Preventive interventions for vulnerable mothers offered in pregnancy
Submitting InstitutionBirkbeck College
Unit of AssessmentPsychology, Psychiatry and Neuroscience
Summary Impact TypeSocietal
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
Jacqueline Barnes' evaluations of government initiatives promoting
parenting and child development for vulnerable families have directly
affected major policy decisions since 2008. Her study of the Home-Start
programme demonstrated limited benefits of unstructured volunteer support,
and informed recent NICE guidance on early intervention. Her subsequent
evaluation of the Family Nurse Partnership (FNP) programme for vulnerable
mothers changed government policy. The success of FNP, as demonstrated
during the initial evaluation phase, led to ministerial decisions to more
than double the provisions of this programme in 2010 and 2013. FNP has now
been rolled out widely in England, Scotland and Northern Ireland.
The first phase of this research involved the evaluation of Home-Start, a
volunteer home visiting programme for vulnerable mothers during late
pregnancy and after birth (Grant G1). Can a voluntary unstructured and
variable home-visiting service reduce depression and stress, change an
infant's temperament over 12 months, and improve infant cognitive
development? Research assessments at 2 and 12 months included
semi-structured interviews, observations and questionnaires, and compared
supported mothers, case-matched controls and those offered but not
receiving support. Results showed that Home-Start led to few measurable
benefits: While those receiving Home-Start reported a greater reduction in
parenting stress, there were no significant differences in alleviation of
postnatal depression and no positive impact on infant cognitive
development at 12 months of age. The study led to the conclusion that this
type of home-based volunteer support is of limited value, and is useful
only if volunteers follow a theoretically driven strategy, over a set
number of visits, with a standardised set of materials (Barnes et al.,
2009). These conclusions were integral to recent guidance published by the
National Institute for Health and Clinical Excellence (NICE; section 4).
A potentially more effective approach is the US-based Nurse Family
Partnership (NFP) programme, which offers curriculum-based support from
nurses to first-time vulnerable mothers. Based on positive results from
randomized controlled trials in the USA, it was decided in 2006 to
introduce NFP in England (renamed as Family Nurse Partnership, FNP).
Results from abroad are of limited value when introducing such programmes
in the UK, as care systems are different. Barnes won the contract to
conduct the implementation evaluation of FNP for 1200 women in ten sites
in England, starting in 2007 (Grants G2-G4). Goals were to determine the
feasibility of implementing FNP within the NHS, to evaluate short-term
impacts on practitioners, the service community, and on children and
families, and to develop eligibility criteria for a wider rollout of FNP.
The evaluation showed that FNP was very acceptable to clients and nurses.
Clients reported a high regard for the nurses throughout, fathers
participated, and attendance was high through pregnancy, infancy and
toddlerhood. Reduced smoking in pregnancy and higher breast-feeding rates
were found. Mothers were positive about their parenting and reported
higher self-esteem, with increased confidence and higher aspirations for
themselves and their children. Children were developing in line with age
group norms, which is particularly important for children at risk for poor
development. These findings (Barnes, 2010; Barnes et al., 2011a, 2011b,
2013; Barnes & Henderson, 2012) formed the basis for the government's
decision to expand FNP in 2010, and to further expand this programme in
2013 (section 4). Additional research funded by the Department of Health
(Grants G5-G6) showed that a follow-on programme (Group FNP) is also
effective and can be offered to women not eligible for FNP. In 2013,
Barnes won an award from the National Institute for Health Research to
extend this research with a randomised trial of Group FNP within
Children's Centres at seven sites in England (Grant G7).
References to the research
Barnes, J., Senior, R. & MacPherson, K. (2009). The utility of
home-visiting volunteer support to prevent maternal depression in the
first year of life. Child: Care, Health and Development, 35(6),
Barnes, J. (2010). From evidence-base to practice: implementation of the
Nurse Family Partnership programme in England. Journal of Children's
Services. 5(4), 4-17.
