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HealthylivesEarlyyears

April2016

ThisworkisfundedbytheHealthFoundationandproducedbyC3CollaboratingforHealth.TheHealthFoundationisanindependentcharitycommittedtobringingaboutbetterhealthandhealthcarefor

peopleintheUnitedKingdom.

1.Executivesummary.......................................................................................................................................2

2.Introduction..................................................................................................................................................4

3.Thebigissues–thecurrentposition............................................................................................................4

3.1Thefirstthousanddays...........................................................................................................................4

3.2Infantmortality.......................................................................................................................................5

3.3Maternalandfamilyrelationships..........................................................................................................6

3.4Earlyyearsandlifestylebehaviour..........................................................................................................6

4.Whatworksandwhatdoesn’t......................................................................................................................9

4.1Introduction.............................................................................................................................................9

4.2Research-basedevidence........................................................................................................................9

4.3Whatishappeninginpractice?Practice-basedevidence.....................................................................10

4.4Doweknowwhatworksandwhatdoesn’t?........................................................................................14

5.Challengesandgaps....................................................................................................................................14

6.Talkingpoints..............................................................................................................................................16

Annex1:Keyplayers.......................................................................................................................................17

Annex2:Evidencetables................................................................................................................................18

Table1:Summariesoftheevidencebaseforearlyyearsinterventions....................................................18

Table2:Smoking–systematicreviews.......................................................................................................19

Table3:Dietandobesity–systematicreviews..........................................................................................20

Table4:Parenting–systematicreviews.....................................................................................................21

References.......................................................................................................................................................22

2 EarlyYearsbriefingpaper www.c3health.org

1.ExecutivesummaryTheaimofthispaper(seesection2)istoprovidebackgroundinformationandanoverviewofcurrentevidencearoundfactorsaffectingthehealthandwellbeingofchildrenunderfive,setinthecontextofthreethemesfromtheMarmotReviewFairSociety,HealthyLives,namely:giveeverychildthebeststartinlife;enableallchildren,youngpeopleandadultstomaximisetheircapacitiesandhavecontrolovertheirlives;andstrengthentheroleandimpactofill-healthprevention.Liketheotherpapersinthisseries(onChildrenandYoungPeople,WorkplaceHealthandCommunities),itisarapidreview,notafull-scalesystematicreviewoftheliterature.

Section3reviewsthebackgroundandcurrentposition.WhilethehealthofUKchildreninmanyrespectshasimprovedoverthelastfewyears,progressdoesnotcomparefavourablywithsimilarcountriesinnorthandwestEurope.Thereisincreasingevidencethatthemostcriticalperiodinlifeisthefirstthousanddays–fromconceptiontoagetwo.Duringthisearlyperiod,developmentisverysensitivetodisruptionbyenvironmentalinfluences(suchasmaternalobesity,gestationaldiabetes,poornutritionandexposuretoenvironmentalpollutantssuchastobaccosmoke,toxins,heavymetalsandairbornemicroparticles).Thesecanaffectthegrowthandmaturationofvitalorgansandtheprogrammingofkeyphysiologicalandbiochemicalprocesses,andthereforeimpactonhealthlaterinlife.Thispaperhighlightstheimportanceofaddressingthedeleteriousimpactoftheseenvironmentalfactorsbyinterveningearly,includingbeforeconception–exposurecanimpactontheoffspringofpotentialfathersaswellasmothers.Neonatalmortalityisoneexampleofapotentiallypreventableoutcome,themainriskfactorsbeingpretermdeliveryandlowbirthweight.Otherpossibleadverseoutcomes,suchasanincreasedriskofdevelopingtype2diabetes,cardiovasculardiseaseorcancer,maynotbeevidentforsomeyears,andtheriskscanbedecreasedbyappropriateinterventionsduringchildhood,adolescenceandadulthood–butidentificationofthoseathighriskandearlyinterventionaimedatpreventionofadverseeffectsisthebestapproach.

TherearesomealarmingstatisticsrelatingtohealthbehavioursofUKchildrenunderfive–forexample,highlevelsofsugarintakeandinsufficientphysicalactivity,whichresultintoothdecayandoverweight/obesity.Ratesofhospitaladmissionsofchildrenunderfivewithricketshavebeenontherisesincethebeginningofthiscentury;sofar,numbersofchildrenaffectedaresmall,butitisunacceptablethatthisdisease,whichisentirelypreventable,isfoundintheUnitedKingdominthe21stcentury.Itissignificantthatthesecasesoccurmainlyinchildrenfromdisadvantagedfamiliesandthisisjustoneexampleofthestrikinginequalitiesinhealthacrossthecountry-childrenlivinginthemostdeprivedareasaresignificantlymorelikelytohavepoorhealthandloweracademicachievementthantheirmoreaffluentpeers.Oneimportantmitigatingfactoristhequalityofmaternalandfamilyrelationships–accordingtotheWorldHealthOrganization,‘Warmandresponsivecaregivingisnowknowntoextendsomeprotectiontochildreninotherwiseadversesituations.’

Thereisageneralconsensusthatearlyinterventiontoprevent/addressanundesirableoutcomeisthemosteffectivewaytogivechildrentheopportunitytoleadhealthierlivesintoadulthood.Insection4theevidencebasearoundsomerelevantinterventionsispresented.Theyvaryfromlegislationtocounselling,motivationalinterviewing,useofinternet/socialmediaandeducational/self-helpmaterials.Thereisavarietyoftargets(individuals,families,teachers,healthprofessionals)andlocations(thehome,school,healthcaresettings,thecommunity)–orcombinationsthereof.Onthebasisofthesystematicreviewslistedinsection4.2theresearch-basedevidenceismixedandatbestreportedmodestpositiveoutcomes,althoughitisarguedthatthismayhaveasignificantimpactatthepopulationlevel.Multicomponentinterventionsseemedtobemoreeffectivethanthosewithsinglecomponents.Themethodologyisdifficultandseveralreviewauthorscommentedonpoorstudydesign,smallsamplesizeandshortduration.

Insection4.3anumberofcasesaredescribedthathavebeenintroducedinpracticeandevaluated(orhaveongoingevaluationplanned).TheyincludeSureStartandtheFamilyNursePartnership,whichhaveinvolvedsignificantinvestmentonthepartofgovernment,onthebasisofpositivebenefitsfordisadvantagedchildrenthathavebeendemonstratedinothercountries;sofar,theevaluationsindicatelesspositiveimpactintheUnitedKingdom,suggestingthatinterventionsmayneedtobespecificallytailoredtothenationalorlocalcircumstances.Examplesofmorefocusedinterventionsimplementedbylocalauthoritiesarealsodescribed,withsomeinitiallypositiveresults,butwhetherthesearesustainableinthelongertermisuncertain.Thesecasestudiesillustratethechallenges/difficultiesinknowingwhathas


workedandwhathasn’t,andoftensufferfromthefactthattheyarefundedforaspecifictimeandarevulnerabletoeconomictrendsandthatthecontinuouslychanginglandscapemakesevaluationdifficult.Inanattempttounravelthis,theDepartmentforEducationhassetupSEED–StudyofEarlyEducationandDevelopment–whichisfollowingthousandsofEnglishchildrenfromagetwothroughtotheirearlyyearsatschool.Thefindingscanbefollowedoverthenextfewyears.

