The expectations of families and patterns of participation in a Trailblazer Sure Start.
The aim of this case study was to evaluate the local impact of an innovative Sure Start located in the east of England. The evaluation addressed the expectations of parents/carers for themselves and their children, and the extent to which Sure Start contributed to their achievement. A distinction was made between regular users and families that did not engage with services. Methods included individual interviews, events data linkage, goal attainment scales for parents and children and group review with stakeholders. The participants were 67 local families (160 individuals), all of whom had at least one child born between August 2001 and April 2004. An exploration of the utilisation of services over time and consumer engagement with services showed that the programme became more effective at engaging families. The role of community practitioners in the early promotion of Sure Start became apparent. Certain entry points, such as a home visit by a health visitor, were associated with more contacts, and more sustained pathways through the programme. Families that were actively engaged with Sure Start identified a range of benefits, especially greater social inclusion. The expectations of families who were 'active users' of Sure Start services matched the aims of Sure Start, and were being met.
Sure Start, community development, social inclusion Community Practitioner 2008; 81(2): 24-28.
Introduction--children living in poverty England is an economically advanced nation, but UNICEF found the proportion of children living in poverty or experiencing specific disadvantage was higher than in comparable European nations. (1) In particular, by the time they were assessed at school (during 2000 to 2003) UNICEF reported that many English children had poor relationships with both parents and peers. (1) Sure Start was introduced as 'the cornerstone of the UK government's drive to tackle child poverty' (2) and this study from 2004 to 2005 reports on an English, Sure Start initiative for families with preschool children.
Across Europe, growing up in poor circumstances is a major factor in health inequalities throughout life. (3) In the UK, the Audit Commission has identified a range of local quality of life indicators to support community development initiatives. (4) These are centred round community, health, education and economic well-being.
Sure Start has been the most ambitious of the schemes collectively known as Early Years Enrichment Programmes. (5) In 1999, when Sure Start programmes began, government investment to overcome inequalities and social exclusion focused on area-based initiatives (eg Education Action Zones, Health Action Zones). Sure Start programmes were located within areas with high indices of deprivation. Initially, each locality had considerable flexibility in the services they developed, to suit neighbourhood priorities. Local planners were faced with a difficult transition period during 2005, since all English programmes would be 'mainstreamed' across all local authorities. (6)
The setting for this study
This study was set in one of the 60 'Trailblazer' sites for the National Sure Start Programme, situated in the east of England. The criteria for becoming a Trailblazer site included low educational attainment in local schools, high rates of teenage pregnancy, workless households dependent on benefits, and a large concentration of children facing the most severe deprivation. Later 'waves' of programmes were located in areas with progressively less and less child poverty. (7) This Trailblazer became fully operational in 2001, and so had time to accumulate more experience of developing services to respond to specific local needs than most of the other 523 Sure Starts. It was not included by the National Evaluation of Sure Start among its aggregated 150 projects, nor as a separate case study. (8) Before this evaluation, little was known about the value of services to parents and families, nor how services contribute to the health and well being of the wider community. (9) At that time, there were growing public concerns about the value of Sure Start, nationally. (10)
As part of a Quality Improvement Project, this study focussed on use of services and local residents' expectations of the Sure Start initiative for themselves, their children and the local community.
Design and participants
Data were collected over an eight-month period between August 2004 and April 2005. Advantage was taken of the existing birthday visits offered to all local families. All families receiving a first or third birthday visit were invited to participate. Second-birthday visits were not appropriate because language tests were prioritised at this age. Maternity and primary care records were used to identify children's birth dates. Uptake of first-birthday visits was lower than third-birthday visits. A structured interview for use during birthday visits was jointly designed by the authors with Sure Start staff and local parent-researchers (who acted as interviewers). This looked at patterns of engagement with specific services and rated the attainment of each family's goals on a simple, nine-point scale. (11) Collated attendance records from 69 local services were used for electronic data linkage (12) of the pattern of contacts for family members over time. To preserve confidentiality, database records were anonymised before collection and analysed by an author who never met the families. Preliminary findings were reviewed by a stakeholder group to identify priorities for future service development. The data collected are summarised in Table 1.
