Tackling Social Exclusion: the Role of Home Visiting Jane Barlow Reader in Public Health

1. Tackling Social Exclusion:the Role of Home VisitingJane BarlowReader in Public Health

2. Structure of Paper • Relationship between parenting and social exclusion • Focus on the evidence about parenting of infants • What works for mothers and infants? • Supporting vulnerable parents – the role of home visiting

3. Parenting and Social Exclusion?

4. Parenting and Social Exclusion… • Parenting is a significant determinant of developmental outcomes that are critical for social and economic success in adolescence and adulthood • Parenting mediates the effect of poverty

5. The Evidence… • Promiscuous sex and teenage pregnancy (Scaramella et al., 1998) • Healthy eating (Kremers et al., 2003) • Smoking (Cohen et al., 1994) • Alcohol misuse (Garnier et al., 1998; Egland et al., 1997) • Educational achievement; School drop-out (Desforges, 2003) • Behaviour problems, delinquency, criminality, violence (Patterson et al., 1989; Farrington, 2003) • Drug and Mental and physical health in adulthood (Stewart-brown and Shaw, 2004)

6. Parenting and later outcomes Attachment Smoking/drugs Self-esteem Promiscuity Mental health Education Poverty Unemployment Etc Parenting Behaviour School failure Emotional Regulation Delinquency Relationships Obesity Communication

7. Parenting Is Socially Patterned • Child abuse higher where there is social deprivation • Lower SES parents more likely to use physical punishment and other authoritarian methods • Maternal depression nearly twice as high among mothers living in poverty • Parenting attitudes – lower SES parents value conformity and higher SES parents value self-direction • Lower SES less likely to use to use positive methods of parenting

8. Unsupportive Parenting Is Common • Approaches to discipline - 52% of population sample of parents hit/smacked children under 1 year at least one a week (Nobes and smith, 1997) • Communication with/closeness to teenagers - half of adolescents do not think they can confide in their parents; Substantial minority do not feel loved or cared for (NFPI, 2000)

9. How Can We Support Parenting?

10. Key aspects of infant development

11. Parenting That Meets the Needs of the Infant • Nurturance • Behavioural and emotional regulation • Verbal and cognitive stimulation

12. Nurturance/ Emotional and Behavioural Regulation Quality of parent-infant relationship important: • Sensitivity/attunement • ‘Mind-mindedness’ • ‘Mirroring’ • ‘Containment’ • Continuity of care

13. Behavioural and Emotional Regulation • Scaffolding and positive experiences • Positive discipline • Deleterious effects of negative discipline

14. Verbal and Cognitive Stimulation • Verbal responsiveness • Amount of verbal interaction • Being read to • Scaffolding • Physical (home) environment

15. Key Points for Supporting Parenting (1) • Pre birth – anxiety/depression; Substance abuse; Domestic violence; Unresolved trauma; Dysfunctional attitudes to pregnancy/baby • Birth– bonding • Early infancy (4-6 weeks) – empathic caregiving; Postnatal depression • 9 months – attachment and cognitive development • 15-24 months (toddlerhood) – developing independence – emerging behaviour problems

16. Key Points for Supporting Parenting (2) • 2-5 years (preschool) – ongoing use of ‘helpful’ parenting practices including positive methods of discipline • 6- 12 years – Sibling and peer relationships; academic achievement; good self-esteem etc • Teenage/Adolescence – Developing Independence; Difficult feelings; Transitions

17. Health Visitors Supporting Parents • Intervening to support parents • All have some evidence of effectiveness • All can be used by health visitors to support parenting across the developmental spectrum • Examples of Universal; Selective and Indicated Interventions

18. Pregnancy

19. Infancy

20. Toddlerhood

21. Preschool years

22. The Role of Home Visiting in Supporting Vulnerable Parents

23. Home Visiting Programmes • Widespread visiting of pregnant women and new mothers at home by public health nurses in many countries • Based on growing recognition of importance of first three years of life • HDA review of reviews of home visiting programmes (Bull et al., 2004): A need for ‘more UK trials of home visiting which address the methodological limitations’ identified

24. Health Visitors and Home Visiting Universal home visiting Child Development Programme (Percy and Barker, 1986) First Parent Visitor Programme (Emond et al, 2002) Recent Home Visiting Studies (Barlow et al., in press) (Wiggins et al., 2005)

25. Recent UK evaluations of the effectiveness of Home Visiting programmes • Child Development Programme (CDP) – Percy and Barker (1986) • First Parent Visitor Programme (FPVP) – Emond et al., 2002 • Postnatal support workers – Wiggins and Oakley et al., 2005 • Oxfordshire Home Visiting study – Barlow et al., in press

26. Home Visiting Programmes: the evidence Home visiting programmes can be effective in: • Improving parenting and child behavioural problems • Cognitive development • Reducing accidental injury and improving detection and management of PND (Bull et al., 2004. Ante and post-natal home-visiting programmes: a review of reviews. HDA. )

27. NURSE FAMILY PARTNERSHIP • Program with power • Nurses visit families from pregnancy through child age two • Makes sense to parents • Solid empirical & theoretical underpinnings • Focuses on parental behavior and context • Rigorously tested

28. FAMILIES SERVED • Low income pregnant women • Usually teens • Usually unmarried • First-time parents

29. NURSE FAMILY PARTNERSHIP’STHREE GOALS • Improve pregnancy outcomes • Improve child health and development • Improve parents’ economic self-sufficiency

30. Visitation 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

31. Nurse Activities • Goal-driven • Motivational Interviewing • Self-efficacy theory - behavioral change • 3 volumes of program guidelines • Not a cookbook • Adapted to families’ needs and concerns • Professional judgment • Essential for participant engagement • Balance between protocol- and family-driven

32. TRIALS OF PROGRAM 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

33. CONSISTENT RESULTS ACROSS TRIALS • Improvements in women’s prenatal health • Reductions in children’s 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

34. Arrests 61% Convictions 72% ELMIRA SUSTAINABLE RESULTS: Benefits to Mothers Days in Jail* 98% * Impact on days in jail is highly significant, but the number cases that involved jail-time is small, so the magnitude of program effect is difficult to estimate with precision 15-YEAR FOLLOW-UP

35. Abuse & Neglect 48% Arrests 59% Adjudications as PINS* (Person In Need of Supervision) for incorrigible behavior 90% ELMIRA SUSTAINABLE RESULTS: Benefits to Children * Based upon family-court records of 116 children who remained in study-community for 13-year period following end of program. 15-YEAR FOLLOW-UP

36. Nurse Family Partnership Home Visiting for at-risk mothers/children Parent-child interaction therapy System of care/wrap around programs Family Preservation Services Programs Healthy Families America Comprehensive Child Development Program Infant Health and Development Program Summary Report: http://www.wsipp.wa.gov/rptfiles/04-07-3901.pdf $17,180 $6,197 $3,427 -$1,914 -$2,531 -$4,569 -$37,397 -$49,021 Benefits Minus Costs of Child Welfare & Home Visiting Programs

37. Public Health Continuum Community-based Public Health Individual and Family Public Health For example For example Smoking cessation Family plans Parenting groups Screening Immunisation Obesity programmes Treating PND