Knowledge Makes Change seminar 3 - Opening the doors to Early Child Development: Home Visiting

Ca94a517cd7492e4a34d2c9db0530082?s=47 NCB Early Years
June 14, 2017

Knowledge Makes Change seminar 3 - Opening the doors to Early Child Development: Home Visiting

Emeritus Professor Dame Sarah Cowley DBE from Kings College London shares her experience of home visiting, and highlight from research its importance in supporting young children's health, well being and early development.


NCB Early Years

June 14, 2017


  1. Welcome Knowledge Makes Change seminar 3 Emeritus Professor Dame Sarah

    Cowley DBE Opening the door to Early Child Development: Home Visiting 20 June 2017
  2. Welcome and introduction Dr Cathy Hamer Chair of Early Years

    and Childhood Partnership and Associate, National Children’s Bureau Michelle Cumming Operational Lead for Child and Family Services at Family Nursing and Home Care
  3. Michelle Cumming Operational lead for Child and family Services

  4. My 3 Ps for home visiting •Privilege •Partnership •Positive Outcomes

  5. MECSH • One programme for delivery of intensive home visiting

    by Health Visitors with specific outcomes which FNHC have adopted locally • Evaluation outcomes • Mental Health Practitioner • Embedded in Universal Services with all Health visitors trained and delivering • Working in partnership with clients and multi agencies.
  6. Agenda Working together to develop an outcomes framework for early

    years – progress so far. Celine McStravick Director, National Children’s Bureau in Northern Ireland Opening the door to Early Child Development: Home Visiting Emeritus Professor Dame Sarah Cowley DBE Questions and table discussions Final words and evaluation
  7. Celine McStravick Director, National Children’s Bureau Developing an outcomes framework

    for Jersey
  8. Early Childhood Development Programme Aim: to provide tools and expertise

    to build capacity of the early years sector, leading to improved outcomes for children. • The programme is funded by UBS Optimus Foundation UK and started in April 2016 (3 Years) • Led by National Children’s Bureau in partnership with the States of Jersey and Jersey Child Care Trust • Informed by stakeholders including the Education Department, Health and Social Services Department, the Early Years and Childhood Partnership and the Jersey Safeguarding Partnership Boards.
  9. Core strands of activity underway: • Developing an Early Years

    Outcomes Framework informed by Outcomes Based Accountability and via stakeholder engagement • Making it REAL (Raising Early Achievement in Literacy) • Knowledge Makes Change Improving knowledge of ‘what works’ for families via seminar series & newsletters
  10. What is an outcomes framework? • A set of outcomes,

    i.e. the conditions of well-being that we want for children • A series of measurable indicators to assess if outcomes are being achieved • Action Plans for implementation: how do we turn the curves? - Alignment of programmes/initiatives to outcomes and indicators - Effective systems for impact measurement - Structured processes for reviewing progress and continuous improvement
  11. Why use an outcomes framework? • To help align the

    aims of the Early Childhood Development project and the programmes/services being implemented • To provide a framework with which to co-ordinate the efforts of key departments, agencies, and services provider organisations to improve early childhood outcomes; • To help target resources towards evidence-based/informed actions that have been shown to positively impact on improving early childhood outcomes; • To enable agencies/organisations to monitor progress and strengthen transparency and accountability; and
  12. Outcomes & indicators: story so far Part 1: What do

    we know about children in Jersey? • What does the data tell us? Report 1: Analysis of data • What services are being delivered? Mapping exercise Part 2: Prioritising indicators • Be healthy – Obesity – Breastfeeding – Low birth weight • Be safe • Achieve and do – Child development indicators
  13. Outcomes & indicators: story so far Part 3: Turning the

    curve on priority indicators: • Building engagement- getting everyone involved in planning • Identifying what works to do better
  14. Opening the door to Early Child Development: Home Visiting Sarah

  15. Directions 1. Inequalities and why they matter 2. Early Child

    Development (ECD) and inequalities 3. The power of home visiting: research and practice 4. Enhanced home visiting programme: MECSH (Maternal and Early Childhood Sustained Home Visiting)
  16. Inequality affects life chances OECD (2017), Income inequality (indicator). doi:

    10.1787/459aa7f1-en (Accessed on 04 June 2017) Jersey: income inequality slightly worse than UK Added data about Jersey on all slides from Jersey Health Profile (2016)
  17. Inequality affects all of society

  18. None
  19. Jersey = 81 (M), 84 (F)

  20. None
  21. NB Jersey: Housing costs Population churn Others?

  22. Jersey = lower than UK

  23. Jersey: 22% physically active >1hour day; 75% have medium/high self-esteem

  24. Jersey: 24% report being bullied in last month

  25. Jersey: cf England Higher life satisfaction, Feeling worthwhile Happiness Anxiety

    NB: Inequalities Suicide + self-harm Alcohol +drugs
  26. Social Determinants of Health Age, sex and hereditary factors General

    socio-economic and environmental conditions Lifestyle factors 1 2 3 4 Housing Agriculture and food production Education Work environment Unemploy- ment Water and sanitation Health services Etc Dahlgren and Whitehead (1991)
  27. A ‘Powerful Equalizer’ • Early Child Development is a determinant

    of • health, • wellbeing, and • learning skills • across the balance of the lifecourse. (Irwin et al 2007)
  28. Early Child Development (ECD) • What children experience in their

    early years (from conception to age 7 years) sets a ‘critical foundation’ for their entire life • ECD includes the domains: • Physical – health and development • Social and emotional • Language and cognitive – ECD strongly influences • Basic learning, school success, • Economic participation, • Social citizenry • Health (Irwin et al 2007)
  29. Health is . . . . • ‘the ability to

    adapt and self manage’, • incorporates positive (strengths, well-being) as well as negative (risk, disease) elements and • encompasses dimensions of physical, social and mental health Huber et al (2011) World Health Organization
  30. Early Childhood - best investment

  31. The Heckman Equation

  32. Foundations of Health Harvard University (2010) • Stable and responsive

    environment of relationships • Safe and supportive emotional and physical environments • Sound and appropriate nutrition Lancet ECD Series 3 (2017) Nurturing care: an overarching concept incorporating: –a stable environment sensitive to a child’s: • Health • Nutrition • Security and safety • Responsive caregiving • Early learning Supported by a large array of social contexts including home, childcare, schooling, community, work and policy
  33. Social contexts = where families and children live – Community

    and public health: homes, schools, communities, culture •
  34. • Breast milk is the best nourishment for babies aged

    up to six months. • Important in reducing health inequalities. • Benefits include promoting emotional attachment between mother and baby. • Breastfed babies have a reduced risk of respiratory infections, gastroenteritis, ear infections, allergic disease and Sudden Infant Death Syndrome. • Breastfed babies may have better neurological development and be at lower risk of tooth decay and cardiovascular disease in later life. • Women who breastfeed are at lower risk of breast cancer, ovarian cancer and hip fractures/reduced bone density. Foundation for health = appropriate nutrition
  35. •UK review • Supporting mothers to breast feed exclusively to

    four months would save an estimated £11m a year to NHS, by reducing infections (Pokhrel et al 2015) • Major impact on obesity (Cathal et al 2012) Jersey • 73% infants breast-fed at birth • 54% at 6 weeks old • 17% receiving any breast milk at 9 months old (Jersey Health Profile 2016) Breastfeeding
  36. •Overall mental health of family is important, including fathers •NB:

    Mother with – Previous history of mental illness – Antenatal anxiety or depression – Traumatic birth – History of stillbirth or miscarriage – Relationship difficulties – Social isolation •Up to one in seven mothers experience perinatal mental illness •Can cause substantial impairment of wellbeing of mothers and infants •Estimated total long-term cost to society of about £8.1 bn. for each one-year cohort of births in the UK, of which £1.2bn. is in health and social care (Bauer et al 2011). Foundation for health = stable and responsive relationships
  37. – Jersey – prevalence estimates 1: 10 • Around 1000

    births p.a. = 100 depressed mothers – Trial evidence that specially trained health visitors can be successful in • Preventing (Brugha et al 2010), • identifying and treating post- natal depression PND (Morrell et al 2009) Maternal (perinatal) mental health
  38. •Attendance at UK emergency departments (EDs) has increased by half

    in 10 years – especially in children under five (DH 2012) •Leading causes of hospital admission in 0-5s are gastro- enteritis, upper respiratory tract infection (URTI), injuries/accidents •Removal of teeth is commonest cause for anaesthesia in 0-5s •Parents feel guilty and criticised for seeking or not seeking care (Neill et al 2012) Foundation for Health: Safe environment In Jersey, an average of around 4,000 children under five attend A&E each year
  39. •Delivering Services: – Provision mandated in policy – May specify

    number + purpose of home visits – May be universal, targeted, progressive or proportionate – May incorporate interventions and programmes •Delivering Interventions – Usually brief (e.g., advice, information) or over a circumscribed period (e.g., listening visits, behavioural support) – Immense variety of potential interventions •Delivering Programmes – Specified length – usually longer than interventions – May be manualised with specified content, ‘curriculum’ – Most trials of home visiting refer to programmes, rather than services Home visiting
  40. Core forms of health visiting practice •Literature review (Cowley et

    al 2013) • Older and more recent research papers described three core practices: • health visitor-parent relationships • health visitor home visiting • health visitor needs assessment • Which all operate together as a single process •Voice of service users (Donetto et al 2013) • Qualitative research led to descriptions of a fourth core practice: • Health visiting outside the home
  41. RCT of universal home visiting •Randomised - 4777 ‘resident births’

    in Durham, N. Carolina •Intervention: 3-7 contacts – nurse ‘triages and concentrates resources to families with assessed higher needs’. – 1-3 home visits between 3-8 weeks of infant age •Result: 50% less total emergency medical care •“The most likely mechanism through which this preventive impact occurs is through the nurse home visitor’s – success in identifying individual family needs, – intervening briefly to address those needs when risk was moderate, and – connecting the family with targeted community resources to meet those needs for families having higher risk.” Dodge et al (2013)
  42. •Reviews of (mainly North American) home visiting programmes show: •

    Improvements in parenting • Improvements in some child behavioural problems • Improved cognitive development • especially among some sub-groups of children, e.g., those born prematurely or with low birth weight • A reduction in accidental injury among children • Improved detection and management of post-natal depression •Ciliska et al, 1996, Robinson et al 2000, Bull et al 2004 •Meta-analysis showed best effects from programmes that were: – Proactive, comprehensive, multi-component – Long-term; focused on developmental needs of child and family – Used strengths-based, empowerment approach – Lasting more than 6 months, with 12 or more visits •Macleod and Nelson 2000 Home visiting as a ‘delivery strategy’
  43. European Early Promotion Project •Non-randomised comparison study of 824 families

    in five European countries, one arm in London • The programme consisted of one promotional interview ante-natally and one post-natally, resulting in an assessment of need. • Home visiting or sessions at well baby clinic offered to those families judged to be in need. •The London health visitors all received Family Partnership Model (FPM) training. •705 (85.6%) families were retained for the outcome assessment. •Outcomes • significantly improved interaction between mothers and their children • improvements in the home environment Davis, H., Dusoir, T., Papadopoulou, K. et al. (2005)
  44. Social support and family health •731 first-time mothers randomised to

    one of 3 arms: •Control = usual care health visiting (one home visit) •Support health visitor (SHV) monthly home visit; HV trained to respond to queries, but not to raise issues herself •Community group support (CGS): group + telephone and home visits available •Primary outcomes: – No significant difference in child injury, maternal smoking or depression. •Secondary outcomes • Mothers less anxious about their children; more relaxed mothering experience • Less use of GP services, but more (appropriate) use of health visitor and social work • Fewer subsequent pregnancies at 18 months • SHV popular: low attrition – 94% stayed full year • CGS: low uptake; 19% Wiggins, M., Oakley, A., Roberts, I. et al. (2005)
  45. Oxford Intensive Home Visiting •Multicentre RCT in 40 GP practices:

    • Eligible primiparous women randomised: n=67 - received programme of weekly, structured home visits; 6 months pregnant to 1 year n=64 - standard service • Health visitors trained in Family Partnership Model and • baby massage, • baby dance; • songs and music; • elements of Brazelton technique. •Outcomes: – Improved maternal sensitivity and infant cooperativeness – Increased identification of families with vulnerable infants that needed removal. – Non-significant increase breast feeding at six months – No difference in maternal mental health or home environment Barlow, J., Davis, H. et al. (2007).
  46. Post-natal health visiting – Cluster RCT of ‘low risk’ first

    time mothers in Northern Ireland – Intervention 136 women = six weekly visits from 2-8 weeks post-natally – Control 159 women = usual care; mean of two home visits •Intervention group • Higher EPDS score at 8 weeks, but not at 7 months (‘varies between health visitors’) • Higher service satisfaction • Significantly less likely to have used emergency services • ‘Baby nurture’ and maternal self-efficacy – no difference Christie, J., and Bunting, B. (2011)
  47. •Three trials in USA, including long term follow-up •Intensive nurse

    home visiting: up to 64 visits to young mothers, from early pregnancy to infant aged 2 • Improvements: – Reduced smoking in pregnancy – Reduced child abuse – Improved home environment and child development – Improved school readiness – Long term benefits – few mental health problems (aged 12) delinquency (aged 15 – 19) – Parents – child spacing, life choices Olds et al 2007 •Trial in England: 18 sites, teenage first-time mothers – 823 FNP; 822 usual care •Primary outcomes – no significant improvement: – Smoking late pregnancy; Birth weight; Subsequent pregnancy Emergency/hospital care •Secondary outcomes – Fewer development concerns, including language delay – Higher breastfeeding intention, not initiating or continuing – FNP group – more A/E attendance for injuries/ingestion – Social care + safeguarding events – higher in intervention group Robling et al 2016 Nurse Family Partnership (NFP/FNP)
  48. Developing services 20%

  49. Programmes AND services – “…….the expansion of home visitation […

    ] through carefully structured clinical trials that engage a well- specified target population. [… ] is valuable but insufficient to achieve the type of population-level change that such reforms generally promise. – We propose a home-visitation policy framework that embeds high-quality targeted interventions within a universal system of support that begins with an assessment of all new parents. – This assessment process would carry the triadic mission of assessing parental capacity, linking families with services commensurate with their needs, and learning to do better.” Daro and Dodge (2010, page 79)
  50. Maternal and Early Childhood Sustained Home Visiting (MECSH) •Australian RCT

    (111 intervention vs. 97 controls); deprived area – all pregnant women eligible •Intervention: – Programmed home visiting from ante-natal to two years (25 visits) – Community visibility – Group activities •Embedded within universal services Manualised programme:: •Social need - psycho-social distress in pregnancy as marker of vulnerability •Strengths based practice through partnership working •Programme to promote and encourage (parent and child) development – aspirational; ‘parenting despite’ Kemp et al ( 2011, 2013, 2016).
  51. MECSH Outcomes •Key Outcomes • Mothers: • more emotionally and

    verbally responsive • Could name 2+ measure to reduce cot death • Children: • Improved cognitive development, • Breast-fed longer (mean 7.9 wks) • Improved HOME environment •Best results: • Where mothers experienced psycho-social distress in pregnancy (EPDS >10) •Mothers experienced: • Higher rate of unassisted vaginal births/better perinatal health • Improved maternal health • Enabled mums to care for their baby and themselves • Improved engagement with services Longer term • Able to deal with things • Continued to use programme learning
  52. Programmes and services

  53. Conclusions • Early childhood development is a key focus for

    reducing inequalities • Home visiting services and programmes offer an effective approach
  54. References 1 • Barlow, J., Davis, H., McIntosh, E., Jarrett,

    P., Mockford, C., Stewart-Brown, S., 2007. Role of home visiting in improving parenting and health in families at risk of abuse and neglect: results of a multicentre randomised controlled trial and economic evaluation.Arch. Dis. Child. 92 (3), 229–233. • Britto PR, Lye SJ, Proulx K et al. Nurturing care: promoting early childhood development Lancet 2017; 389: 91–102 • Bull J., McCormick G., Swann C. & Mulvihill C. (2004). Ante-natal and Post-natal home-visiting programmes, a review of review. Health Development Agency, London. • Bauer A. et al (2014) The costs of perinatal mental health problems London, Centre for Mental Health and London School o fEconomics, for Maternal Mental health Alliance • Bull J et al (2004) Ante- and post-natal home-visiting programmes: a review of reviews. London: Health Development Agency • Brugha TS, Morrell CJ, Slade P & Walters SJ (2010). Universal prevention of depression in women postnatally: cluster randomized trial evidence in primary care. Psychological Medicine, 41: 739-748 • Cathal, M.C., Layte, D.R., Breastfeeding and risk of overweight and obesity at nine years of age, Social Science & Medicine (2012), doi: 10.1016/j.socscimed.2012.02.048 • Center on the Developing Child at Harvard University (2010). The Foundations of Lifelong Health Are Built in Early Childhood. • Christie, J., and Bunting, B. (2011) The effect of health visitors’ postpartum home visit frequency on first-time mothers: Cluster randomised trial. International Journal of Nursing Studies, 48 (6) 689-702. • Ciliska D, Hayward, Thomas H et al (1996) A a systematic overview of the effectiveness of home visiting as a delivery strategy for public health nursing interventions. Canadian Journal of Public Health 87: 193-8 • Cowley S, Whittaker K, Grigulis A, Malone M, Donetto S, Wood H, Morrow E & Maben J (2013) Why health visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. National Nursing Research Unit, King’s College London • Donetto S, Malone M, Hughes, Morrow E, Cowley S, J Maben J (2013) Health visiting: the voice of service users. Learning from service users experiences to inform the development of UK health visiting practice and services. National Nursing Research Unit, King’s College London
  55. References 2 • Daro, D. & Dodge, K.A. Strengthening home

    visitation intervention policy: Expanding reach, building knowledge. In: Investing in young children: new directions in federal preschool and early childhood policy, eds. Haskins R & Barnett WS. 79-88, Washington DC: Centre on Children and Families at Brookings and the National Institute for Early Education Research. 2010 • Davis H., Dusoir T., Papadopoulou al. (2005) Child and Family Outcomes of the European Early Promotion Project. International Journal of Mental Health Promotion 7, 63-81. • Dodge KA et al (2013) Randomized Controlled Trial of Universal Postnatal Nurse Home Visiting: Impact on Emergency Care Pediatrics 132; S140 • Huber, M., André Knottnerus, J., Green, L., et al . How should we define health? BMJ (Online), 2011, 343(7817). doi: 10.1136/bmj.d4163. • Irwin LG, Siddiqi A & Hertzman C. Early Child Development: A Powerful Equalizer, A Report for the WHO Commission on Social Determinants of Health. 2007 Geneva: WHO • Health Intelligence Unit, Public Health Statistics Unit & Public Health Strategy Unit .2016 Jersey Health Profile. States of Jersey • Huber, M., André Knottnerus, J., Green, L., et al . How should we define health? BMJ (Online), 2011, 343(7817). doi: 10.1136/bmj.d4163. • Kemp L, Harris E, McMahon C, et al (2011) Child and family outcomes of a long-term nurse home visitation program: a randomised controlled trial. Archives of Disease in Childhood 96:533-540. • Kemp L, Harris E, McMahon C, et al (2013) Benefits of psychosocial intervention and continuity of care by child and family health nurses in the pre and postnatal period: Process evaluation. Journal of Advanced Nursing 69(8), 1850-1861 • Kemp L, Bruce T, Byrne F (2016) Parenting effectively despite: the Maternal Early Childhood Sustained Home-visiting Program. Australian Nursing & MidwiferyJournal (ANMJ) 24(2): 43. • Macleod J, Nelson G. (2000) Programs for the promotion of family wellness and the prevention of child maltreatment: a meta-analytic review. Child Abuse & Neglect 24(9): 1127-49. • Morrell CJ, Warner R, Slade P, Dixon S, Walters S, Paley G, Brugha T (2009). Psychological interventions for postnatal depression : cluster randomised trial and economic evaluation. The PONDER trial. Health Technology Assessment 13, 1–176.
  56. References 3 • Neill, S. & Carter, B. (2012) ‘Do

