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The Scottish Government is committed to reducing inequalities in the early years and is therefore anxious to investigate the effectiveness of interventions that address a spectrum of issues, from early sexual activity through to the development of confident, secure, healthy school-age children. This Research Findings summarises the key messages and characteristics of effective interventions outlined in a review of literature, prepared by the Scottish Government's Health Analytical Services Division, to assess the effectiveness of interventions to address inequalities in the early years.

Main Findings

• The evidence base addressing the effectiveness of interventions aimed at parents and children in the early years is extensive and since it is children from the most disadvantaged sections of society who are most affected by these issues, there are important lessons for policy and practice. However, it is difficult to extract meaningful messages from the evaluation of initiatives which have focused on a range of outcomes and to ascertain whether findings are relevant to the most disadvantaged families.
• Home visiting programmes during pregnancy and the first year of life allow a range of issues to be addressed, support provided and, if appropriate, referrals and access to other services to be facilitated. Families which are hard to reach by traditional services may feel more comfortable with appropriately trained and supported volunteers from their own community.
• Parent education programmes have been shown to have positive child outcomes and parent outcomes, with evidence of effectiveness apparent for some specific programmes such Triple P, Incredible Years and Mellow Parenting. However, the positive effects of parent education programmes are not universal and the most disadvantaged families are least likely to benefit.
• Use of mass media programmes is important to promote positive images of parenting, as well as individual issues such as breastfeeding. In addition, evidence supports the use of universal low cost approaches that help to build the bond between parent and child, such as baby massage, for the most disadvantaged groups.
• Education on sex and contraception has been shown to be effective in averting pregnancy at a young age. However, as the most vulnerable are least likely to engage with educational systems, tapping into alternatives such as using computers may be a way of engaging a wider spectrum of young people.
• Evidence suggests that investment in early years parenting and care until children are 5 years old pays off almost immediately as children are better prepared when they start school. Subsequent savings for health, welfare and criminal justice systems are also likely. Evidence however is mainly from the US, highlighting a need for good quality, longitudinal Scottish studies.

Background

The Scottish Government is committed to reducing inequalities in the early years and is therefore anxious to investigate the effectiveness of interventions that address a spectrum of issues, from early sexual activity through to the development of confident, secure, healthy school-age children. This informed the discussions of the Ministerial Task Force on Inequalities, which reported to Cabinet in May 2008 and, subsequently, the Government's Early Years Framework.

Aims

This paper presents a summary of the key messages and characteristics of effective interventions outlined in a review of literature to assess the effectiveness of intervention to address inequalities in the early years. The review has been prepared by the Scottish Government's Health Analytical Services Division to:

Investigate the relevant evidence base and advise policy colleagues of the known effectiveness of specific interventions.

Coordinate relevant information being gathered by colleagues across the Scottish Government and more widely to support policy development and delivery.

Methodology

This summary and the review is based on an analysis of data from a number of sources including: publications/work in progress recommended and/or produced by colleagues within the Scottish Government, NHS Health Scotland and those conducting relevant research within universities and other organisations across Scotland.

In the main, data fell into two categories: reviews of earlier work and primary studies.

Reviews - every attempt was made to extract data relevant to the inequalities agenda and to reproduce the authors' views on the effectiveness of interventions, the gaps in the evidence base and the methodological strengths and weaknesses of the evidence. In several instances the same material was found to have been used in more than one document, sometimes with different findings reported. As far as possible, such instances have been highlighted, although the original studies have not been revisited.

Primary studies - findings were synthesised and Health Analytical Services Division assessed and commented on the quality of the data and the validity of any recommendations made by the researchers.

Findings: Characteristics of effective interventions

As the review is not a systematic review of the relevant literature, it is not possible to make evidence-based recommendations on interventions at the expense of other initiatives. However, the review identifies a number of key messages for each of the areas considered and these are summarised below:

Pregnancy at a young age

Evidence supports school and community-based sex and relationship education as effective in averting pregnancy at a young age.

Parenting programmes and antenatal care programmes may improve outcomes for both teenage mothers and their infants.

Although not evaluated yet, the use of technology may offer opportunities for young people to engage in issues relating to relationships and the care of young infants e.g. Baby Think It Over ( BTIO) programme.

Maternal and foetal health during pregnancy

More intensive and direct interventions such as vouchers, provision of food, certain dietary supplements) have a greater chance of success in improving nutritional status than simply providing advice and information.

Multifaceted initiatives e.g. information, advice and counselling are more likely to be effective than those offering a single service to address smoking cessation.

Providing a range of health education, psycho-social and developmental topics in antenatal classes at an appropriate stage during pregnancy to increase receptivity of parents, appears to be a promising approach.

Educational/informational interventions during pregnancy can improve knowledge but are less likely to have an impact on behaviour or psycho-social wellbeing.

Parents in Partnership - Parent Infant Network ( PIPPIN) uses a variety of professionals to engage fathers and mothers in preparing for and adjusting to parenthood and evidence exists that this approach helped parents to enjoy more positive relationships with their babies and each other.

Maternal and child nutrition and physical and mental health

Multifaceted interventions i.e. interventions that span the ante and postnatal period and draw on repeated contacts with professionals and/or peer educators focussing specifically on breastfeeding, appear to be most effective.

Supporting parents to achieve a smoke-free home environment appears to work better than focusing on stopping smoking.

Broad measures to improve income in disadvantaged households, and improve access to cheap, nutritious food, are more likely to be effective than providing information and education about nutrition.

It is likely that a combination of approaches (including information, education, practical healthy eating options, support and free dental checks) will be most effective in reducing dental decay in young children.

Relatively low cost road safety initiatives can be effective, as can interventions that address issues via a range of modes e.g. legislation, education, safety equipment and environmental factors.

Home visiting programmes in general, shown to be capable of producing improvements in parenting, child behaviour problems, cognitive developments in high-risk groups, reduction in accidental child injury and improved detection and management of post-natal depression.

There is some evidence of positive outcomes from aspects of programmes such as Sure Start, Starting Well, Child Development Programme & Community Mothers Programme e.g. improved child behaviour, improved trust in community-based services and maternal self-esteem benefits.

Child development and early education

A variety of evaluated projects that have sought to investigate the effects of pre-schooling on children's development, including the Effective Provision of Pre-school Education Project ( EPPE) and the High/ Scope Perry Preschool Study, have shown that pre-schooling can have positive effects on child development and early education, for certain types of children e.g. results from one longitudinal study fund that children 'at risk' of poor cognitive development benefited from integrated centre and nursery, while children 'at risk' of poor social behaviour benefited from integrated centres, nursery classes and playgroups.

Parenting in the early years

Parent education programmes that actively engage parents have shown to be effective in producing positive outcomes for both parents and children in the short- to medium-term, with group-based programmes the most cost effective.

Involving both parents and the child directly in tackling both family and child behaviour problems has resulted in improved family outcomes.

Evidence of effectiveness relating to three specific parenting programmes (Triple P, Incredible Years and Mellow Parenting) is building, although further, good quality, independent evaluation of the programmes is required.

Groups that are particularly vulnerable

Family centres were seen as providing safe environments and playing a positive role in providing emotional and social support to vulnerable families.

Health professionals who were able to take time to understand problems, explain information and provide practical advice and support were the most valued service professionals.

Evaluated initiatives for families who are at risk of becoming homeless, such as the Dundee Families Project, has shown to be appreciated by families and potentially cost effective.

In relation to supporting looked after children, placement stability and the encouragement of carers is important for achieving educational success.

The longer term impacts of investment in the early years

There is stronger evidence for specialist, targeted services than for universal family support services, although these do tend to be low cost and well received.

Easier to improve outcomes for younger children.

Home visitation interventions show some benefits, with initiatives such as the Nurse Family Partnership proving to be cost effective for both high and low risk families.

Parent training programmes, such as the UK Incredible Years programme can produce positive outcomes for both parents and children and is relatively low cost.

Early intervention programmes, such as PIPPIN and The Circle of Security that address core issues of empathy, have been shown to be successful and cost-effective in reducing violence or the root causes of violence.

Limitations, weaknesses and gaps in the evidence base

There are significant challenges in engaging the most disadvantaged families, vulnerable and ethnic groups, or those subject to multiple risks from smoking, poor diet and negative psychosocial factors. For example, the most disadvantaged families are least likely to benefit from parent education programmes, owing partly to the finding that they are least likely to engage with the programme. Therefore, the effectiveness of many programmes and interventions for these groups is not known.

Methodological quality of many existing studies is poor and/ or focussed on a range of outcomes. For example, there are a number of methodological weaknesses in studies carried out to date concerning breastfeeding, such as the precise definition of breastfeeding. This makes it difficult to draw meaningful messages about the effectiveness of individual interventions.

The evidence base is thin in places. For example, in relation to initiatives targeting families who are or at risk of becoming homeless, misuse drugs and alcohol and young people who are, or have been, looked after.

In many areas, there is little evidence relating to the UK in general and Scotland. For example, in assessing the longer term impacts of investment in the early years, studies tend to have been conducted out with the UK.

There is often little evidence that any improvements gained from interventions are sustained over time, although this is often owing to a lack of evaluation evidence for long-term outcomes rather than a failure of the interventions themselves. For example, there is little evidence that improvements found from parent education programmes are sustained over time owing to a lack of good quality longitudinal research.

Conclusions

The evidence base on the effectiveness of interventions aimed at parents and children in the early years is extensive and, since it is children from the most disadvantaged sections of society who are most affected by these issues, there are important lessons for policy and practice.

However, it is difficult to extract meaningful messages from the evaluation of initiatives which have focused on a range of outcomes and to ascertain whether findings are relevant to the most disadvantaged families.

As much of the evidence originates from the United States, it is not known whether the results would be transferable to the Scottish context, nor is the longevity of many improvements known.

However, despite a number of weaknesses and gaps in the evidence base, there is increasing evidence that investing in the early years (and focusing on young people while they are at school to promote sexual health and prevent early pregnancy) can have long term benefits and, ultimately, play a significant role in reducing health inequalities.

This document, along with "The effectiveness of interventions to address health inequalities in the early years: A review of relevant literature" the full research report of the project and further information about social and policy research commissioned and published on behalf of the Scottish Government, can viewed on the Social Research website at: www.scotland.gov.uk/socialresearch . If you have any further queries about social research, please contact us at socialresearch@scotland.gsi.gov.uk or telephone 0131 244 7560.

If you have any enquiries about social research, please contact us at:

Scottish Government Social Research

Tel: 0131 244-7560
Fax: 0131 244-5393
Email: socialresearch@scotland.gsi.gov.uk
Website: www.scotland.gov.uk/socialresearch

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