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The Effectiveness of Interventions to Address Health Inequalities in the Early Years: A Review of Relevant Literature

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CHAPTER EIGHT: INVESTMENT IN THE EARLY YEARS - COSTS AND BENEFITS

8.1 Introduction

There is no shortage of interventions designed to address problems which have a disproportionate impact on the most disadvantaged families in society during the earliest years of a child's life. The earlier chapters of this document have highlighted a range of these. Many initiatives have been the subject of rigorous evaluation (whether or not this has yet been in the UK) and have shown good outcomes in the short-term; others appear promising, based on the evidence to date. However, information on the cost of individual interventions, factors affecting cost, and the longer-term impact of investing in the early years is extremely sparse. This chapter highlights work that has examined the financial implications of moving from a focus on those with the most complex needs to earlier, more integrated intervention. It then (briefly) examines the evidence base on long-term outcomes and returns on investment, and attempts to identify the major gaps.

This chapter also looks at the issue of creating and fostering non-violence in society, since violent crime currently costs the UK more than £21 billion per annum (Hosking and Walsh, 2005). This is particularly relevant to the inequalities agenda, since violence is triggered in high propensity people by exposure to a range of adverse social conditions and so investment in inhibiting the development of propensity to violence is of vital importance.

8.2 The 'spiral of decline'

In deprived areas of Scotland, many children's prospects are damaged by an accumulation of risk factors, each one making it increasingly unlikely that the child will be able to fulfil his or her potential in later life. Reducing health inequalities in the long-term means taking an intergenerational perspective, as discussed in the earlier chapters of this document and a broad overview of the costs and benefits of interventions over a number of years.

Figure 8.1 (below), which is taken from the Chief Medical Officer's annual report ( NHS Scotland, 2005), provides a useful illustration of how health, behavioural and social risk factors can combine and negatively impact on child health and wellbeing, potentially requiring a number of different service responses (from a range of agencies). Figure 8.1 also illustrates the importance of intervening at the early stages of a problem's development, or even before the problem is identified (supporting pregnant women to make healthy choices in terms of lifestyle and nutrition during pregnancy, for example) in order to increase the opportunities of the pre-school child.

Figure 8.1: 'Spiral of decline' in the potential of a pre-school child suffering multiple deprivation

Figure 8.1: 'Spiral of decline' in the potential of a pre-school child suffering multiple deprivation

8.3 Costs and outcomes in services for children in need

Services for children depend, and will continue to depend, on a limited supply of resources, so it is vital that available resources are used well. The English Government recently commissioned a programme of research on Costs and Outcomes in Services for Children in Need, in which each of 14 studies included an economic component that attempted to describe the way resources were used, or to link costs to the results achieved. The focus was broader than the early years, but the studies included health visiting, therapeutic family support and Home-Start (see Chapter Four). Findings were drawn together into an overview report, aimed at helping commissioners and managers by illustrating the possible impacts of their decisions to spend money in particular ways (Department for Education and Skills, 2007, summarising Beecham and Sinclair, 2007 10).

The importance of taking a long-term approach to decisions on spending and planning is acknowledged: shifting resources from the small group with the most complex needs to earlier and more integrated intervention is unlikely to save money in the short-term, and may increase pressure on resources as more children in the earlier stages of need are identified.

Based on the 14 studies, the authors conclude that the most rational approach to decision-making is likely to depend on:

  • Understanding the current position:
    • Analysing variations in how local authorities and their partner agencies use resources
    • Undertaking an audit of children and young people in the highest-cost placements
    • Analysing the performance of different services in terms of meeting needs, cost and quality
  • Planning and designing services:
    • Shifting resources from 'heavy-end' higher-cost services that currently absorb most resources and often do not lead to positive outcomes
  • Linking costs and outcomes:
    • Using the resources released to develop the kind of services that currently seem to have the best chances of success ( e.g. services with a clear rationale targeted on 'high risk' children who are at a turning point or transition in their lives (such as birth or first entry to school)
  • Improving information about what works:
    • Actively supporting research and other ways of increasing our knowledge of what works
    • Agencies monitoring and evaluating the impact and cost of services they provide

The summary includes a section on what the research says about what works. Findings from the 14 research studies appear to be consistent with what is already known from evaluations of early intervention services, i.e.:

  • Tightly controlled interventions with a clear rationale tend to have better outcomes than less strictly controlled 'standard' interventions
  • It is easier to improve outcomes with younger children than with older ones

The authors conclude that the evidence base is much stronger for specialist programmes (usually targeted work with vulnerable families - for example intensive home visiting) than on universal family support services which promote general wellbeing (such as Home-Start), although universal services that have been evaluated appear to be both relatively low cost and very well received.

