Rationale

a. Interventions for parents of infants and children in the early years

i. Delivering antenatal interventions

ii. Ensuring implementation success

b. Interventions for parents of older children

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 below Box 8).

Box 8: Supporting parents and families with a progressive universal approach [1]

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 interventions [1]

• 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 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 (continued) family engagement.

ii. Ensuring implementation success [1]
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 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).[2]

Box 9: Supporting implementation success [1]

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/inter-professional 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 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.

b.Interventions for parents of older children [3]
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 model 1 and model 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
people aged between the ages of 7 and 19 that improve attainment, behaviour and emotional outcomes are:[3]

• 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. [3] 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.[4] 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.
• 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.

References:

1. Scott E, Woodman K. Guidance about Effective Interventions to Support Parents, Their Infants and Children in the Early Years. A paper to the Scottish Government Early Years Taskforce; 2012. Available from (external link): www.scotland.gov.uk/Resource/0041/00413580.pdf

2. Early Years Public Health Guidance 40 published by NICE (2012) in Scott E, Woodman K. Guidance about Effective Interventions to Support Parents, Their Infants and Children in the Early Years. A paper to the Scottish Government Early Years Taskforce; 2012. Available from (external link): www.scotland.gov.uk/Resource/0041/00413580.pdf

3. Scott E, Woodman K. Evidence summary: Public health interventions to support parents of older children and adolescents. NHS Health Scotland; 2014. Available from: http://www.healthscotland.com/documents/23153.aspx

4. Macintyre S. Inequalities in health in Scotland: what are they and what can we do about them? Glasgow: MRC Social & Public Health Sciences Unit; 2007.