Outcomes Framework for Scotland’s National Parenting Strategy March 2014
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This report should be cited as: Ford J1, Scott E1, Woodman K1, McAteer J2. Outcomes Framework for Scotland’s National Parenting Strategy. NHS Health Scotland. Edinburgh. 2013 Acknowledgements Thank you to all of the members of the parenting community in Scotland that have contributed to this work and given their time to participate in workshops and discussions to develop the logic models. Particular thanks to the Scottish Government Children and Families Team (Hilary Third3) and Analytical Services Division (Fiona McDiarmid) for their guidance in developing this framework. NHS Health Scotland Scottish Collaboration for Public Health Research and Policy, University of Edinburgh 3 Formerly the lead for developing the National Parenting Strategy, currently working in the Scottish Government Equality Unit. 1 2
Published by NHS Health Scotland 1 South Gyle Crescent Edinburgh EH12 9EB © NHS Health Scotland 2014 All rights reserved. Material contained in this publication may not be reproduced in whole or part without prior permission of NHS Health Scotland (or other copyright owners). While every effort is made to ensure that the information given here is accurate, no legal responsibility is accepted for any errors, omissions or misleading statements. NHS Health Scotland is a WHO Collaborating Centre for Health Promotion and Public Health Development.
Contents 1.
Introduction
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2.
Context
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3.
Aim
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4.
Definitions and terminology
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5.
Target audience
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6.
Components of the outcomes framework 6.1 Outcomes triangle 6.2 Logic models 6.3 Multiple results chains
7 7 8 9
7.
Focusing on inequalities 7.1 Reach
10 11
8.
External factors
11
9.
Equality Impact Assessment
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10.
Scope and limitations of the framework 10.1 An important note on using the framework
12 13
11.
Development of the outcomes framework 11,1 Identifying and agreeing the outcomes 11.2 Developing the logic models 11.3 Evidence
15 15 16 16
12.
Sources of evidence included 12.1 NHS Health Scotland 12.2 Scottish Collaboration for Public Health Research and Policy, University of Edinburgh in partnership with the University of Glasgow MRC Social and Public Health Sciences Unit
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Logic models Logic model 1: Strategic logic model Logic model 2: Interventions to support parents and families Logic model 3: Structures and systems
20 22 23 24
13.
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14.
Rationale (evidence/theory) supporting logic models 14.1 Rationale for logic model 1: Strategic logic model 14.2 Rationale for logic model 2: Parents, family and society
25 25 32
Appendix 1: Policy, information and guidance
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Appendix 2: Glossary for the National Parenting Strategy Outcomes Framework
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Appendix 3: Summary strategic logic model
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References
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1. Introduction In 2007, the Scottish Government set out a National Performance Framework (NPF) to guide public reporting on progress towards achieving the five cross- government strategic objectives: Healthier; Wealthier and Fairer; Safer and Stronger; Smarter and Greener. 1 The NPF also sets out a range of national outcomes which sit below the strategic objectives against which the performance of public sector organisations will be assessed and publicly reported. The Scottish Government tasked NHS Health Scotland with providing resources (outcomes frameworks) which help people link local activities with the NPF and move toward an outcomes approach. The outcomes frameworks can be used or amended to fit local needs. They can also help service partners clarify the links between the outcomes of the services they provide and the shared outcomes that they are working to achieve. Outcomes frameworks have been created by NHS Health Scotland in collaboration with partners in a range of areas including alcohol use, tobacco, healthy weight, health and work, and mental health improvement. These outcomes frameworks are available on the interactive website available at www.healthscotland.com/OFHI/index.html The site also includes a series of additional resources and simple guides on how to use the frameworks. In 2012, the Scottish Government’s Children and Families team approached NHS Health Scotland for support to develop an evidenceinformed outcomes framework to inform development and support the implementation of Scotland’s National Parenting Strategy. 2 This paper describes the development of the work and presents the outcomes framework for the Strategy.
2. Context In recent years, there has been an increasing focus in international and UK policy on improving the life chances of children and young people. This is reflected in Scotland’s own policy environment. Work to tackle poverty and the determinants of social and health inequalities also provides an important context within which the National Parenting Strategy is operating. This is discussed further in sections 7 and 8.
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Scotland’s National Parenting Strategy was developed with a focus on supporting parents and those in a parenting role as a key way of improving the life chances of children and young people, as advocated by the World Health Organization: ‘the nurturant qualities of the environments where children grow up, live and learn – parents, caregivers, family and community – will have the most significant impact on their development. In most situations, parents and caregivers cannot provide strong nurturant environments without help from local, regional, national and international agencies.’ 3 There is a broad range of Scottish policy and work areas that provides important context for the implementation for the National Parenting Strategy and for the evidence presented later in the paper (see Appendix 1). Most recently, two developments in Scottish policy that will provide particular support to the implementation of the National Parenting Strategy are ‘Getting it Right for Every Child’ 4 (GIRFEC) and the Children and Young People (Scotland) Act. 5 The National Parenting Strategy will also provide real opportunities to enable the vision of these two areas to be realised. GIRFEC is the national cross-cutting programme which has been developed to outline an approach to working with children and families in Scotland. Based on individual need, the wellbeing of the child is placed at the centre of the approach, which establishes the principle of giving all children and young people the best possible start in life as a priority for all services (see Appendix 1 for further details). As a national approach to meeting the needs of all children and young people, GIRFEC is the vehicle to deliver the other key national action plans and frameworks in the early years, including Better Health Better Care, 6 the Early Years Framework, 7 Equally Well 8 and Achieving Our Potential. 9 Elements of the GIRFEC approach will also now be enshrined in the Children and Young People (Scotland) Act 2014 that aims to put children and young people at the heart of planning and delivery of services and ensuring their rights are respected across the public sector. 10 In particular the Act: •
reflects in domestic law the role of the United Nations Convention on the Rights of the Child (UNCRC) by influencing the design and
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• • •
•
delivery of policies and services by placing new duties on the Scottish ministers and the public sector and by increasing the powers of Scotland’s Commissioner for Children and Young People improves the way services support children and families by promoting cooperation between services, with the child at the centre strengthens the role of early years support in children’s and families’ lives by increasing the amount and flexibility of funded early learning and childcare ensures better permanence planning for looked after children by improving support for kinship carers, families and care leavers, extending corporate parenting across the public sector, and putting Scotland’s National Adoption Register on a statutory footing strengthens existing legislation that affects children and young people by making procedural and technical changes in the areas of children’s hearings support arrangements, secure accommodation placements, and school closures.
The Act also enshrines the GIRFEC ‘Named Person’ role in statute, and places the GIRFEC definition of wellbeing in legislation. It is important that the reader considers other distinct but complementary areas of Scottish policy where there are contributions to the same longterm and national outcomes (e.g. child poverty, child protection, alcohol, and mental health improvement).
3. Aim The National Parenting Strategy is the Scottish Government’s strategy that sets out ‘one clear purpose: to act as a vehicle for valuing, equipping and supporting parents to be the best that they can be so that they, in turn, can give the children and young people of Scotland the best start in life.’.2 The aim of the work presented here was to develop an outcomes framework which identifies the key outcomes for the National Parenting Strategy and specifies actions which could be undertaken to achieve them. The framework is intended to support an outcome-focused and evidence-informed approach to planning and performance. Before progressing to look at the models and evidence, it is recommended that time is taken to read the introductory sections that explain the design,
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development and applications of the framework, and also highlight some important issues and challenges (sections 7–11).
4. Definitions and terminology Definitions and terminology are hugely important in developing a shared understanding across all partners. We have tried to be as clear, concise and jargon-free as possible. The definitions and terminology used in the logic models have been the subject of much discussion during the development of the models, in collaboration with a wide range of partners. In order to enable a clear understanding of the activities and outcomes in the models, a glossary of key terms has been included in Appendix 2. Some of the main terms used are outlined below in order to guide the reader. Throughout the document and the models the term children and young people has been abbreviated to CYP. For the purposes of this outcomes framework the term 'parents' is intended to include all those individuals and agencies in a parenting role. For instance, this may include birth parents, parents of looked after children, adoptive parents, foster parents, carers, kinship carers, and corporate parents. The role of the wider family was also discussed frequently during the development of the framework. This is reflected in the language used in the models where often the actions and outcomes refer to parents and families. There is evidence to suggest a clear link between the impact of parenting and the quality of the parent and child/adolescent relationship on a range of health and wellbeing outcomes for children and young people. It was proposed that this reflects the ‘nurtured’ aspect of GIRFEC’s SHANARRI outcomes (see Appendix 1), and that this was a gap in existing Scottish Policy where the National Parenting Strategy could make an important contribution to improvements. Connectedness therefore became a key focus for the development of the long-term outcomes for the Strategy. Although there remains some disagreement in the literature around the definition of ‘connectedness’, for the purposes of this outcomes framework we use the definition provided by the World Health Organization: ‘A positive, stable, emotional bond between parents and children is an important protective factor for child health and development. Connection is made up of behaviours that convey to children that
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they are loved and accepted. It is a dimension of the parent–child relationship that is otherwise called warmth, affection, care, comfort, concern, nurturance, support or love. It is also important to consider the child's contribution to the bond.’ 11
5. Target audience The outcomes framework is designed to help community planning partners develop an outcomes-focused approach to planning and performance. It has also been created to support policymakers, planners, evaluators and researchers. The aim of supporting policy development in this way is to help make it more systematic, explicit and targeted.
6. Components of the outcomes framework The outcomes framework is divided into three components (or tools): • • •
An outcomes triangle – provides an overview of the topic area. Logic models – make explicit the link between activities and outcomes, and interconnections between outcomes. Multiple results chains – show the contribution of different sectors to achieving higher level outcomes.
The components are described in detail in this section.
6.1 Outcomes triangle The outcomes triangle is a diagram which presents an overview of the topic area. It categorises outcomes at different hierarchical levels and shows how they relate to the national outcomes in the National Performance Framework. It is not explicit about the links between activities and outcomes or interconnections between the outcomes. Figure 1 presents the outcomes triangle for the National Parenting Strategy. The top two thirds of the diagram contain long-term and intermediate outcomes. Long-term outcomes are concerned with population health outcomes. Some relate to general health outcomes such as healthy life expectancy, others relate specifically to the impact of parenting on outcomes for children and young people. Intermediate outcomes are changes in the ‘determinants’ of these high-level long-term outcomes. In this case these are parenting behaviours and family circumstances that mediate outcomes for children and young people.
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Short-term outcomes are the more immediate results of service delivery and reflect the contributions of specific organisations, partnerships, services or programmes. As such, they are more appropriate for performance management within service delivery organisations that is required to underpin Single Outcome Agreements (SOAs). Figure 1: Outcomes triangle for the National Parenting Strategy
6.2 Logic models Outcomes are the focal point of logic models. Logic models clarify the activities which can be undertaken and which population group can be targeted to achieve a desired outcome. Logic models also map out the sequence in which the outcomes need to be achieved. Evidence underpins the models where it is available but is not a limiting factor (see section 11.3). Where evidence is lacking or limited, the models present supporting plausible theory. Figure 2 is a simplified logic model for illustrative purposes only.
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Figure 2: A programme logic model 12
The logic models for the National Parenting Strategy are presented in section 13.
6.3 Multiple results chains Improving long-term outcomes can only be achieved by different sectors working together in partnership. Multiple results chains are a way of showing the contribution of different sectors to longer-term outcomes and could be used by local partners to show how local activities contribute to achieving shared long-term outcomes. Figure 3 provides an illustrative example of potential multiple results chains for the National Parenting Strategy.