Barnes, J., Ball, M. & Niven, L. (2011a). Providing the Family-Nurse
Partnership programme through interpreters in England. Health &
Social Care in the Community. 19(4), 382-391.
Barnes, J. et al. (2013). First steps: study protocol for a randomized
controlled trial of the effectiveness of the Group Family Nurse
Partnership (gFNP) program compared to routine care in improving outcomes
for high-risk mothers and their children and preventing abuse. Trials,
14, 285. Open access: http://www.trialsjournal.com/content/14/1/285
Barnes, J., Ball, M., Meadows, P. Howden, B., Jackson, A., Henderson, J.
& Niven, L. (2011b). The Family-Nurse Partnership Programme in
England: Wave 1 implementation in toddlerhood and a comparison between
Waves 1 and 2a of implementation in pregnancy and infancy: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_123366.pdf
(G1) Barnes, J., Senior, R. & Waller, B. Right from the start:
evaluation of Home-Start with mothers of new-born infants. Health
Foundation. £371,991, 1/1/02 - 31/03/05.
(G2) Barnes, J., Ball, M. Meadows, P. Belsky, J. & McLeish. J.
Evaluation of the first phase of Health-Led Parent Support demonstration
sites. DCSF. £548,349, 15/03/07 to 31/03/08.
(G3) Barnes, J., Belsky, J., Meadows, P. & Ball, M, Evaluation of the
first phase of Health-Led Parent Support demonstration sites. Year Two.
DCSF. £475,125, 1/4/08 to 31/3/09.
(G4) Barnes, J., Meadows, P. & Ball, M. Family Nurse Partnership
programme — Formative evaluation of Wave 1 test sites: Years 3 and 4.
Department of Health, £487,712, 1/4/09 to 31/12/10.
(G5) Barnes, J. Formative evaluation of the FNP and Group-Based Antenatal
Care Project. Department of Health. £63,699. 1/9/09 to 30/6/11.
(G6) J Barnes. Evaluation of gFNP development (phase 3). Department of
Health. £39,537, 15/10/2012 to 30/3/2013.
(G7) Barnes, J., Allen, L., Barlow, J., Elbourne, D., Macdonald, G.
Melhuish, E. Petrou, S. & Spiby, H. Randomised trial of the
effectiveness of Group Family Nurse Partnership (gFNP) in improving
outcomes for high-risk mothers and preventing abuse. NHS National
Institute for Health Research. £1,195,254,1/2/2013 to 31/1/2016.
Details of the impact
The research had immediate impacts on major government policy decisions
to introduce and expand the FNP programmes, and contributed directly to
official guidance on early years intervention. Barnes' finding that
Home-Start showed very limited benefits was integral to NICE guidance
"Social and economic wellbeing: Early years" (2012, source S1), which
informs commissioners of services, health visitors, practioners and early
years staff. This guidance stated that volunteer support may not be
effective, and also recommended the implementation of professionally
delivered programmes with strong evidence, such as FNP. As part of NICE
guidance on early interventions to promote the social and emotional
wellbeing of vulnerable children under 5 years, Barnes also provided an
in-depth expert review paper on Home-Start (2011, source S2).
The FNP evaluation extended over four years. Even before it was
concluded, the strength of the evidence and the quality of delivery
identified by Barnes' research was sufficient for policy to be changed. In
2010, Health Secretary Andrew Lansley announced that the programme was
successful enough to warrant launching a randomized trial in England and
to more than double its provision from 6,000 to 13,000 families by 2015.
In direct reference to Barnes' report, Lansley stated "We know that
early intervention — as provided by the Family Nurse Partnership
programme — can help young parents to look after their children better,
and can help break inter-generational patterns of disadvantage. And it
can improve the health and wellbeing of the parents themselves — they
are reducing smoking during pregnancy, are coping better with pregnancy,
labour and parenthood and are improving their confidence and
self-esteem. The evidence base for expanding this programme is clear.