    I, don’t I ask for help?’: The perpetual dilemma of parents whose children are ill at home. Journal of Child Health Care. 16(4), 317-319. 1741-2889. • OECD (2017), Income inequality (indicator). doi: 10.1787/459aa7f1-en (Accessed on 04 June 2017) • Olds D, Sadler, Kitzman H (2007) Programs for parents of infants and toddlers: recent evidence from randomized trials. Journal of Child Psychology and Psychiatry 48:3/4 355–391 • Pokhrel et al (2015) Potential economic impacts from improving breastfeeding rates in the UK. Arch Dis Child 2015;100:334– 340. • Puura, K., Davis, H.,et al. (2005). The outcome of the European Early Promotion Project: mother-child interaction. International Journal of Mental Health Promotion, 7, 82-94 • Robling M et al (2016) Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial The Lancet • Wiggins, M., Oakley, A., Roberts, I. et al. (2005) Postnatal support for mothers living in disadvantaged inner city areas: a randomised controlled trial. Journal of Epidemiology and Community Health, 59, 288-295. • Wilkinson R & Pickett K (2009)The Spirit Level London, Penguin
  57. Agenda Working together to develop an outcomes framework for early

    years – progress so far. Celine McStravick Director, National Children’s Bureau in Northern Ireland Opening the door to Early Child Development: Home Visiting Emeritus Professor Dame Sarah Cowley DBE Questions and table discussions Final words and evaluation
  58. Discussion on your table • Examples of successful home visiting

    practice in Jersey and the benefits for young children, families and/or practitioners. • What are the challenges for home visiting practice in Jersey and learning from today which can help overcome these?
  59. Forthcoming opportunities • A REAL approach to early maths -

    one-day training opportunity Tuesday 12 September 2017 • Next Knowledge Makes Change Seminar: Nabiah Sohail Speaking about supporting bilingual families 12 October 2017 • Knowledge Makes Change newsletter feedback survey Contact Kate Elson on for further details on workshops/ training and to sign up for the newsletter.
  60. None
  61. Jersey Festival of Words 2017 is a five day literary

    festival: - enriching the cultural life of the Island - adding to its range of opportunities in the development of event-led tourism - and providing a wide and varied education programme for schoolchildren. September 27th – October 1st
  62. Festival website:

  63. LAUREN CHILD Children’s Laureate and creator of Charlie and Lola

    talks about her creative process (7+) OPERA HOUSE, SAT SEPT 30 10.00-11.00
  64. KRISTINA STEPHENSON …presents her new book Sir Charlie Stinkysocks and

    the Dinosaur’s Return ARTS CENTRE, SUN 1st OCT, 2-3pm
  65. HEATHER’S HOUSE OF STORIES …presents Charlie and Lola story time

    at Jersey Library SAT 30th SEPT, 11.30 Followed by a book signing by Lauren Child
  66. • Classic Children’s Books in English, Polish and Portuguese: JERSEY

    LIBRARY – FRIDAY 29th September – 11am • French reading of Charlie and Lola 2pm JERSEY LIBRARY – SATURDAY 30th SEPT – 2pm

  68. Final words Thank you Please fill in your evaluation form

    – we really want to hear your feedback to inform the seminar series.