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Figure 3: Illustrative multiple results chains for National Parenting Strategy
7. Focusing on inequalities While the National Parenting Strategy has an important contribution to make to the lives of families, it is crucial that this is placed within the context of the social factors that can significantly influence longer-term outcomes for children and young people. Poverty and social inequalities during the early years are important social determinants of children’s health and development and lifelong health inequalities. 13 Health inequalities are the unfair differences in health within the population across social classes and between different population groups. 14 These unfair differences are not random but largely socially determined, and they are not inevitable. A child’s early life circumstances and experiences shape their physical, social, mental, cognitive and emotional development and negative experiences can have a lifelong impact on health, learning and behaviour. 15 Poorer outcomes are a consequence of many adverse and complex social factors coming together rather than the result of a single cause, and these factors can impact on parents' ability to meet the needs of their children. They are not
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set in stone, but interact and can be influenced by interventions which tackle the context in which people live. Policies which address the interaction of multiple risk factors and reduced access to resources to mitigate against these risk factors and address these fundamental causes of poverty at a structural level in society (such as lack of work, poor quality of housing and basic educational achievement) are essential to support the wellbeing and optimal development of all Scottish children. 16 Opportunities to reduce the inequalities that result from these factors decline as a child gets older.15 For further discussion on the impact of child poverty and a full analysis of health inequalities readers are referred to the following documents: • Briefing on child poverty 17 • Evidence summary: Interventions to support parents, their infants and children in the early years (pregnancy to 5 years)15 • Health Inequalities Policy Review for the Scottish Ministerial Task Force on Health Inequalities 14 • Maternal and Early Years Network website 18 • Supporting Community Planning Partnerships in maximising income for pregnant women and families with children under 5 19 • A Response to the Scottish Government’s Expert Working Group on Welfare (EWGW) call for evidence16
7.1 Reach This outcomes framework incorporates ‘reach’ in the logic models and can therefore be used to track potential differential impact of specific activities on certain population groups (e.g. universal services for all parents and targeted, enhanced services for families with socially complex needs). In order to achieve population health improvement, enough of the right people need to be reached, and this forms a key underlying assumption in the models. By considering reach in the models this helps to ensure that inequalities are being effectively addressed and that actions are designed and implemented in a way that reduces inequalities. Well-planned monitoring and evaluation will enable local areas to track the impact on health inequalities.
8. External factors The outcomes of the National Parenting Strategy will be dependent on a range of external economic and policy factors that are not within its direct sphere of influence. This will include UK-wide legislation and policy drivers
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such as those for welfare and child poverty, and Scottish policy drivers such as housing and education. Poverty and adverse life circumstances in the early years can have an enduring impact on outcomes in later life (see section 7). It is known that approximately one-fifth of children in Scotland are currently living in relative poverty. 20 It is also predicted that there is potential for the welfare reforms being introduced by the UK government to further worsen the levels of child poverty across Scotland. However, potentially effective interventions for tackling the underlying social causes of child poverty include addressing structural changes to the tax and benefits systems and legislative controls and enforcement.14 The role of the wider economic environment will have an impact on the circumstances in which many families are living. It is therefore essential that the role of the wider macro-economic environment, as well as other elements of policy, are taken into account as potentially influential factors when considering the contribution of the National Parenting Strategy to the longer- term outcomes of parents, families and CYP. Despite the challenging economic circumstances we are currently experiencing, the outcomes that the National Parenting Strategy aims to improve and the actions required to achieve them do not change, although any potential impact should be monitored, evaluated and interpreted with this important context in mind. For further information about the potential impact of welfare and deprivation on inequalities in outcomes for families and CYP in particular the reader is referred to the resources listed in section 7.
9. Equality Impact Assessment
The Equality Impact Assessment 21 for the National Parenting Strategy states that the strategy includes people who are covered by each of the protected characteristics and will not adversely disadvantage any equality groups. The Scottish Government stated that as they implement the Strategy they will consider how to ensure that parents from all equality groups are able to gain access to and benefit from the work taken forward to improve the support for all parents.
10. Scope and limitations of the framework The Scottish Government has been encouraging the use of outcomesfocused approaches. It has also been argued that we need new approaches to evaluate public health interventions, which are typically multi-faceted and complex, involve a range of organisations and have diverse impacts on individuals, communities and populations. 22 NHS
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Health Scotland has created the outcomes frameworks to address these complementary agendas. However, this is a developing area and work is ongoing within NHS Health Scotland to evaluate the use and impact of these outcomes frameworks. The purpose of the outcomes framework is to identify key outcomes for the National Parenting Strategy and outline which actions can be carried out to achieve them based on evidence or plausible theory. The framework: • • • • •
is not a causal model for parenting and subsequent outcomes does not try to explain all of the interactions between activities and outcomes does not depict the true complexity of the parenting agenda; it only attempts to clarify some of the key paths to achieving intermediate and long-term outcomes is a resource for policymakers, planners and practitioners to help them clarify what outcomes they want to achieve and what can be done to achieve those outcomes presents a snapshot of what is currently known about valuing, equipping and supporting parents.
10.1 An important note on using the framework In reading the framework there may be a number of questions that arise. This section attempts to answer some of these and offer explanation about how the framework is attempting to address important issues around evidence, planning and evaluation. (i) There are some areas where evidence is lacking, weak or developing, leaving the potential for gaps in evidence to be interpreted in different ways: • The frameworks have set out to provide a logical explanation and plausible statements for activities, links and outcomes even where there is no highly processed evidence available. Users of the frameworks are guided to form their own views about whether particular work provided constitutes sufficient evidence. The evidence available can then be used to make more informed choices based on local need and priorities. • There are underlying assumptions in the rationale provided for the models. We are aware that the incorporation of ethics in the rationale for the models has the potential to cloud the issue of evidence, the difference in plausibility and using ethics, and
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•
plausibility as a reason to carry on what you were doing before, and also the fact that we are only presenting evidence and not being directive. Although we currently do not intend to change the process, it is a key issue to be aware of and important to track any potential ‘misuse’ of the models. A clear example is in relation to ‘knowledge and awareness’ where evidence of any impact on behaviour change is not clear. These pathways in the models are based on an assumption that improved knowledge and awareness will result in behaviour change among parents and service provider staff, and subsequently in improved outcomes. These actions are included as part of a comprehensive package of approaches, but caution must be applied due to a lack of clear evidence in this area and the complex nature of behaviour change. In these instances the framework should not be used to provide legitimacy and resources for prioritisation of actions where no clear evidence exists, particularly at a time of significant economic constraints.
(ii) The evidence presented may appear to be more qualitative (e.g. do interventions work?) than quantitative (e.g. how much benefit do they produce?). In order for policymakers, planners and funders to make effective, informed decisions about priorities, and the relative value of different interventions, particularly in the current economic climate, more detailed information on effect size and cost effectiveness could be important: • Local decision-making based on need is key to this process and the effective use of the framework. The approach we have used reflects national guidance and, where available, highly processed evidence (e.g. Cochrane, NICE). This framework can provide the overview for use and adapting locally, and to do this local users of the frameworks might want to look at specific areas of this evidence (and specifically cost-effectiveness evidence) in more detail. The emphasis of the frameworks is on their role in pointing towards evidence, guidance, etc, and they are not intended to dictate to local areas what they should be prioritising. Priorities for different activities and outcomes in the models may vary at the local level based on local needs. We provide a rationale for the links between actions and outcomes which will indicate the strength of these connections based on available evidence. It is for others to identify which outcomes to focus on. NHS Health Scotland will continue to provide support locally in developing the frameworks for use in planning and evaluation.
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(iii) Some of the pathways and outcomes in the models are based on an assumption that services and service provider staff will have the capacity and resources to respond to existing and any increased demand: • There may be a need for additional staff resource in certain support and service areas if demand for services were to increase, or roles were expected to change in response to some of the actions outlined. It would be necessary to ensure that service provider staff were adequately supported in delivering this agenda to ensure effective implementation of actions and interventions. (iv) We recognise that current knowledge of the parenting agenda is imperfect and that there is a degree of uncertainty which surrounds a number of issues in the area. This outcomes framework seeks to ensure the knowledge we do have is used to inform decisions which have to be taken, despite a lack of evidence in some areas: • The value of this approach is that it enables us to bring together different sources of evidence and highlight areas where better evidence is needed. This can then be used to encourage better evaluation planning that will add to the evidence base. This framework provides an opportunity to begin to fill gaps in evidence through a programme of monitoring and evaluation. • The logic models should be used to challenge the status quo, not rationalise it, and this should be done jointly with partners. Monitoring and evaluation plans will be instrumental in testing the rationale that has been provided for actions, pathways and outcomes in the models.
11. Development of the outcomes framework A collaborative approach was adopted in developing the outcomes framework. A core group of NHS Health Scotland, Scottish Government and Scottish Collaboration for Public Health Research and Policy (SCPHRP) colleagues developed the framework in collaboration with a range of partners, including individuals involved in parenting work from the Scottish Government, local government, local Health Boards, and the third sector.
11.1 Identifying and agreeing the outcomes The starting point for identifying the key outcomes for improvement was connected to the Scottish Government’s development of the National Parenting Strategy in 2012. Following an initial discussion group with a range of relevant stakeholders to identify the key outcomes for the
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National Parenting Strategy, a core project team was set up to take the work forward. A collaborative method to create and refine the outcomes framework was agreed. One of the cornerstones of this process was bringing together the core project team and working collaboratively with key stakeholders that were already contributing to the development of the National Parenting Strategy through the National Parenting Strategy Policy Advisory Group, Early Years Network and National Parenting Network. This process brought together representatives from across the public and third sectors and provided an invaluable source of expertise in defining the key outcomes for the framework. As highlighted in section 4, the importance of nurturing children and young people and improving connectedness formed a key, evidence-informed focus for the development of the long-term outcomes for the National Parenting Strategy.
11.2 Developing the logic models A series of key outcomes form the basis for the three logic models which underpin the outcomes framework. An initial draft of the strategic logic model (model 1) was developed following discussion with stakeholders and refined by the core group for sharing with additional stakeholders. This stage was followed up with further discussion groups to inform the development of the ‘nested’ models. These models were developed in two areas that would, in theory, enable the identified intermediate outcomes to be achieved. The two areas set out in the models are: • •
Model 2, Parents, family and society: the interventions and services required to support parents, families and the relevant workforce. Model 3, Systems and structures: the service providers, workforce and systems required to support parents and families.
11.3 Evidence A key principle of the outcomes framework is that it is evidence-informed, that is, the links between the various components of the model are informed by the available evidence and, where appropriate, plausible theory. A series of evidence reviews carried out by NHS Health Scotland and the Scottish Collaboration for Public Health Research and Policy have informed development of the framework and been used to refine the logic models.
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Consideration of the evidence presented should also take account of the existing policy context, legislation and current practices in Scotland (see sections 2, 7 and 8, and Appendix 1).
Identifying and summarising evidence of effectiveness Evidence of effectiveness from research and evaluation studies helps us to identify areas for effective action. While the outcomes of individual primary outcome studies are important, these may be atypical, and potentially biased. Such issues may only become apparent when studies are repeated or interventions rolled out on a wider scale. Evidence and evidence-informed recommendations from systematic reviews and reviews of reviews seek to reduce bias by providing an overview of the findings of a number of studies. These form the basis of ‘highly processed evidence’, for example practice guidelines, produced by organisations such as the National Institute for Health and Clinical Excellence (NICE). While we acknowledge that other sources of evidence may be available, because of time constraints and in the interests of quality assurance, the evidence presented here is primarily ‘highly processed evidence’ as opposed to primary outcome studies. Due to inevitable gaps in strong scientific evidence, the feasibility and desirability of adopting a purely evidence-based approach to health improvement and reducing health inequalities are limited. Activities that lack a strong evidence base may have important contributions to make to the overall impact as part of a package of interacting activities. In judging whether to include certain possible activities it may be useful to draw on the NHS Health Scotland approach, whereby plausible theory and ethical principles are used to guide decision-making, in addition to the available evidence. 23 Specifically, when considering the evidence of effectiveness about parenting interventions, the following points are noteworthy: • While the evidence provides an overview of what is currently known from the identified highly processed evidence sources, it is apparent that in some instances the evidence is limited in that there remains a lack of robust, relevant primary outcome studies in several areas of intervention, e.g. in relation to key vulnerable groups. • It is important to draw attention to methodological issues of evidence presented, such as the extent to which the included studies have been undertaken in the USA, which raises questions about the transferability/generalisability of findings to the Scottish context.
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•
We acknowledge that much of the evidence reviewed by NICE is only part of the material that they consider to inform their recommendations for action as part of NICE Guidance. Expert opinion is also central to how evidence informs decisions about new action to be taken.
Plausible theory For a variety of reasons (e.g. overwhelming demand for effectiveness evidence; skewing of effectiveness evidence due to a focus on traditional evidence ‘hierarchy’; inadequacy of effectiveness evidence) we do not always have ‘good evidence’. Furthermore, in some instances we are often presented with equivocal evidence, the use of different terminologies, definitions and outcome measures, uncertainty about the direction of causality and attribution of outcomes to activities. This lack of evidence, however, does not necessarily mean there is no link between two components in a logic model. Similarly, lack of evidence should not always prevent us from acting. In some instances, therefore, plausible theory has been drawn on to explain the links in the models. However, it is vital that this theory is then tested through monitoring and evaluation in order to gather evidence of progress or otherwise to enable appropriate amendments to be made to existing programmes of work as new evidence emerges.
12. Sources of evidence included The evidence presented in this outcomes framework has been taken from a series of accompanying and related evidence reviews completed by NHS Health Scotland and by the Scottish Collaboration for Public Health Research and Policy, University of Edinburgh, in partnership with the University of Glasgow MRC Social and Public Health Sciences Unit. These evidence reviews were specifically commissioned to support the development of the National Parenting Strategy and a review of Modernising Nursing in the Community. 1 Where relevant, we have signposted the read to additional sources of evidence. However, it is important to note that this is not an exhaustive review of all relevant evidence.
1
www.mnic.nes.scot.nhs.uk/children,-young-people-families.aspx
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12.1 NHS Health Scotland Evidence summary: Interventions to support parents, their infants and children in the early years (pregnancy to 5 years) (2012) Eileen Scott and Kate Woodman This rapid review presents an overview of highly processed evidence related to public health interventions to support parents, their infants and children in the early years (pregnancy to 5 years). Available from: www.healthscotland.com/documents/6089.aspx Evidence summary: Public health interventions to support parents of older children and adolescents (Forthcoming) Eileen Scott and Kate Woodman This rapid review presents an overview of highly processed evidence about public health interventions to support parents of older children and adolescents. The included evidence mainly covers parents of children and adolescents from the age of 7–19, however reviews may feature papers including parents of children from birth to 20 years. The evidence is very limited and as a result it was felt appropriate to include these papers and to highlight, where possible, the age range of children of participating parents. Peer Support for Breastfeeding: Guidance for Scotland (2013) Kate Woodman This guidance is intended to inform professionals in Health Boards, and voluntary sector agencies who have responsibility for local breastfeeding activities, about the most up-to-date policies and evidence about breastfeeding peer support. Available from: www.healthscotland.com/documents/22529.aspx Briefing papers on parenting programmes (2013): • Briefing on The Family Nurse Partnership • Briefing on The Incredible Years Parenting Programmes • Briefing on Triple P Positive Parenting Program Eileen Scott
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This series of briefing papers on parenting programmes currently used in Scotland is intended as a source of information for the early years workforce, providing an overview of the programme and supporting evidence. Available from: www.healthscotland.com/documents/21625.aspx
12.2 Scottish Collaboration for Public Health Research and Policy, University of Edinburgh in partnership with the University of Glasgow MRC Social and Public Health Sciences Unit Characteristics of effective and ineffective adolescent health interventions with a parental component John McAteer, Ruth Jepson (SCPHRP, University of Edinburgh), Daniel Wight, (MRC Social and Public Health Sciences Unit, University of Glasgow), and Caroline Jackson, (SCPHRP, University of Edinburgh) This review aimed to identify 1) which parenting interventions have been effective and for which adolescent outcomes, and 2) the characteristics of these interventions. This was a review of reviews of interventions that were delivered solely to parents, or included parental components, to influence the health of their adolescent children. Available from: www.scphrp.ac.uk/parenting_report
13. Logic models Three logic models are presented on the following pages: • In the logic models you will see different colour lines. This is simply to enable the pathway of the arrows to be easily distinguished. • Each link in the models is numbered. To make explicit the assumptions we are making in the models, we have provided a rationale for these connections using the evidence and, where no evidence is available from the sources used, plausible theory. • The outcomes framework is not a fait accompli; it represents our best understanding of valuing, equipping and supporting parents at this point in time and involves a process of reflection and continual improvement. It will need to be reviewed and locally modified to reflect local priorities as we continue to understand more about work in this complex area. A summary version of Model 1 is provided in Appendix 3. This is intended to present a simplified overview of the intermediate and long-term
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outcomes for the National Parenting Strategy and is useful for communication purposes. Figure 4 illustrates the flow of pathways in the three logic models. The ‘nested’ models set out the actions, reach and short-term outcomes for the strategy. These flow in to the ‘strategic’ model that sets out the intermediate and long-term outcomes for the strategy as well as identifying the national outcomes the strategy will contribute to. Figure 4: How to read the National Parenting Strategy logic models
For the purposes of the current work, evidence has been presented for children and young people in three different age group categories based on the evidence reviews that informed this work (see section 12). These are: • •
•
Interventions for parents of infants and children in the early years: pregnancy to 5 years Interventions for parents of older children: included evidence mainly covers parents of children and adolescents from the age of 7–19, however reviews may feature papers including parents of children from birth to 20 years. Interventions for parents of adolescents: reviews included those targeting adolescent outcomes.
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Logic model 1: Strategic logic model Intermediate Outcomes Society and communities understand the value of families and recognise their role in supporting them
National Outcomes
Long-term Outcomes 1.1
Scotland has a society and culture that values and supports the role of parents, CYP and strong families.
1.6 1.1
1.1 More resilient, stable, strong families
Reduced parental isolation and anxiety Model 2 : Interventions to support parents and families
Increased parental self-efficacy & self-worth Parents are motivated and enabled to support the holistic development of CYP
1.2
Families engage in regular shared activities
1.4
More positive, healthy, nurturing relationships within families and strengthened parent/CYP and family connectedness
All parents and families get the high quality, tailored support they need when they need it
1.3
Our children have the best start in life and are ready to succeed. We live longer healthier lives. We have tackled the significant inequalities in Scottish Society. We have improved the life chances for children, young people and families at risk.
1.5 Strengthened social and emotional competence for all CYP
Reduction in risky behaviours by all CYP
Parents and families provide supportive, secure boundaries, guidance, and emotional stability and support for CYP
Increase in CYP positive and health enhancing behaviours
Parents and families are positive adult role models for CYP through healthy lifestyle choices and positive behaviours
Increased CYP aspirations and CYP participation in learning, training or work
1.6
1.6
Improved health and wellbeing for all CYP
Parents and families promote positive aspirations for CYP and provide an enriched home learning environment
Model 3 : Structures & systems
CYP are better prepared for parenthood (and link to model 2)
All CYP feel valued by their parents, family and society
Improved and open communication in families Parents and families develop sensitive, responsive care-giving
1.1
1.7
Our young people are successful learners, confident individuals, effective contributors and responsible citizens. We have strong, resilient and supportive communities where people take responsibilities for their own actions and how they affect others We realise our full economic potential with more and better employment opportunities for our people
Parents and families value and promote a culture of learning and actively participate in CYP learning
***Please note that the different colours used in the lines are simply to distinguish between them.***
GIRFEC Outcomes Safe Healthy Active Nurtured Achieving Respected Responsible Included
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Logic model 2: Interventions to support parents and families Actions Provide support to enable local networks and peer support, and participation in society and work (e.g. creches, facilities, resources)
Reach Parents, families and communities; Relevant service providers; Workplaces
2.1
Develop and communicate appropriate, evidence-informed messages about the value of parenting to individuals and society
Develop and communicate appropriate, evidence-informed messages about CYP development and attachment
Evidence-informed, tailored action to prepare individuals for parenthood
Short-term Outcomes 2.1
2.2 Population level; Targeted for parents; Targeted for relevant workforce (to be defined locally)
2.3 Improved understanding of how to support and nurture CYP development and contribution to that
2.3 2.4
Action to promote secure attachment & sensitive, responsive parenting (e.g. skin to skin contact, infant carriers, infant massage)
Expectant parents; CYP engaged and not currently engaged in education or training; Foster & adoptive parents, kinship carers and others with parenting role
2.3
2.6
Improved understanding of attachment and CYP development and behaviour
Individuals are better prepared for parenthood
2.8
Parents are knowledgeable, skilled and confident in ways to support the holistic development of CYP
Model 1 : Strategic model
2.5
Interventions to promote the social, emotional and cognitive development of CYP (e.g. home visits, early years education, enhanced specialist early intervention)
Parents understand the importance of providing supportive, secure boundaries
2.5
Action to promote open communication between parents & CYP
2.5
2.5
Action to improve sensitive appropriate responses to CYP behaviour
2.7
Workforce are better prepared to support parents and families
Improved understanding of appropriate responses to CYP behaviours
2.7
2.10
All parents and families
Action to promote parental involvement in CYP play, learning, training and work (e.g. Curriculum for Excellence - Parents as Partners, Play@home)
Parents confident and enabled to utilise information and engage with support and services when they need them
Improved understanding of aims and benefits of support and services
2.9
Early interventions and support for parents and families delivered proportionate to need (e.g. home visits, targeted support, Family Centres, welfare advice, family friendly work policy)
2.9
2.9
2.9
Improved knowledge and understanding about what support is available for parents and families and how to access it
Relationship support for families
Action to increase knowledge and awareness of services and support available
2.2
Improved understanding of the value of a parent and family role and how to support this
2.2
Parents, families and communities feel enabled to actively support and participate in the lives of CYP
2.9
Support needs identified early by parents, families and workforce and early intervention provided
Parents confident in identifying their own support needs
2.9
All parents and families; Strategic leads and workforce
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Logic model 3: Structures and systems Actions
Reach
Short-term Outcomes 3.5
Reduced organisational barriers to engaging parents
All services developed to be accessible, appropriate, evidence-informed and tailored to the needs of individual families
3.1
3.5 Parents and families are active partners in their support and care
3.5
Antenatal, childrens, adolescent and adult services and support
3.5
3.3 Provide support for parents that is universal, non-stigmatised and delivered proportionate to need
Use of routine assessments to identify support needs
Positive, supportive, respectful and non-judgemental environment for parents to ask for help
Workforce have shared knowledge and understanding about delivering GIRFEC and other relevant approaches to support parents and families
3.4
3.6
Develop strong strategic leadership and collaborative working to support parents and families and implement GIRFEC
Actions to ensure and support appropriate sharing of information
Relevant workforce (to be locally defined)
3.10
Improved leadership and strategic support to implement a positive shift in culture, systems and practice
3.5
Improved engagement of parents and families
Workforce are confident, skilled and motivated to engage and support parents and families
3.10
3.10
Provide appropriate support to workforce (service capacity & management)
3.5
Support needs identified early by parents, families and workforce and early intervention provided
3.5
3.2 Action to ensure parents and families have a voice in service development
Workforce development
Increased confidence and trust in workforce, support and services
3.10
3.12
3.10
Parents receive consistent information and advice in language helpful to service users
3.10 Regular and reliable communication and information sharing between services and families
Workforce has the support, training and supervision they need to work with parents and families
3.10
Improved signposting to appropriate support and services available for parents and families
3.7 Strategic planners, managers and workforce understand their own and each others role and impact in supporting parents and families
3.11 National leadership; Relevant strategic leads (to be locally defined)
3.9
3.11 Shared understanding within and across all agencies and workers of the importance of the parent/ family role
Increased early identification of CYP in a family/home by adult and child services/workforce
3.11
3.11
3.8
Model 1 : Strategic model
3.11
Improved, transparent and appropriate sharing of information
3.11 3.11 Improved capacity to share information across agency boundaries when appropriate and relevant
3.11
Improved local coordination and awareness of available support and services
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14. Rationale (evidence/theory) supporting logic models 14.1 Rationale for logic model 1: Strategic logic model Link 1.1 There is evidence of an association between the intermediate outcome that society and communities understand the value of families and recognise their role in supporting them and the long-term outcome that Scotland has a society and culture that values and supports the role of parents, CYP and strong families. Rationale Improving the specified short-term and intermediate outcomes detailed in models 2 and 3 will contribute to a shared understanding in society about the value and of parents, CYP and families and this will, in turn, contribute to a more supportive role for society. There is a need for further evidence around this element of model 1, but in future if work to support parents and families can be demonstrated to have contributed to national outcomes through the monitoring and evaluation of the National Parenting Strategy, this will also contribute to a shared understanding of the value of parents, CYP and families and help to build a more supportive society. Evidence shows that an area which requires attention in Scotland is in relation to enabling participation through family-friendly working practices, childcare and early education. Although the UK has a relatively generous entitlement to maternity leave among high-income countries, this largely consists of unpaid leave and the UK is currently in the lower half of Organisation for Economic Co-operation and Development (OECD) nations with regard to paternal leave provision.16 The OECD defines family-friendly working practices as those that facilitate the reconciliation of work with family life, and which firms introduce to complement statutory requirements. 24 Evidence suggests those areas where policy could support parents through family friendly work, education and childcare policy. For instance, extra-statutory leave from work arrangements, employer-provided childcare, out-of-school-hours care, elderly care supports and flexible working time arrangements could be delivered through employment policy and statutory regulation.16
Links 1.2–1.5 There is evidence of an association between the intermediate outcomes, supported by the actions set out in models 2 and 3, and one or more of the
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long-term outcomes in model 1. The intermediate outcomes will contribute to improvements in parental isolation, anxiety, self-efficacy and self-worth, and will also contribute to positive changes in parenting behaviours. The resulting positive, nurturing relationships and strengthened family connectedness will support positive outcomes for CYP. Rationale Note: The reader is referred to model 2 for further evidence relating to a range of interventions for parents and families and CYP in different age groups. The following examples are included as support for model 1 as evidence is available to demonstrate impact on the long-term outcomes for parents, families and CYP: a. Interventions for parents of infants and children in the early years i. Supporting secure attachment Evidence shows 25: • there are links between a child’s attachment style and later social and emotional outcomes. However, this association is not deterministic • secure attachment is associated with positive outcomes including self-esteem, self-confidence, resilience and emotional regulation. Disorganised attachment is a strong predictor of later relationship and emotional difficulties. • promotion of secure attachment and sensitive, responsive parenting has the potential to reduce health inequalities in Scotland. ii. Maternal mental health and wellbeing15 There is evidence that maternal mental health and wellbeing is recognised as a key influence on a child’s development during the early years of their life, and interventions which enhance maternal mental health and wellbeing and those that promote positive parent– infant relationships can have long-term benefits. iii. Home-visiting programmes and early years education 26 There is evidence that: • action to provide home-visiting programmes and early years education can lead to longer-term improvements in outcomes for children and young people • home-visiting programmes are associated with improvement in some child cognitive outcomes, improvement in positive health behaviours and the prevention of injury.
26
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 reported. (See model 2, ‘Home visiting’ and ‘Early childhood educations/children’s centre’ and model 3 ‘Ensuring implementation success’ for further detail) Moderate review-level evidence15 indicates: • that overall home visits in the post-partum period may improve outcomes for a range of vulnerable parents, particularly if delivered by nurse practitioners. The evidence of effective interventions in response to the support needs of families at risk of significant dysfunction or child abuse remains inconclusive • lasting improvements in cognitive development for at-risk or disadvantaged young children from studies of developmental prevention programmes, (including structured preschool programmes, centre-based developmental day care, home visitation, family support services and parental education). The largest effects were observed in relation to educational success during adolescence, reduced social deviance, increased social participation, and cognitive development. Evidence relating to preschool education and interventions delivered in day care or educational settings has a differential impact on the most vulnerable children, with full-day programmes shown to be more effective for improving the cognitive development of children who are particularly disadvantaged (see model 2 ‘Early childhood educations/children’s centre’ for further detail). b. Interventions for parents of older children i. •
Supporting parents and family functioning 27 There is evidence that the relationship between family-centred helpgiving (characterised by practices that treat families with respect and dignity; information-sharing; family choice regarding
27
•
•
involvement and provision of services and parent/professional collaboration and partnerships) and child outcomes is indirect and mediated through self-efficacy. This approach is also associated with more positive and less negative parent, family and child behaviour and functioning. There is review-level evidence of an association between community-based interventions with families, parents and carers of children and young people aged between 7 and 19 years and some improvements in attainment, behaviour and emotional outcomes. The findings suggest that community-based programmes have the potential to improve child behaviour, welfare, and reduce the amount of time spent in care and levels of juvenile crime. There is evidence that analysis of parents perceptions of taking part in a parenting programme (mainly Incredible Years) suggest that perceptions of control and confidence in ability to parent, guilt, social influences, knowledge and skills and mothers needs are key themes.
(See model 2 ‘Interventions for parents of older children’ for further detail) ii. Multi-component initiatives27 There is evidence from multi-component initiatives (including both universal services and targeted services) of post-intervention improvements in children and young people’s outcomes: 1. Universally available and targeted services for higher-need families are associated with improvement in adolescent outcomes. 2. Parenting programmes are associated with reduction in youth crime, child abuse and improvements in child behaviour; no evidence on child healthy behaviours. 3. Support to parents linked to improved family relationships. 4. Training for treatment of children with a conduct disorder improved child behaviour. 5. Strategies to enhance positive parenting improved parent and child functioning in the short term. They were also associated with improved parent outcomes but no/inconclusive evidence regarding the long-term impact on child behaviour is provided. 6. Telephone helplines and innovation services: limited evidence of improvements in family relationships and child behaviour, but most parents felt that accessing web and social media sites did not have a direct impact on their children. 7. General parenting programmes to improve attendance and behaviour in school (often in combination with helplines) are associated with improved child behaviour.
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(See models 2 and 3 ‘Multi-component initiatives’) c. Interventions for parents of adolescents Evidence suggests links between parenting and adolescent health behaviours, uptake of health services and susceptibility to illness in adulthood. 28, 29, 30, 31, 32, 33 Based upon a literature review and expert consensus meetings, the World Health Organization (WHO) identified five dimensions of parenting contributing to adolescent health: connection, behavioural control, respect for individuality, modelling, and provision (see glossary for definitions).11 i. Parenting styles and adolescent health outcomes In general, reviews of observational studies conclude that the authoritative parenting style b (high warmth, high control) produces better adolescent health outcomes (see Box 1). 34 This is consistent with the WHO dimensions of parenting, which embody both the high warmth (connection) and high control (behavioural control) features of this parenting style. Box 1: Adolescent outcomes associated with the authoritative parenting style34 • • •
Lower levels of substance abuse and risky sexual behaviour. Higher levels of academic achievement, healthy eating and physical activity. Parenting behaviours that are consistent with the authoritative parenting style have been shown to be associated with better adolescent outcomes, for example, parental modelling of healthy behaviours, nurturance, open communication, acceptance, autonomy-granting, and open communication and behaviours that promote connectedness have been shown to be associated with a range of positive health and wellbeing outcomes. In contrast, studies have shown associations between the authoritarian, permissive and neglectful parenting styles and poorer adolescent health outcomes, such as greater levels of substance use and lower levels of healthy eating and physical activity.
McAteer et al34 conclude that there is good-quality review level evidence relating to the impact of interventions aimed at reducing sexual risk b
Configurations of parental behaviours that vary according to levels of parental warmth and 34 control (Hoeve et al, 2009 in McAteer et al 2014 ). See glossary for full definitions.
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behaviour, substance, tobacco and alcohol use in adolescents (see also model 2 ‘Interventions for adolescents and parents of adolescents’ for further discussion of the interventions). The evidence suggests that such interventions can influence adolescent health outcomes. However, the evidence is predominantly US-based and it is unclear to what extent findings might translate into the Scottish context. McAteer et al34 also conducted an analysis of the characteristics of interventions reported in those reviews focusing upon substance, tobacco and alcohol use in adolescents. A total of 21 interventions were included, nine of which reported an effect upon behaviour, and 11 reporting no effect (see the full review for further detail). Effective interventions tended to be delivered in a community or home setting, provided by a trained deliverer, consist of at least eight weeks’ contact time, and informed by theory. A greater proportion of interventions reporting an effect used techniques targeting the WHO dimensions of ‘connection’ and ‘behaviour control’, consistent with findings related to the authoritative parenting style. Although this review found that descriptions of specific intervention techniques were sparse; some observations were made based upon the available evidence (see Box 2). Box 2: Intervention techniques used in effective and ineffective interventions involving parents to influence adolescent alcohol, substance and tobacco use34 Intervention reporting an effect: • A higher proportion of the effective interventions focused upon providing encouragement in relation to communication between the child and parent and parent/bonding. Additionally, half of these interventions incorporated provision of encouragement around parental rule-setting, etc. Almost half of the effective interventions provided the opportunity for parents and children to rehearse skills learned as part of the intervention. Interventions reporting no effect: • Behavioural contracts or commitments with parents were a characteristic of almost half of the ineffective interventions. Taken as a whole, the evidence suggests that support for parents – including information, and other support materials, and formal interventions – with adolescent children should focus upon promoting ‘connection’ and ‘behaviour control’ through fostering open, and
30
responsive communication, relationship support to foster bonding, and sensitive appropriate responses to behaviour.34 Those delivering content through parenting interventions should be mindful that such interventions appear to be most effective when they are delivered in a community or home setting, provided by a trained deliverer, consist of at least eight weeks’ contact time, and informed by theory.34 There is promising evidence of the effectiveness of existing interventions (see also model 2 ‘Interventions for adolescents and parents of adolescents’ for further discussion of the interventions). However, these are predominantly US-based and it is unclear how they might translate into the Scottish context. UK based evaluations are needed.
Link 1.6 Improving the specified short-term and intermediate outcomes will contribute to improved long-term outcomes for CYP and this will in turn contribute to these CYP being better prepared for parenthood themselves in future. Rationale In the shorter term, improved outcomes for children and young people are likely to contribute to the long-term outcome of more positive, healthy, nurturing relationships within families and strengthened parent/CYP and family connectedness. In the longer term, positive outcomes for CYP could result in improvements in their own future life circumstances. Evidence shows that children’s early life experiences and the social circumstances in which they live strongly influence their outcomes in later life, emphasising the importance of a life course approach to supporting children, young people and families. For further discussion see sections 7 and 8.
Link 1.7 Improving the specified long-term outcomes will contribute to the national outcomes set out in model 1. Future work to monitor and evaluate the National Parenting Strategy through supporting parents and families can be used to demonstrate any contribution to national outcomes. Rationale For instance, there is evidence that:
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• • • •
that the promotion of secure attachment and sensitive, responsive parenting has the potential to reduce health inequalities in Scotland.25 there is a link between socio-economic disadvantage during the early years and health inequalities, but the opportunity to reduce the impact of these inequalities is likely to decline with age.17 a life course approach to the early years can potentially reduce the negative impact of their family circumstances.26 home visiting interventions; early year’s education / child care and enhanced specialist early intervention programmes effectively promote child development and wellbeing in the early years. These can reduce the risk of poor outcomes for economically disadvantaged children in both the short and longer term.26
As discussed in sections 7 and 8, a child’s early life circumstances and experiences shape their physical, social, mental, cognitive and emotional development, and negative experiences can have a lifelong impact on health, learning and behaviour. Action to reduce the impact of poverty can mitigate against these risk factors. For instance, there is evidence that effective interventions to address the health impact associated with child poverty include:26 • • •
interventions which maximise household income and resources intensive support to families who are experiencing or who are most likely to experience poorer outcomes. This includes the provision of intensive home visiting and preschool education/childcare. potentially effective interventions for tackling the underlying social causes of child poverty include addressing structural changes to the economic, tax and benefits systems and legislative controls and enforcement.
14.2 Rationale for logic model 2: Parents, family and society A note to the reader: this model is based on an assumption that increased knowledge and awareness, and appropriate support for parents and families will result in improved long-term outcomes by impacting positively on changes in motivations and behaviours of individuals. This is a long and complex process and will impact on different individuals to varying degrees. This is an area where there are gaps in existing evidence and the need for further research and evaluation to assess the impact of awareness on behaviours of parents and families and also of the relevant workforce.
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As discussed in model 1 link 1.6, a life course approach to supporting CYP, parents and families is essential. Although the logic models appear to be very linear, the reality is that the pathways to outcomes specified in all three models are iterative and interlinked. Model 2 sets out the effectiveness evidence for interventions to support parents and families. However, readers should note that this model will be supported by the actions and outcomes in model 3 that sets out the structures and systems required to deliver this support.
Link 2.1 Action: • Provide support to enable local networks and peer support, and participation in society and work (e.g. crèches, facilities, resources). Action to provide support to enable local networks and peer support, delivered for parents, families, communities and the relevant workforce, will contribute to an improved understanding of the value of a parent and family role and how to support this, and to parents, families and communities feeling enabled to actively participate in, and support the lives of, CYP (see model 1 link 1:1). Rationale This action is based on the rationale that: • this type of practical support enables individuals to participate in society (e.g. participate in education, work or taking part in services and interventions). It is important that appropriate structures are in place to support this action (for discussion of potential barriers see Box 9) • parents and families seek different kinds of support from different sources and appropriate provision of facilities and structures can support this more informal access of support (see section Box 7 for further detail).