8.4 0-5: How Small Children Make a Big Difference

One recent paper to address the long-term impacts of focusing resources on issues of parenting and care is 0-5: How Small Children make a Big Difference (Sinclair, 2007). The recommendations made by the paper are sweeping and do not seem to be particularly helpful, but the main messages are useful.

Early engagement pays a very high rate of return. Growth modelling on early years investment by the Brooking Institute led to the conclusion that, in the USA 'using reasonable assumptions, we project that GDP would be $988 billion larger within 60 years' (Dickens et al, 2006).

Sinclair's key message is that the most important six years of a person's life are up to the age of five, a position highlighted by the 'spiral of decline' at the start of this chapter. If in the first 3 years of a child's life there is sensitive care, children will feel better in themselves, be more resilient and appreciate other people's feelings. Families and not schools are the major contributors to inequality in student performance. Remedial work for young people from an impoverished environment becomes progressively more costly the later it is attempted.

As yet, no one has modelled the dynamic and complex factors that would affect growth in the UK. However, investment would promote economic growth by creating a more able workforce and, ultimately, reduce the costs borne by criminal justice, health and welfare systems. Sinclair's vision sees costs rising for screening and support services during pregnancy through to parenting and enrichment for children from 0 to 5, and again at 16-18 as more young people stay on at school. However, attainment in education would start improving from primary year one, with children arriving at school with better behaviour, motivation and language.

Cost savings would start to kick in at around age 12, when the first savings would be to the criminal justice system. Health savings would start to be realised in the teenage years, with first pregnancies occurring later and fewer costs associated with drug and alcohol misuse. From 18 onwards, more people would be in work and there would be a fall in the number of young people not in education, employment or training. Tax payments would increase and there would be less demand on benefits.

In the US a series of studies targeted at higher risk families followed up over time have estimated a payback of between 3 and 7 times the original investment by the time the young person reaches the age of 21. The most well known is the Perry Preschool project (see Chapter Six) where groups have been followed up regularly, most recently at 40 years old. The programme measured major benefits to the criminal justice system, health, educational attainment, employment and income levels, reduced dependency on welfare, lower levels of drugs misuse. Programme participants were also more likely to be raising their own children and to be getting along very well with their families. By the time the participants reached the age of 40, the return was estimated to be $17 on each dollar originally spent (Schweinhart, (in press).

8.5 The costs and benefits of early intervention

Analyses of data from the Perry Preschool Project have been widely quoted to argue that early interventions can pay for themselves in terms of reduced costs to society later on. However, it is risky to extrapolate from studies conducted 20 or 30 years ago to those in effect today, considering that the problems of the children served are likely to be more severe and that the definition of particular outcomes may have changed over time. Also, as noted by Currie (2000), the Perry Preschool Project is not representative of average early intervention programmes. To date, most studies of such programmes have not reported measures of costs and benefits.

In addition, cost-benefit calculations are generally sensitive to the assumptions underlying them. For example, since the costs of the programme are borne 'up front' while some of the benefits appear only later (and some may appear much later, as noted above) the rate at which society is willing to trade off future benefits for current benefits (the discount rate) will affect the estimated value of the benefit.

Benefits may appear larger or smaller depending on what is counted in the trade off. For example, benefits due to child care provision may or may not be included. Other categories of benefits that have been included in cost-benefit studies include reductions in criminal activity and welfare use. A complete cost-benefit analysis would consider not only whether all the benefits of a particular programme were greater than its costs, but also whether the benefits of the programme were greater than those of alternative programmes aimed at improving child outcomes.

In order to make accurate cost-benefit calculations, the costs accruing to a number of different agencies need to be included and, in the long-term, a reduction of costs in one sector (for example health or criminal justice) is likely to be offset by higher costs in another (for example education and lifelong learning).

A review of the cost benefit of interventions with parents (London Economics, 2006: http://www.dcsf.gov.uk/research/data/uploadfiles/DCSF-RW008.pdf) focused on interventions targeted directly at parents, with the objective of directly or indirectly affecting child outcomes. Papers from studies undertaken in the last ten years (published and unpublished) were included in the review, as long as they were in the English language and focused on evaluation of interventions, either quantitative or qualitative. Data from the UK were complemented with international evidence (a large proportion of studies considered were US-based).

Key findings and conclusions:

  • Parenting interventions to promote child educational outcomes (Peers Early Education Partnership; Family Learning; Bookstart; Parent-child Home Programme; Home Instruction for Parents of Pre-school Youngsters) show mixed results -
    • There are some positive findings for both parents and children, although specific findings are often difficult to interpret.
    • Findings are further complicated by the lack of rigorous evaluation of many interventions. This also makes it difficult to determine the key elements of different projects, given that all have some positive effects and, therefore, it is difficult to compare between them.
    • There are few examinations of the costs and benefits of these programmes, and so many caveats hedge the evaluations that have taken place that it is difficult to take useful messages from them
    • However, some interventions in this area are very low cost. Both Bookstart and Family Learning are cheap to run and, consequently, the benefit-cost ratio is likely to be positive
      • Home visitation interventions (Home-Start; Nurse-Family Partnership; Healthy Families America; Parents as Teachers) show some benefits, although effects across a range of child outcomes are likely to be modest -
    • Several programmes have found positive results in some measures of parenting behaviour and attitudes although, overall, the evidence on effects from home visitation programmes is mixed. Several measures rely on maternal self-reporting, which limits the reliability of the findings
    • Few economic evaluations of home visitation services exist, although those that do are generally positive. However, there have been three different cost-benefit analyses of the Nurse-Family Partnership programme and the indications are that the programme is most effective when serving high-risk individuals (a return of $5.70 per dollar) although the programme would have been cost-effective even if aimed only at the low risk sample, with a cost-benefit ratio of $1.26 (Karoly et al., 1998)
    • Little cost-benefit analysis exists within the UK. One study showed that an intensive home visitation programme could be cost-effective compared with a standard home-visiting service. In addition, a survey of primary school parents provided some evidence that society values the reduction of child maltreatment more than the associated costs. This provides support for the continuation of home visitation and other programmes aiming to achieve this (Barlow et al, 2007b). This study is also one of the 14 included in Beecham and Sinclair, 2007 - discussed earlier in this chapter
      • Parent training interventions (Incredible Years; Triple P). The majority of evaluations of parent training programmes assess the ability of programmes to address child behavioural problems (such as conduct disorder) -
    • There is increasingly strong evidence that parent training produces positive results in addressing child conduct disorder, including both children who already have behaviour problems and those at high risk of developing difficulties in the future.
    • However, the heterogeneity of the programmes themselves, as well as the evaluation techniques used in the studies, makes comparison of programmes and the identification of key elements of programmes difficult. Problems are further exacerbated by the lack of methodological rigour in many studies.
    • Several studies indicate that parent training can have positive impacts on parents and children. This includes both reviews of multiple evaluations ( e.g. Dretzke et al., 2004) and randomised controlled trials of individual studies ( e.g. Hutchings et al., 2002). The majority of studies remain US-based, but recent evaluations have indicated that benefits from parent training can also be achieved in the UK, based around the Incredible Years programme. While there are methodological problems with some of these studies, the majority of reviews are able to draw positive conclusions (Dimond and Hyde, 1999).
  • Positive effects are not limited to child outcomes, with impacts also found on a range of other outcomes, including parental depression (Hutchings et al., 2007), maternal anxiety, self-esteem and relationship with the mother's partner (Barlow et al., 2003) and parenting behaviour (Lundahl et al., 2006).
  • Evidence showing that there are benefits to parent training is supported by the existing cost-effectiveness analysis, although the extent of the analysis remains limited due to the lack of studies examining the long-term effectiveness of parenting programmes.
  • While it appears that the cost of parent training is low, further evidence of the long-term monetary benefits is needed. However, the long-term benefits of any parenting programme would only have to be small to make the very small investments in parenting programmes efficient.
  • Analysis of the change in service costs over a six-month period suggests that a parent training programme will not pay for itself in the short-run. The implementation of the Incredible Years programme in Sure Start centres in Wales (see Chapter Five) found a net cost to the intervention group of £1,992. Cost effectiveness analysis showed that the programme was more effective for children with more severe problems (Edwards et al., 2007b)

Summary: what do we know about the costs and benefits of early intervention?

  • A long-term approach to decisions on spending and service planning needs to be taken if resources are to be shifted towards intervention earlier in life and earlier in the development of problems for high risk children
  • The evidence base is stronger for specialist, targeted services than for universal family support services although, when evaluated, the latter have appear to be both relatively low cost and well received
  • It is easier to improve outcomes for younger children - and remedial work for young people becomes progressively more costly the later it is attempted
  • Early engagement pays a high rate of return. High quality longitudinal research of an innovative preschool initiative from the US indicates major benefits to the criminal justice system, health, education, employment and income levels and a return of $17 dollars for every dollar spent by the time participants reached the age of 40
  • However, it is risky to extrapolate from studies conducted 20 or 30 years ago (and outwith the UK). The problems of the children served are likely to be more severe and the definition of particular outcomes may have changed over time
  • No one has yet modelled the dynamic and complex factors that would affect growth in the UK if greater investment was made in the early years.
  • Evidence on the effectiveness of parenting interventions which focus on improving educational outcomes for children is inconclusive and further complicated by lack of rigorous evaluation of many interventions, and few examinations of costs and benefits. However interventions in this area may be low cost and so the benefit-cost ratio is likely to be positive
  • Home visitation interventions show some benefits, although effects across a range of child outcomes are likely to be modest. However, cost-benefit analyses of the Nurse-Family Partnership indicate that the programme is most effective when serving high-risk individuals and would be cost-effective even if aimed only at low-risk families
  • There is strong evidence that parent training produces positive results in addressing child conduct disorder, although it is difficult to identify the key elements of programmes which achieve better outcomes for children
  • Several studies (including recent evaluations of the Incredible Years programme in the UK) indicate that parent training can have positive impacts on both parents and children
  • The cost of parent training is relatively low and the long-term benefits of parenting programmes need only be small to justify the investment

8.6 Creating and fostering non-violence in society

8.6.1 The WAVE Trust

Violent crime is increasing in western society. In 2001, it was estimated to cost the UK more than £21 billion per annum and only a tiny fraction of this is spent on prevention. As noted by Hosking and Walsh (2005), violence is triggered in high-propensity people by social factors such as unemployment, poor housing, overcrowding, economic inequality, declining moral values and stress, and alcohol plays a significant role in the timing of violence. Since these factors reflect long-term trends that are difficult to reverse, investment in reducing the number of people with propensity to violence is a strategic imperative.

The WAVE Trust (Worldwide Alternatives to Violence) was formed to identify and disseminate best practices for creating and fostering non-violence in society, through a soundly-researched understanding of the root causes of violence. In 2005, the Trust published results from an eight year study of the root causes of violence (Hosking and Walsh, 2005). Main findings included the following:

  • The propensity to violence develops primarily from wrong treatment before the age of three
  • The structure of the developing infant human brain is a crucial factor in the creation (or not) of violent tendencies, because early patterns are established not only psychologically but at the physiological level of brain formation
  • Empathy is the single greatest inhibitor of the development of propensity to violence. Empathy fails to develop when parents or prime carers fail to attune with their infants. Absence of such parental attunement combined with harsh discipline is a recipe for violent, antisocial offspring
  • The single most effective way to stop producing people with the propensity to violence is to ensure infants are reared in an environment that fosters their development of empathy. The surest way to achieve this is by supporting parents in development attunement with their infants
  • WAVE's search for global best practice in prevention of violence identified many effective early interventions. These include programmes which develop attunement and empathy in tomorrow's parents while they are still in school; current parents; parents-to-be
  • Just a tiny fraction of the cost of violence in the UK is spent on prevention, and most of what is spent focuses on the least effective age groups ( e.g. 5-15). Early intervention (0-3) is fruitful and cost effective. Negative cycles can be transformed and children given the opportunity to grow into contributing, personally fulfilled adults (and future parents)

8.6.2 Rand Corporation economic evaluations

The authors of the WAVE report note that several studies in the US and Canada have looked at the cost-effectiveness or cost-benefit of approaches to reducing violent crime. Most of these studies were carried out more than 10 years ago, and little detail is included about them in the report, but more information is provided about work carried out by the RAND Corporation (Greenwood et al., 1996). This studied the comparative cost-effectiveness of five approaches to reducing serious crime, including prison and training for parents of 5-7 year olds. The evaluation took a narrow view of the financial benefits of parent training, putting no financial value on the prevention of child abuse (which it did not treat as a crime) and ignoring benefits other than crime reduction ( e.g. better educational achievements, employment history, emotional development and mental health).

Even with this restricted view, parent training emerged as highly cost-effective for preventing serious crime: £4,000 per serious crime prevented, compared with £9,000 for both teenage supervision and prison. Since parent training has more impact when carried out well before children reach the age of five, earlier training may be expected to compare still more favourably.

8.6.3 Key interventions to reduce violence or the root causes of violence

In the course of the research for the WAVE report, over 400 interventions that might reduce violence, or the root causes of violence, were examined. However, most have not been evaluated, meaning their effectiveness cannot be objectively determined.

From the evaluation process, four programmes stood out as being of particular interest. They combined three qualities:

  • They addressed the core issues of developing both empathy and attunement
  • They intervened at optimum times (ideally before the birth of the first child)
  • They had research evidence to support their effectiveness.

The four programmes were:

  • Nurse-Family Partnership (supporting first time parents from pregnancy onwards)
  • PIPPIN (preparing parents-to-be during the first pregnancy)
  • The Circle of Security (a programme to increase sensitivity between parents and children)
  • Roots of Empathy ( ROE) (preparing parents-to-be while still children)

The first two of these have been discussed in Chapter Two (and the Nurse-Family Partnership earlier in this chapter).

8.6.4 Nurse-Family Partnership

The Nurse-Family Partnership topped WAVE's evaluation system, and was also recommended by the Sure Start review, "Blueprints" by the US-based Centre for the Study and Prevention of Violence, Support from the Start (Sutton et al., 2004) and "A guide to promising approaches, second edition," (2005), Communities that Care.

The RAND economic evaluation of the programme showed savings (reduced welfare and criminal justice expenditures and increased tax revenues) exceeding programme costs by a factor of four over the life of the child. The original investment was returned well before the child's fourth birthday; from then until age 15 the scheme was delivering net economic benefits to society - in addition to lower crime, much reduced child abuse and conduct disorder, and more successful life outcomes for mothers and children (Karoly et al., 1998).

8.6.5 PIPPIN

PIPPIN is well known and highly regarded by several senior directors of children's charities in the UK. It has been recommended by the Health Select Committee Report ( HMSO, 1997), the Expert Committee for the European Regional Council of the World Federation for Mental Health, and is recommended by the Sure Start Guide to Evidence Based Practice, Trailblazer Edition (Sure Start, 1999). However, the WAVE report does not quote any specific evidence relating to the costs and benefits of the programme.

8.6.6 Circle of Security

The programme is a 20-week, group-based, parent educational and psychotherapeutic intervention designed to shift patterns of care-giving interactions in high-risk, caregiver-child pairs. Support between meetings is provided by teachers and family service coordinators. High-risk families are originally identified and assessed by a university-based assessment team and Circle of Security therapists. The programme is designed to:

  • Decrease risk factors among families who demonstrate disordered attachment patterns, and who show potential for resilience and the capacity to change
  • Enhance caregiver observational skills, functioning and empathy
  • Facilitate caregivers' ability to create more secure attachments with their children
  • Foster understanding and community support related to attachment issues of high-risk families

It appears from the references in the WAVE report that the programme is relatively recent, and it appears to be confined to the US at present. There is also no mention of any economic evaluation of the programme to date. However, early findings suggest that the intervention has:

  • Increased ordered child and caregiver strategies
  • Increased secure caregiver strategies
  • Increased secure child attachment
  • Increased caregiver affection, sensitivity, delight and support for exploration
  • Decreased caregiver rejection, neglect, flat affect and role reversal

8.6.7 Roots of Empathy

Roots of Empathy ( ROE) is a widely applied and evaluated parenting programme for children aged 3-14 (not yet delivered within the UK). Its goal is to break the intergenerational cycle of violence and poor parenting. The WAVE research was particularly interested in ROE because of the ways in which it prepares schoolchildren for parenthood. It emphasises, models and provides literal hands-on experience of how to handle and interact with a real-life baby.

In a classroom setting, children share in 9 monthly visits with a neighbourhood parent, infant, and trained ROE instructor. The instructors conduct 18 further visits without the family. Babies are aged 2-4 months at the beginning of the intervention and about 1 year at the conclusion, a period of enormous growth and development. Over this time, the students learn to see and feel things as others see and feel them, and understand how babies develop. They become attached to 'their' baby and observe the infant's development, learning about its needs and interacting with it. The programme also links to the school academic curriculum: students use maths skills to measure, weigh and chart the development of the baby, and write and read stories and poems that tap and help them relate to their own emotions.

A number of projects have evaluated the ROE programme. Findings indicate that ROE children (relative to comparison children) demonstrated significant improvements from pre-test to post-test in the following areas:

  • Increased emotional knowledge
  • Increased social understanding
  • Increased pro-social behaviour with peers
  • Decreased aggression with peers
  • Decreased proactive aggression ( e.g. bullying)

WAVE carried out an in-depth review of ROE and was highly impressed with the findings. The report does not discuss issues of transferability, although the Canadian-based initiative is now being piloted in Australia and Japan. The WAVE report does not include any findings relating to cost-benefit analysis of the ROE programme.

8.6.8 Recommendations of the WAVE report

The WAVE report recommended that:

  • Adoption of these recommended programmes by local communities should be encouraged under the umbrella of Sure Start, with adequate funding made available to support them
  • Government funds should be ring fenced under a new 'Early Prevention Initiative' and allocated to local authorities and primary care trusts willing to run pilot studies of a list of approved early prevention programmes
  • Specific pilot studies of the four front-running programmes should be funded.

Weblink to the WAVE report: http://www.wavetrust.org/index.htm?http://www.wavetrust.org/WAVE_Reports/index.htm

Summary: what do we know about creating and fostering non-violence in society?

  • Violence costs the UK more than £21 billion per annum. A tiny fraction of this is spent on prevention, and most of what is spent focuses on the least effective age groups ( e.g. 5-15)
  • Violence is triggered in high-propensity people by social factors such as unemployment, poor housing, overcrowding, economic inequality, declining moral values and stress. Alcohol plays a significant role in the timing of violence
  • The propensity to violence develops primarily from wrong treatment before the age of three
  • Early interventions (0-3) are fruitful and cost effective. Negative cycles can be transformed and children given the opportunity to grow into contributing, personally fulfilled adults (and future parents)
  • The structure of the developing infant human brain is a crucial factor in the creation (or not) of violent tendencies
  • Empathy is the single greatest inhibitor of the development of propensity to violence. Empathy fails to develop when prime carers fail to attune with their infants
  • Parent training has evaluated as highly cost-effective for preventing serious crime: £4,000 per serious crime prevented, compared with £9,000 for both teenage supervision and prison. Training carried out before children reach the age of five may be expected to compare still more favourably
  • The WAVE Trust examined over 400 interventions that might reduce violence, or the root causes of violence. The Trust identified 4 programmes as being of particular interest because of their focus on addressing core issues of empathy; intervening before the birth of the child; having research evidence to support their effectiveness. The programmes were:
    • the Nurse-Family Partnership (supporting first time parents from pregnancy onwards)
    • PIPPIN (preparing parents-to-be during the first pregnancy)
    • The Circle of Security (a programme to increase sensitivity between parents and children)
    • Roots of Empathy (preparing parents-to-be while they are still children)
  • The WAVE report recommended that adoption of the above programmes should be encouraged under the umbrella of Sure Start, and supported by new, ring fenced funding, with resources invested in specific pilot studies of the 4 front-running programmes