That's why I want to see the numbers of families who get this intensive
support to double by 2015. This, together with our plans to put 4,200
new health visitors into the workforce, will ensure that more and more
young families — particularly those living in disadvantaged areas — get
the help they need." (source S3). In 2013, a second expansion of FNP
to 16,000 mothers was announced by Health Secretary Dr Dan Poulter, again
citing Barnes' findings as justification (source S4).
The main findings of Barnes' FNP evaluation were made publicly available
in a press release by the Department of Health (May 2011, source S5), and
in a DoH information pack for NHS Trust CEs, directors of nursing and
children's support services, other health and educational professionals,
and local authority CEs (April 2012, source S6). Based on this evidence,
the government's evidence-based commitment to expand FNP was reinforced in
the Cabinet Office's policy paper `Breaking Barriers, Opening Doors'
(2011, source S7), and by a statement of Public Health Minister Anne
Milton on 11 May 2012. The evidence basis for the successful
implementation of FNP was also highlighted in a recent independent
government review (Allen review: Early intervention: the next steps, 2011;
source S8), which refers extensively to the results of Barnes'
implementation evaluation. FNP is one of a small number of programmes that
are recommended for early intervention by this review.
In addition to providing the evidence basis for government policy
decisions to expand the FNP programme, results from the FNP evaluation
study at Birkbeck also have direct implications on how FNP will be
implemented in subsequent waves of programmes. In a recent DoH report
aimed at directors of public health, nursing, and children's support
services (source S9), Ailsa Swarbrick (FNP Project Director at the DoH)
stressed the importance of the evaluation for expansion of the programme
and for informing implementation of subsequent phases. According to
Swarbrick, key points highlighted by the evaluation were the need to
improve practitioners' use of data to monitor their delivery of FNP
services, to identify the organisational support necessary for good
implementation, and to prepare local health organisations for FNP before
Barnes has disseminated her research findings on the effectiveness of
preventive interventions to a wide range of practitioners, including those
delivering or planning to deliver the FNP programme. Audiences included
Primary Care Trust (PCT) members, local authority staff, government
officials, and parenting charities such as the Fatherhood Institute. For
example, she was the keynote speaker at the Healthy Development Adelaide
meeting (2011) that was attended by over 200 delegates from government,
health care and clinicians, and gave a grand rounds at the Women's and
Children's hospital in Adelaide. Research design and methods have also
been shared with the evaluators looking at introducing FNP in Scotland,
Northern Ireland and in Australia.
Sources to corroborate the impact
(Full URLs and additional tinyurl links have been provided for all
weblinks. Copies of all source materials are available upon request if
external weblinks are no longer operational.)
S1. Public Health Interventions Advisory Committee (PHIAC) (October 2012)
Social and emotional wellbeing early years guidance PH40. NICE:
S2. Schrader-McMillan, A., Barnes, J. & Barlow, J. (2011) Primary
study evidence on effectiveness of interventions (home, early education,
child care) in promoting social and emotional wellbeing of vulnerable
children under 5. PH40 Social and emotional wellbeing — early years:
expert report 1. London: National Institute for Health and Clinical
S3. Andrew Lansley MP, Health Secretary. Press release, Dept. of Health,
28 October 2010:
http://collections.europarchive.org/tna/20110720072732/http://dh.gov.uk/en/MediaCentre/Pressreleases/DH_121040 ; http://tinyurl.com/lhf4tb3
S4. Dr. Dan Poulter, MP, Health Secretary. Press release, Dept. of
Health, 4th April 2013:
S5. Young Mums and Dads get help from Innovative Programme. Press
release, Dept. of Health, 5th January 2011:
S6. The Family Nurse Partnership, Information leaflet. Dept. of Health,
S7. Opening Doors, Breaking Barriers, A strategy for social mobility
(2011). Nick Clegg. Cabinet Office:
S8. Graham Allen (2011). Early Intervention: The next steps. An
Independent report to HM Government:
S9. Ailsa Swarbrick, Foreword in: Ball, M. Barnes, J, Meadows, P. (July
2012). Issues emerging from the first 10 pilot sites implementing the
Nurse-Family Partnership home-visiting programme in England: