Young, vulnerable and pregnant: family support in practice.
Intervention in the early years, including family support, can
reduce inequality and disadvantage across the life course. This paper
reports on an evaluation of a local project, which aims to increase
resilience and avert crisis among vulnerable young mothers. It suggests
that paraprofessional link workers, spanning the antenatal-postnatal
period, may contribute to maternal health and wellbeing and increase use
of support services and networks. However, challenges for inter-agency
and interprofessional working remain.
Family support, young mothers, link workers
(Care and treatment)
Family services (Management)
Family life education (Services)
Medical personnel (Services)
|Publication:||Name: Community Practitioner Publisher: Ten Alps Publishing Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2009 Ten Alps Publishing ISSN: 1462-2815|
|Issue:||Date: Oct, 2009 Source Volume: 82 Source Issue: 10|
|Topic:||Event Code: 200 Management dynamics; 360 Services information Computer Subject: Company business management|
|Product:||Product Code: 8010000 Medical Personnel NAICS Code: 62 Health Care and Social Assistance SIC Code: 8099 Health and allied services, not elsewhere classified; 8322 Individual and family services|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
The early years are recognised as a critical period when intervention can reduce disadvantage across the life course. (1) National policy also emphasises the need to close the gap between the most disadvantaged children and their peers. Access to child care, pre-school education, family support services, informal support networks and the creation of social capital are all fundamental to this target. (2) However, the evidence base does not always offer the guidance that policy makers and practitioners require when it comes to implementing such programmes locally. Less is known, for example, about the role of family support in primary as opposed to tertiary prevention, strategies for reaching the most disadvantaged families and what determines effectiveness in a local context. (3)
This paper reports on the findings of a service evaluation of a pilot project that is centrally related to this evidence base and these challenges. The Malezi Project aims to work with vulnerable first-time young mothers (aged 17 to 25 years) to increase resilience and avert crisis. It reflects the current emphasis on partnership working and the acceptance that problems such as health inequalities require holistic thinking. (4) It also develops the notion of the link worker as a contact point for the family who can provide information, signposting and emotional support, help co-ordinate services and empower clients. It shares many of the concerns of the Family Nurse Partnership programme, which aims to provide nurse-led home visiting for vulnerable first-time parents. (5) One notable difference is that the project is not nurse-led but relies instead on paraprofessionals--health visitor or midwifery assistants.
The Malezi Project
The Malezi Project was based on a review of the evidence base relating to maternal and child outcomes, together with consideration of city-specific problems, such as levels of deprivation and under-18 conceptions. (6) Building on the existing family support network, it aimed to:
* Improve the health and wellbeing (emotional and social functioning) of young vulnerable families
* Increase the use made of support services
* Improve inter-agency working. Drawing on the evidence, it sought to:
* Improve self-esteem and confidence
* Reduce smoking or minimise risks to the baby
* Increase breastfeeding rates
* Reduce isolation and foster support
* Identify service-related problems constraining access. (1,7)
These aims were to be delivered in a yearlong pilot phase through five Malezi link workers (three whole-time equivalents). The link workers were health visitor assistants or midwifery assistants who received project-specific training--smoking cessation and smoking in pregnancy, child protection, social attachment and the UNICEF breastfeeding course. They were supervised by a part-time project manager (a senior health visitor, already working in the city) and based in two children's centres in order to establish the project's profile with local agencies, community-based healthcare professionals and young families. It was funded from the children's centre budget and accountable to them and the city council through a strategic multi-agency steering group, including senior health visiting and midwifery staff.
Clients could be referred into the project if they were a first-time mother aged 17 to 25 years at level 1 or 2 vulnerability on the local child concern model (where the carer was under stress that might affect their child's health and development). (8) Typical problems encountered included isolation, lack of confidence, housing stress, financial problems, unstable relationships and chaotic lifestyles. The intention (determined by funding rather than the evidence base) was that one-to-one support could be delivered until the baby was six months old. Reflecting the emphasis on early intervention, most referrals were from midwives, but the pilot also encouraged referrals from health visitors and other professionals. It was the intention that healthcare professionals would remain accountable for their client, with the link workers providing an additional service with project-specific lines of accountability.
Core features of successful home visiting programmes include early identification of families via the health service, together with the early initiation and sustained provision of support services, integration with existing services and voluntary participation. (9) However, the effectiveness of professionals as opposed to paraprofessionals remains uncertain in a UK context and the subject of wider debate. (10-12) Precedents exist to suggest that empathy, information and support are important in increasing parenting capacity, and are not restricted to professionals. (12,13) The pilot project was also subject to evaluation and this paper draws on the findings of this gathered from baseline and follow-up questionnaires, activity sheets, reflexive logs and interviews with clients, link workers and referrers. Specifically, it focuses on work with 38 referrals (the six-month case-load for three workers) to the project in 2007 to 2008, to explore the ability of a local paraprofessional model to improve outcomes for young, vulnerable families.
Improving health and wellbeing
A link worker-administered questionnaire (developed in consultation with Malezi Project staff) recorded clients' health and health-related behaviour on entry and again at six months or case closure. Comparison of the returns (relating to 22 cases) suggested improvement in several areas that might be attributed, at least in part, to the project.