This method of participant recruitment ensured that all local families were given the opportunity to contribute to the study, including those with relatively few contacts with Sure Start services, or those whose children were not born in the local area.
Independent ethical scrutiny was provided by Anglia Ruskin University, in arrangement with the commissioners at the local authority. The parent researchers were identified with the help of the primary care trust and received training from the project team, for example on confidential and sensitive issues, to enable them to collect data for this study in the course of their existing role in providing birthday visits. The decision was taken not to ask questions about family demographics that might be perceived as prying or intrusive, for example that might jeopardise any benefits received by the family.
The families who took part in this study had between one and six children (median = three). 42 of the 67 families had just one child under the age of five (63%). 34 families (51%) had lived in the local area for less than five years. In 34 of the families (51%) all the children were born in the local area, in 17 (25%) some of the children were born locally and in 16 (24%) none of the children were born locally. Five children visited (7.5%) were known to have special educational needs. English was not the first language for two parents (3%).
The judgement as to whether a participant was an 'active user' was made during the birthday visit by the interviewer based on that participant's recollection of services they had used and prior to receipt of the data by the project team. 41 of the 67 families were assigned as active users of Sure Start (61%) and 26 families as nonactive users (39%). For the family member with the most types of service used, the range observed was two to 27 types out of 69 local services. The mean difference between active and non-active families was 4.84 services used (95% CI with unequal variances, 2.8 to 6.9).
Both the attendance records and responses to the questionnaire survey were collated in databases. Anonymously coded records from the same family could be linked across the two sets of data. Subsequent review of records suggested a modest tendency to underestimate the number of contacts, from either source.
The battery of statistical tests used included a non-parametric test (Mann-Whitney U) to compare subgroups of families, and where confidence intervals (CI) were calculated, the modified t-test for unequal variances was used. For the associations between different services attended, ?2 or Fisher's exact test were used. For all tests, the threshold for significance was p < 0.05.
The survey contained open-ended questions about the hopes and expectations of families in relation to Sure Start. Nearly all these goals could be thematically grouped into four categories of response, which were agreed reliably by two readers. Respondents rated the attainment of each goal on a nine-point scale, where zero was 'not at all' and eight was 'completely'.
More details of the methods are available in the quality improvement report for the commissioners. (13)
The observations are summarised according to two main themes:
* Families' contact with Sure Start and engagement with its services
* The hopes and expectations of parents/carers.
Reasons for using or not using Sure Start Participants first heard about Sure Start from a range of sources, of which health visitors and midwives were the most common for both active and non-active users. The most common reasons given for first using services included the facilities available, the need for support or help or a desire for their child to mix with other children. The most common reasons given for why families continued to use Sure Start services included friendly people, enjoyment and help received.
The most common response why families who were non-active users chose not to use services was lack of time.
The events data highlighted that fathers tended to have less engagement with services than mothers. Services were predominantly available between 9am and 5pm, Monday to Friday. The subsequent introduction of weekend activities enabled better engagement with working parents.
Engagement with services
The first one or two contacts were typically located in the local health centre or at home; for example, with a midwife, health visitor or volunteer 'community mother'. Families whose first recorded contact was a home visit were likely to have more contacts and more varied engagement than other families. Health visitors played a key part in this engagement, for example in families initially engaged by a health visitor the person who used the most types of service accessed a mean of 11.17 different services, compared to a mean of 7.17 for families whose initial gateway to Sure Start was a midwife (a difference of four more services, 95% CI of the difference 0.485 to 7.530). Whereas, entry to the programme via a health visitor gave access to both generic services (eg, the creche or toy library) and specialist services (eg, speech therapy for children or postnatal depression support for mothers) none of those four examples was accessed by any family who first learned about Sure Start from the midwives.
During 2005, a common 'gateway' was developed, by co-locating the midwives and health visitors within the building that in 2006 became the children's centre.
During this evaluation, we observed an improvement in the early engagement of families with new children and in the subsequent range of services these families used. Of the 43 children born in the local area in 2001 to 2002, half did not have any contact with Sure Start in the first six months, and they had a mean contact with 2.93 different services in their first year. Whereas, the 12 children born in 2003 to 2004 were all involved in Sure Start by the time they were one month old and they had a higher mean of 7.00 contacts (U = 61.5, p<0.001) with different services in their first year (a difference of 4.07 more services, 95% CI of the difference 2.088 to 6.052).