Links 2.2–2.4 and 2.7–2.10 Actions: • Develop and communicate appropriate evidence-informed messages about the value of parenting to individuals and society. • Develop and communicate appropriate evidence-informed messages about CYP development and attachment. • Evidence-informed, tailored action to prepare individuals for parenthood.
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Rationale The theory for designing, developing and communicating appropriate evidence-informed messages for the population (tailored for different groups), relevant workforce, and expectant parents, is that it will improve understanding and awareness of a range of topics (e.g. value of parenting, CYP development and attachment, preparation for parenthood) and contribute to individuals becoming enabled and motivated to seek support. This, in turn, could lead to engagement with services and individuals being better prepared to support the holistic development of CYP. A key element of this action is also ensuring the relevant workforce are provided with evidence-informed training and development to enable them to support parents and families – see model 3 for further discussion of workforce development. Further evidence is needed to support this pathway. It is important to acknowledge that characteristics of interventions that are less likely to be effective in reducing health inequalities include information-based campaigns (mass-media information campaigns), written materials (pamphlets, food labelling), campaigns reliant on people taking the initiative to opt in, and campaigns/messages designed for the whole population. 35 It is essential that to minimise the risk of increasing health inequalities that the provision of information is evidence-informed and tailored to the needs of different groups.
Links 2.4–2.8 and 2.9–2.10 Actions: • Evidence-informed, tailored action to prepare individuals for parenthood. • Action to promote secure attachment and sensitive, responsive parenting (e.g. skin-to-skin contact, infant carriers, infant massage). • Interventions to promote the social, emotional and cognitive development of CYP (e.g. home visits, early years education, enhanced specialist early intervention). • Action to promote open communication between parents and CYP • Action to improve sensitive appropriate responses to CYP behaviour. • Action to promote parental involvement in CYP play, learning, training and work (e.g. Curriculum for Excellence – Parents as Partners, play@home). • Early interventions and support for parents and families delivered proportionate to need (e.g. home visits, targeted support, family centres, welfare advice).
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• •
Relationship support for families. Action to increase knowledge and awareness of services and support available.
There is evidence of an association between this range of actions for parents and families and one or more of the short-term outcomes in model 2. This is based on the rationale that providing (a) universal support for all parents and families, and (b) additional/enhanced tailored support for parents and families with additional needs, will provide them with the knowledge, understanding and skills to enable them to support the holistic development of children and young people. While the specified actions are intended to support all parents and families, it is important that local areas consider the needs of different groups including those with additional support needs when planning specific actions (see Box 8). Evidence suggests that a progressive universal model of care is the mechanism by which families with additional needs/risks may be identified and appropriately supported.26 Some of the individual reach groups are considered in the sections below. However, as noted in section 11.3, there remains a lack of robust evidence in relation to key vulnerable groups. Rationale a. Interventions for parents of infants and children in the early years i. Interventions delivered in the antenatal period Antenatal classes15 Overall, there is a lack of evidence regarding the best mechanism for delivering antenatal education, with further research required to establish the most effective means of supporting the delivery of antenatal classes. There is some evidence that group-based prenatal care may improve birth outcomes at no additional cost. Breastfeeding promotion15 Antenatally, the evidence supports the use of: • antenatal group work (with an interactive component) • peer support schemes that involve local, experienced breastfeeders as volunteers to prepare parents for breastfeeding • multi-modal education/social support programmes combined with media campaigns
35
•
1:1 tailored education sessions, which may be more effective for low-income women who had planned to bottle feed and group support for women who had planned to breastfeed.
Low birthweight15 There is moderate review-level evidence on the modest effect of psychosocial interventions on the reduction of low birthweight, indicating that smoking cessation programmes were the only interventions that were effective in reducing low birthweight. Smoking cessation15 Evidence suggests that effective smoking cessation interventions have a behavioural focus, aim to change beliefs about smoking, and address stress management. Combining behavioural interventions with rewards for smoking cessation and social support may enhance the effectiveness of these interventions. ii. Preparation for parenthood Transition to parenthood15 Evidence about the effectiveness of antenatal group-based training programmes to prepare parents for their transition to parenthood (that focus on issues such as emotional changes, bonding and attachment) is extremely limited. Further evidence is needed to conclusively establish the effectiveness of these interventions. There is some evidence from two trials suggests that group-based parenting programmes (some of which extend beyond birth) have the potential to improve a range of parent and child outcomes postnatally, including couple adjustment and relationship satisfaction, satisfaction with the parent–infant relationship and maternal mental health. Preparation for fatherhood15 There is limited evidence that suggests: • antenatal classes can help to prepare men for fatherhood and enhance their support of their partners both ante- and postnatally. • a standard six-session antenatal programme enhanced by additional sessions about postnatal psychosocial problems and play was associated with increased maternal satisfaction with their partner’s support in relation to practical tasks, (e.g. domestic chores and childcare). iii. Pregnant women with socially complex needs 26 Interventions that are aimed at reducing the impact of socially complex needs in pregnancy focus on the role of maternity care services and specifically on improving a woman’s access (physical and cognitive) to
36
and maintenance of contact with services (see model 3 ‘Delivering antenatal interventions’). Women who have socially complex needs in pregnancy do not necessarily attend for their first antenatal (‘booking’) appointment later than women who do not have such needs. However, they may require greater support in order to be able to establish and maintain contact with antenatal services. However, the evidence that enhanced antenatal care provision, (i.e. services that are provided over and above routine universal care) improves specific outcomes for vulnerable pregnant women and their babies remains unclear. An ongoing relationship that includes both continuity of care and of carer(s) facilitates effective communication and enhances the antenatal experience of specific groups of women with socially complex needs in the following ways:26 • •
• •
For women who misuse substances (alcohol and/or drugs), a named carer with specialist knowledge/experience improves their engagement. For women who are recent immigrants/who do not speak or understand written English easily, continuity of care helps staff to understand religious, cultural and social differences and can help these women to navigate their way around the NHS systems. For women under the age of 20, continuity of care may help to maintain their ongoing contact with antenatal services. For women experiencing domestic abuse who may not disclose their situation during initial appointments, an ongoing relationship can facilitate disclosure and referral to specialist support services.
Domestic abuse26 There is limited evidence of effectiveness to support the impact of specific interventions in response to, or to prevent, domestic abuse in pregnant women. Maternal mental health and wellbeing26 In addition to the risk factors related to complex needs in pregnancy outlined above, maternal mental health and wellbeing is recognised as a key influence on a child’s development during their early years of life. The high-level evidence outlining the risk factors for developing postnatal depression is strong. In contrast, the evidence about the risk factors and treatments in relation to other mental health problems and the promotion and maintenance of mental wellbeing is relatively weak.
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iv. Interventions delivered in the postnatal period Breastfeeding promotion: Postnatal hospital stay15 There is strong evidence that skilled breastfeeding support, offered by trained peers or professionals to women who want to breastfeed can promote breastfeeding. Unrestricted feeding and unrestricted kangaroo/skin-to-skin care from birth also promote breastfeeding. Likewise regular breast drainage/treatment of mastitis, including the provision of antibiotics for infective mastitis can also promote breastfeeding. Peer support15 Evidence suggests that this is effective as a stand-alone intervention in women who want to breastfeed, but not in those who had already decided to bottle feed. Women who have decided to bottle feed may benefit from tailored 1:1 breastfeeding education that commences antenatally and continues postnatally. However, there is evidence that multifaceted interventions may be effective in its promotion. Effective interventions tend to include a peer support programme combined with health education programmes, media programmes, and legislative and structural changes to the healthcare system. The key messages about peer support for breastfeeding are outlined in Box 3. Box 3: Peer support for breastfeeding 36 Evidence-informed guidance about peer support for breastfeeding mothers was developed to inform professionals in Health Boards and voluntary sector agencies with responsibility for local breastfeeding support about the most up-to-date policies and evidence related to breastfeeding peer support. Key messages: 1. Providing breastfeeding peer support was a key recommendation in NICE public health guidance 11: Improving the nutrition of pregnant and breastfeeding mothers and children in low-income households. 37 2. Peer support is the focus of two activities in Improving Maternal and Infant Nutrition: A Framework for Action. 38* 3. Providing peer support aligns with community development endeavours and asset-based approaches. 4. Health Boards’ peer-support-related activities contribute to the achievement of the key Quality Ambitions in The Healthcare Quality
38
Strategy for NHSScotland 39 and is relevant to the ethos of the Commission on the Future Delivery of Public Services. 40 5. Breastfeeding peer support is popular among health practitioners and voluntary sector agencies in Scotland. 6. Current thinking, beyond the evidence, suggests that breastfeeding peer support activity needs to take full account of the context in which it is delivered and the needs of the local population. 7. The provision of breastfeeding peer support is complex. It needs to be fully integrated with local service planning and delivery regarding the recruitment, training and ongoing supervision of the peer supporter. 8. Breastfeeding peer support may be intensive, involving one-to-one and/or group-based support. 9. Overall, recent review-level evidence indicates that peer support is an effective intervention for breastfeeding. 10. Breastfeeding peer support needs to be appropriately evaluated with due reference to the accepted principles of good evaluation practice. 11. The benefits of peer support need to be evaluated more broadly than exclusively focusing on breastfeeding duration. Context is important, as is taking full account of other measurable benefits at both an individual and community level. 12. As local evidence indicates that peer support is a transactional activity, evaluation of its effectiveness needs to consider both the experiences of the peer supporter and the breastfeeding mother. 13. Future activity related to breastfeeding peer support in Scotland needs to be explicitly defined and guided by well-established ethical principles, especially equity. For further discussion and detailed information about specific interventions readers are referred to the source document. * These activities were based on the best available evidence at the time of its publication. v. Promoting positive relationships with infants and children Evidence shows that a child’s attachment style develops from birth in response to their multiple experiences of their caregiver’s sensitivity to their need for safety and protection.26 Secure attachment is
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increasingly recognised as vital to the healthy development of infants and children. Providing information about attachment to parents can increase their knowledge about attachment and parenting.26 This may improve parent–child interaction and promote the development of secure infant attachment. There is evidence that:26 • interventions that focus exclusively on and effectively enhance maternal/caregiver sensitivity towards the child are universally effective. • information about parenting can be effectively provided through a variety of approaches, including group-based training, videos and one-to-one interventions. • encouraging close physical contact through interventions such as the use of soft baby carriers or kangaroo care, (i.e. holding the infant close to their parent’s chest) may enhance the development of secure attachment. There is limited evidence:15 • that infant massage may have a beneficial impact on hormones that influence stress, sleep, crying and the mother–infant interaction. However, these findings are based on limited evidence and thus have limited potential in relation to making recommendations for practice. • that interventions including father–toddler groups, the use of the NBAS and infant massage and parenting groups with enhanced sessions for men may be effective as means of support for fathers. Further research is therefore needed to explore the optimal duration, long-term and differential impact of effective interventions for fathers. • of an association between interventions to promote early childhood cognitive development (e.g. book-sharing programmes and community-based early intervention programmes) and maternal and child outcomes. • of an association between anticipatory guidance to prevent or address early infant/toddler problems for a range of issues (sleep, a child’s temperament, promoting time out and reducing TV viewing, behavioural interventions to improve maternal sensitivity and/or infant attachment, interaction guidance, and parent–infant psychotherapy), and improving outcomes in a number of areas, but requires further research.
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vi. Preventing unintentional injuries in the home There is evidence to show that children under the age of 5 are more likely to experience injuries in the home, (e.g. falls, burns and scalds) than in other locations compared to older children.26 Efforts to prevent unintentional injuries should balance the potential risks against the benefits that children experience, particularly in outdoor play and leisure activities. Families may lack both the information to enable them to identify and manage risks in their home and the means by which to purchase and install home safety equipment. There is evidence that effective interventions that may reduce unintentional injuries, related to socio-economic inequalities, combine the provision of home safety equipment and education.26 These include: • the provision of home safety advice and free or discounted appropriate safety equipment that is supplied and fitted, (e.g. smoke alarms, stair gates) to families at high risk of unintentional injury • education and information about general child development. vii. Supporting social and emotional wellbeing There is evidence that to ensure all children have the best start in life, a life course approach to the early years should be recommended.26 This emphasises that focusing on the social and emotional wellbeing of vulnerable children under the age of 5 who are at risk of, or who are already experiencing, problems is the foundation for their healthy development.26 This can potentially reduce the negative impact of their family circumstances. Evidence shows that:26 • providing support to parents, children and families who have different levels of need requires input from a range of services. The evidence suggests that home visiting interventions; early year’s education/childcare and enhanced specialist early intervention programmes effectively promote child development and wellbeing in the early years. These can reduce the risk of poor outcomes for economically disadvantaged children in both the short and longer term. • these interventions can be delivered as part of progressive universal provision. Universal services are those that are available to all families, e.g. health and education services. Enhanced services describe those that are provided in addition to, or involve the adaptation/increase of universal services, in response to the specific needs of families who have been identified as vulnerable.