Therefore,addressingthefirstMarmotprinciple–giveeverychildthebeststartinlife–ischallengingandthebestplacetostartispreconceptionandthefirstthousanddaysoflife,followedbythepreschoolyears,asdiscussedinsection5.When,whereandhowtointerveneisnotclear,despitealltheeffortsfromresearchersandpractitionerstoascertainareliableevidencebase.Whatisclearisthatallyoungchildrenneedhigh-qualitycareandeducation,withsupportfortheirparents/carersthatissensitivetosocialandculturaldifferences,andthatpoliticiansandpolicymakersmustbeconvincedoftheresultingeconomicbenefits.


2.IntroductionThisaimofthisbriefingpaperistoprovidebackgroundinformationandanoverviewofcurrentevidencearoundfactorsaffectingthehealthandwellbeingofchildrenfrom0–5,togetherwithexamplesofinterventionsdesignedtopreventoraddresshealth-detractingbehaviours.Afurther,complementaryreportinthisseriesexploresthehealthandwellbeingofchildrenandyoungpeoplefromages5–19.BothpapersarepresentedaspartofthewiderHealthyLivesprogramme,whichalsolooksatcommunityandworkplacehealth.

ThepaperparticularlyhighlightsissuestoaddressthreeofthethemesintheMarmotReview,FairSociety,HealthyLives(Marmot2010):

• giveeverychildthebeststartinlife;

• enableallchildren,youngpeopleandadultstomaximisetheircapabilitiesandhavecontrolovertheirlives;and

• strengthentheroleandimpactofill-healthprevention.

3.Thebigissues–thecurrentpositionWhiletherehavebeenconsiderableimprovementsinchildhealthworldwide,therearestillanumberofareasthatarecausingconcernintheUnitedKingdom,oneofwhichishowpoorlytheUKfaresinhealthandwellbeingleaguetableswhencomparedwithotheraffluentcountries,particularlyinEurope.Thissectionhighlightstheimportanceofthefirstthousanddaysoflife(conceptiontoagetwo),maternalandfamilyrelationshipsandotherlifestyleandenvironmentalfactorsthatareofparticularconcernforthehealthofchildrenunderfive.ItalsohighlightsthepartthatsocialdisadvantageappearstoplayinhealthinequalitiesintheUnitedKingdom,anditsimpactoninfants.

3.1ThefirstthousanddaysNHSChoices(PregnancyandBabyCare)(NHSChoices2016b)providesextensiveadviceonhealthandlifestylefactorsforpregnantwomenandmothersofinfantsandyoungchildrentohelpthemgivetheirchildthebeststartinlife–includinghealthydietsforpregnantwomen,theharmsmokingandalcoholcancausetheunbornbaby,andbreastfeeding.However,theimportanceofthefirstthousanddaysoflife,startingwithconception,isnotwidelyrecognised,despitetheincreasingbodyofresearchshowingthatearlydevelopment(theperiodfromconception–andthereforepreconception–toagetwo)isverysensitivetodisruptionbyenvironmentalinfluencesthataffecttheriskofdevelopingnon-communicablediseases(NCDs)inlaterlife(Wadhwaetal.2009;HansonandGluckman2014).ThisrelativelynewareaofresearchisknownasDOHaD(DevelopmentalOriginsofHealthandDisease)andthereisevidencethattheriskofdevelopingNCDsinlaterlifecanbepassedontofuturegenerationsthroughtheprocessofepigenetics.

‘Barker’shypothesis’emergedintheearly1980s‘fromepidemiologicalstudiesofbirthanddeathrecordsthatrevealedahighgeographiccorrelationbetweenratesofinfantmortalityandcertainclassesoflateradultdeathsaswellasanassociationbetweenbirthweightandratesofadultdeathfromischemicheartdisease’(Wadhwaetal.2009).TheseobservationsledtothetheorythatundernutritionduringpregnancyprogrammesthemetabolismofthedevelopingfoetusandthatthiscanleadtoanincreasedriskofdevelopingNCDsinlaterlife.Anumberofotherfactorscandisruptearlydevelopment,includingmaternalobesity,infantoverfeedingwithformulaproducts,pretermbirth,gestationaldiabetesandexposuretotobaccosmoke,toxinsandpollutantssuchasheavymetalsandairbornemicroparticles(HansonandGluckman2014).Exposuretoharmfulenvironmentalfactorscanaffectdevelopmentofvitalorgans(includingtheheartandbrain)andtheprogrammingofbiochemicalandphysiologicalprocesses(forexample,theimmunesystemandthesatietyresponse),whichhaveimpactsonhealththroughoutlaterlife.

TheimpactofairpollutionishighlightedinarecentreportfromtheRoyalCollegeofPhysiciansandtheRoyalCollegeofPaediatricsandChildHealth,EveryBreathWeTake:theLifelongImpactofAirPollution(RCP/RCPCH2016).Damagecanstartfromconceptionandparticularlyvulnerabletimesaregestation,


infancyandearlychildhoodwhentheyoungbodyisgrowinganddevelopingrapidly.Themostvulnerablearethosewholiveindeprivedareasthathavepoorhousingandindoorairqualitywithlimitedaccesstogreenspace,andthosewhospendsignificanttimenearbusyroads.Thereisalsosomeevidencethattheseenvironmentalfactorscanaffecttheepigeneticgenomeofthespermofpotentialfathers,andhencethedevelopmentoftheiroffspring(Soubry2015).

In2004,theInternationalSocietyforDevelopmentalOriginsofHealthandDiseasewassetuptopromotemultidisciplinaryresearchinthisarea.AwhitepaperpublishedinthejournalEnvironmentalHealth(Baroukietal.2012)concludedthattheDOHaDevidencewasrobustenoughtojustifyfutureinvestmentinresearchanddisease-preventionstrategiesthataretargetedattheperiodofearlylife,includinggestation.ArecentsupplementinReproductiveHealthwasdevotedtopreconceptioncareandhighlightstheimportanceofnutritionaladviceforwomenofchild-bearingage,particularlyadolescents(Deanetal.2014)andtheneedforbetterunderstandingofthepossibleadverseeffectsofsubstanceabuseonfuturepregnancies(Lassietal.2014).

Followingthis,theUK’sNationalChildbirthTrustprogramme,TheFirstThousandDays(NCT2016),wassetup;itseekstoeducateandsupportparentsfrompregnancythroughtoeducationofyoungchildren.NCTisalsocarryingoutamajorstudytofindoutwhatlifeislikefortoday’sparentsinthefirstthousanddays.

Thelinkbetweenearlydevelopmentandhealthinlaterlifehasledtotheargumentthat‘ifweactearlywecanpreventharm’(BertramandPascal2014).Thisreportstressedthatamixofuniversalandtargetedinterventionsisthebestwayforward.Thisisparticularlyimportantinthecaseofpreterminfants,whoaremoresusceptiblethanchildrenbornattermtoabnormalitiesthataffecttheirfuturehealthandwellbeing,suchasmotordevelopment,behaviourandschoolperformance(Moreiraetal.2014).

3.2InfantmortalityA2014reportfortheRoyalCollegeofPaediatricsandChildHealth(Wolfeetal.2014)showedasteadyandcontinuingdeclineininfantmortalityratesover30years,yetin2012morethan3,000babiesdiedintheUnitedKingdombeforetheirfirstbirthdayand523childrendiedbetweentheagesofoneandfour.ThereviewhighlightsthattheUnitedKingdomperformspoorlyonseveralmeasuresofchildhealthandwellbeing,includingmortality,withstarkdifferencesinsurvivalbetweenrichandpoor–andconcludesthatmanychildren’sdeathsarepotentiallypreventable(estimatessuggestthat21percentinvolvemodifiablefactors).

Infantmortalitycanbedividedintoneonatalmortality(deathsupto27daysafterlivebirth),andpost-neonatalmortality(deathsfrom28daysto12months).IntheUnitedKingdom,themajorityofinfantdeathsoccurintheneonatalperiod,andthemaininfluencesarepretermdeliveryandlowbirthweight;riskfactorsincludematernalage(mothersunder20andover35beingthemostvulnerable),smokinganddisadvantagedcircumstances.Injuriesarethemostfrequentcauseofdeathafterthefirstyearoflife(Wolfeetal.2014).

Internationalcomparisonsofinfantmortalitycanbedifficultbecauseofdifferencesindefinitionsandcollectionofdata.However,latestfiguresshowthattheUK’sinfantmortalityrateof3.8per1,000livebirthsin2013isfalling,butisstillbehindmanyotherEuropeancountries,withFinlandandIcelandthelowestat1.8(OECD2016).DatafromtheEuropeanPerinatalHealthReport(citedinWolfeetal.2014),basedonharmoniseddefinitionsanddata,showthatneonataldeathsforbabiesbornat24weeksormoreare0.8per1000livebirthsinIcelandcomparedwith2.0inEnglandandWales,2.1inScotlandand3.0inNorthernIreland.Romaniahasthehighestrateat4.3.Thereportarguesthatmorechildrensurviveincountrieswherewealthissharedmoreequitablythanthosethathavewidegapsbetweentheveryrichandtheverypoorandconcludethat‘socialandeconomicinequalitiesaremattersoflifeanddeathforchildren’.

AmongitsrecommendationstheWolfereportcallsformorerobustactiononsmokingcessationinpregnancy,researchtostrengthentheevidence-baseforchildmortality,withaparticularfocusonbetterunderstandingthecausesofprematurityandlowbirthweight,andenhancedpromotionofbreastfeeding.


3.3MaternalandfamilyrelationshipsTheimportanceofmaternalandfamilyrelationshipswasstressedinaWorldHealthOrganizationreviewoftheoriesandevidenceontheroleofcaregiver–childrelationshipsinthesurvivalandhealthydevelopmentofchildren(WHO2004).Itfoundthatthose‘whosecareisdisturbedordistortedinsomeway,areatriskofnotreceivingsufficientnutrition,beingsubjectedtostress,notgrowingwell,notbeingpsychologicallystimulatedandofdevelopingmalnutrition.Warmandresponsivecaregivingisnowknowntoextendsomeprotectiontochildreninotherwiseadversesituations.’Accordingtothereport,thisistrueforchildrenworldwide,althoughitrecognisesthatmostresearchinthisareahasbeencarriedoutindevelopedcountries.Itstressestheextenttowhichpoverty–themostimportantexacerbatingfactorinchilddevelopment–placesstressontherelationshipwithinfamilies,includingbetweenmotherandchild.Otheradversechildhoodexperiences(ACEs),suchasthedeathofaparent,separation/divorce,andphysicalorsexualabusecanalsohavenegativeeffectsonhealthandwellbeinglaterinlife(Sacksetal.2014;Hughesetal.2016)(seetheChildrenandYoungPeoplepaperinthisseries,section3.7).

Thequalityoftheparents’relationshipimpactsonchildren’sbehaviourproblemsatagesthreeandfive,accordingtoapaperbasedontheUKMillenniumCohortStudy(KiernanandGarriga2014).Theseresearchersfoundthatawarmrelationshipwiththemotherdidnotreducethedetrimentaleffectofapoorrelationshipbetweenparents,andthatmaternalconflictexacerbatedit.Theeffectofthequalityoftheparents’relationshipwasstrongestamongstchildrenfrompoorerfamilies.

Usingdatafromthesamecohort,economicdeprivationand/ormaternaldepressionhasbeenshowntoreducethecognitiveandemotionalwellbeingofchildren;thisisattributable,atleastinpart,tolessnurturingandengagedparenting(KiernanandHuerta2008).Areviewdiscussingtheevidenceforassociationsbetweenparentalmentaldisordersandoffspringoutcomes,fromfoetaldevelopmenttoadolescence,concludedthatsomeofthefactorsunderlyingtransmissionofdisturbance,suchasqualityofparenting,arepotentiallymodifiable(Steinetal.2014).Mostoftheinterventionsreviewedinthatstudyareaboutmaternaldepressionandprovidesupportforthepropositionthatemphasisshouldbeonbothtreatingtheparent'sdisorderandhelpingwithassociatedcaregivingdifficulties.Thestudyunderlinestheneedforearlyidentificationofparentsathighriskandformoreearlyinterventionsandpreventionresearch,especiallyinsocioeconomicallydisadvantagedpopulationsandlow-incomecountries.

3.4Earlyyearsandlifestylebehaviour

3.4.1.Diet,exerciseandobesity

TheWorldHealthOrganizationGlobalStrategyonDiet,PhysicalActivityandHealth,whichwasadoptedbytheWorldHealthAssemblyin2004,highlightschildhoodobesityasoneofthemostseriouspublic-healthchallengesofthe21stcenturybecauseoverweightandobesityinchildhoodarelikelytocontinueinadulthoodandleadtoanincreasedriskofdevelopingnon-communicableconditionssuchascardiovasculardiseaseanddiabetesatarelativelyyoungage(WHO2004).TheWHO’sCommissiononEndingChildhoodObesity(ECHO)reportedin2016,emphasisingthatmanychildrenaregrowingupinanobesogenicenvironmentthatresultsinenergyimbalancefromacombinationofahigh-energydiet(encouragedbytheaccessibilityandmarketingofhigh-caloriefoods)andasedentarylifestyle.Thereportconcludedthatnosingleinterventioncanhalttheriseofthegrowingobesityepidemicandthatthereneedtobeeffectivestrategiestoaddresstheobesogenicenvironment,bearinginmindtheeffectsatcriticalstagesinthelifecourse(i.e.preconception/pregnancy,infancy/earlyyearsandchildhood/adolescence)(WHO2016).

Riskfactorsforoverweight/obesityarepoordietandlackofexercise,andNHSChoicesprovidesextensiveadviceandrecommendationsforahealthydiet(NHSChoices2016b)andphysicalactivitylevels(NHSChoices2016a)forpregnantwomenandchildrenunderfive.Theimportanceofahealthydietinpregnancy–withplentyoffruitandvegetablesandavoidinganexcessofsugaryandhigh-fatfoods–ishighlighted,andthereisadviceontakingsupplementssuchasvitaminDandfolicacid.Thereisalsoinformationonbreastfeeding,expressingbreastmilkandbottlefeeding.


TheNHSrecommendsthatinfantsareexclusivelybreastfedforatleastsixmonthsandthenbreastfeedingiscontinuedforanothersixmonthswhileotherfoodsareintroduced.However,theresultsofaninternationalsurveyofbreastfeedingreportedinTheLancetfoundthatonly34percentofUKwomenbreastfeedforsixmonths,andonly0.5percentcontinuetobreastfeedfor12months(Victoraetal.2016).Thiscomparesbadlywithotherhigh-incomecountries–forexample,inNorway35percentofwomencontinuetobreastfeedfor12months,whileinlow-incomecountriessuchasIndiathefigureisover90percent.Theauthorsalsodescribedevidenceforthehealthbenefitsofbreastfeedingbothtothemother(itprotectsagainstbreastcancer,andpossiblyalsoovariancancer)andchild(itprotectsagainstinfectionandmayalsodecreasetheriskofobesityanddevelopingdiabetes).Theyconcludedbypointingoutthatprotection,promotionandsupportofbreastfeedingisdirectlyrelevanttoGoals2(improvenutrition)and3(ensurehealthylivesandpromotewellbeingforallatallages)oftheSustainableDevelopmentGoals(UN2015).

Recognisingtheimportanceofnutritionfortheunder-fives,since2015thegovernmenthasprovided189mloffreemilkadayforchildrenattendingapprovedday-carefacilitiesfortwohoursormore(NurseryMilkScheme2015).

Latestfigures(PHE2016a)showthat9percentofchildrenenteringreceptionclassesatage4–5areoverweightorobeseand,althoughtherearesignsthatchildhood-obesitylevelsarelevellingoff(vanJaarsveldandGulliford2014),PublicHealthEnglandhaswarnedthatthereisnoroomforcomplacencybecauseobesityratescontinuetoriseamongthemostdeprivedchildren.Theconsequencesofobesityarenotjustaconcerninlaterlife–obesityisdamagingforyoungchildren,withdiagnosisoftype2diabetesinchildrenasyoungasseven,andincreasedrisksofasthma,sleepdisturbance,mental-healthdisordersandmusculoskeletalproblems(PHE2016b).Riskfactorsforoverweight/obesityarepoordietandlackofexercise,andNHSChoicesprovidesextensiveadviceandrecommendationsforahealthydiet(NHSChoices2016b)andphysical-activitylevels(NHSChoices2016a)forchildrenunderfive.

ExcesssugarintakeisaparticularissuethatwasrecentlyreviewedbytheScientificAdvisoryCommitteeonNutrition(SACN2015a).Inlightoftheavailableevidence,theCommitteerecommendednew,lowerlevelsofsugarintake;freesugarsshouldmakeupnomorethan5percentofdailyenergyintakeforeveryoneovertwoyearsold,andchildrenaged4–6shouldnotconsumemorethan19g(orfivesugarcubes)aday,whichwouldruleoutmanypopularfizzydrinksandjuices.The‘obesogenic’environmentthatpromoteshighlevelsofsugarintakeisdiscussedfurtherinsection3.2.3ofthebriefingpaperonChildrenandYoungPeopleinthisseries.

Lackofphysicalactivityisalsoanissueofconcern(BHF2015);only9percentofchildrenaged2–4inEnglandmeettherecommendationsofthreehoursofphysicalactivityaday,and84percentareactiveforlessthanonehourperday.Negativeeffectsonweight,cognitivedevelopmentandpsychosocialhealthareassociatedwithhighlevelsofscreentime,andthisisinfluencedbythetimefamiliesasawholespendwatchingscreens.Screenuseinchildrenunderthreeisalsolinkedtonegativehealthoutcomes,includingincreasedBMI,decreasedcognitiveandlanguagedevelopmentandreducedacademicsuccessaccordingtoasystematicreview(Duchetal.2013).68percentoftheseunder-threesusescreenmedia(suchastelevision,DVDsandvideogames)onadailybasisandthereisevidencethathighlevelsofsedentarybehaviourinearlylifetendtocontinuethroughoutchildhood.

Astudyinvolving87teachersoffour-tosix-year-oldpreschoolchildrenfromsixEuropeancountries(deDeckeretal.2013)foundthatteachersperceiveshortageofspaceasoneofthemainreasonsforlackofphysicalactivity,andreportthatchildreninthisagegroupspendmoretimeoncomputersthanwatchingtelevision.Theauthorsrecommendinterventionsthatraiseteachers’awarenessandsupporttheminfindingwaysofenablingchildrentobemorephysicallyactive.

3.4.2Toothdecay

Thefirstnationalsurveyoftheoralhealthofthree-year-oldchildreninEnglandwaspublishedinSeptember2014(PHE2014).Itfoundthat12percentofthechildrensurveyedhaddentaldecayand,whilethismeantthatalargemajorityhadentirelyhealthyteeth,thewidevariationsacrossthecountrywascauseforconcern–from2percentinsomeareasto34percentinothers.Onaverage,childrenaffectedhadthreedecayedteeth.PublicHealthEnglandisencouragingparentsandcarersofyoungchildrentotake


stepsthatwillhelppreventtoothdecayinthisagegroup,stressingthatwithoutlifestylechangesthereisamuchhigherchanceofdecayinpermanentadultteeth.AndtheSACNreport(SACN2015a)oncarbohydratesandhealthincludedareviewofstudiesshowingalinkbetweenintakeofsugarinchildren’sdietsanddentalcaries–hencetherecommendationthatchildrenaged4–6shouldnotconsumemorethan19gofsugaraday(seesection3.4.1).

3.4.3Rickets

Rickets–aconditionthataffectsbonedevelopmentininfantsandchildrenbecauseofinadequatevitaminDorcalciumintake–ispreventableandvirtuallydisappearedfromthewesternworldduringthe20thcentury.ItisthereforealarmingthatinEnglandhospitaladmissionratesforricketsarenowontheincrease,withchildrenunderfivethemostlikelytobeaffected(Goldacreetal.2014).Rateswerelowinthe1960sand1970s,fallingfurtherinthe1980sand1990s.Prevalencestartedtoriseagainin2000–ariseseeninthewhitepopulationbutmorecommoninthenon-whitepopulation;itisarguedthatthereisacaseforanationalconfidentialauditofrickets.

VitaminDcanbemadebyourbodiesifthereissufficientsunlight;however,intheUnitedKingdom,particularlyinwinter,adequatelevelscanonlybeachievedinmostpeoplebyensuringthatthediethassufficientnaturalvitaminorbytakingsupplements.ThereisincreasingevidencethatvitaminDmayplayaroleinmanybiologicalprocesses,includingbraindevelopmentandfunctioningoftheimmuneandcardiovascularsystems,butadraftreportonvitaminDandhealthbySACN(2015b)concludedthatitseffectonmusculoskeletaloutcomesshouldbeabasisforsettingnewrecommendationsforvitaminDintake.Thisdrafthasbeenoutforconsultationandtheresponsesarecurrentlybeinganalysed.CurrentrecommendationsforvitaminDintakeforpregnantwomenandtheirbabiescanbefoundonNHSChoices(NHSChoices2016c).

3.4.4Healthinequalities

Therearestrikingvariationsacrossthecountryinhealth,cognitivebehaviourandwellbeingofchildrenunderfive.TheNationalChildren’sBureauobservesthat‘simplybygrowingupinacertainpartofEnglandachildismorelikelytohavepoorhealththatwillimpacttherestoftheirlives’(NCB2015).ItusesthelatestpublisheddataforEnglandtoanalysevariationinfourkeyoutcomesforchildren’shealthanddevelopmentintheearlyyears:obesityinfour-tofive-year-olds;toothdecayinfive-year-olds;hospitaladmissionduetoinjuryintheunder-fives;andchildrenachievingagoodlevelofdevelopmentbytheendofreception.ComparisonsaremadeacrossEnglishlocalauthoritiesandregionsusingtheIndicesofMultipleDeprivationtoassessthelinkbetweentheextentofdeprivationinalocalauthorityareaandearly-yearshealthanddevelopmentoutcomes.