Mapping the contacts of some families showed an initial contact with Sure Start, but then an intermittent pattern over three years. Where there was a gap of six months or more, a birthday visit or the two-year check could re-engage them with Sure Start services.
Hopes and expectations
The 41 parents/carers categorised as active users were asked to identify up to four expectations of Sure Start for their child, and up to two expectations for themselves and for their local community. They were also asked to rate how much Sure Start was meeting these expectations. The 26 parents/carers who were categorised as non-active users were asked to identify up to four short-term hopes/expectations for their child and up to two expectations for themselves and for their local community. They were also asked to state the degree to which these expectations were being met.
Expectations fell into four main categories: social inclusion, health and well-being, education and general aspirations (Table 2).
Expectations of social inclusion for children covered mixing with other children, making friends and learning to share. Expectations of parents/carers for themselves included meeting and mixing with other 'mums'.
Parents/carers who were active users were also asked whether they had made friends through Sure Start. More than half the active users made new friends, and this was associated with use of the centre's cafe (Fisher's exact test, p=0.011). A relationship emerged between making friends and the child's birth date (U=67.0, p<0.001) with steadily improved inclusion of the families with more recent births.
Expectations for their child within this category related to improving language skills for active users, and to starting and doing well at school for non-active users. Parents/carers had fewer expectations for themselves and for active users this mainly related to receiving advice relating to a child's behaviour. Only one non-active parent/carer referred to their own education.
Health and well-being
Expectations for active users included quite specific issues such as support with breastfeeding, baby massage and improving confidence, for their children. For nonactive users, expectations tended to relate to general good health. For active users the expectations of parents/carers for themselves related to having a break or some peace. For non-active users, expectations included getting more sleep and having another baby.
The expectations in this category were similar for active and non-active users. General aspirations for a child tended to relate to their happiness, independence and success, but there were a few more specific comments, such as more money or a garden to play in. The general aspirations that parents/carers had for themselves were divided between issues like being more organised and more personal goals, such as returning to work or passing a driving test.
Table 2 profiles the expectations of parents/carers, which differ for active and non-active users. The social inclusion category accounted for the biggest percentage of the expectations for both their child and parents/carers themselves for active users of Sure Start.
The extent to which expectations were being met was measured using a nine-point scale, where zero was 'not at all' and eight was 'completely' met.
In Table 3 there is marked difference between the active and non-active users, although many non-active users were unable to provide any rating. The mean difference for the child was 2.09 points (95% CI of the difference 0.12 to 4.05) and for the parent 3.56 points (95% CI of the difference 1.59 to 5.53) out of a maximum of eight. Active users rated the extent to which their expectations were being met quite highly for both their child and themselves in the social inclusion, education, and health and well-being categories.
Expectations for their local community
Expectations relating to the local community were more varied, and some just stated that they did not know. Active users identified factors such as somewhere for parents and children to do activities and make friends, and for it to benefit families more generally. The 15 parents/carers who rated whether their expectations had been met gave a mean rating of 6.67, between 'a lot' and 'completely'. Non-active users wanted more information about schools, a swimming pool, more for older children to do, or more for teenage parents. Only four of these expectations could be rated, with a mean attainment of 1.75, between 'not at all' and 'slightly' (a difference of 4.92 points, 95% CI of the difference 1.40 to 8.43). When asked about their expectations for their local community, three of the parents/carers who were non-active users just stated that they did not like the area.
Very little has been published about the Trailblazer local programmes, although these had the longest development period, before national policy changed to 'rolling out' 3500 generic children's centres 'for every community'. (14) In this study, there was convergence between the aim of Sure Start and the goals identified by parents/carers in a neighbourhood previously singled out for its poverty. The achievement of the individual expectations and aspirations shows that Sure Start was able to meet some of these needs, particularly in relation to social inclusion, providing opportunities to interact with others through a range of activities and settings. Some of these activities were delivered by parents acting as volunteers.
