Transcript Slide 1

Early intervention, the Family
Nurse Partnership programme,
and father involvement
Professor Jacqueline Barnes
Birkbeck, University of London
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What will be covered
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Why early intervention/prevention
Some examples
Brief description of FNP
FNP engaging with fathers
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Risk factors and poor outcomes
Wealth of data from life course studies
linking adversity in early life to:
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poor literacy
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anti-social and criminal behaviour
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substance abuse
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poor mental and physical health
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adult mortality
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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:
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Earlier and better identification of at risk families
Earlier and more effective intervention and
prevention
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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
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(Shore R, Rethinking the Brain, 1997)
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Experience affects Brain Development
o Conditions in early life affect the differentiation and
function of billions of neurons and trillions of
synapses in the brain
o Early experience sets up neurological and
biological pathways in the brain that affect well being
throughout life affecting health, learning and
behaviour
o The more positive stimuli a baby is given, the
more brain cells and synapses it will be able to
develop.
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But - Brain vulnerability
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The disadvantage of the human brain’s
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.
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Differences in brain development following
severe sensory neglect
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Prevent before problems emerge
If people keep falling off a cliff,
don’t 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
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Small change early leads to large
impact later
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Rates of return to human capital investment
(Heckman 2000)
Rate of
return to
investment
in human
capital
Preschool programs
Schooling
Job training
Preschool
0
School
Post-school
Age
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Brain Development – Opportunity and
Investment
Spending on Health, Education, Income
Support, Social Services and Crime 
Public Expenditure
Intensity of Brain's Development
 Brain Malleability
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Conception Birth
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3
10
Age
60
80
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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 3+years
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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
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Abecedarian Project (Ramey et al., 2000)
Results up to age 21 years
- Intervention group showed
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Higher cognitive development from 18 months
upward
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Greater social competence in preschool
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Better school achievement
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More college attendance
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Delayed child bearing
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Better employment
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Less smoking and drug use
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Early Head Start ------ 0-3year olds
(Love et al, 2003, 2005)
3000 disadvantaged families studied from birth –
randomly assigned: Home-based programme, Centrebased 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 > centre > > home-based
• Better implementation overall  better effects
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UK, Sure Start Local Programmes
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Most disadvantaged neighbourhoods
From birth to fourth birthday
All families living in the area so nontargeted
Locally driven agenda allowing for
diversity
Enhancement of existing services
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Some positive impacts
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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.
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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)
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Pregnancy and the first 3 years are vital to child
development, life chances and future achievement
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Pregnancy and birth of a child is a ‘magic moment’ of
opportunity when parents are uniquely receptive to
support
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Universal midwifery and health visiting services are
ideally placed to identify children and families at risk
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Embedding the principle of ‘progressive universalism’
into maternal services should be a priority to ensure that
additional support is provided to those children and
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families at greatest risk
The potential of the Family Nurse
Partnership programme
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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
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FNP approach
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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
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FNP
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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
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FNP GOALS
Connecting with families to:
1.
Improve pregnancy
outcomes
2.
Improve child health and
development and future
school readiness and
achievement
3.
Improve parents’
economic self-sufficiency
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Visiting Schedule
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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
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Programme domains
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Personal health
Environmental health
Life Course Development
Maternal role
Family and Friends
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THREE RANDOMISED TRIALS OF PROGRAMME
Elmira, NY
1977
Memphis, TN
1987
Denver, CO
1994
N = 400
N = 1,138
N = 735
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Low-income
whites
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Low-income
blacks
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Large portion of
Hispanics
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Semi-rural
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Urban
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Nurse versus
paraprofessional
visitors
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Findings across at least two trials
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Improvements in women’s prenatal health
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Reductions in children’s injuries
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Fewer subsequent pregnancies
Greater intervals between births
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Increases in fathers’ involvement
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Increases in employment
Reductions in welfare and food stamps
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Improvements in school readiness
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Cumulative Cost Savings: Elmira
High-Risk Families
$30,000
Cumulative
dollars
per
child
Cumulative savings
$25,000
S
O
C
I
A
L
$20,000
$15,000
R
E
T
U
R
N
$10,000
$5,000
Cumulative Costs
$0
0
2
5
10 15 20 25 30 35 40 45 50 55 60 65
Age of child (years)
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FNP at the heart of current
government policy
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Health Inequalities – progress and next
steps
The Children’s Plan
Healthy Child Programme
Think Family
Excellence and Fairness: achieving world
class services
Youth Crime Action Plan
Child Health Strategy
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Testing the NFP in England
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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
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Aims of the implementation research
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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
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FNP Identified vulnerable population
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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 < or >recommended range
Indicates simple selection system, under 20
and first time mother will identify appropriate
group cf. those in USA trials
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Father involvement high
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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)
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Fathers rated well in understanding,
slightly lower in involvement
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Mean understanding during visit
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Mothers
Fathers
4.5,
4.1,
4,.6
4.1
Mean involvement during visit
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Mothers
Fathers
4.7,
3.9,
4.7
3.8
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Fathers do not expect to be involved
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“I liked that she [FN] wasn’t just involving
[client], she was involving me as well.”
“I did not expect to be involved I thought
it would be more for my girlfriend’s
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 don’t mind doing the worksheets;
I find them really useful.”
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Proud to be a Dad?
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FN was first one who asked this
young father “Am I proud that I’m
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’.”
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Strength based, not intrusive
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“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 hasn’t been like
that.”
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Unsure at first, broad coverage attracts
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“It’s been better than what I thought it
might be. I wasn’t 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 haven’t really got much of a clue so
maybe I’ll stick it out.’”
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Getting involved in the activities
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[Father who has children from previous
relationship] “Sometimes we all get
carried away and we’re chatting for ages.
[FN] gets loads of questionnaires each
time. Like try to remember how you feel,
or something like, she’ll 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.”
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Learning, for both new and
experienced fathers
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“The Family Nurse brought a little baby to
show us how the baby is actually born.
I’ve 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.”
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Helping behaviour change for fathers
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[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.
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Keeping a bit distant is OK
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“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] I’ll
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.”
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FNP and parental relationship
“We used to do nothing but argue but we
have both calmed down, we don’t argue
because we know the baby can hear
everything.” (mother)
“It’s like she cares about my situation
[partner in prison]; she’s doing her job but
she actually goes a step further.”
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Conclusions
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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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