Health was not a major concern for new clients, with only two rating their health (on a Likert scale) other than good. Nevertheless, six clients recorded an improvement in their health across the course of the project. Movement from pregnancy to motherhood may have been a contributory factor here. However, one-toone support from link workers and the provision of health-related information may also have contributed.
Wellbeing was similarly investigated through six Likert-scaled questions. These rated levels of satisfaction with life as a whole, pending motherhood, availability of personal time, someone to talk to, and the support received from family, local groups and services. Overall, wellbeing was good both on engagement with the project and at exit. This suggests that the project might not have reached those most in need. (14) However, the baseline questionnaire was administered on entry to the project when clients may have been unwilling to admit to problems, while the postnatal challenges anticipated by those who referred them would not yet have emerged.
Indeed, interviews with the young mothers suggested that the project had had a positive effect on their self-esteem and confidence and that, in contrast to their questionnaire responses, motherhood was often an unexpected event with related anxieties that the link workers had countered. This was supported in interviews with referrers, who identified clients who had 'definitely moved forward... I can see in them that they're more positive attending things'. It is thus important to triangulate survey results and not rely exclusively on quantitative scales to measure progress.
In the UK, teenage mothers are more likely to smoke before or during pregnancy than mothers aged over 20 years. (15) It is therefore unsurprising that the majority of the sample (60%, n=13) were either smoking or had been smoking prior to becoming pregnant. Only one client had never smoked either before becoming pregnant or during pregnancy. In addition, 13 clients identified that somebody else smoked in their household.
Activity sheets (n=29) recording a range of project-related interventions showed that this was a sensitive issue, with clients often 'not ready to give up'. Professionals working in such situations are frequently wary of damaging embryonic relationships by appearing judgemental. (16) However, information on smoking cessation was offered to half of these households (n=14), and a positive outcome was recorded in over half (n=16), primarily the achievement of a smoke-free home. This is not the same as stopping smoking (only two clients stopped and three cut down, while no-one is recorded as using smoking cessation services). However, Prochaska and DiClemente's stages of change model suggests that adoption of a smoke-free home represents an important step along the continuum from pre-contemplation to action and maintenance. (17)
The majority of clients (60%, n=13) wanted to formula-feed their baby as opposed to breastfeed. This is again unsurprising, as only 51% of mothers aged 20 or under in the UK breastfeed their baby at stage one, as opposed to 84% of mothers aged 35 and over. (15) However, the rates for the Malezi sample are low compared even to the national average.
No significant changes were recorded among this group in terms of baby-feeding preferences but the activity sheets showed about half (n=14) of the young mothers had been given advice on breastfeeding, often including attendance at a breastfeeding workshop with some 'already set on bottle-feeding'. This highlights the need for both early intervention and a community approach, with feeding preferences often established pre-birth and prior to contact with healthcare professionals. (18)
While only one-quarter (n=7) initiated breastfeeding, all but one of these attended a breastfeeding support group. In these instances, it was apparent from link worker records and client interviews that the Malezi Project had been influential in engendering confidence and--importantly for both personal and community capacity-one mother also attended peer support training. The background and experience of link workers had an impact on their confidence and efficacy in this role--a midwifery background helped engagement.
Use of available support
It was hoped that the second aim of the Malezi Project--to increase use of available support services and networks--would increase parenting capacity, reduce social isolation and increase self-confidence. All clients had been advised to attend local mother-and-baby groups, and accompanied visits were a vital part of the link workers' role. This could be a very time-consuming process but one where gains in confidence were apparent:
She now knows two faces here so is confident to attend by herself (link worker, reflexive log).
The activity sheets revealed the variety of advice and support provided in relation to benefits, work, education and relationships. Housing was a particular stressor, with 28% of these clients (n=8) receiving help with housing from their link worker. This ranged from completing grant applications to attending the housing office with the family, or accompanying clients on visits to the mother-and-baby unit. In such instances, it was not only a case of offering organisational skills and persistence but also confidence, advocacy and occasionally interpretation of professional terminology. It was obvious from interviews, activity sheets and reflexive logs that the link workers provided not only practical but emotional support. In part, this was attributed to the one-to-one support provided and the trust established with their clients: [The link worker] was really easy to talk to, I felt comfortable and she was very welcoming (Malezi client 1, interview).
Improved joint working
The third aim of the Malezi Project was to develop inter-agency working. A wide variety of agencies were accessed, including social services, housing, mental health services and debt advisers. Mapping these various support services, establishing contacts and sharing information was an important part of the link workers' role. However, sharing information was not always easy and raised a number of issues for interprofessional working. Maintenance of computerised health visiting records was a particular difficulty, with link workers spending a considerable amount of time getting from one base to another and working in locations with which they were not familiar.
