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Early intervention, the Family Nurse Partnership programme, and father involvement

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Title: Early intervention, the Family Nurse Partnership programme, and father involvement


1
Early intervention, the Family Nurse Partnership
programme, and father involvement
  • Professor Jacqueline Barnes
  • Birkbeck, University of London

2
What will be covered
  • Why early intervention/prevention
  • Some examples
  • Brief description of FNP
  • FNP engaging with fathers

3
Risk factors and poor outcomes
  • Wealth of data from life course studies linking
    adversity in early life to
  • poor literacy
  • anti-social and criminal behaviour
  • substance abuse
  • poor mental and physical health
  • adult mortality

4
Need to intervene
  • Have been reductions in child poverty,
    unemployment and crime, but there are still
    families caught in a cycle of disadvantage and
    exclusion.
  • To divert trajectories related to disadvantage
    there is a need for
  • Earlier and better identification of at risk
    families
  • Earlier and more effective intervention and
    prevention

5
Emerging knowledge on neurological development
  • Brain development depends on both genes and
    experiences
  • Rapid brain development takes place in the first
    year of life
  • Early interactions directly affect the way the
    brain is wired
  • Early relationships set the thermostat for later
    control of stress response
  • (Shore R, Rethinking the Brain, 1997)

6
Experience affects Brain Development
  • Conditions in early life affect the
    differentiation and function of billions of
    neurons and trillions of synapses in the brain
  • Early experience sets up neurological and
    biological pathways in the brain that affect well
    being throughout life affecting health, learning
    and behaviour
  • The more positive stimuli a baby is given, the
    more brain cells and synapses it will be able to
    develop.

7
But - Brain vulnerability
  • The disadvantage of the human brains plasticity
    is that it renders it vulnerable to trauma.
  • The brain of an abused or neglected child is
    significantly smaller than the norm.
  • The limbic system (which governs emotions) is
    20-30 per cent smaller with fewer synapses.
  • The hippocampus (responsible for memory) is also
    smaller.

8
Differences in brain development following
severe sensory neglect
9
Prevent before problems emerge
  • If people keep falling off a cliff, dont
    worry about where you put the ambulance at the
    bottom. Build a fence at the top and stop them
    falling off in the first place.
  • Source Allen Duncan-Smith, 2010

10
Small change early leads to large impact later
11
Rates of return to human capital investment
(Heckman 2000)
12
Brain Development Opportunity and Investment
? Brain Malleability
? Conception
? Birth
1
3
10
60
80
Age
13
Early years interventions for disadvantaged
populations
  • Examples, USA
  • Nurse Family Partnership home-visiting
    pregnancy to 2 years
  • Abecedarian Project childcare/preschool 0-6
  • Early Head Start childcare/ home visit 0-3
  • Perry Preschool Project preschool 3years

14
Abecedarian Project (Ramey et al., 2000)
  • 111 African-American disadvantaged children
    randomly assigned at age 3 months to
  • High quality centre-based provision
  • (day-care and preschool)
  • Control group
  • - Both groups followed into adulthood

15
Abecedarian Project (Ramey et al., 2000)
  • Results up to age 21 years
  • - Intervention group showed
  • Higher cognitive development from 18 months
    upward
  • Greater social competence in preschool
  • Better school achievement
  • More college attendance
  • Delayed child bearing
  • Better employment
  • Less smoking and drug use

16
Early Head Start ------ 0-3year olds (Love et
al, 2003, 2005)
3000 disadvantaged families studied from birth
randomly assigned Home-based programme,
Centre-based programme, Centre and home visits,
Control group
  • At age 3 intervention improved Cognitive and
    Language Development, more sustained attention
    and reduced aggression
  • Improved parent-child interaction , Improved home
    environment (more reading less spanking)
  • Centre and home gt centre gt gt home-based
  • Better implementation overall ? better effects

17
UK, Sure Start Local Programmes
  • Most disadvantaged neighbourhoods
  • From birth to fourth birthday
  • All families living in the area so non-targeted
  • Locally driven agenda allowing for diversity
  • Enhancement of existing services

18
Some positive impacts
  • At 3 years children in Sure Start areas had
    better social development with more positive
    social behaviour, more independence, better self
    regulation. They received more immunisations and
    fewer accidental injuries.
  • Parents showed less negative (harsh) parenting
    with more stimulating home environments.
  • More use of child and family services.

