Interventions to reduce inequalities in health and early child development in Europe from a qualitative perspective

A key requirement for healthy early child development (ECD) is a secure relationship with a primary caregiver [1, 2]. Resilience is the capacity to thrive in adverse circumstances [3] and families provide the most important relationships and nurturing environments for enhancing it [4]. Many families that face daily challenges due to their socioeconomic circumstances are not able to create the necessary nurturing environments for their children [4, 5]. Social protection policies, access to appropriate services and sufficient income help families provide a protective environment that fosters children’s resilience [6, 7]. Lifelong inequalities start before birth and accumulate across the lifecourse [8]. An analysis of inequalities across cohorts from 12 European countries, which also forms part of the Drivers project [9], illustrated intergenerational transmission of inequity; poor health was greater amongst children of mothers with low education. Longitudinal birth cohort studies such as these provide data which can help monitor health inequalities and the impact of early years interventions. The Growing Up in Scotland longitudinal birth cohort commissioned by the Scottish Government showed that at age 4, differences in child health outcomes were less evident than those in risk factors. However, negative outcomes may become more apparent in later life [10].

Interrupting intergenerational transmission of inequalities is an important consideration [11]. Early years interventions, designed to reduce inequalities in health and development and their social determinants, may address these [12, 13]. This can be achieved by focusing on actions which give all children the best start in life and are delivered with intensity proportionate to the social needs of children and their families [14–16]. Ensuring the best start in life for children can be fostered by improving outcomes in the different domains of early child development, namely; cognitive, communication and language, social and emotional and physical [5, 17–19]. Interventions are commonly aimed at children, their parents or both. A systematic review of early years interventions carried out within Drivers [18], found that the majority of interventions identified were targeted at reducing social inequalities of children living in deprived areas but not at levelling the social gradient in health [8]. The objective of this study was to identify early years interventions in different European country contexts and assess their effectiveness in reducing inequalities in health and development through action on the social determinants of health [20, 21]. To achieve the study objective, five early years case studies were selected from a number of proposals - using pre-set criteria (see Methods section) - and in-depth investigations were carried out to identify the efficacy, reach and impact on parenting and developmental outcomes of the interventions represented by the studies.

The study formed part of the DRIVERS Project [4, 22] - a three-year research project funded by the European Union 7th Framework Programme - which focused on three of the key drivers to reduce health inequities: early childhood development, fair employment and working conditions, and welfare, income and social protection. It assessed the impact of policies and programmes and provided policy recommendations and advocacy guidance to reduce health inequalities within Europe. Research was a collaborative effort carried out with non-academic institutions: not-for-profit organisations and agencies across Europe. The project was co-ordinated by EuroHealthNet and Eurochild, partnership organisations focussing on health equity and child well-being within Europe.

Information obtained from interviews and focus groups is provided below in response to questions explored during data collection. The results have been structured following the topics listed in the interview guide. The information within each topic has been grouped according to an emerging outline with the following themes listed below as section headings.

This study illustrates early years initiatives delivered in Romania, Hungary, Austria and in the UK. Ensuring a sufficient range of countries to reflect the different contexts in Europe was one of the selection criteria for interventions included in this study. This was accomplished to reflect qualitative evidence of early years interventions carried out in countries which were not represented in published literature [23]. Respondents from these countries described interventions being delivered within a context of insufficient children’s social and health service provision. These were delivered, in part, to bridge the gap of insufficient services to families mostly from disadvantaged backgrounds. Programmes provided activities to stimulate children’s learning through structured play and provided support and assistance for parents. In these, parents were actively involved in activities and respondents referred to long-lasting trust based relationships between staff and parents as one of the basis for the success of these programmes. These were open to the community; however, activities had a special focus on children and families with disadvantages, with the exception of the universal health visitor programme, which targeted the entire population.

Programmes included in the study were aimed at improving child development during early childhood before children entered preschool. Programmes aimed to involve parents in structured play related activities together with providing them with counselling, parenting classes and support. Evaluation studies published elsewhere [26] showed that Let’s Play in Tandem, a compensatory education programme which also involved parents and structured play, improved results tests of academic knowledge, receptive vocabulary, inhibitory control and school readiness. Strengthening parenting abilities helped them assist in their children’s learning and development. Interventions involved learning through play and were flexible to ensure parents’ participation. In like manner, The Incredible Years programme [27] which focuses on children’s social and emotional development involved parents and was delivered through play. It encouraged involvement to promote positive management skills and self - regulation. Other previous studies illustrated ways in which parenting activities delivered across income groups [8, 11] were not limited to cognitive gains, but also included physical, social, and emotional gains, all of which are determinants of health over the life course [12, 23, 28–30]. However, while focusing on parenting is important, it is also necessary to address the conditions of daily life which make positive parenting difficult. This requires policies aimed at children through an explicit, multi-dimensional and integrated strategy [15] and investment in reducing child poverty and improved living conditions [28, 29].

Our findings, concur with previous studies which described that an important aspect of early years programmes is establishing quality relationships between the deliverer and the recipient as well as ensuring that the recipients receive programmes relevant to their needs As described by the majority of staff, delivering an intervention - aimed at young children and their parents - effectively, entails recognising the knowledge and capacities of parents and involving them in the programme as key agents. Similarly, a qualitative evaluation carried out on the Healthy Schools programme showed that parental engagement was viewed by staff as a key factor [30]. The Childhood Development Initiative-Early Years care and education programme provided home visits and activities for parents based on their specific needs. Children receiving the service scored higher in rating scales and the Parents Plus Community Course improved children’s home learning environment [31]. Further studies found that providing a range of different levels of intensity according to need and tailoring to parents’ necessities and circumstances showed favourable outcomes in child behaviour. It also reduced abusive parenting styles, an example of this is the Positive Parenting Programme delivered in the UK and in Scotland [7, 31].

Programmes within this study were delivered by staff from different disciplines, some such as Netzwerk Familie were provided by a network of multidisciplinary professionals. A comprehensive range of services with the potential to improve child development were delivered by staff with different backgrounds. An previous study showed that Sure Start in the UK also collaborated with existing services and showed a multidisciplinary approach [32].

Beneficiaries referred to fear of being judged as a barrier as well as some reluctance towards the programmes. In addition, insufficient capacity and resources limited the number of children, families and/or mother attending the centres. The exception to this consensus was the health visitor programme in Hungary. Staff and parents put forward different views, while both groups agreed that limited available resources and space were a barrier, staff identified parents’ reluctance to attend some services and parents highlighted a bureaucratic approach by staff. Funding was described as a very important obstacle by staff working in programmes which were not funded by the government. Stigmatisation of users and/or showing some mistrust towards service providers and programmes may be common - particularly within a prevailing culture of low levels of service provision. Furthermore, the gap in service provision was accompanied in some areas by a reduced use of existing infrastructures and lack of intersectoral collaboration. Staff referred to knowledge, expertise and experience within the team as key enablers. Similarly, CDI Early Years, a child care and education programme which provides support to families living in an area of disadvantage is delivered by specialised staff. This was described as one of its pivotal elements [30]. Providing parents with support to engage with local area amenities and services and other families was also described by staff as an enabler for ensuring positive and less stressful parenting styles. Providing support in early stages helped ensure these were maintained. The Preparing for Life home-visiting programme, provided parents with support and showed positive outcomes: at 24 months children in the high treatment group showed stronger cognitive development and problem-solving skills. They showed fewer problem behaviours such as dysregulation, sleep problems, or clinically significant levels of internalising and externalising problems [12]. Likewise, establishing links with other local services and with the community has been described elsewhere as a key point for successful programme delivery [33]. As further studies showed, programmes which create bonds with the family home and establish links between it, the community, schools and other multiple stakeholders, present opportunities for multidisciplinary working and synergies for the delivery of child services [12].

Staff and users gave very similar accounts across programmes through their experiences, parents expressed a high level of satisfaction. This could be due to the fact that parents, who were facing adverse and very challenging circumstances, showed gratitude toward the provision of services which may have alleviated their situation and provided support. This could be reinforced with positive relationships with the staff who listened and did not judge, according to parents. Furthermore, parents were described by staff and themselves as being very overburdened. They may have avoided appearing overly critical or ungrateful with the programme fearing it may have led to discontinuing to receive services. In a similar way, staff who were aware of the limited services in their areas and the high level of disadvantage of families, may have seen any possible limitations of programmes as issues which could be improved rather than outright negative features.

Parents referred to feeling supported by non-judgmental staff. This could possibly be a key enabler not only for programme delivery but for other factors which were described in the interviews and focus groups as facilitating elements for successful delivery of programmes. These were establishing long lasting and trust based relationships, overcoming the fear of being judged as bad parents, being stigmatised or being referred to social services.

Based on the accounts of both parents and staff, the establishment of a long term trust based relationships is a key enabler in the delivery of programmes and services, especially to socially isolated or hard to reach families and children. Programmes described by staff as being successful in providing support and building on parent’s capacities, delivered services that adapted to the needs and circumstances of parents and their children providing activities carried out by teams which included social service workers, doctors, and staff with early years training. Adapting to and understanding the families’ circumstances and involving parents was seen by staff as necessary to contribute to empowering parents and developing their own skills and in turn assist in their children’s learning. According to staff, this also had a positive effect on children.

It is important to provide access to a comprehensive range of quality early year services to reduce inequalities during the early development of children, especially for those from disadvantaged backgrounds. Services should be tailored to social and economic need. It is important to recognise the knowledge and capacities of parents if interventions aimed at young children and their parents are to be delivered effectively and sustained over time. To ensure that parents have an active involvement in early years programmes, they should be empowered and receive support and information to understand and contribute to the optimal development of their children. Existing ECD institutions and structures should be strengthened to promote working between the social, education and health sectors. The recognition, representation and funding of ECD in all areas of work and policy should be enhanced through high-level leadership. This includes promoting support for children who are deprived or vulnerable. Programmes delivered in families’ homes and in accessible centres should be evaluated so as to compare outcomes when using one or other of these settings or a combination of the two.