Comparingthe30mostdeprivedlocalauthoritieswiththe30mostaffluent,thereportfindsthatchildrenunderfiveinpoorareasaresignificantlymorepronetoobesity,toothdecay,accidentalinjuriesandlowereducationaldevelopment.Forexample:

• reception-agechildreninBarkingandDagenhamareovertwoandahalftimesmorelikelytobeobesethanachildofthesameageinRichmonduponThames,only18milesaway;

• afive-year-oldinLeicesterisoverfivetimesmorelikelytohavetoothdecaythanachildofthesameageinWestSussex;and

• youngchildrenontheIsleofWightareoverfourtimesmorelikelytobeadmittedtohospitalwithaninjurythantheircounterpartsinWestminster.

Aliteraturereviewofearlyyears(BertramandPascal2014)revealedthegrowingextentofchildpoverty,inequalityandsocialimmobilityandthewideningextentandnatureofearlychildhoodinequality,bothintheUnitedKingdomandinternationally.TheauthorssaytheirfindingschimewellwithMarmot’searly-yearsrecommendations,namelytheneedto:

• reduceinequalitiesintheearlydevelopmentofphysicalandemotionalhealth,andcognitive,linguisticandsocialskills;


• ensurehigh-qualitymaternityservices,parentingprogrammes,childcareandearly-yearseducationtomeetneedacrossthesocialgradient;and

• buildtheresilienceandwellbeingofyoungchildrenacrossthesocialgradient.

Aswellashighlightingthedeprivationattributedtopoverty,thereviewexaminedtheethnicityandgendergapsinearlyeducationalachievement,concludingthatworking-classboys,regardlessofethnicity,arelikelytobeoneofthemostdeprivedgroups.

4.Whatworksandwhatdoesn’t4.1IntroductionThereisageneralconsensusamongresearchersthatearlyinterventiontoprevent/addressanundesirableoutcomeisthemosteffectivewaytogivechildrentheopportunitytoleadhealthierlivesintoadulthood(BertramandPascal2014;EarlyInterventionFoundation2015;HansonandGluckman2014;Steinetal.2014;Wadhwaetal.2009;Wolfeetal.2014).Targetsforinterventionincludethechild,themother’shealthduringpregnancy,thefamilysetting,thelocalenvironmentincludingpreschool,andthenationalcontext/governmentpolicies.Outcomemeasuresincludevariousaspectsofchilddevelopment,parentingasassessedthroughinteractionbetweentheparentandchild,andthedevelopmentofknowledgeandskillsofparents,carersandteachers.TheEarlyYearsLiteratureReview(BertramandPascal2014)pointsoutthat,whilethereislittledoubtthatearlyinterventioncancontributetocombatingeducationalandhealthdisadvantages,thedesignofinterventionsandtheapproachtoservicedeliveryiscrucialtosuccess.Theyreportthatthemosteffectiveareearly,intensive,multisystemapproachesthatincludeeducationandtheinvolvementoftrainedprofessionalsasacoreactivity.

AreviewofsixmajorEuropeanstudies(Inskipetal.2014)proposedthatearlyinterventionshouldstartbeforeconception.Theauthorsconsideredthatawoman'seducationhasastronginfluenceonherownandherchildren'shealthbehavioursandthatpsychologicalbarriersareimportantcontributorstoapoordietandlackofexercise.Theysuggestthatagoodwaytostartimprovingtheeducationofwomenofchild-bearingageisschool-basedinterventionsaimedatadolescents.

4.2Research-basedevidenceThereisanenormousresearchliteraturereportingonevidenceoftheeffectivenessofawholerangeofinterventionsdesignedtoimprovetheprospectsofahealthylifeforinfantsandyoungchildren.DocumentspublishedbyPublicHealthEngland(PHE2015),theEarlyInterventionFoundation(EarlyInterventionFoundation2015),andtheLocalGovernmentAssociationandNationalFoundationforEducationalResearch(EastonandGee2012)provideinformationabouttheevidencebaseunderpinningavarietyofprogrammesavailableintheUK(Annex2:Table1).

Annex2:Table2givessomeexamplesofrecentsystematicreviewsthatpresentanalysesoftheresearch-basedevidenceforavarietyofinterventionstargetedatpregnancy/earlychildhood.Thesearejustasmallfraction,notnecessarilyrepresentative,oftheavailableliterature,buttheydogivesomeideaoftheissuesassociatedwiththistypeofresearch.Theinterventionsrangefromlegislation(thesmokingban)tocounselling,motivationalinterviewing,useofinternetandsocialmedia,andeducational/self-helpmaterials.Someinterventionsaretargetedatindividuals,othersatfamilies,teachersorhealthprofessionals,andlocationscanbeinthehome,school,health-caresettingsorthecommunity,oracombinationthereof.Outcomemeasuresalsovarywidely,includingmeasurementsofchilddevelopment,diet,physicalactivityandparentingskills.

Themethodologyisdifficultandthestudydesignsvaryfromrandomisedcontrolledtrials(RCTs),throughquasi-experimentaldesigns,toqualitativeresearchandassessment.Severalauthorsquestionedthequalityofthestudiestheyreviewed;particularissueshighlightedweresmallsamplesize,shortdurationandgeneralpoorstudydesign.AlthoughRCTsareconsideredtobethe‘goldstandard’indrugtrials,their


applicationtolifestyleinterventionsisdifficultbecausethereisamultitudeofconfoundingfactorsandtoallowfortheseadequatelyrequiresverylargenumbersofparticipants.

Acrosstheseexamplestherewererelativelyfewinstancesofanythingmorethanmodestpositiveoutcomes,thoughseveralauthorscommentedthatmulticomponentinterventionsweremoreeffectivethansinglecomponents.Furthermore,itisnotevencleartowhatextentsmoke-freelegislationhasplayedapartinreductionsinpretermbirths(seeAnnex2:Table2).

4.3Whatishappeninginpractice?Practice-basedevidenceTheevidencebaseforpublic-healthinterventionshastraditionallyreliedonfindingsfromempiricalstudies/research-basedevidencesuchasthoselistedinsection4.2.However,arecentsystematicreview(NganddeColombani2015)highlightedtheimportanceofconsidering‘practice-basedevidence’andproposedthatsuccessfulinterventionsshouldmeetmostofthefollowingcriteria:relevance,communityparticipation,stakeholdercollaboration,ethicalsoundness,replicability,effectiveness,efficiencyandsustainability.Inaddition,evenifthereisverygoodevidencethataparticularinterventioniseffective,policymakersandlocalcommissionersincreasinglywantevidenceoftheextentofpotentialcostsavingsonimplementation(EastonandGee2012).

Thissectionhighlightssomecasestudiesofinterventionsthathavebeen/arebeingimplementedandevaluated.

4.3.1Examplesofnational,multicomponentprogrammes

TheUKgovernmenthasrecognisedtheneedtoprovidechildrenunderfivewiththebeststartinlifeandhassetupanumberofstudiesandprogrammestoachievethis.Aslongagoas1998theBlairGovernmentsetuptheSureStartprogramme,mainlyacrossEnglandbutwithslightlydifferentversionsinScotland,WalesandNorthernIreland.Theaimwastoestablishlocalcentresindisadvantagedareaswherehelpandadvicewouldbeavailabletoparentsofyoungchildrenand,insomecases,provideearlylearninganddaycareforpre-schoolchildren.Originallythenetworkoflocalprojectswasfundedcentrally,butcontrolofchildren’scentresmovedtolocalauthoritiesin2005.Evaluationisongoing,carriedoutbytheNationalEvaluationofSureStart(NESS)teamatBirkbeckCollege,London.

TheeffectivenessofSureStarthasbeencontroversialwithlittleinthewayofpositiveoutcomesreportedinitially,buttheNESSevaluation(NESS2010)demonstratedsignificantpositiveeffectsforeightof21outcomeswhenover7,000disadvantagedfamiliesandtheirfive-year-oldswhohadbeeninvolvedinSureStartLocalProgrammeswerecomparedwithsimilarfamiliesinareaswhereSureStartwasnotavailable.AmongtheSureStartchildrentherewasevidenceoflowerBMIandbetterphysicalhealth;mothers/familiesreportedmorestimulatingandlesschaotichomeenvironments,lessharshdiscipline,andgreaterlifesatisfaction.However,significantlymoremothersinSureStartareasreporteddepressivesymptomsandparentsintheseareaswerelesslikelytovisitschoolsforplannedmeetings.Afurtherevaluationwhenchildrenreachedsevenyearsold(NESS2012)compared15outcomesrelevanttochildandfamilyfunctioninginover5,000familiesrecruitedfrom150SureStartareaswithsimilarfamiliesoutsideaSureStartarea.Therewasasignificanteffectonmothers,whoreportedthatasaresultofSureStarttheywereprovidingamorestimulatinghomelearningenvironmentandengaginginlessharshdiscipline;significantlymorereportedalesschaotichomeenvironmentforboys(forgirlsthiswasnotsignificant)andsingleparentsandworklesshouseholdsreportedbetterlifesatisfaction.

TheNESSteampointsoutthatonmostoutcomesnodifferencewasfoundandthatmostoftheimprovementsaffectedparentsandfamiliesratherthanchildren,andthattherearemethodologicalchallengesassociatedwithlonger-termfollow-up.However,theysuggestthatthevalueofSureStartchildren’scentresisimproving,althoughgreateremphasisneedstobegiventofocusingservicesonimprovingchildoutcomes,particularlylanguagedevelopment,ifschoolreadinessistobeenhancedforthechildrenserved.

TheEducationCommitteeoftheHouseofCommonsconsideredevidencefortheeffectivenessofSureStartcentres.Itsreportconcludedthatthesecentresarepopularandwellused,butthereisalackofclarityintheirpurpose.Thereport(HouseofCommonsEducationCommittee2013)recommendedareviewof


thecorepurposeofSureStartcentresandconsiderationofatripartitemodelwiththreetypesofcentre,offeringdifferentlevelsofservice:fullcentres,basedaroundnurseryschools;centresthatarepartofschools;andfamilycentres.Localauthoritiesmustbemoreaccountablefortheperformanceofthesecentres.However,thecoalitiongovernmentdidnotagreethatthecorepurposewasinneedofreview(HouseofCommonsEducationCommittee2014).

Thefuture/evolutionofSureStarthasbeenamatterofdebatebysuccessivegovernmentssinceitslaunchin1998.Abriefingpaper(BateandFoster2015)thatsummarisesthehistoryofSureStartcentresinEnglandconcludedbynotingtherecommendationsinapre-electionreportfromtheAllParliamentaryGrouponSureStartChildren’sCentresthat,whichevergovernmenttookofficeaftertheelection,Children’sCentresshouldbeattheheartoflocalserviceprovision,andthatinJune2015theparliamentaryunder-secretaryofstateforschoolsstatedthattherewouldbeaconsultationtoconsidertheroleofSureStart.

The150localauthoritiesinEnglandhavereceivedfundingtodelivertheParentingEarlyInterventionProgramme(discussedindetailinthebriefingpaperonChildrenandYoungPeople,section4.2.1.3).Thisisweightedtowardsdisadvantagedfamiliesandismadeupofevidence-basedprogrammesthathavebeenimplementedsuccessfullyoutsidetheUnitedKingdom.Threeoftheprogrammes(FamiliesandSchoolsTogether(FAST)andStrengtheningFamilies,StrengtheningCommunities,whichbothoriginatedintheUnitedStates,andPositiveParentingProgram(TripleP),whichoriginatedinAustralia)includechildrenunderfiveandwereshowntobeeffectiveinimprovingoutcomesforparentsandchildren,withtheseoutcomesmaintainedoneyearonfromtheendoftheprogramme.Therewasapositiveeffectonparents’mentalwellbeingandstyleofparenting,aswellasontheirchildren’sbehaviour(Lindsayetal.2011).

TheFamilyNursePartnership(FNP)isbasedonanotherprogrammethathasbeensuccessfullyimplementedintheUnitedStates.Itisahome-visitingprogrammeaimedathelpingfirst-timemothersaged19orundertohaveahealthypregnancy,improvetheirchild’shealthanddevelopment,plantheirownfuturesandachievetheiraspirations.Aspeciallytrainedfamilynursevisitstheyoungwomanregularly,fromtheearlystagesofpregnancyuntilherchildistwo.Usingapsycho-educationalapproachandafocusonpositivebehaviourchange,FNPprovidesintensivesupportformothersandbabies,aswellasfathersandotherfamilymembersifmotherswouldlikethemtotakepart.

FNPwasintroducedinEnglandin2007andisdeliverednationally(135localauthoritiessignedup)throughtheFNPNationalUnit.ArandomisedcontrolledtrialcommissionedbytheDepartmentofHealth(Roblingetal.2015)foundsomeimprovements,forexampleinearlylanguagedevelopmentat24months,andpossibleprotectionofchildrenfromseriousinjury,abuseandneglect,withsomesmallimprovementinmothers’socialsupport,relationshipqualityandself-efficacy.Thewomenwerepositiveabouttheprogrammeandfeltithadhelpedthemtobegoodparents.Theyespeciallyvaluedthecloseandtrustingrelationshipwiththeirfamilynurse.However,theauthorsconcludedthatFNPdidnothaveanimpactacrossthestudy’sfourmainshort-termoutcomes–prenataltobaccouse,birthweight,subsequentpregnancyby24monthsandA&Eattendancesandhospitaladmissionsinthefirsttwoyearsoflife.ResultswerelesspositivethantrialsoftheUSscheme,whichtheauthorssuggestmaybeexplainedbytheyoungmothersnotbeingasdisadvantagedasthoseintheUStrials,aswellasthehigherlevelsofuniversalandspecialistservicesavailableintheUnitedKingdom.

TwoprogrammesdesignedtoimproveoutcomesforchildrenunderfivehavebeenimplementedandevaluatedintheRepublicofIreland.TheEarlyYearsProgrammeofChildhoodDevelopmentisahigh-quality,two-yearearly-childhoodcareandeducationprogrammerunbytheChildhoodDevelopmentInitiativeinTallaghtWest,anareawithahighproportionoffamiliesdescribedaslivinginpovertyandsupportedbytheIrishDepartmentofChildrenandYouthAffairsandAtlanticPhilanthropies.Anevaluationoftheprogramme(Hayesetal.2013)examinesitseffectsonchildren'scognitive,languageandsocialdevelopment,onparentalstressandthehome-learningenvironment,andonprogrammequality.Thetwo-yearcurriculum-basedinterventioninvolvedapractitioner-to-childratioof1:5,whichismorefavourablethanthenationalcomparisonof1:6orhigherforasimilarservice.Observationofchildren’slearningenabledpractitionerstodevelopchild-centredfollow-upworkplansincollaborationwithparentsduringhomevisits.Nutritiousfood,physicalplayandrecreationopportunitieswereprovided,aswellasspecialist


primaryhealth-caresupportintheareasofdentalhygieneandpsychologicalassessment,withaccesstoadedicatedspeechandlanguagetherapisttosupportchildrenintheirlanguagedevelopment.

Modestbenefitscomparedtoacontrolgroupwereobservedinanumberofareasacrossdifferentelementsoftheintervention.Thestrongestwasinthequalityofthecurriculumandactivitiesprovidedininterventionservices.Intermsofoutcomesforchildren,gainswereindicatedinareassuchasimprovedbehaviourandsocialskills,childattendance,andbetterspeechandlanguageprognosisonentrytoschool.An‘indirect’effectonparentingwasdiscovered,withthequalityofthehome-learningenvironmentbeingpositivelyassociatedwiththenumberofparentsessionsattended,butfurtherfollow-upisneededtodetermineifchildrenandtheirsiblingsarelikelytobenefitinthelongtermfromamorepositivehome-learningenvironment.

TheNationalEarlyYearsAccessInitiative(NEYAI)isathree-yearprogrammeaimedatimprovingqualityandoutcomesinIreland’searly-yearssector.NEYAIcomprises11projectsmainlylocatedindisadvantagedareasofDublin,CorkandLimerickandtworurallocations.ItwasofficiallylaunchedbytheIrishgovernmentinJune2011whenitwasdescribedasbeingmadeupoflocaldemonstrationprojectswith‘afocusonevidence-basedpracticeandongoingprojectevaluationforthepurposeofadvisingfuturepolicyandthemainstreamprovision’.

NEYAIprojectsinvolvedchildrenaged0–6andtheirparents;theyweremultidimensional,operatingacrossmanysites,andcouldincludestafftrainingandmentoring,parentingcourses,familysupportservicesandinteragencycollaborations,acrossmanysites.Thisdiversityofactivityandlackofcommonthemescreatedchallengesforthenationalevaluation(McKeownetal.2014).Toovercomethis,theevaluationfocusedononeage-groupofchildren,namelythoseattendingthe2012/13FreePre-SchoolYear,andcomparedchildoutcomesinNEYAIwiththoseintheSíoltaQualityAssuranceProgramme(SíoltaQAP),whichisa12-stepqualityimprovementprocessforearly-yearscentres.ThereportfoundthatchildrentakingpartinbothNEYAIandSioltaQAPimprovedduringthecourseoftheinterventioninallareascoveredbytheinternationallyusedEarlyDevelopmentInstrument,whichcoversphysicalhealth,socialcompetence,emotionalmaturity,languageandcognitivedevelopment,communicationskillsandgeneralknowledge.However,becausetherewasnocontrolgroupthecontributionmadebyNEYAIorSioltaQAPtotheseimprovementswasunclear.

4.3.2Examplesofmorefocusedinterventionsimplementedbylocalauthorities

Inadditiontonational,multicomponentinitiatives,thereisawholehostofinterventionsbeingdeliveredbylocalauthorities.Someexamplesaredescribedintheboxes.HealthyEarlyYears(HEY),HealthyExerciseNutritionfortheReallyYoung(Henry)andTrimTotsinvolvecoursesforchildrenandtheirparentsaimedataddressingdietandhealthbehaviours.Positiveresultshavebeendemonstratedforall,butmuchlonger-termfollow-upisneededtoseeifthesechangesaresustained.

Inpartnershipwithlocalstakeholders,LambethCouncilhasintroducedamulticomponentprogrammeforpregnantwomen–LEAP(LambethEarlyActionPartnerships).Onecomponent,aimedatpregnantwomenwithaBMIofmorethan25,hashadpositiveeffectsonhealthbehaviours.

Casestudy1:HealthyEarlyYears(HEY)course

HEYisdeliveredbytheCommunityHealthandLearningFoundation,fundedbyDanoneNutricia.Ittakestheformofahealth-literacyinterventionlastingsevenweeks,targetingparentsofchildrenaged1–3wholiveindeprivedcommunities,andcoveringhealthyeating,shoppingonabudgetandcookingfromscratch.Providersaroundthecountryinclude61children’scentresandtwolocalauthorities–LeicestershireCountyCouncilandBuckinghamshireCountyCouncil.

Externalevaluationfindings(SharedIntelligence2015)indicateimprovementinknowledgeabouthealthybehaviours,whichhasledtochangessuchasincreasedfruitandvegetableintakeandinvolvementoftoddlersincooking.


Casestudy2:TheHenryProgramme(HealthyExerciseNutritionfortheReallyYoung)

Thisisaneducationalinterventionthataimstoprotectpre-schoolchildrenfromthephysicalandemotionalconsequencesofobesity,workingwithfamiliesandpractitionersacross32localauthorities.Ittakestheformeitherofaneight-weekcourseforparents/carersor,inthecaseoffamilieswithyoungchildrenathighriskofbecomingobese,one-to-onesessions.

Anevaluation(Willisetal.2013)foundsignificantpositivebenefits,includingbetterworkingrelationshipsbetweenfamiliesandprofessionals,increasedconsumptionoffruitandvegetablesandlowerintakeofsugar,positivechangesinmealtimebehaviourandreducedscreentime.

Casestudy3:TrimTots

Amulticomponentprogrammewithanemphasisonfamilyinvolvementandlearningthroughartandplay,TrimTotsaimstopreventobesityinchildrenaged1–5.The24-weekinterventionisdeliveredasonetwo-hoursessionperweek.Itincludesnutritioneducation,physicalactivityandbehaviour-changecomponentsofferedatchildren’scentresthroughoutthecountry.IthasbeenassessedintworandomisedcontroltrialswiththefindingspublishedinTheLancet(Laniganetal.2013).ThetrialsindicatedfavourableresultsintermsofBMIandwaistcircumference.

Casestudy4:LambethEarlyActionPartnerships(LEAP)

Fundedover10yearsbytheBigLottery,aspartofitsABetterStartprogramme,LEAPsupportsfamiliesfrompregnancyuntilthechildreachestheageoffour,workingwitharangeofstakeholderstoimproveservices.Theprogrammeaddressesthesocial,emotional,communicationandlanguagedevelopmentofbabiesandchildren,andtheirdietandnutrition,aswellasparents’wellbeing,theirsocialnetworksandthestrengthoftheircommunitiesandwiderenvironment.ItincludespeersupportthroughthecreationofParentChampions.