19
Pregnancy- A magic moment of opportunity?
Like it or not, the most important mental and
behavioural patterns, once established, are
difficult to change once children enter
school Nobel Laureate James Heckman (2005)
  • Pregnancy and the first 3 years are vital to
    child development, life chances and future
    achievement
  • Pregnancy and birth of a child is a magic
    moment of opportunity when parents are uniquely
    receptive to support
  • Universal midwifery and health visiting services
    are ideally placed to identify children and
    families at risk
  • Embedding the principle of progressive
    universalism into maternal services should be a
    priority to ensure that additional support is
    provided to those children and families at
    greatest risk

20
The potential of the Family Nurse Partnership
programme
  • To transform the life chances of the most
    disadvantaged children and families
  • A new professional role for nurses
  • Transformation of universal services in pregnancy
    and the first years of life
  • Impact on community parenting
  • Strengthen the health contribution to child and
    family services

21
FNP approach
  • Builds on the strengths of existing universal
    health visiting and midwifery services
  • Builds on policy for children and families (Every
    Child Matters and the National Service Framework
    for maternity and children)
  • Multi-faceted risks need multi-faceted but
    integrated responses

22
FNP
  • Nurses visit first time parents from pregnancy
    until child age two
  • Solid clinical theoretical underpinnings
  • Has been rigorously tested over 30 years of
    development and 3 large scale randomised trials

23
FNP GOALS
  • Connecting with families to
  • Improve pregnancy outcomes
  • Improve child health and development and future
    school readiness and achievement
  • Improve parents economic self-sufficiency

24
Visiting Schedule
  • 1/week first month
  • Every other week through pregnancy
  • 1/week first 6 weeks after delivery
  • Every other week until 21 months
  • Once a month until age 2
  • Each visit covers 5 domains and uses materials
    and activities to build self-efficacy, change
    behaviour, promote attachment

25
Programme domains
  • Personal health
  • Environmental health
  • Life Course Development
  • Maternal role
  • Family and Friends

26
THREE RANDOMISED TRIALS OF PROGRAMME
Elmira, NY 1977
Memphis, TN 1987
Denver, CO 1994
N 400
N 1,138
N 735
  • Low-income whites
  • Semi-rural
  • Low-income
  • blacks
  • Urban
  • Large portion of Hispanics
  • Nurse versus paraprofessional visitors

27
Findings across at least two trials
  • Improvements in womens prenatal health
  • Reductions in childrens injuries
  • Fewer subsequent pregnancies
  • Greater intervals between births
  • Increases in fathers involvement
  • Increases in employment
  • Reductions in welfare and food stamps
  • Improvements in school readiness

28
Cumulative Cost Savings Elmira High-Risk
Families
Cumulative savings
Cumulative dollars per child
S O C I A L R E T U R N
Cumulative Costs
Age of child (years)
29
FNP at the heart of current government policy
  • Health Inequalities progress and next steps
  • The Childrens Plan
  • Healthy Child Programme
  • Think Family
  • Excellence and Fairness achieving world class
    services
  • Youth Crime Action Plan
  • Child Health Strategy

30
Testing the NFP in England
  • 10 PCT/LA sites
  • Somerset, Manchester, Slough, Tower Hamlets,
    Derby City, Walsall, Southwark, County
    Durham/Darlington, SE Essex, Barnsley
  • Teams drawn from health visiting and midwifery
  • 100-150 clients per site
  • Approximately half have reached 2 years

31
Aims of the implementation research
  • To examine the feasibility of implementing the
    Nurse-Family Partnership model in England
  • To determine the most effective method of
    presenting the model to prospective clients
  • To estimate the cost
  • To illuminate the experience of practitioners,
    the wider service community, and children and
    families
  • To determine short-term impacts on practitioners,
    the wider service community, children and
    families

