2 BACKGROUND AND INTRODUCTION
2.1 The pregnancy report
This is the first interim report for the evaluation of the Family Nurse Partnership ( FNP) programme in Scotland. The focus of this report is on the early implementation and pregnancy 2 period and presents data relating to:
- The early implementation of the programme
- Recruitment, training and supervision of the Family Nurse team
- Engagement of clients with the programme
- Enrolment and characteristics of clients
- The relationship between clients and the programme
- Visiting schedules, content of contacts and workload
- Programme management and inter-agency relationships.
The sources for the report include:
- Routine monitoring data
In depth interviews with
- members of the FNP delivery team
- Family Nurses, and
- key stakeholders in Scottish Government, NHS Lothian, City of Edinburgh Council and the Department of Health (England).
2.2 The Family Nurse Partnership ( FNP) programme
The Family Nurse Partnership Programme ( FNP) is a preventive programme, developed in the USA by Professor David Olds at the University of Colorado ( UCD) and based on the research of Professor Olds and his colleagues over the last three decades (Olds et al, 1986). The programme's goals are to improve pregnancy outcomes, the health and well-being of vulnerable first time parents and their children, child development and families' economic self-sufficiency. It aims to achieve these outcomes via an intensive, Nurse-led home visiting programme, beginning during pregnancy and continuing until the child is two years old. This visiting programme is aimed at helping first-time mothers to engage in good preventative health practices, supporting parents in providing responsible and competent care and positive parenting, and helping them to have a more coherent vision for their future. It focuses on vulnerable (particularly young) first-time mothers who are more likely to have low uptake of prenatal care and services, are at higher risk of engaging in unhealthy behaviours during pregnancy, are more likely to have poorer obstetric outcomes, and whose children may have poorer developmental outcomes than more advantaged mothers.
The programme involves the development of a one-to-one "therapeutic relationship" or "alliance" between a highly trained Family Nurse and the client. This support also extends to fathers and other family members. Three key theories underpin the programme: ecological theory (highlighting the importance of understanding the context in which people live their lives); attachment theory (in particular in relation to the formation of the bonds between parent and child as a basis for subsequent healthy child development); and self-efficacy theory (i.e. engendering a belief that individuals can take control of their lives in order to achieve certain outcomes).2.2.1 The FNP evidence base
The evidence base for FNP from the USA suggests that it is likely to be most valuable for single women of low socioeconomic status and/or teenage mothers (who are often - though not always - from relatively deprived socio-economic backgrounds, Olds et al, 1986). Positive outcomes have been noted in relation to diet, aspects of child safety and maternal well-being and support. FNP has been subject to three randomised controlled trials ( RCTs) in the USA (Olds et al, 1986; Kitzman et al, 1997; Olds et al, 2002).
Barnes et al (2008) summarised the short and long-term outcomes for FNP, evidenced by these RCTs in the USA. These, in the short-term (that is, during pregnancy and up to 24 months postpartum 3) include: greater service use, fewer pregnancy-related complications, enhanced maternal health behaviours, improved status of newborns, improved child behaviour and development, more responsive parenting, more attempted breast-feeding, fewer subsequent pregnancies, less welfare dependency, enhanced cognitive development for the children, improvements in child health and less maltreatment. Longer-term outcomes include more positive parenting, less welfare dependency, greater pregnancy spacing, enhanced behavioural and cognitive development and, in the much longer-term, evidence for the FNP children of reduced offending behaviour.2.2.2 FNP Core Model Elements and fidelity 'stretch' goals
FNP is a licensed programme, based on over 30 years of development and research in the USA. There are 2 main systems for ensuring that the programme is implemented with fidelity to the original research. First, there are various 'Core Model Elements' which are a requirement of the licensing conditions. The Core Model Elements cover:
- the visiting regime (a closely specified frequency of Family Nurse visits to clients throughout pregnancy until the child is two)
- staffing requirements (for example, the professional and personal characteristics of Family Nurses)
- client eligibility (for example, relating to the point in pregnancy by which mothers should be enrolled), and
- the supporting organisational structures and processes needed to support the programme (for example, requirements relating to training, supervision and administrative support).
Second, the FNP Management Manual ( DH FNP National Unit, amended for Scottish FNP sites, November 2010) sets out various fidelity goals - described as ' stretch goals'. These are goals based on the research evidence which, if met, may help maximise the likelihood of the programme achieving the same results as the US sites where the programme has been comprehensively evaluated. The fidelity 'stretch' goals cover client retention, visit 'dosage' (in terms of the numbers and length of visits to clients at different stages of their participation in the programme), and coverage of different 'domains' or topics during visits. The FNP Management Manual notes that achieving these fidelity 'stretch' goals can be challenging in the testing phase, but that they can be used by the Supervisor and the Family Nurses to monitor progress towards meeting them (see Appendix E for a full list of the Core Model Elements and Fidelity 'stretch' goals).2.2.3 Testing FNP in the UK
The FNP programme is currently being tested in over 50 sites in England, with a planned expansion to double the number of families able to receive FNP at any one time, to at least 13,000 by 2015. An RCT is being conducted in 18 sites. In 2009, the first Scottish FNP programme was established in Edinburgh, to test FNP in a Scottish context. The Scottish Government commissioned formative and summative evaluation of the implementation of FNP in Edinburgh that would:
- develop a monitoring and evaluation framework
- work with the implementation team 4 to identify appropriate process and outcome measures, using monitoring and routinely collected data
- assess programme fidelity
- explore levers and barriers to implementation
- assess the acceptability and perceived value of the programme for service users, programme practitioners and key stakeholders, and
- distil key considerations for any future implementation in Scotland.
More recently, an FNP programme has been established in NHS Tayside and plans have been announced to look at FNP extension in NHS Greater Glasgow & Clyde region. However, this evaluation is focused solely on the first Scottish FNP test site in Edinburgh.
2.3 The policy context in Scotland
There is now clear recognition that the earliest experiences, even pre-birth, can have long-lasting effects on children's development. It is also recognised that inequalities can appear early and that by age 3, differences in child development can be clearly related to socio-economic and emotional deprivation. The testing of FNP in Scotland reflects the Scottish Government's strong interest in early years, child and maternal health and has the potential to contribute to a number of key Scottish Government policies and targets.
The Early Years Framework, published in 2009 and developed in partnership between the Scottish Government, the Convention of Scottish Local Authorities ( COSLA) and other partners, provides an overarching strategy for policy in relation to early years in Scotland (while providing local flexibility in implementing the framework, reflecting the 2007 concordat between the Scottish Government and COSLA). This long-term strategy addresses the needs of families with children from pre-birth to age 8. A central theme of the Framework is the reduction of inequalities, particularly health inequalities. Its broad strategic approach towards achieving better outcomes for Scotland's children includes not just development of specific support services for children and families (ante-natal and post-natal care, childcare, early education, health and family support) but also consideration of how other key determinants of health and well being (e.g. housing, deprivation) impact on outcomes for children.
The Framework is based on the key principles set out in the United Convention on the Rights of the Child ( UNCRC) and seeks to promote and uphold children's rights. The Framework also sets out parental responsibilities. It embeds the principles and values set out in Getting it Right for Every Child ( GIRFEC). GIRFEC aims to 'help practitioners and organisations to remove the obstacles that can block children's paths on their journey from birth to adulthood'. Of particular relevance to the Family Nurse Partnership, GIRFEC's core components include:
- A focus on improving outcomes for children, young people and their families based on a shared understanding of well-being
- Streamlined planning, assessment and decision-making processes that lead to the right help at the right time
- A lead professional to co-ordinate and monitor multi-agency activity where necessary
- Maximising the skilled workforce within universal services to address needs and risks at the earliest possible time.
In relation to health inequalities more generally, the report of the ministerial task force on health inequalities, Equally Well, (Scottish Government 2008) was followed by the Equally Well Implementation Plan (December 2008). This brought together thinking on poverty, lack of employment, children's lives and support for families and physical and social environments, as well as on health and wellbeing and on the need to develop appropriate and timely interventions to produce better outcomes for children and families.
The Scottish Government Health Directorate has established a core set of ministerial objectives, targets and measures for the NHS. The targets for Health improvement, Efficiency, Access and Treatment, known as the HEAT targets, include three specific targets relating to maternal and child heath improvement:
- At least 60% of three and four year olds in each Scottish Index of Multiple Deprivation ( SIMD) quintile to have fluoride varnishing twice a year by March 2014.
- Achieve agreed completion rates for child healthy weight intervention programme by 2010/11.
- Increase the proportion of new-born children exclusively breastfed at 6-8 weeks from 26.6% in 2006/07 to 33.3% in 2010/11.
The Family Nurse Partnership has the potential to contribute to achieving these HEAT targets through an improvement in ante-natal and post-natal health, nutrition and support.
2.4 The Family Nurse Partnership in Edinburgh
The development of FNP in Scotland followed extensive discussion with David Olds at the University of Colorado and with the DH FNP National Unit. The license to implement the programme is held by Scottish Government and is under-pinned by a Consultancy agreement with the DH FNP National Unit, which provides training, access to expertise and support.
The first Scottish FNP programme is based in Edinburgh Community Health Partnership ( CHP). It is wholly funded by Scottish Government and is delivered by NHS Lothian. The choice of Edinburgh was due, in part, to a view that it would be preferable to locate the test site in one city with relatively high teenage pregnancy rates and which was contained within one local authority area (that is, with co-terminus boundaries). It was also considered that the extensive joint working already in place in Edinburgh between health and local sector agencies would facilitate the venture. This included City of Edinburgh Council's work on parenting support strategies and the fact that Edinburgh tested "Getting It Right For Every Child" ( GIRFEC) in two areas before rolling it out citywide from April 2010.
Chapter 8 provides a fuller description of the management and funding structures.
The NHS Lothian FNP delivery team is comprised of:
- The Supervisor
- 6 Family Nurses
- An Administrator/Data Manager
The Supervisor and Family Nurses collectively have experience drawn from previous roles in acute and community nursing.
The delivery team is supported by a local FNP Lead, based with the delivery team in NHS Lothian. The local FNP Lead role was established at the request of NHS Lothian to implement the programme at a local level and to ensure that it integrates with other services within Lothian as a whole and within NHS Lothian in particular. In addition, the local FNP Lead within NHS Lothian is responsible for providing anonymised, aggregated reports on FNP data relevant to outcomes of interest to the FNP evaluation. The local FNP Lead role in NHS Lothian incorporates elements similar to the Project Manager role in the English FNP test sites, but while in England the Project Manager role is a short-term role to set-up infrastructure for the local team, the local FNP Lead in NHS Lothian was a full-time secondment for 2 years.
The National FNP Implementation Lead Scotland - whose role is distinct from that of the local FNP Lead for Edinburgh based in NHS Lothian - was appointed in April 2009 to support the implementation of this programme across Scotland.
In order to meet the programme's Core Model Elements and fidelity 'stretch' goals, 148 clients who met the key criteria for participation were recruited over a nine month period 5. The Core Model Elements also required clients to be first time mothers and planning to continue with the pregnancy, less than 28 weeks gestation at the point of enrolment, and to opt in to the programme voluntarily. More specific client eligibility criteria are not set out in the Core Model Elements, but were agreed with the National Unit at the Department of Health (England) based on evidence from their own research, their experience of implementing the programme in England and on evidence from the USA. The eligibility criteria for the Edinburgh test site were: age 19 or younger at conception (based on age at last menstrual period ( LMP)) and living within Edinburgh CHP.
The process of engaging clients with the programme began on 25 th January 2010 and the first client was enrolled on 1 st February 2010. Enrolment was completed in October 2010.
2.5 Report structure
The structure of the remainder of this report is as follows:
Chapter 3 presents a summary of the research methods used to evaluate the implementation of FNP in Scotland. A fuller description of the methods, including the development of the monitoring and evaluation framework and logic models can be found in Appendix B, C and D.
Chapter 4 explores early engagement with and enrolment of clients. It draws on the monitoring data for the recruitment phase in relation to programme fidelity and on interviews with clients and Family Nurses.
Chapter 5 considers the early pregnancy phase, particularly from the perspective of clients and Family Nurses and explores their views and experiences of programme delivery.
Chapter 6 presents clients' views of the impact of the programme in relation to their health behaviours, use of services and infant feeding intentions.
Chapter 7 considers the FNP team's experiences of recruitment, training and supervision.
Chapter 8 describes the views of the key stakeholders in relation to management, funding and links with the National Unit at the Department of Health, England.
Chapter 9 summarises and discusses the emergent findings and key learning from this report.
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