Evidence to support improved outcomes for

Evidence to support
improved outcomes
for children and
Alison Macdonald
NHS Health Scotland
The evidence
• Evidence work to inform the development of an
outcomes framework for the National Parenting Strategy
• Covers the risk and protective factors and effective
interventions from pregnancy to 5 years
• Includes additional evidence drawn from our other EY
evidence work.
• Modernising Nursing in the Community summaries of
review level evidence .
– 21 topics aligned with A New Look at Hall 4 and
universal pathway (2011)
Protective factors of social, emotional and cognitive
difficulties (0-5 years)
• Positive (protective) factors:
 High socio-economic status
 High income
 Early years education /childcare
 Parental relationship: married, positive relationship at
 Parenting: positive parenting style
 Child factors: girl, first born, higher birth weight, older in
academic year, higher British Ability Scale Scores ,
ethnicity (white mother, English only language spoken)
 Maternal factors: education, older, self-rated health, ever
having been in employment, positive about pregnancy.
Blank et al., (2012a)
Factors linked to increased risk of social, emotional
and cognitive difficulties (0-5 years)
 Low socio-economic status
 Low income (unemployment, workless household)
 Housing (social housing, deprived area, housing
 Parental relationship: lone parent, unemployed lone
parent, co-habiting, living with stepfather, disagreement
between parents on parenting child, high level of
 Child factors: ethnicity (Indian, Pakistani, Bangladeshi,
Black African)
 Maternal factors: depression, psychopathology, alcohol
misuse, smoking during pregnancy, living away from
home prior to the age of 17.
Factors related to social, emotional and cognitive
difficulties (0-5 years)
• Most prevalent risk factors - low income linked to lone
parent status and living in social housing.
• Less prevalent risk factors - ethnicity, maternal and
child factors - but these are increased among those
with low income or lower social and economic status.
• Lack of national data on the prevalence of parenting
risk factors
• Absolute risk - maternal age, education and health and
housing are the factors associated with the highest
levels of absolute risk that a child will experience
social, emotional and cognitive difficulties.
Child poverty impact on health
Reducing the impact of factors leading to
unequal outcomes
Prevent - Fundamental socio-economic and political measures of
reducing the gaps in income and power. Structural changes to
economic, tax and benefits.
Undo - social circumstances are improved through the provision
of resources for living, education, employment, and improved
living conditions or environment.
Mitigate - The progressive universal model of care is the best
mechanism to identify and support families with additional
needs/ risks.
This model supports the implementation of GIRFEC.
Includes services offered to all families, such as health visiting
and pre-school education, along with the additional/ enhanced
services provided to families with specific needs and/ or risks,
such as children and family services, FNP and family centres.
Promoting positive relationships
• Sensitive, responsive care is associated with
secure attachment.
• Interventions which enhance parental sensitivity
are universally effective (including high risk
• Most effective interventions are brief and
behaviourally focused, e.g.
– Encouraging close physical contact i.e. soft
carriers and kangaroo care
– Providing information on attachment and
sensory and perceptual capabilities of infants.
Reducing domestic abuse
• Routine enquiry can increase rates of disclosure
• Counselling and management of care following
• Effective liaison between universal services and other
agencies providing support for those experiencing
domestic abuse
• Evidence about the effectiveness of specific
interventions to treat of prevent domestic abuse is very
Preventing Unintentional Injuries
• Most injuries in the under 5s occur at home
• Strong policy, legislation and enforcement
are important
• Families may lack both the information to
enable them to identify/manage risks and
the means to purchase and install home
safety equipment
• Effective interventions combine education
with provision of home safety equipment.
Promoting child development
approach to the early years has been recommended as
& course
provides foundation for healthy development
• Providing support to parents, children and families who have different
levels of need requires input from a range of services can reduce the risk
of poor outcomes for economically disadvantaged children in both the
short and longer-term
• Interventions can be delivered as part of progressive universal provision
or enhanced services
• Universal provision enables identification and progression of vulnerable /
at risk families to enhanced interventions
• Skills, experience and rapport building family of practitioners is essential
to assessing / addressing a family’s vulnerability.
Home Visiting
Home visiting
Good quality evidence to suggest that home visiting
interventions improve social and emotional
– Structure and intensity is linked to effectiveness.
Structured, intensive interventions delivered by
specialist nurses over first 18 months of life
most effective (e.g. family nurse partnership)
– Lower intensity, peer or lay provider less
Blank et al., (2012b)
Early childhood education / children’s
• Preschool education shown to reduce disadvantage,
especially among poorest families
• Quality of provision is key, including staff personal
qualities, training, good management and valuing of
social development
• Full day programmes most effective with most
disadvantaged families.