32
FNP Identified vulnerable population
  • 80 without 5 or more A-C GCSEs
  • 78 not employed
  • 67 not living with partner
  • 75 below poverty line
  • 24 report physical abuse in past 12 months, 11
    during pregnancy
  • 50 BMI lt or gtrecommended range
  • Indicates simple selection system, under 20 and
    first time mother will identify appropriate group
    cf. those in USA trials

33
Father involvement high
  • Young fathers show great interest in FNP, and
    many want to be present for visits or complete
    the activities
  • Pregnancy, 51 father present for at least one
    visit, on average 24 of all visits (2220/9270)
  • Infancy, 57 father present for at least one
    visit, on average 24 of all visits (2213/9236)

34
Fathers rated well in understanding, slightly
lower in involvement
  • Mean understanding during visit
  • Mothers 4.5, 4,.6
  • Fathers 4.1, 4.1
  • Mean involvement during visit
  • Mothers 4.7, 4.7
  • Fathers 3.9, 3.8

35
Fathers do not expect to be involved
  • I liked that she FN wasnt just involving
    client, she was involving me as well.
  • I did not expect to be involved I thought it
    would be more for my girlfriends benefit but
    when I turned up she said she would help me as
    well. I have learned about being a parent and
    that has helped a lot. I dont mind doing the
    worksheets I find them really useful.

36
Proud to be a Dad?
  • FN was first one who asked this young father Am
    I proud that Im going to be a Dad, am I getting
    ready for everything and he concluded his
    interview by saying
  • I would say, Come to the visits it is a good
    thing to do.

37
Strength based, not intrusive
  • When I first heard about it I thought it would
    have been all about client being a teenage
    mother, not giving information but trying to
    check up, prying into our pregnancy, but it
    hasnt been like that.

38
Unsure at first, broad coverage attracts
  • Its been better than what I thought it might
    be. I wasnt very sure at first.
  • I was a bit wary at the beginning, and when she
    went through one or two things I thought well,
    its not for me really, its just for client but
    then after a couple of sessions I started to get
    a bit more involved. When she started saying
    stuff like about the finance and what the baby
    needs, how to look after the baby properly, I
    thought right, I havent really got much of a
    clue so maybe Ill stick it out.

39
Getting involved in the activities
  • Father who has children from previous
    relationship Sometimes we all get carried away
    and were chatting for ages. FN gets loads of
    questionnaires each time. Like try to remember
    how you feel, or something like, shell give one
    to her client and one to me and see if we get
    the same sort of answers. Last time it was how
    many babies would you like to have.

40
Learning, for both new and experienced fathers
  • The Family Nurse brought a little baby to show
    us how the baby is actually born. Ive never
    seen a birth before and it was quite
    interesting.
  • First off I thought this is going to be boring
    and I did think I knew everything had child
    already with another mother but when she FN
    did come there is so much more that I have found
    out and so much more that I can still find out
    from her.

41
Helping behaviour change for fathers
  • Father with three teenage children from a
    previous relationship
  • The FN has updated me on certain information
    and refreshed me on others, and she is going to
    be helping me with stopping smoking
  • thought he went on to say that he usually
    stayed in a separate room during the visits.

42
Keeping a bit distant is OK
  • When she visits I am not always in the same
    room. Because I feel like if I am needed to be
    spoken to obviously my girlfriend will come and
    get me. Sometimes I am in there sometimes I am
    out of the way. In the future Ill probably
    just go along with everything. Like when I go
    and leave my girlfriend and the nurse to it. If
    I am needed I will be there.

43
FNP and parental relationship
  • We used to do nothing but argue but we have both
    calmed down, we dont argue because we know the
    baby can hear everything. (mother)
  • Its like she cares about my situation
    partner in prison shes doing her job but she
    actually goes a step further.

44
Conclusions
  • FNP initiated during pregnancy, to have maximum
    potential impact for mother, father and child
  • Received well by families
  • Father involvement is good and sustains beyond
    the pregnancy phase
  • Potential to reduce inequality for children born
    in disadvantaged circumstances, and enhance the
    life course of parents.
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