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•
•
universal provision enables the identification and progression of vulnerable/at-risk families (who are most likely to benefit from such interventions) to enhanced interventions, (e.g. intensive home visiting, Incredible Years). the skills and experience of practitioners, coupled with their relationship with a family is essential to assessing/addressing a family’s vulnerability.
viii. Home visiting26 Evidence shows that home visiting programmes can effectively improve a range of health and wellbeing outcomes for both children and their parents. Factors including the intensity and duration of home visiting and the skill of those providing it have been demonstrated to impact on its overall effectiveness. Home visiting during pregnancy and in the first year and beyond is effective for those identified as being at risk of poorer outcomes, e.g. deprived families or those with low birthweight babies. There is good evidence that home visiting during pregnancy and in the first year and beyond is effective for those identified as being at risk of poorer outcomes, e.g. deprived families or those with low birthweight babies. Home visiting has been linked to: • improvement in the home environment • improvement in family wellbeing, parent–child interactions and maternal sensitivity • improvement in maternal wellbeing, quality of life and contraception use • improvement in the social, emotional and cognitive development of children, including pre-term infants • increased infant attachment security. Both parents and children may benefit most from intensive home visiting interventions. However, the effectiveness of home visiting in response to the support needs of families at risk of significant dysfunction or child abuse remains inconclusive. There is evidence of an association between action to provide home visiting programmes and: • higher levels of mother–infant interaction, breastfeeding initiation, parenting and medical knowledge, parenting satisfaction, and a sense of being supported • a reduction in the symptoms of maternal depression and anxiety • improvement in some child cognitive outcomes
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•
improvement in positive health behaviours and the prevention of injury.
Teenage mothers26 There is evidence of an association between enhanced home visiting of teenage mothers, delivered by specialist nurses during pregnancy and the first 18 months of a child’s life and a positive impact upon the social and emotional development of vulnerable children and their mothers, (e.g. Family Nurse Partnership – see Box 4). The best outcomes are seen in children of mothers with low emotional intelligence and/or poor mental health. Home visiting interventions delivered to teenage mothers, with the specific aim of increasing maternal–infant attachment have not shown clear benefits. However, other targeted nurse-led home visiting programmes have been shown to be effective in helping young mothers to understand their infant’s behaviour and cues. Substance misuse26 Although postnatal home visits may increase the engagement of substance misusing mothers with drug treatment services, there is no clear evidence that such engagement improves maternal or infant outcomes. While this would seem to be counter-intuitive, it may well be that the complexity of substance misuse is such that it cannot be ameliorated by a single intervention. Smoking cessation26 Smoking cessation during pregnancy can reduce the level of low birthweight babies. The provision of home visits and social supports aimed at reducing the stress of pregnant women can effectively increase smoking cessation. Interventions delivered postnatally in the home by nurses or other health practitioners that aim to increase parental self-efficacy may reduce maternal smoking and children’s exposure to tobacco. Providing written information/details of cessation services alone is ineffective as an intervention to support smoking cessation. ix. Early childhood education/children’s centres26 Preschool education and interventions delivered in day care or educational settings, (e.g. Sure Start) can help to reduce the poor outcomes of vulnerable children that are linked to their disadvantage. Such interventions can result in sustained improvements in their social,
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emotional and cognitive development. Services should be run by well trained, qualified staff, (including graduates and teachers) and focus on social, emotional and educational development, delivered within well maintained and pleasant environments. Full-day programmes have been shown to be effective for improving the cognitive development of children who are particularly disadvantaged. These children gain more from intensive preschool interventions and do not show any negative behavioural consequences associated with the additional hours spent in early education. However, half-day programmes may be sufficient for children of middle or higher socioeconomic status or income for whom more than 30 hours shows a tapering off of cognitive benefits and intensification of negative socialemotional effects. 41 The home learning environment is also important to the child’s social and cognitive development. High-quality early years education beginning in infancy, combined with home visits to improve the homelearning environment that is targeted at high risk groups can result in improved cognitive and academic achievement that lasts into adulthood. Evidence suggests that the quality of the preschool is important (see model 3 links 3.6, 3.7–3.12 for further detail). See also model 1 links 1.2–1.5 for details of the potential impact long-term outcomes. x. Enhanced specialist programmes – Group-based parenting programmes26 The evidence provides support for the effectiveness of group-based/ media-based parenting programmes, (e.g. Incredible Years) in improving emotional and behavioural problems in children aged 3 and under. However, it is still not clear whether group-based parenting programmes are effective as primary prevention interventions delivered to all parents, (i.e. preventing the onset of problems) rather than secondary/tertiary prevention, (i.e. the treatment of early mental health problems). Incredible Years and Triple P have been shown to effectively reduce behavioural problems in children over the age of 3. Further information and evidence relating to three parenting programmes is presented in Boxes 4 to 6.
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NHS Health Scotland does not endorse the use of any specific parenting programme over another. Decisions to use a particular programme should consider the effectiveness of the programme and the local delivery context. Local considerations include cost, need, resources and workforce implications (including ongoing training and supervision). Box 4: Family Nurse Partnership42 The programme provides intensive, structured home visiting by specialist nurses from early pregnancy (before 28 weeks) until the child is 2 years old. It is based on the principles of self-efficacy, human ecology and the promotion of infant attachment security. It aims to improve pregnancy outcomes, child health and developmental outcomes and families’ economic self-sufficiency. Key messages: • The FNP is a licensed preventive programme delivered to first-time teenage mothers. The goals of FNP are to: o improve outcomes of pregnancy by helping women improve their prenatal health o improve child health and development by helping parents to provide more sensitive and competent care to their child o improve parent’s life course and self-sufficiency by helping them to plan their own future, plan future pregnancies, complete education and find work. • Evaluation by the Commissioning Toolkit indicates that there is strong evidence from the USA that Family Nurse Partnership (based on studies of the Nurse–Family Partnership) provides both long- and short-term benefits for young mothers and their children. • Evidence from the USA suggests that FNP provides a good return on investment.
Box 5: Incredible Years (IY) 43 The parent, child and teacher programmes are separate but interlocking training programmes targeted at children up to the age of 12 that exhibit, or are at risk for, behavioural problems. Key messages: • IY aims to strengthen parent–child relationships, promote children’s social and emotional skills and prevent and reduce aggressive and oppositional behaviour.
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• •
IY offers separate but interlocking training programmes for parents, children and teachers. In relation to the IY parent training programme: o Evaluation by the Commissioning Toolkit indicates that there is strong evidence that IY Pre-School/Early Childhood (2– 6 years), promising evidence that the IY Toddler (1–3 years) and preliminary evidence that the IY School Age (6– 12 years) programmes effectively improve child and parent outcomes. o It is important that the programme is delivered as designed by the developer, who provides detailed implementation guidance. o Evidence from Ireland suggests that Incredible Years may provide a good return on investment.
Box 6: Triple P 44 Triple P aims to prevent and treat behavioural, emotional and developmental problems in children by enhancing the knowledge, skills and confidence of their parents. The system includes five levels of intervention for parents of children aged 0–16. These increase in intensity from a universal population-based approach to intensive, targeted interventions for children with more severe difficulties. Key messages: • The Triple P – Positive Parenting Program (Triple P) is delivered to parents and carers of children up to 12 years, with Teen Triple P for parents and carers of 12- to 16-year-olds. • It is a multilevel programme that aims to prevent and treat behavioural, emotional and developmental problems in children and teenagers. • The five levels of Triple P intervention increase in intensity from a universal population-based approach to intensive, targeted interventions for children with more severe difficulties. • Families can enter Triple P at any level. • Evaluation by the Commissioning Toolkit indicates that the evidence for the effectiveness of Triple P interventions ranges from preliminary to strong. • Evidence from Australia suggests that Triple P may provide a good return on investment.
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b. Interventions for parents of older children i. Community-based interventions27 There is review level evidence of an association between communitybased interventions with families, parents and carers of children and young people aged between the ages of 7 and 19 and some improvements in attainment, behaviour and emotional outcomes. The findings suggest that community-based programmes have the potential to improve child behaviour, welfare, and reduce the amount of time spent in care and levels of juvenile crime. Successful programmes focus on parenting skills programmes or support to manage housing, employment or education. (See also model 1 ‘Supporting parent and family functioning’.) For further discussion of community-based interventions the reader is referred to Boxes 4–6 which outline evidence relating to a number of specific parenting programmes. ii. School-based interventions27 There is review-level evidence of an association between school-based interventions with families, parents and carers of children and young people aged between 7 and 19 years and some improvements in attainment, behaviour and emotional outcomes. School-based interventions that involve parents and carers can improve child behaviour, school attendance, improve relationships, prevent or reduce substance misuse and potentially increase educational attainment. Offering support through full service extended schools or through a single point of contact for parents can improve both parental engagement and child outcomes. iii. Multi-component interventions27 There is limited review level evidence of an association between multicomponent interventions with families, parents and carers of children and young people aged between 7 and 19 years and some improvements in attainment, behaviour and emotional outcomes. Multicomponent or mixed interventions can have a positive impact on children and family functioning. However, as a consequence of the limitations of the current evidence, the comparative benefits of multicomponent versus single interventions are unclear. iv. Engaging parents and families (service development and engagement)27 See also model 3 section ‘Interventions for parents of older children’
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There is qualitative evidence that the key factors for positively engaging parents in parenting programmes are as follows: • • • • • • • •
Parents acknowledge that there is a problem. The seriousness of consequences of conduct disorder is understood. Increased knowledge and skills in handling children’s behaviour to be gained by participation are emphasised. Control and confidence in one’s ability to parent effectively. Provision of non-judgemental support from professionals throughout process of gaining new knowledge, skills and understanding and implementing parenting skills. Parents need peer support. Parents’ need for their own needs to be recognised. Mothers’ need for support from their spouse/partner.
Evidence from a review of interventions with families, parents and carers of children and young people aged between 7 and 19 years that improve attainment, behaviour and emotional outcomes (UK and North America), identified that the support needs of parents are often not sufficiently addressed in designing services. Parents and children’s views should be taken into account through means such as surveys and focus groups or consultation. Parents seek certain types of support from friends and family and other types from professionals. This preference should also be taken into account when developing support services (see Box 7). Parents require support in the form of advice and practical skill development, emotional support, personal and social skills support, family relationship building skills, opportunities to learn, education and training and financial support. Support can be preventative or treatment; some families may require both forms of support. Box 7: Types of support for parents27 Evidence suggests that: • families and friends are the main sources of support for child rearing • family, friends and health practitioners are accessed for support on child health issues • social services are accessed for support on financial help, and ethnic minority parents are more likely to turn to other family members for financial support. Evidence suggests that the type of support needed by parents falls into six
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main categories: a. Information, advice and practical skills: support on a range of information and practical skills. b. Emotional support: parents want an empathic person to support them. This is reported as a strong parental need when their child had characteristics that increased their risk of poor outcomes; e.g. children with conduct disorders. c. Personal and social skills: support to improve the personal and social skills of parents through confidence and communication skills training d. Family relationship-building skills: studies conclude that family relationship building is important in improving child outcomes. e. Opportunities to learn, education, training and employment: interventions designed to improve parental learning, access to education and employability and their impact on child outcomes are considered. The direct effect on child outcomes within the timeframe measured is minimal; however supporting these needs is likely to have a longer-term indirect impact on child outcomes. f. Financial support; housing provision: the evidence is inconclusive about any direct benefits to children during the time frame of studies and the outcomes measured. However, such interventions may relieve basic pressures on families and have long-term benefits.
v. Family-centred help-giving approach27 There is evidence that: • the use of a family-centred help-giving approach (primarily USbased), is associated with more positive and less negative parent, family and child behaviour and functioning. • family-centred helping was significantly associated with participant satisfaction, self-efficacy beliefs, social support, child behaviour, wellbeing, and parenting behaviour. The outcomes most strongly related were satisfaction (with programme practitioners and services), self-efficacy and social support. • the more family-centred the approach used, the more families were satisfied with the approach, experienced increased self-efficacy beliefs and the more helpful they perceived the support and/or resources provided by the help-giver. Child behaviour and
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functioning, wellbeing and parenting behaviour were also significantly associated but effect sizes were smaller. These findings suggest that the method of interaction between a helpgiver and the family has an influence on family functioning. vi. Parents’ experiences and perceptions of parenting programmes27 Analysis of parents perceptions of taking part in parenting programmes (mainly Incredible Years) suggest that perceptions of control and parental confidence in ability to parent, guilt, social influences, knowledge and skills and mothers needs are key themes. Acquiring knowledge, skills and understanding along with feelings of acceptance and support from other parents may enable parents to regain control and feel more able to cope with their parenting role. In turn, this reduces feelings of guilt and social isolation and increases empathy with their children and confidence in managing their children’s behaviour. c. Interventions for adolescents and parents of adolescents There is good quality review-level evidence (primarily US-based) relating to the impact of interventions aimed at reducing substance, tobacco and alcohol use in adolescents (see also model 1 ‘Interventions for parents of adolescents’):34 •
Substance use:34 Although there is insufficient evidence to draw conclusions about the impact of interventions to prevent or reduce drug use by young people in non-school settings, some interventions appear to have a potential benefit e.g. the Strengthening Families Programme and Preparing for the Drug Free Years. There is, however, a need for trials to test their applicability within the UK/Scottish setting, and a need for independent evaluation. Interventions were designed to improve family functioning and effective interventions were those that used techniques and activities to promote authoritative parenting (e.g. communication, parental rule-setting/boundaries/expectationssetting, etc), and included opportunities for skill rehearsal.
•
Tobacco use:34 Some family-based programmes to help family members strengthen non-smoking attitudes and promote nonsmoking children or adolescents or their family members, appear to have potential benefit. Strengthening Families appeared to be the intervention with the longest post-intervention impact. Intensity of training and fidelity of implementation seemed to be associated with
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more positive outcomes. Effective interventions focused upon the promotion of authoritative parenting. •
Alcohol use:34 There is some evidence of effectiveness of familybased psychological and educational prevention programmes in preventing alcohol misuse compared to other types of intervention or no intervention. The Strengthening Families Programme and Preparing for the Drug Free Years demonstrated post-intervention impact at eight years. There is also some evidence that genderspecific interventions are effective, specifically those that target mothers and daughters. Effective interventions focused upon the promotion of authoritative parenting.
•
Sexual health:34 There is some evidence of effectiveness from interventions focused on improving parent–child communication about sex in order to change adolescent sexual behaviour, although the parenting component was limited in most interventions. The evidence for the effectiveness of parenting interventions in relation to the sexual behaviour of their children is less pronounced than for alcohol, tobacco and substance use. However, there are some promising interventions. Again, these promote authoritative parenting. Effective interventions focused upon the promotion of authoritative parenting.
14c. Rationale for logic model 3: Structures and systems A note to the reader: this model is based on the recognition that the National Parenting Strategy is dependent on positive changes in the way services are designed, delivered and supported at the strategic level. It should be noted that due to the nature of the evidence reviews completed for this outcomes framework, the inclusion of material relating to service design, workforce development and strategic support is limited. Examples of existing supporting evidence have been provided where possible to support the rationale for the model.
Links 3.1–3.5 Actions: • All services developed to be accessible, appropriate, evidenceinformed and tailored to the needs of individual families. • Action to ensure parents and families have a voice in service development.
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• •
Provide support for parents that is universal, non-stigmatised and delivered proportionate to need. Use of routine assessments to identify support needs.
There is evidence available to support the theory that these actions will contribute to the reduction of organisational barriers and in turn will improve engagement of parents and families and the early identification of support needs. Rationale a. Interventions for parents of infants and children in the early years Evidence suggests that a progressive universal model of care is the mechanism by which families with additional needs/risks may be identified and appropriately supported (see Box 8). Box 8: Supporting parents and families with a progressive universal approach26 A progressive universal service offers a continuum of services that have been planned and are delivered in response to identified need. This includes services offered to all families, (such as primary health care) and the additional/enhanced services that are provided to families with specific needs and/or risks. Universal services have a key role in identifying families with additional needs, providing enhanced services and making referral or signposting to additional services. Local areas decide which enhanced services to offer over and above universal services. They also decide who delivers these enhanced services with reference to the local delivery context. Decisions about which services to offer should take account of the evidence of effectiveness for an intervention alongside the issues of identified need, cost, resources and workforce capacity. i. •
Delivering antenatal interventions26 Evidence suggests that enhancing access to antenatal services is two-fold: (1) physical access relates to the woman’s ability to engage physically with antenatal services while (2) cognitive access describes their ability to connect fully with services following uptake. This is largely dependent upon effective communication between
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•
•
•
the women and her care provider(s) that enables/encourages her to receive optimal care. This cognitive component of access is particularly important if women have socially complex needs. An ongoing relationship that includes both continuity of care, and of carer(s), facilitates effective communication and enhances the antenatal experience of specific groups of women with socially complex needs (see model 2 ‘Pregnant women with socially complex needs’). There is evidence of an association between environmental factors, parent’s perceptions of the benefits to families and children and their perception of staff skills, and the subsequent influence on family engagement and the maintenance of contact. There is evidence that spacious, well maintained and pleasant facilities that are linked to good public transport are important to family (continued) engagement.
ii. Ensuring implementation success 26 Evidence from studies of home visiting demonstrates that to ensure that programmes and interventions are effective it is important that they are delivered as designed, following any implementation guidance from developers. Box 9 sets out an illustrative example about home visiting and early childcare/education). Although the evidence is unclear about the optimal duration, intensity and other characteristics of home visiting implementation, the benefits are maximised when home visiting: • lasts more than six months • involves more than 12 visits • begins antenatally or at birth rather than later • is delivered by professionals rather than paraprofessionals/lay providers • is structured and focuses on a broad range of outcomes for both the mother and child. The recent Early Years Public Health Guidance 40 published by NICE, (2012) recommends that health visitors or midwives should offer a series of intensive home visits by appropriately trained nurses to those families assessed as being in need of additional support, (Recommendation 3). 45
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Box 9: Supporting implementation success26 Barriers and facilitators (of home visiting and early childcare/ education) The time commitment required for delivering home-based interventions is viewed as a potential barrier to parents’ ongoing engagement. Flexibility in timing to accommodate parents’ needs is important. It has been suggested that home visitors should be proactive in recognising signs of disengagement by parents and offer possible solutions in trying to reengage them, e.g. by offering a break from the programme, changing its content and/or working differently with families to meet their needs. However, offering a break in service may conflict with evidence that missing too many appointments is associated with parents’ disengagement. The relationship between parents and staff influences whether parents continue to use services. Regular interaction (as part of an intensive home visiting programme) enables parents to develop open, non-judgemental collaborative relationships with health visitors. Home visiting interventions improve parents’ skills and confidence and are particularly beneficial to parents who lack emotional support, especially those who are reluctant to seek support from family or friends. However, some parents, particularly young women, report concern about how they might be perceived or judged as parents. Fathers may take longer to engage but find programmes to be beneficial. Professional roles and practices Staff enthusiasm and their belief both in a programme and working with vulnerable families are regarded as vital to the success of a programme. This may enable staff to cope with the demands and challenges of their role. The skills of staff are key to the success of programmes. Suitably skilled staff and supportive, flexible management are highlighted as contributing to programme success. There is a need for role clarity and responsibilities to enable staff to manage challenges around interagency/interprofessional team working and issues relating to previous organisation/current service. Home visitors described issues around engaging with clients and service delivery as frustrating. In particular, they noted the following as sources of frustration: • Not being able to reach or maintain engagement with their clients. • Delivering interventions which they felt were too short or which they
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•
were unsure were effective. Balancing the competing needs of the families in their caseload.
The evaluation of the Sure Start interventions in England indicates that higher implementation proficiency is linked to better outcomes for families. Organisational and management issues Organisational and management issues were identified as being important, especially that of establishing good management links and inter-agency working. Positive factors include: • Balanced representation on partnership boards. • Established multi-agency team working. • Well-functioning centres with low staff turnover. • Good pre-existing relationships with local agencies. • Clear and early establishment of purpose. Negative factors include insecure funding, funding freezes and funding deficits.
b. Interventions for parents of older children27 There is evidence that the use of a family-centred help-giving approach is associated with more positive, and less negative, parent, family and child behaviour and functioning. (see also models 1 and 2 ‘Interventions for parents of older children’ for further evidence relating to these approaches). There is evidence that the support needs of parents are often not sufficiently addressed in designing services. Parents and children’s views should be taken into account through means such as surveys and focus groups or consultation. Parents seek certain types of support from friends and family and other types from professionals; this preference should also be taken into account when developing support services. Parents require support in the form of advice and practical skill development, emotional support, personal and social skills support, family relationship-building skills, opportunities to learn, education and training and financial support. Support can be preventative or treatment, although some families may require both forms of support. Evidence suggests that the components of effective practice for interventions with families, parents and carers of children and young
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people aged between the ages of 7 and 19 that improve attainment, behaviour and emotional outcomes are:27 • • • •
Offering 1:1 relationships enabling engagement with parents through a single point of contact. Face-to-face support: interaction between staff and parents ensures that parents share complete and accurate information about their child schooling. Services in one location: families using multiple services can benefit from the co-location of these. Providing services through a school can also reduce stigma. Maintaining the intervention effects: reunion sessions for those who have attended parent skills training, ensuring maintenance of effects.
Evidence suggests that ensuring that parents feel comfortable in receiving help and making access to support as easy as possible are the key facilitators in the delivery of interventions with families, parents and carers of children and young people aged between 7 and 19 years that improve attainment, behaviour and emotional outcomes.27 Six key factors were identified from the available evidence: • • • • • •
Accessible delivery Physical and practical barriers Non-stigmatising environment Choice and confidence School collaboration Under-represented populations
Evidence shows that: • overall, addressing the barrier of negative stigma and ensuring that parents feel comfortable in receiving help through non-judgemental, empathic support from staff is a key facilitator to engaging parents. • giving parents a choice to opt in to services also enhances involvement. However, an important caveat here relates to the potential for increasing health inequalities. Evidence shows that interventions that require individuals to opt in are least likely to be effective in reducing health inequalities.35 This is an essential consideration for service planners when considering such interventions, particularly for more vulnerable groups. • service provision in a school setting is less stigmatising than when located in other services and can facilitate engagement.
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• •
making access to support as easy as possible through accessible facilities is important (e.g. sites on parents usual routes, via public transport), as is the provision of childcare. fathers and ethnic minority parents face particular barriers to access which should be considered as part of service design and delivery.
Links 3.6, 3.7–3.12 Actions: • •
Workforce development Providing appropriate support to the workforce (service capacity and management
Workforce development activities to support the relevant competencies (to be defined by, for instance, local need, national and professional guidelines) should include different service provider staff in contact with parents and families, and individuals in contact with children and young people. They should be delivered on an ongoing basis, and will contribute to the intended outcomes by enabling them to optimise early identification of parents and families in need, and to provide appropriate, timely advice, guidance and referral where necessary. Rationale Ongoing development (e.g. with training, continued professional development and induction processes, or by making this a part of routine assessments) of the relevant competencies of service provider staff will contribute to improved knowledge and understanding of their own and others’ contribution to supporting parents and families, and increased numbers of service provider staff that are skilled and motivated to support parents and families. It must also be recognised that this activity is dependent on local decisions around use of resources and priorities for training based on local need. It is also dependent upon the capacity of services and staff to deliver in this field (e.g. staffing levels and workforce planning, allocation of workloads). There are examples available from the evidence that illustrate the importance of workforce competencies, which would be gained and enhanced through action to support workforce development and appropriate strategic and management support of that workforce: • Evidence suggests that one key factor in positively engaging parents in parenting programmes is the provision of nonjudgemental support from professionals throughout the process of
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•
•
gaining new knowledge, skills and understanding and implementing parenting skills.27 There is evidence of an association between early childhood education/children’s centres and positive outcomes of at-risk or disadvantaged children (see also model 2 ‘Early childhood education/children’s centres’).26 Evidence suggests that the quality of the preschool is important. Characteristics that lead to positive child outcomes include the following: • Staff who have warm interactive relationships with children • A trained teacher as a manager • A good proportion of trained teachers on the staff • Staff who regard educational and social development as complementary and equally important. The recent Early Years Public Health Guidance 40 published by NICE, (2012) recommends that services should be run by welltrained, qualified staff, (including graduates and teachers) and focus on social, emotional and educational development, delivered within well maintained and pleasant environments, (Recommendation 4).45
(See also Box 9 – Professional roles and practices)
Links 3.8, 3.9–3.12 Actions: • Develop strong strategic leadership and collaborative working to support parents and families and implement GIRFEC. • Actions to ensure and support appropriate sharing of information. Activities to develop strong strategic leadership and collaborative working for supporting parents and families should include all relevant service providers and will contribute to improved links, pathways and processes for supporting individuals and families. This will, in turn, contribute to more consistent approaches, holistic, integrated and timely support for parents and families with any support needs or additional issues. Rationale Developing strong strategic leadership and collaborative working will contribute to improved and more integrated systems across service providers, and subsequently contribute to increased commitment and understanding across a range of partners and service providers in the system that supports parents and families. It will also contribute to increased commitment and motivation to support parents and families,
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ensure strategic commitment to lead staff in this area and motivate them to provide support. Limited highly processed evidence is currently available to support this rationale. Although there is no highly processed evidence presented that partnerships in public health lead to improved health outcomes, in order to achieve an integrated, holistic approach to the support of parents and families, collaborative working between service providers will be an essential component. Box 10 outlines two key Scottish policy drivers that will help to strengthen this action. Box 10: Scottish policy note The Scottish Government has developed two key areas that will provide strategic leadership at a national and local level to support the actions and outcomes specified in model 3. ‘Getting it right for every child’ (GIRFEC)4 GIRFEC is the national cross-cutting programme which has been developed to outline an approach to working with children and families in Scotland. Based on individual need, the wellbeing of the child is placed at the centre of the approach, which establishes the principle of giving all children and young people the best possible start in life as a priority for all services. The Children and Young People (Scotland) Act5 Elements of the GIRFEC approach will also now be enshrined in the Children and Young People (Scotland) Act that aims to put children and young people at the heart of planning and delivery of services and ensuring their rights are respected across the public sector. See section 2 and Appendix 1 for further detail.
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Appendix 1: Policy, information and guidance Other key policies and sources of information and guidance which contextualise the evidence presented here include the following: United Nations Convention on the Rights of the Child Available from: www.unicef.org/crc/ The UN Convention on the Rights of the Child is an international human rights treaty which grants all children and young people a comprehensive set of rights. The Convention comprises 54 articles that cover different aspects of childhood, rights and freedoms. All children and young people up to the age of 18 years are entitled to all rights in the Convention. Some groups of children and young people, for example those living away from home, and young disabled people, have additional rights. The UNCRC was ratified by the UK Government on 16 December 1991. The Scottish Government (2011) A New Look at Hall 4. The Early Years. Good Health for Every Child Available from: www.scotland.gov.uk/Publications/2011/01/11133654/0 This guidance sets out the way forward for the successful delivery of Health for All Children (Hall 4) in the early years. The Health for All Children document, (also known as ‘Hall 4’), offers guidance to support the implementation of the recommendations of the Royal College of Paediatrics & Child Health’s fourth review of routine child health checks, screening and surveillance activity. The review examined the evidence for existing child health surveillance and screening activity, including the purpose, content and timing of interventions. It also took into account the impact of social, economic and environmental factors on children's health. The Scottish Government (2008). The Early Years Framework Available from: http://www.scotland.gov.uk/Publications/2009/01/13095148/0 The Early Years Framework defines early years as pre-birth to 8 years old in recognition of the importance of pregnancy in influencing health, social, emotional and cognitive outcomes for children and families. The Framework, which is based on principles of early intervention and the tailored delivery of services, outlines the steps that the Scottish Government, local partners, and practitioners in early years services need to take to maximise positive opportunities for children so that they get the best start in life. The Early Years Collaborative (EYC) is an outcomes-focused, multi-agency quality improvement programme that will deliver nationally on the vision and priorities of the Early Years Taskforce and bring focus and clarity to agreed objectives, outputs and outcomes. The ambition of the Early Years Collaborative is to make Scotland the
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best place in the world to grow up in by improving outcomes, and reducing inequalities, for all babies, children, mothers, fathers and families across Scotland to ensure that all children have the best start in life and are ready to succeed. (www.eycollaborative.co.uk/about-the-collaborative) ‘Getting it right for every child’ (GIRFEC, 2008) Available from: www.scotland.gov.uk/Topics/People/YoungPeople/childrensservices/girfec ‘Getting it right for every child’ is the national cross-cutting programme which outlines an approach to working with children and families in Scotland. Based on individual need, the wellbeing of the child is placed at the centre of the approach, which establishes the principle of giving all children and young people the best possible start in life as a priority for all services. GIRFEC builds upon the universal services of health and education and sets out a national programme of transformational change to ensure that each child is: • • • • • • • •
Safe Healthy Active Nurtured Achieving Respected Responsible Included
These principles inform or influence choices and action across a wide range of roles and contexts. As a national approach to meeting the needs of all children and young people, GIRFEC is the vehicle to deliver the other key national action plans and frameworks in the early years. The Scottish Government (2011). A Refreshed Framework for Maternity Care in Scotland Available from: www.scotland.gov.uk/Publications/2011/02/11122123/0 The refreshed framework is designed to address all care from conception, throughout pregnancy and during the postnatal phase. The term ‘maternity care’ in this document is intended to refer to any NHS service that provides maternity care to women and their babies, including care provided by midwives, obstetricians, general practitioners, anaesthetists, paediatricians, neonatologists, public health nurses, pharmacists, optometrists, dentists and allied health professionals.
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The Scottish Government (2011). Improving Maternal and Infant Nutrition. A Framework for Action Available: http://scotland.gov.uk/Publications/2011/01/13095228/0 The framework for action is designed to be taken by NHS Boards, local authorities and others to improve the nutrition of pregnant women, babies and young children in Scotland. The Scottish Government (2011). Reducing Antenatal Health Inequalities. Available from: www.scotland.gov.uk/Publications/2011/01/13095621/0 This guidance was designed to provide details of the specific actions needed to strengthen antenatal healthcare at NHS Board and national level. The Scottish Government (2013) Play Strategy for Scotland and Action Plan. Available from: www.scotland.gov.uk/Publications/2013/06/5675 and www.scotland.gov.uk/Publications/2013/10/9424 The Scottish Government’s Play Strategy sets out an aspiration to improve the play experiences of all children and young people, including those with disabilities or from disadvantaged backgrounds in Scotland. The Strategy was be followed by an action plan that supports the Play Strategy by setting out what actions need to be taken, in the domains of home; nursery and school; community; and positive support for play to realise this vision for play. The Scottish Government (2013) Supporting Young People’s Health & Wellbeing. A Summary of Scottish Government Policy Available from: www.scotland.gov.uk/Publications/2013/04/4112 This document was been prepared for the Youth Health Improvement and Health Inequalities Strategic Leads Group. It sets out the key government policies that aim to support young people’s health and wellbeing. The Scottish Government (2011) Commission on the Future Delivery of Public Services Available from: www.scotland.gov.uk/Publications/2011/06/27154527/0 The Commission on the Future Delivery of Public Services, (The Scottish Government, June 2011), sets out in detail what it sees as the scale of the challenge facing public services in Scotland. This document emphasises the following: • •
A decisive shift towards prevention. Greater integration of services, better partnership, collaboration and
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• • • •
effective local delivery. Greater investment in the people who deliver services. A focus on improving performance through greater transparency, innovation and digital technology. Assets-based approaches.
Growing Up in Scotland (GUS) Study Growing Up in Scotland is a longitudinal research study which began in 2005. GUS follows a cohort of 8000 Scottish children and their families, and focuses on a range of outcomes, from birth through to their teenage years. A series of reports that outline the findings of the research to date have been produced by GUS. These include topics such as maternal mental health and children’s social, emotional and behavioural characteristics. The GUS reports are available from: www.crfr.ac.uk/gus/ Parenting Across Scotland Available from: www.parentingacrossscotland.org/ Parenting across Scotland is a partnership of charities that offers support to children and families in Scotland through their information service and partners' helplines.
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Appendix 2: Glossary for the National Parenting Strategy Outcomes Framework The following are some of the key terms used in the models and accompanying evidence. Attachment: this describes the bond from a child towards their parent or primary caregiver. Attachment behaviour is the behaviour children use to gain the attention of, or to remain close to, their carer in situations when they are tired, unwell or scared. Authoritative parenting style: this parenting style is categorised as high warmth (refers to parenting behaviours that make the child feel comfortable and approved) and high control (refers to parenting behaviours that involve respectfully placing demands and exercising control). Evidence suggests this parenting style is most likely to produce better adolescent health outcomes.34 Connectedness: for the purposes of this framework we use the definition provided by the World Health Organization: ‘A positive, stable, emotional bond between parents and children is an important protective factor for child health and development. Connection is made up of behaviours that convey to children that they are loved and accepted. It is a dimension of the parent–child relationship that is otherwise called warmth, affection, care, comfort, concern, nurturance, support or love. It is also important to consider the child's contribution to the bond.’11 Dimensions of parenting: The World Health Organization (WHO) categorised parents’ roles into the following five dimensions:11 • Connection: Behaviours that convey to adolescents that they are loved and accepted. • Behaviour control: Parents’ actions aimed at shaping or restricting adolescents’ behaviours. • Respect for individuality: Allowing the adolescent to develop a healthy sense of self, apart from his or her parents • Modelling: Parents become role models – their behaviours and attitudes providing examples of how to behave. • Provision: Efforts by parents to seek out relationships and opportunities within the community that can supplement what the family is able to provide. Evidence-informed: The Evidence for Action team of NHS Health Scotland informs decision-making by providing effectiveness evidence, advice and expertise by: • gathering together evidence and evidence-informed recommendations relating to the effectiveness of action in key public health areas
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• •
synthesising and communicating these pieces of information in ways that help policymakers, organisations and practitioners to develop and deliver effective action promoting and contributing to the further development of approaches to evidence-informed decision-making.
Family-centred helpgiving: this is characterised by practices that treat families with respect and dignity; information-sharing; family choice regarding involvement and provision of services and parent/professional collaboration and partnerships. Health inequalities: these are the unfair differences in health within the population across social classes and between different population groups.14 These unfair differences are not random but largely socially determined, and they are not inevitable. Holistic development of CYP: for the purposes of this framework this includes social, emotional, cognitive, educational and physical development. Parents: for the purposes of this outcomes framework the term 'parents' is intended to include all those individuals and agencies in a parenting role. For instance, this may include birth parents, parents of looked after children, adoptive parents, foster parents, carers, kinship carers, and corporate parents. Social and emotional competence of CYP: we include the assets empathy resilience, self-efficacy, self-worth and self-awareness.
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Appendix 3: Summary strategic logic model Intermediate Outcomes
Society and communities understand the value of families and recognise their role in supporting them
Model 2: Interventions to support parents and families
Long-term Outcomes
National Outcomes
Scotland has a society and culture that values and supports the role of parents, CYP and strong families.
CYP are better prepared for parenthood (and link to model 2)
Reduced parental isolation and anxiety
Parents are motivated and enabled to support the holistic development of CYP
Increased parental self-eficacy & self-worth
Our children have the best start in life and are ready to succeed. We live longer healthier lives. More positive, healthy, nurturing relationships within families and strengthened parent/CYP and family connectedness
Model 3: Structures and systems
More resilient, stable, strong families Improved wellbeing for all CYP
More effective, supportive parenting
Parents and families get the high quality, tailored support they need when they need it
We have tackled the significant inequalities in Scottish Society. We have improved the life chances for children, young people and families at risk. Our young people are successful learners, confident individuals, effective contributors and responsible citizens. We have strong, resilient and supportive communities where people take responsibilities for their own actions and how they affect others We realise our full economic potential with more and better employment opportunities for our people
***Please note that the different colours used in the lines are simply to distinguish between them.***
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