Home visiting and early year’s education
Long term outcomes:
• There is evidence that early childhood
interventions, including home visiting and early
education, result in lasting improvements in the
outcomes of at risk or disadvantaged children.
The greatest positive effects include:
• Improved cognitive development
• Educational success during adolescence
• Reduced social deviance
• Increased social participation
• Smaller improvements in family wellbeing and
social-emotional development have also been
Enhanced Specialist Programmes
Group based parenting programmes:
• Evidence indicates effectiveness of group based /
media based parenting programmes, (e.g.
Incredible Years) in improving emotional and
behavioural problems in children aged <=3 years
• Remains unclear whether group based parenting
programmes effective in preventing onset of
problems rather than treating existing ones
• Incredible Years & Triple P shown to effectively
reduce behavioral problems in children > 3 years.
Programme implementation to promote social and
emotional development
• Professional roles and practice
– Staff skills and beliefs about programme
– Management support/ flexibility/ clarity of role/ training and supervision
– Negative impact of high stress and complex workloads
• Organisation and management issues
– Partnership approach/ clarity of purpose/ organisation
– Negative – financial insecurity
• Engaging families
– Mother’s perceptions of benefits and quality of intervention
– service reputation/ physical and cognitive accessibility/ personal
– Maintaining contact
– perceived benefits to children and quality of service
– parental involvement and personal reasons
– timing of programme
• Home-based interventions
– relationship with staff key - especially beneficial to parents lacking in
emotional support
Key Messages
• Children’s life circumstances impact on their physical,
psychological and wider development from before birth
• There is a link between socio-economic disadvantage and
health inequalities during the early years; in particular there is
an increased risk of unintentional injuries, social emotional
and cognitive difficulties
• Adverse and complex social factors experienced during
pregnancy have the earliest impact on the health of the infant
and their mother
Key Messages cont…
• Effective communication between pregnant women
and their carer(s), and in particular continuity of care
and carers, improves the antenatal experience of
women with complex social needs.
• A progressive universal model of care is the
mechanism by which families with additional
needs/risks may be identified and appropriately
• Interventions which enhance maternal mental health
and wellbeing and those that promote positive parent
infant relationships can have long term benefits
Key Messages cont…
• Effective interventions that may reduce unintentional
injuries linked to socio-economic status, combine the
provision of home safety equipment and education
• Effective interventions to promote social, emotional
and cognitive development include:
– Pre and postnatal home visiting of vulnerable children
and their families, led by suitably skilled health
professionals (public health nurses / health visitors - e.g.
– High quality early years childcare and education, (e.g.
children's centres – Sure Start)
– Enhanced specialist group-based parenting programmes,
that have been shown to be effective for secondary and
tertiary prevention, (e.g. Triple P, Incredible Years)
Key Messages cont…
• Programme implementation fidelity is key
• Environmental factors, parent’s perceptions of the
benefits to families and children and their
perception of staff skills influence family
engagement and the maintenance of contact
• Spacious, well maintained and pleasant facilities
that are linked to good public transport are
important to maintaining family engagement.
Exploration of the information support
needs of parents
Parent information/support is undermined when parents feel marginalised
‘Trust’ shapes how information is sought, received and used - 2 way conversation
Parents respond most positively to personalised information and support – not one size fits
Want sufficiently detailed/understandable info re health, illness and chronic/acute conditions
Value peer support/social networks
Source important – respected practitioner, but not automatically accorded trust. Dependent
on quality of relationship and past experience. Rejection of TV, radio, newspapers,
magazines and commercial publication
Internet valued as secondary source but websites failed to provide bespoke, contextualised
Highly rate NHS24, SG and NHS “branded” resources but scepticism about credibility of
Social media not important as a primary source
Exploration of the information support needs of parents: http://www.healthscotland.com/uploads/documents/19013-RE001FinalReport1112.pdf
Useful links for evidence
• Guidance about Effective Interventions to Support
Parents, their Infants and Children in the Early Years
• Modernising Nursing in the Community
Contact details
• [email protected][email protected]
Learning & Workforce Development
• Health Behaviour
Change eLearning
suite for partners
referring to Health
• Scotland’s Mental
Health First Aid for
Young People
• Improving Health :
Developing Effective
Practice for children
and young people
(coming in 2014)
Decision-making in Public Health
Health Scotland’s principles
Do good
Do not harm
Social responsibility
Health issues
Causal factors
Risk of harm