way of working with the neediest families. It is strength based and focuses on an expectant mother's intrinsic motivation to do the best for their child. It consists of structured home visits using materials and activities that build self-efficacy, change health behaviour, improve care giving and increase economic self-sufficiency. At the heart of the model is the relationship between the client and the nurse. A therapeutic alliance is built by specially trained nurses, which enables the most at risk families to make changes to their health behaviour and emotional development and form a positive relationship with their baby.

New babiesFNP is a licensed programme, developed in the US at the University of Colorado, where it is known as the Nurse-Family Partnership (NFP). Over 30 years of rigorous research has shown significant benefits for vulnerable young families in the short, medium and long term across a wide range of outcomes including:-

  • improved early language development and academic achievement
  • improvements in antenatal health
  • reductions in children's injuries, neglect and abuse
  • improved parenting practices and behaviour
  • fewer subsequent pregnancies and greater intervals between births
  • increased maternal employment and reduced welfare use
  • increases in fathers' involvement
  • reduced arrests and criminal behaviour for both children and mothers

In an international review by The Lancet in 2008 the FNP was named as one of only 2 programmes shown to prevent child maltreatment.

FNP in the UK

FNP has been tested in England since April 2007 with over 16,000 families having received FNP so far. 

Group of womenFNP is targeted on teenage first time mothers as a large body of research shows this group have a high level of need and that their children are at high risk of poor outcomes in the future. US evidence also shows that it is young disadvantaged first time mothers who benefit most from the programme.

The testing of FNP in NHS Lothian has been evaluated by an externally commissioned research team and the final reports have been produced, the focus being on the transferability of this model.

Early signs from this evaluation show that the programme is well received by clients, attrition is low at this stage and enrolment is high. Education and training for the role is highly regarded by the Family Nurses and links with wider services such as housing and social work are effective.

FNP Evidence

Father with babyA strong and rigorous US evidence base developed over 30 years has shown FNP benefits the most needy young families in the short, medium and long term across a wide range of outcomes helping improve social mobility and break the cycle of inter-generational disadvantage and poverty.

Evidence from 3 large scale trials in America which have followed children and families up to age 19 points to significantly improved health and wellbeing for disadvantaged children and their families including:

  • improved early language development and academic achievement
  • improvements in antenatal health
  • reductions in children's injuries, neglect and abuse
  • improved parenting practices and behaviour
  • fewer subsequent pregnancies and greater intervals between births
  • increased maternal employment and reduced welfare use
  • increases in fathers' involvement
  • reduced arrests and criminal behaviour for children (at 15) and mothers

The benefits are greatest where the mother is young (teenage), has low psychological resources (low IQ, poor mental health, low SES/living in poverty) which is consistent with the eligibility criteria used to target the programme on first time teenage mothers across the UK.

In an international review by The Lancet in 2008 FNP was named as one of only 2 programmes shown to prevent child maltreatment.

FNP is consistently rated by high quality evidence reviews as one of the most effective preventative programmes for vulnerable young families.

Recently published US evidence provides further evidence of FNP effects enduring through childhood and into adulthood. This showed that FNP improves school achievement, reduces the use of cigarettes, alcohol or marijuana and anxiety and depression amongst 12 year olds and, also reduced arrests and convictions for girls up to age 19. The life course of FNP mothers was improved through strengthened mother-partner relationships, a greater sense of mastery, less parenting role impairment due to drugs and alcohol use and reduced family poverty. The Government saved more than the cost of the programme in welfare payments alone by the time the children were age 12.

More Specific Detail on Benefits

FNP improves pregnancy outcomes, child health and development and mother's life course in the short, medium and longer term. In the US research FNP children and mothers, mainly those who were high risk with low psychological resources, compared to children and mothers in the comparison group had:-

Improved Pregnancy Outcomes

  • 79% reduction in premature birth amongst mothers who smoked
  • Fewer pregnancy related complications and infections
  • 31% fewer closely spaced subsequently pregnancies

Improved Child Health and Development

Increase in Children's Development
  • 50% reduction in language delays at 21 months;
  • 67% reduction in behavioral/intellectual problems at age 6
Increase in Academic Achievement
  • 26% higher scores on school reading and maths achievement in Grades 1-3**
Better Mental Health and Risk Taking Behaviour
  • Lower rates of anxiety and depression at age 12
  • Less use of tobacco, alcohol and marijuana at age 12
  • Girls had had fewer pregnancies by age 19
Reduction in Criminal Activity
  • 59% reduction in child arrests at age 15
  • 90% reduction in PINS (US equivalent of supervision orders)
Reduced Child Abuse and Maltreatment
  • 39% fewer injuries
  • 56% reduction in emergency room visits for accidents and poisonings
  • 48% reduction in child abuse and neglect

Improved Maternal Self Sufficiency and Life Course Development

Fewer Unintended Subsequent Pregnancies
  • 23% fewer subsequent pregnancies by child age 2
  • 32% fewer subsequent pregnancies
Increase in Labour Force Participation by the Mother
  • 83% increase by the child's fourth birthday
Reduction in Welfare Use
  • 20% reduction in months on welfare
  • Saved the government over $12,300 per family in welfare payments alone by time children aged 12 , greater than the programme cost of $11,511
Increase in Father Involvement
  • 46% increase in father's presence in household
More Sustained Relationships with Partner
  • 18% longer with current partner
  • Longer time with an employed partner
Reduction in Criminal Activity
  • 60% fewer arrests
  • 72% fewer convictions

Put another way, FNP families compared to comparison group had:-

Pregnancy and Birth
  • 25% reduction in cigarettes smoked amongst smokers
  • Improvements to diet
  • Fewer pregnancy related complications
  • 79% reduction in premature birth amongst mothers who smoked
  • Increased birth weight amongst very young mothers
Age 2
Child
  • 50-70% fewer hospitalisations for injuries and ingestion
  • 50% reduction in language development delay at 21 months
Mother
  • 23% fewer subsequent pregnancies
  • 31% fewer pregnancies within 6 months of birth of first child
  • Fewer beliefs about child rearing associated with child abuse and neglect
Age 4
Child
  • 50% reduction in language development delay (standardised effect size 0.31)**
  • Better behavioural development and executive functioning**
Mother
  • 20% longer interval between 1st and 2nd births
  • 83% increase in labour force participation
  • 46% increased father presence in household
Age 6
Child
  • 67% reduction in behaviour and intellectual problems
At Age 9
Child
  • Lower mortality from preventable causes*
  • 26% higher scores on school reading and maths achievement in Grades 1-3**
Mother
  • 12% less time on welfare since birth of child
  • 10% less time on food stamps
  • 18% more time with current partner
  • 41% fewer substances used in last 3 years (illegal drugs or moderate to heavy alcohol use)*
  • 21% longer intervals in months between birth of first and second child
At Age 12
Child
  • Improved academic achievement**
  • Less use of cigarettes, alcohol or marijuana
  • Reduced levels of clinical and borderline anxiety and depression
Mother
  • Longer partner relationships
  • Less time on welfare and food stamps
  • Less money from Government for welfare assistance
  • Less role impairment due to alcohol and drug use
At Age 15
Child
  • 48% less verified incidents of child abuse and neglect
  • 59% reduction in arrests
  • 90% reduction in adjudication as persons in need of supervision (PINS) for incorrigible behaviour
Mother
  • 61% fewer arrests
  • 72% fewer convictions
  • 20% less time on welfare*
  • 32% fewer pregnancies
  • 19% fewer subsequent births
At Age 19
Child
  • 43% fewer arrests (between 15 and 19, girls)
  • 58% fewer convictions (between 15 and 19, girls)
  • 57% fewer lifetime arrests (girls)
  • 66% fewer lifetime convictions (girls)
  • had fewer children (girls)

The information above is drawn from 3 different NFP Trials, each of which has followed families up at different points in time and measured different things which is why different outcomes are evident at different ages. This list sets outs the main benefits observed, it isn't exhaustive. There were also a number of measures that showed no significant differences between the FNP group and the comparison groups, again these varied between the trials and time points.

*only significant at 0.10

**for mothers with low psychological resources

FNP and Other Early Childhood Programmes

The size of FNP effects are relatively large compared to other home visiting programmes and FNP is consistently rated by high quality reviews of evidence based programmes as one of the most effective preventative home visiting programmes for vulnerable young mothers and their children (e.g. Aos 2004, 2008, 2009, Blueprints Centre for Violence Prevention, Coalition for Evidence based Policy).

FNP has many of the features identified by research as associated with effective early childhood interventions including:-

  • focus on specific populations
  • uses evidence based implementation practices
  • provides intensive services
  • involve both parents and child
  • has mechanisms for ensuring fidelity to programme model is achieved so benefits are reproduced

Evidence from FNP in England and Implications for Scotland

FNP was evaluated through a major RCT across eighteen sites and reported in October 2015.  The primary outcomes measured were maternal smoking, birthweight, admissions to hospital including A & E attendance and subsequent pregnancies.

The study also looked at a range of other outcomes, including child development up to age 2.

We will use these findings to inform the next steps for FNP in Scotland, working with colleagues across the UK.  More detail on our new approach will be shared over the coming months.

Randomised Control Trial Findings are published here - http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00392-X/abstract

David Olds commentary on the findings are published here - http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00476-6/abstract

References

  1. Olds, D.L., Henderson, C.R. Jr, Phelps, C., Kitzman, H., & Hanks, C. (1993). Effect of prenatal and infancy nurse home visitation on government spending.
  2. Karoly, Lynn A., M. Rebecca Kilburn, Jill S. Cannon. 2005. Early Childhood Interventions: Proven Results, Future Promise. Santa Monica, Calif.: RAND Corporation.
  3. S.Aos, R. Lieb, J. Mayfield, M. Miller, & A. Pennucci. (2004) Benefits and costs of prevention and early intervention programs for youth. Olympia: Washington State Institute for Public Policy, Document No. 04-07-3901.
  4. Stephanie Lee, Steve Aos, and Marna Miller. (2008) Evidence-based programs to prevent children from entering and remaining in the child welfare system: Benefits and costs for Washington. Olympia: Washington State Institute for Public Policy, Document no 08-07-3901.
  5. Julia Isaacs (2007) Cost-Effective Investments in Children (Washington, D.C.: Brookings Institution) http://www.brookings.edu/papers/2007/01childrenfamilies_isaacs.aspx.
  6. Kitzman, H. J., Olds, D.L., Cole, R.E. et al (2010) Enduring Effects of Prenatal and Infancy Home Visiting by Nurses on Maternal Life Course and Government Spending - Follow up of a Randomized Trial Among Children at Age 12. Arch Pediatr Adolesc Med. 2010;164 (5):419-424.
  7. [1] Olds, D.L. (2006). The Nurse-Family Partnership: an evidence-based preventive intervention. Infant Mental Health Journal, 27(1), 5-25.
  8. MacMillan, H.L., Wathen, C.N., Barlow, J., Fergusson, D., Leventhal, J.M. and Taussig, N. (2009) Interventions to prevent child maltreatment and associated impairment. Lancet 373: 250-266.
  9. Barnes, J et al (2009) Nurse-Family Partnership Programme: Implementation in England - Second Year in 10 Pilot Sites: the infancy period. London DCSF.