There was also on-going concern about the referral process. Not all referrals were at the correct level of need (a problem that spanned both ends of the spectrum) or used the correct procedures, with:
* A midwife, health visitor or other professional completing a Common Assessment Framework form
* A subsequent joint visit by the referrer and the link worker
* An agreed care plan, reviewed regularly. Where onward referral was needed, delays could mean that link workers were supporting very vulnerable clients. Additionally, healthcare professionals were not always willing to refer clients into the project, and relationships between midwives and health visitors were often an area of tension. As one midwife explained, the original vision was that Malezi would try 'to tie up the work of midwives, health visitors and children's centres and get those links established'. But there was little evidence that this had been achieved
in the pilot phase. Indeed, the referral process had on occasions caused additional problems and left some feeling that their professional domains had been challenged, despite the extensive efforts of the project manager to visit health visitor and midwife teams and explain how the project might support them in their work.
Link worker characteristics and response
The project demanded that link workers draw heavily on their professional early years' training and interpersonal skills. The challenges of combining a vulnerable client base and an innovative role were nevertheless apparent, with clients' social issues the aspect of the job that caused link workers most concern. Their logs also made obvious the need to challenge both their pre-conceptions--for example, concerning levels of support from other agencies and clients' capabilities--and those of the young mothers.
However, interviews with the clients showed that the 'listening ear' and approachability of the link workers was a highly valued element of support: I can talk to [the link worker] about anything, I can. It's like not just being there to help, she's more like a friend ... I can just ring her, text her and just let her know that I need someone to talk to (Malezi client 2, interview).
The flexible and intensive input of the link workers was also seen as an important addition to the support base by local healthcare professionals, particularly the fact that they had 'time that we haven't got to spend, basically'. However, this close relationship with clients could lead to some overdependency and the requirement to balance intervention with the goal of client independence. Such problems around role definition, boundaries and exit strategies are likely to escalate as the project is mainstreamed if, as in all new roles, clear guidance and effective training is not given. Indeed, several aspects of the evaluation stressed the importance of formalising information exchange as the project developed, with link worker meetings an invaluable resource as much for reducing isolation and sharing concerns as for the provision of formal training.
It is difficult to evaluate changes in health and wellbeing in the short term. This was particularly difficult in the case of the Malezi Project because of the small numbers involved and the pilot nature of the project. This meant that referral criteria were evolving, clients were recruited at different stages of pregnancy and monitoring tools were still being established. It is also difficult to attribute causal explanations in any community initiative, because participants are subject to a diversity of often conflicting influences.
This pilot suggested that health issues were not a major concern for many of the clients, yet this was a group where health-damaging behaviours were apparent. Many young mothers showed resistance to the idea of smoking cessation and information, so advice needed to be tempered with a requirement to deliver support and encourage trust. It was similarly difficult to change clients' views about their preferred baby-feeding methods, but it was important that the project acted as a source of practical and emotional support in decisions to breastfeed.
The project found it easier to achieve its aim of increasing the use made of available support services and networks. Link workers gave advice on an extensive range of issues and this was much valued by the clients. It was also obvious that the process of actively bringing the clients into centres to access mother-and-baby groups was successful. This opens doors to a variety of formal and informal support networks, which are known to increase parenting capacity and reduce risk.
It is more difficult to judge the impact that the project has made on inter-agency working. The referral of Malezi clients into the wider system has reduced individual barriers to information and advice, overcoming problems with confidence, language and process, such as the ability to complete forms. The location of link workers in children's centres appears to be of mutual benefit to both the project and children's centre staff, particularly in terms of improving outreach and bringing people into the centres. However, problems around referral and interprofessional concerns about delegation and core competencies were evident. Such concerns do not appear to be limited to projects that utilise paraprofessionals, but are common challenges for innovatory projects operating across organisational and professional domains.
The project has now completed a second phase, and funding has been secured for a further two years, enabling the employment of 11 link workers and an expansion in the number of children's centres involved. One of the first challenges for the extended project relates to the ability to establish trust and increase reach among the local health sector, particularly midwives. A further challenge is increasing project identity. This relates not only to raising awareness locally, but also the ability to institutionalise learning so that it is embedded in the system rather than vested in individuals. For example, protocols with respect to referral criteria and safety and a central directory of accessible and maintained information on local agencies, groups and contacts are imperative. It is hoped that systematic, sustained and responsive data collection will also enable the continued relevance of the project to be assessed, and for practice to be modified appropriately. As in previous research, the link worker role, the skill mix, the perceived informality of the support and the importance that is attached to home visiting appear to be central to the project's early achievements. (19)
* The employment of paraprofessional link workers spanning the antenatal-postnatal period increased the use made of available support services and networks
* Their ability to contribute to maternal health and wellbeing was less certain, and key barriers included prevailing community norms and stage of referral
* A focus on home visiting was key to facilitating engagement with the wider support network
* Challenges for inter-agency and interprofessional working remained, particularly around referral but also interprofessional concerns about delegation and core competencies
* Key link worker characteristics were their health-related training and credibility together with their empathy, flexibility and availability
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Joyce Halliday PhD, MA
Academic fellow in rural health, School of Law and Social Science,
University of Plymouth
Tina Wilkinson MA, BSc
MPhil/PhD student, School of Applied Psychosocial Sciences, University of Plymouth
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