Babies and bathwater: valuing the early years

A recent evaluation in Glasgow and a systemic review and meta-analysis of Triple P more generally indicate that the long-term effectiveness of the programme is unclear.  This is concerning given the millions of pounds which have been invested in the programme.  All the more so, given the lack of investment in health visiting, which provides a universally trusted and vital service to all families in the early years.

The Positive Parenting Programme (Triple P) is a multi-level behavioural family intervention which has in recent years been proposed and used on a whole-population basis as a 'public health' intervention in addition to its use on a more targeted basis. The public health model involves a stepped approach with interventions ranging from mass media campaigns to highly targeted intensive group work with parents.

Triple P was created by Matthew R. Sanders and colleagues at the University of Queensland in Australia and evolved from a small 'home-based, individually administered training programme for parents of disruptive preschool children' into a comprehensive preventive whole-population intervention programme. Triple P is one of the central components in the newly published National Parenting Strategy for Scotland and a multi-million pound positive parenting initiative is currently running in Glasgow.

In 2009 NHS Greater Glasgow and Clyde launched the Parenting Support Framework (PSF) for Glasgow. A key part of the PSF was 'Triple P' with the University of Glasgow commissioned to conduct an independent evaluation. The year one evaluation report has just been released. This explores the first 18 months of the programme in Glasgow, and provides baseline data about social, emotional and behavioural difficulties experienced by children in Glasgow.

Within the first 18 months 894 staff within Glasgow City were been trained to offer Triple P and 12,818 parents in Glasgow City had attended a group or seminar (an intervention) or received  a fact sheet or a phone call from a health visitor (a single intervention).

Of the 995 participants who attended a group:

• 72.8% were from the most deprived areas in Glasgow, suggesting the programme is reaching some of the most vulnerable families
• Most people attending groups were mothers (66.9%), with 12.2% being fathers
• Most children of participants lived with both natural parents (62.2%) or in lone parent families (27%)
• Just 23.1% of parents were in any employment

Of those attending groups:

• Most were happy with their Triple P experience (the average satisfaction score was 6 out of a maximum of 7)
• If measures were completed, all scores had improved to some extent
• Numbers of parenting problems decreased from 7.5 to 5.7
• Parental depression, anxiety and stress scores all showed improvements

However completion of interventions and data measures was poor. Less than half of parents completed a group intervention (46.8%), and of those, less than half filled in the questionnaires. This means that it is not clear to what extent the changes seen are 'true' for all participants.

Improved data collection in the future alongside planned qualitative work, should provide clearer evidence on whether Triple P is right for the population of Glasgow City.

However, there are concerns that it may not be right and may not justify the millions of pounds being invested in the programme.  A research team involving the universities of Aberdeen, Glasgow and Gothenburg conducted a systematic review and meta-analysis of 33 English language studies which have assessed the outcomes of Triple P programmes.  This indicates that, as a result of the methods most commonly used to determine the success of Triple P, long-term outcomes are impossible to assess.  This does not mean that the programme does not work, but that there is no clear evidence that it does, other than being better than nothing. But there is not nothing.  There is a universal health visiting service which is in crisis through lack of investment.  The study concludes that, given the substantial cost implications of Triple P, health commissioners should apply to parenting programmes the standards used in assessing pharmaceutical interventions. The results are published in the journal BMC Medicine.

The fact that the evidence of long-term effectiveness is limited is a concern, particularly for Glasgow which has invested heavily in Triple P but not in its ever-diminishing health visiting service which is vital to the early years.  Parents and families highly value the role of health visitors as the professional group in contact with all families with children.

In an article for the PAS collection of essays on parenting Wendy Mitchell and Phil Wilson argue that health visitors are universally accepted, and vital to supporting new parents, strengthening child health and intervening effectively in the early years

A recent PAS round table on the importance of health visiting to the early years explored the issues and concluded that the forthcoming Children and Young People Bill is an opportunity to reaffirm Scotland's commitment to health visiting as a vital preventative service in the early years.

A joint briefing from the Royal College of Nursing (RCN) Scotland, PAS and other agencies issued after the round table sets out the main concerns and comments that, given the age profile of the current workforce and a lack of nurses coming forward to train as health visitors, the profession will become unsustainable unless action is taken now to attract and train new entrants.  It also recommends that the Children and Young People Bill should 'prioritise prevention at a time when health visitors on the ground are experiencing a high degree of pressure to focus on complex child protection cases. We […] believe that enshrining children's rights to early years support from health visiting within the Bill is the only way to ensure that universal preventative care is provided at a time of financial constraint.'

Clare Simpson, PAS project manager, said, 'Health visitors are vital to the health of Scotland's children. If we want to make Scotland the best place in the world to grow up, investing in health visiting is a must.'