Houston (15) has suggested that changes may occur due to the evolving nature of Sure Start and cannot always be linked to the local programme itself. However, there were improvements in this programme over time, for example, the quicker and increased engagement of younger children. Parents welcomed the introduction of breastfeeding support and baby massage. The programme made additional improvements, including co-locating its health visitors, midwives and community mothers, adjacent to the healthy cafe. Good practice elsewhere, as in a Community Regeneration Award winner, (16) seems to share the characteristics of responding to grassroots needs and making use of peer support. Some types of service, such as an early home visit by a health visitor or a birthday visit by a volunteer, seemed to be especially valued and to open the gate to other services. This accords with the recent UK survey of health visiting practice. (17)
National reports of Sure Start by Belsky and others, based on less developed programmes, suggest that they have not lived up to early ambitions. (8,18) Belsky reasons the poor engagement of teenage mothers is because 'the workers did not go out and knock on the doors of the poor families'. (8) This contrasts with the outreach visits that were central to the success of this Trailblazer.
Implications for practitioners
In this study, early engagement was associated with utilisation of a wider range of services. The early, multi-professional approach may benefit the forthcoming Nurse Parent Partnership pilots (19) intended to support the most vulnerable young mothers. Facing the future (19) prioritises the lead role of health visitors in preventing social exclusion, promoting child and family mental health and supporting capacity for better parenting. This study suggests that health visitors are effective gatekeepers to a range of services that meet all these needs.
Strengths and limitations
This study has attempted to incorporate the voices of a range of local people and has linked data from multiple sources. Another strength is the consideration of all elements of this multi-service programme, an approach that has not been described elsewhere.
A key limitation is the reliance on subjective accounts, which we could not corroborate with objective data on the health of the local population. Furthermore, each local programme may be a unique case, from which general rules cannot be derived. While community electronic data linkage proved informative, the detail cannot be compared to some inpatient linkage studies, for example one involving over 400 000 Australian birth records. (20)
In this study, Sure Start did appear to be meeting the expectations of participating parents. The first few contacts influence the pattern of engagement over subsequent years.
At a local level, area-based programmes have the potential to develop a responsive system of services to meet the needs of local residents. Within such a system practitioners are both service providers and gatekeepers.
This evaluation was jointly funded by Thurrock Primary Care Trust and Thurrock Council. Our thanks go to Sure Start staff and volunteers for their assistance.
(1) UNICEF. Child poverty in perspective: An overview of child well-being in rich countries. Report Card 7. Florence: UNICEF Innocenti Research Centre, 2007.
(2) Sure Start. Introduction. (a search of Hansard suggested that Baroness Hollis first introduced this 'cornerstone' metaphor in 2000) http://www.surestart.gov.uk/surestartservices/settings/introduction/ ( accessed 12 May 2007)
(3) World Health Organization. Early life. In: Social determinants of health. The solid facts. Copenhagen: WHO Europe, 2003: 14-5.
(4) Audit Commission. Local quality of life indicators--supporting local communities to become sustainable. London: Audit Commission, 2005.
(5) Flanagan C. Early Socialisation. Sociability and attachment. London: Routledge, 1999.
(6) Hassan L, Spencer J, Hogard E. Managing sure start in partnership. Community Practitioner 2006; 79: 247-51.
(7) National Evaluation of Sure Start. Changes in the Characteristics of SSLP Areas between 2000/01 and 2003/04. Research Report NESS/2006/FR/016. London: HMSO, 2006.
(8) Belsky J, Melhuish E, Barnes J, Leyland AH, Romaniuk H. Effects of sure start local programmes on children and families: early findings from a quasi-experimental, cross sectional study. BMJ 2006; 332: 1476-78.
(9) News. Answering the big question - 'does it work?'. UpStart! 2000; 1: 3.
(10) Ward L. Doubts over value of 3bn [pounds sterling] Sure Start. Flagship government scheme to help deprived youngsters may be failing. The Guardian (London) 2005; 13 September: 1.
(11) Caan W. Role of users of health care in achieving a quality service. Quality in Health Care 1995; 4: 65.
(12) Wright J, Sentence S, McKerral A, Caan W. Electronic data linkage--finding patients 'lost in the system'. British Journal of Healthcare Computing & Information Management 1999; 16 (vii): 32-4.
