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CHAPTER ONE: BACKGROUND INFORMATION
1.1 Introduction
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.
The Government has inaugurated a Ministerial Task Force on health inequalities which reported to Cabinet in May 2008. One of the Task Force's main priorities is to investigate what works to address inequalities in the early years, given that inequalities appearing at this time often have a significant bearing on the subsequent development of the child, and its health, happiness and productivity in society. A number of papers have been prepared to inform the work of the Task Force: http://www.scotland.gov.uk/Topics/Health/inequalitiestaskforce/meetingandpapers.
The Scottish Government's Health Analytical Services Division ( ASD) was asked to prepare this paper 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
- This paper is the result of the work. In putting it together, ASD coordinated and analysed data from a number of sources. These included: 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. Source material was analysed as follows:
- 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 ASD assessed and commented on the quality of the data and the validity of any recommendations made by the researchers.
Consequently, this is not itself a systematic review of the relevant literature, and so we are not in a position to make evidence-based recommendations on interventions policy colleagues might want to consider/continue to support at the expense of other initiatives. However, we have tried to synthesise the messages into coherent messages for policy development and delivery.
For the purposes of this paper, the following definitions apply:
'early years' is defined as pre-, or peri-conception, to approximately eight years, in order to acknowledge the interface between health and education services
'early intervention' is described as 'an intervention which takes place prior to the onset of any difficulties for the individual, in order to prevent, or at least mitigate, those difficulties, and enable the individual to reach their full health potential' (Froggatt, 2007 (unpublished paper). Interventions can be directed at whole communities, or at individual families and communities at risk.
1.2 The national policy context
A range of national policy documents and initiatives in Scotland over the last few years are relevant to this agenda, although they are the products of previous administrations. These include:
- Towards a Healthier Scotland (1999) - acknowledges the profound effects of early influences on lifelong health. The White Paper on Health announced broad measures to support better child health and tackle health inequalities in the areas of children's nutrition; reduction of accidents; comprehensive screening, surveillance and immunisation programmes; and working across agencies to help children at risk through behavioural disorders and educational failure. Following publication, the Scottish Executive pledged £15million to support four national demonstration projects to act as test beds for action and learning. ('Starting Well' was the demonstration project in child health.) http://www.scotland.gov.uk/library/documents-w7/tahs-00.htm
- For Scotland's Children (2001) - explicitly calls for children's services to be considered as a single service system and for the coordination of needs assessment and interventionhttp://www.scotland.gov.uk/library3/education/fcsr-00.asp
- Nursing for Health (2001) and Nursing for Health Two Years On (2003) - place special emphasis on the targeting of services to the most vulnerable, and seek active integration between the NHS and local authority partnershttp://www.scotland.gov.uk/Resource/Doc/158673/0043052.pdf; http://www.scotland.gov.uk/Resource/Doc/47034/0013859.pdf
- Health for All Children, fourth edition, 2003 (Hall 4) - advocates both the service redesign of the Health Visitor role and greater multi-agency working; and places greater emphasis on the targeting of resources to greatest need and continued implementation of evidence-based practicehttp://www.dhsspsni.gov.uk/hssmd15-04.pdf (key messages)
- The Mental Health (Care and Treatment) (Scotland) Act 2003 - places a specific responsibility on NHS Boards to provide specialist facilities for admitting mothers with their babies. Mental health problems which occur during pregnancy, or in the first postnatal year, affect 20-15% of women but, if detected, respond well to treatment. Although severe illness is relatively rare, its onset is usually rapid and requires urgent and appropriate intervention http://www.opsi.gov.uk/legislation/scotland/acts2003/asp_20030013_en_1
- Respect and Responsibility: A Strategy and Action Plan for Improving Sexual Health (2005) - aims to ensure that young people are able to make informed choices and to improve access to high quality education and sexual health services for all, including those who face discriminationhttp://www.scotland.gov.uk/Resource/Doc/35596/0012575.pdf
- The Mental Health of Children and Young People: A Framework for Promotion, Prevention and Care (2005) emphasises that the diverse range of early years and childcare services are a vital first 'frontline' in establishing good mental health and wellbeing among the youngest children, since risk factors and vulnerabilities in infancy and early childhood are associated with mental health problems in children and heightened risk of mental illness in adult lifehttp://www.scotland.gov.uk/Resource/Doc/77843/0018686.pdf
- Delivering for Health (2005) - focuses on reducing the inequalities gap. Work is now proceeding on the provision of maternity services and the design of Specialist Children's Services in line with the actions set out in this documenthttp://www.scotland.gov.uk/Resource/Doc/76169/0018996.pdf
- Delivering a Healthy Future: An Action Framework for Children's and Young People's Health in Scotland (2006) - emphasises the importance of effective interagency working, and provision of support which is based on the best available evidence - designed to protect and promote health as well as treating disease - capable of addressing the needs of children who may be vulnerable or at risk, and delivered consistently and equitably throughout the countryhttp://www.scotland.gov.uk/Resource/Doc/110080/0026619.pdf
- Visible, Accessible, Integrated Care (2006) - outlines a new service model intended to create nursing services in the community that support people to live healthier lives in their homes and reduce health inequalities
- Delivering for Mental Health (2006) - outlines specific commitments to improving mental health services for children and young people, including basic mental health training for those working with looked after and accommodated children and young people. It also focuses on enhancing perinatal services http://www.scotland.gov.uk/Resource/Doc/157157/0042281.pdf
As the chapters of this paper will indicate, many of the health problems that need to be addressed by early intervention are the results of inequalities, or rather, differentially affect those in the most disadvantaged sections of society. Furthermore, it is important to break a cycle where poor outcomes are repeated across generations. Those who face disadvantage tend to have children younger and in circumstances where they are less prepared and face greater stresses. This is likely to affect their parenting skills and, hence, their ability to give their children the best start in life.
1.3 Introduction to the evidence base
A number of summary papers/reports have been used throughout this document, because of their relevance to the evidence base in relation to some (or all) of the topics covered. The usefulness of these papers to policy colleagues and other stakeholders is likely to extend beyond this document, so a brief summary of the content of the papers/reports is provided below.
Asthana and Halliday (2006) 'What Works in Tackling Health Inequalities: Pathways, policies and practice through the lifecourse'.
This book provides research review evidence on four critical life stages, including 'early life.' Although the policy background relates primarily to England, the evidence base is international and the book provides helpful information, both about effective interventions and the problems associated with ensuring evaluation of effectiveness is appropriate. The authors suggest that research evidence supports three key targets for intervention in early life: smoking cessation; nutrition; and parenting education.
The book has been particularly useful in putting this paper together because of the helpful way in which it summarises the existing evidence, identifies gaps and points out methodological weaknesses in the evaluative work carried out to date.
Sutton et al (eds) (2004) ' Support from the start: working with young people and their families to reduce the risks of crime and anti-social behaviour'
This report draws attention to the evidence that it is possible to recognise factors, even before birth, that place young children at increased risk of behavioural and other problems as they grow older. It also describes factors that make it less likely children will experience these problems and considers support services capable of reducing risk increasing protections. The authors are practitioners as well as researchers, so the report reflects their hands-on experience, as well as their knowledge of relevant research studies. The particular focus of the report is on the scope for preventing crime and 'anti-social behaviour.' The report is divided into four main life stages: pregnancy; birth to two years; three to eight years; nine to 13 years. For the purposes of this paper, only the first three stages have been considered.
http://www.dfes.gov.uk/research/data/uploadfiles/RR524.pdf
Moran et al (2004) 'What works in parenting support? A review of the International evidence'
This review provides the distillation of the overarching messages from the international (English language) literature on the effectiveness of parenting support programmes. Both universal and targeted services are included. Programmes are sorted into four categories: 'what works,' 'what is promising,' 'what does not work,' and effectiveness 'not known'.
The review includes profiles of all the parenting programmes considered as part of the work that have been robustly evaluated, or have become popular and well known among service providers, although evidence testifying to their effectiveness may still be forthcoming. Salient summary details have been used where relevant in this paper. The full programme profiles can be found on pages 137-175 of the review.
http://www.prb.org.uk/wwiparenting/RR574.pdf
Infant Mental Health: A Guide for Practitioners (2007)
The Short Life Working Group on Infant Mental Health (drawn from health, early education, social services and the voluntary sector) met between December 2005 and May 2006. The Group's remit was to examine models of good practice in Scotland and elsewhere for the promotion of good mental health both in low-risk and high-risk families, and to make recommendations for a strategy for Scotland to ensure the best outcome for all babies. Additional research into the evidence base of effectiveness for various interventions was conducted by two members of the Group.
The output from the Group is a concise and readable summary of the current evidence in a range of topic areas, which has the advantage of being practically oriented. Consequently, services highlighted in the document are included in several places throughout this paper. The search strategy used to identify effective interventions is not detailed in the published version of the report, however, and it is not clear why several of the projects described were selected as specific examples of good practice.
http://www.headsupscotland.co.uk/documents/Infant%20Mental%20Health%20-%20Good%20Practice%20Guide%20-%20Final%20Edit.pdf
Growing Up in Scotland
The Growing Up in Scotland study ( GUS) is an important new longitudinal research project aimed at tracking the lives of a cohort of Scottish children from the early years through childhood and beyond. Focusing initially on a cohort of 5,217 children aged 0-1 and a cohort of 2,859 children aged 2-3, the first wave of fieldwork began in April 2005.
Where relevant, a brief summary of findings from the first sweep of the survey is included to provide context to individual chapters of this document. A series of documents which summarise key findings to date is available on the Growing Up in Scotland website: http://www.growingupinscotland.org.uk/
1.4 Layout of this paper
This paper focuses on specific key areas:
- Pregnancy at a young age
- Maternal and foetal health during pregnancy
- Maternal and child nutrition and physical and mental health
- Child development and early education
- Parenting in the early years
- Groups that are particularly vulnerable
- The longer term impacts of investment in the early years
The documents which have contributed to this paper focus on specific issues or/and slice the topic areas in different ways so, in coordinating them, it is inevitable that there should be some overlap. The most logical approach seemed to be to look at issues particularly relevant to pregnancy, from birth onwards, from three to eight years, initiatives targeting particular vulnerable groups and what is known of the longer term impacts of investment in the early years. Naturally, some issues (such as infant oral and dental health and accidents and injuries), and certain of the initiatives to address them, are relevant throughout the early years, but have been included in one of the 'birth onwards' chapters because of the importance of intervention at an early stage of the child's life. The final chapter draws together key messages about the effectiveness of interventions that have been rigorously evaluated, areas where the evidence base is lacking, and methodological issues that need to be addressed by future research.
Much of the literature comes from other parts of the world, particularly the US, so findings may not be transferable to the Scottish context. Evidence which relates specifically to Scotland is made clear and, throughout the paper, short reports on Scottish initiatives (as part of the international evidence base on a particular topic) have been boxed in the text, for easy reference.
Given the complexity of the evidence base underpinning the various topics, shaded boxes throughout the text include summaries of what we know about the effectiveness of interventions to address particular issues or, where a single initiative (such as Sure Start) has been discussed in detail, whether and how it has been evaluated to date.
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