(13) Pittam G, Northrop M, Caan W. Findings of the Tilbury Sure Start Evaluation. Chelmsford: APU, 2005.
(14) Department for Education and Skills. Sure start children's centre pass the million mark. Press Notice 2007/0063, 11 April 2007.
(15) Houston AM. Partnership working in Sure Start: Rewards obstacles and challenges in Hilldene and Gooshays programme 2003. Romford: Havering Primary Care Trust, 2003.
(16) Harris S, Koukos C. Sure Start: Delivering a needs-led service in Swansea. Community Practitioner 2007; 80: 24-7.
(17) Cowley S, Caan W, Dowling S, Weir H. What do health visitors do? A national survey of activities and service organisation. Public Health 2007; in press.
(18) Griffiths S. Off to a very uncertain start in life. The Sunday Times, 2007; 2 September: 8.
(19) Queen's Nursing Institute. Facing the future: a review of the role of health visitors. London: Department of Health, 2007.
(20) Burns L, Mattick RP, Cooke M. Use of record linkage to examine alcohol use in pregnancy. Alcoholism: Clinical and Experimental Research 2006; 30: 642-8.
Copies of the interview schedule are available from the corresponding author:
Anglia Ruskin University, Faculty of
Health and Social Care
Chelmsford, Essex, CM1 1SQ
Mary Northrop MSc BA DipHE PGCEA RNT RMN RGN Senior Lecturer in Primary Care, Public Health and Social Policy, Anglia Ruskin University
Gail Pittam MSc BSc
Research Officer, Advanced Practice and Research, Anglia Ruskin University
Woody Caan MA DPhil AcSS FRIPH
Professor of Public Health, Anglia Ruskin University
Table 1. Summary of the data collected Data Information Participant source collected group Structured Details of the family, their Parent/carer of a child interview connections with the local receiving a first or area and their use of Sure third birthday visit Start services Goal The expectations of the attainment parent/carer, for scales themselves, for their child and for the local community and the extent to which these are being met Events data Records of family Families of those who had contacts with any Sure taken part in an interview Start services Group Discussion of aspects of Stakeholders, including review the design and preliminary Sure Start staff, findings local parents and representatives from the funding bodies Data Data collection source procedure Data collected Structured Administered by Sure Start 57 third-birthday and interview staff and parent-researchers 10 first-birthday visit interviews Goal attainment scales Events data Records were supplied in Data from the attendance an anonymised format by records of 160 local the local Sure Start people Group Group discussion 11 participants review Table 2. The expectations of parents/carers Active users Non-active users For their For For their For child themselves child themselves Social inclusion 54.7% 37.8% 30.8% 4.6% Education 15.1% 16.3% 30.8% 9.0% Health and 17.0% 27.0% 19.2% 45.5% well-being General 13.2% 18.9% 19.2% 40.9% aspirations Number 53 37 26 22 Table 3. The extent to which parent/carers expectations are met Ratings Active users Non-active users For For their For their For child themselves child themselves Social 0-2 13.5% 0% 25.0% 0% inclusion 3-5 27.6% 21.4% 0% 0% 6-8 69.0% 78.6% 12.5% 0% Not rated 0% 0% 62.5% 100% Number 29 14 8 1 0-2 0% 0% 25.0% 0% Education 3-5 12.5% 0% 12.5% 50.0% 6-8 87.5% 100% 25.0% 50.0% Not rated 0% 0% 37.5% 0% Number 8 6 8 2 0-2 0% 0% 0% 20.0% Health and 3-5 0% 10.0% 20.0% 20.0% well-being 6-8 100% 90.0% 40.0% 0% Not rated 0% 0% 40.0% 60.0% Number 9 10 5 10 0-2 42.6% 14.3% 40.0% 55.6% General 3-5 0% 28.6% 20.0% 0% aspirations 6-8 28.6% 28.6% 20.0% 0% Not rated 28.6% 28.6% 20.0% 44.4% Number 7 7 5 9
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|Author:||Northrop, Mary; Pittam, Gail; Caan, Woody|
|Date:||Feb 1, 2008|
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