ServingoneofthemostdiversecommunitiesinBritain,theSouthLondoninitiativehastwocurrentprojects–CommunityActivityandNutrition(CAN)andFamilyFoundations–bothofwhichareevidence-basedaccordingtotheLEAPwebsite(LEAP2016).AimedatpregnantwomenwithaBMIofmorethan25,CANofferseightweeklygroupsessionswithahealthtraineraswellassupportingmaterialstoencouragehealthylifestyles.CANwasevaluatedaspartofawidernationalstudy,UPBEAT(UKPregnanciesBetterEatingandActivityTrial).ResultspublishedinTheLancetinvestigatedwhethertheprogrammecouldreducetheincidenceofgestationaldiabetesandlarge-for-gestational-ageinfants(Postonetal.2015).Whiletherewasnoevidenceofanyimpactonthisprimaryelementofthestudy,theprogrammewasfoundtobeeffectiveacrossanumberofoutcomes,includingimproveddiet,increasingphysicalactivity,reducinggestationalweightgain,anddecreasingsurrogatemeasuresofmaternalbodyfatness.Overall,theauthorsconcludethattheinterventiondoesprovideameanstoimprovehealthybehavioursinobesepregnantwomen.

Thesecondliveproject,FamilyFoundations,isacourseforcouplesexpectingtheirfirstbabytogether,currentlybeingpiloted.Interventionbeginsbetweenweeks20and30ofthepregnancyandisaimedatcouplesexpectingtheirfirstbaby,includingsamesex-couplesandsurrogatepregnancies,aswellasthosewithadditionalneedsormild-to-moderatedepressionandanxiety.Seven90-minutesessionsarespreadoverthecourseofsevenweeks,deliveredbytwofamilysupportpractitionerstosmallgroupsofcouples.Amidwifeattendsoneofthepre-birthsessionsandahealthvisitorispresentatoneofthepost-birthsessionsforquestionsandanswers.Thereisabreakofabout10weeksforallthewomentogivebirth,duringwhichtherewillbesocialopportunitiesformembersofthegrouptomeetup.


4.4Doweknowwhatworksandwhatdoesn’t?Thissectionhasgivenasmallinsightintothenumberofdifferentinterventionsthatarebeingimplementedinparallelacrossthecountrytoaddresssomeofthekeyissuesaroundthehealthandwellbeingofchildrenunderfive.Theyallhavean‘evidencebase’but,asdemonstratedbytheFamilyNursePartnership,interventionsthatareeffectiveinonesituationdonotnecessarilygivesuchpositiveresultsinadifferentcontext.Evaluationisdifficult,particularlyifaprojectevolvesovertimeandagainstacontinuallychangingenvironment;therefore,evenwithlongertermfollowitwillbedifficulttoassessthecontributionofinvestmentssuchasSureStart.Furthermore,amajorproblemidentifiedintheEarlyYearsLiteratureReviewisthatmanytargetedprogrammesdonotmeetthecriteriaforqualityandefficiency,andprojectsareoftentemporaryandvulnerabletoeconomictrends.Itconcludesthat:‘Thepolicychallengeistorebuildthecurrentsystemssothattheymeetthecrucialdesignfeatures;providehigh-qualityearlyeducationandcareforallchildren,andoutstandinghealthandsocialcaresupportforparentsandfamilies;areintegrated,attractiveandaffordabletoallfamiliesregardlessofsocialclassorminoritystatus;yet,aresensitivetodifferingneeds,workinginachildandfamily-centredwayandabletocompensateforearlydisadvantages’(BertramandPascal2014).

Inanattempttounravelwhatworksandwhatdoesn’t,theDepartmentforEducationhassetupSEED–StudyofEarlyEducationandDevelopment–tohelpprovideevidenceontheeffectivenessofearly-yearseducationandshort-andlonger-termbenefitsfromitsinvestmentinthisarea.UndertakenbyNatCenSocialResearch,theUniversityofOxford,4ChildrenandFrontierEconomics,itfollowsthousandsofchildrenacrossEnglandfromtheageoftwothroughtotheirearlyyearsatschool.Thelatestreport(Speightetal.2015)providesdescriptivefindingsfromthefirstwaveofthelongitudinalsurveyofparents.Morethan5,600familiestookpartinthebaselinesurveyovertheperiodfromOctober2013toNovember2014.Mostchildrenweretwoyearsoldatthetimeandtheaimofthestudyistosetthescenefortheimpactreportsthatwillbeavailablelaterintheevaluation.Asoneoftheaimsoftheevaluationistoexploretheextenttowhichhigh-qualityearlyyearsprovisioncanimproveoutcomesforchildren,especiallyforthosefromdisadvantagedbackgrounds,familieswerelookedatinthreegroups:disadvantaged;moderatelydisadvantagedandnotdisadvantaged.

Thefindingsgenerallyhighlightcleardifferencesbetweenthesegroupsacrossanumberoffactors.Childrenfrombirthtoagetwofromthemostdisadvantagedfamiliesaretheleastlikelytoreceiveformalchildcareorearlyeducation.However,afterturningtwo,whenthegovernmentsupportbecameavailable,overhalfthechildreninallthreegroupswerereceivingformalchildcare.

Childrenfromthemostdisadvantagedfamilies(andthereforelesslikelytoreceivechildcare)hadsubstantiallylessdevelopedlanguageskillscomparedwiththechildrenfromfamiliesthatweremoderatelydisadvantagedorwerenotdisadvantaged.Withinthesetwogroupstherewasevidencethatthosewhoreceivedchildcarebeforeagetwohadbetterlanguageskillsthantheirpeerswhodidnotexperiencenursery/preschool.

DisadvantagedchildrenwerereportedbytheirparentstobeshowinglesspositivebehaviourontheASBIscaleandmorenegativebehaviour.However,whileearlyformalchildcarewasnotlinkedtolessnegativebehaviour,itwasassociatedwithmorepositivebehaviourinallgroups.

ThenextstageintheSEEDprocessisanimpactanalysisthatwillbeabletodrawondatafromfollowupsurveyswhenthechildrenareagedthreeandfour.Itwillalsoaimtounpickthecomplexityoffactorscontributingtooutcomesforchildrenindifferenteconomiccircumstances.

5.Challengesandgaps5.1IntroductionSomeaspectsofthehealthofUKchildren(suchasinfantmortalityandchildhoodobesity)haveimprovedoverthelastfewyears,althoughthelevelling-offofobesitymasksseriousinequalities.However,therateofprogresshasnotcomparedfavourablywithsimilarcountriesinnorthandwestEurope,andtheincreases


(albeitrelativelysmall)inchildrenunderfivewithtoothdecayandrickets,whicharebotheasytoprevent,areunacceptableinthe21stcentury.Itisalsoclearthatthebiggestburdenofchildhooddiseasefallsonthoselivingindeprivedareas.Politiciansandpolicymakersarewellawareoftheimportanceoftheimportanceofthehealthofmothersandtheirchildrenintheveryearlyyears,asdemonstratedbyvariousinquiresandreportsfromparliamentarySelectCommitteesandgovernmentdepartments(suchasChildhoodObesity–BraveandBoldAction(HouseofCommonsHealthCommittee2015)andPublicHealthEnglandreports(PHE2014and2015).Thechallengeisthattheyalsoneedtoconsiderpoliticalissuesandbeconvincedthatproposedinterventionshavecost–benefitsorarecost-effective.

5.2ThefirstthousanddaysAsdiscussedinsection3.1,thereisincreasingevidencethatthefirstthousanddaysoflife(conceptiontoagetwo–andthereforepreconception)arethemostcriticalbecausedevelopmentduringpregnancyandearlylifeisverysusceptibletoarangeofenvironmentalfactors–forexample,diet,exposuretomicro-organisms,tobaccosmoke,drugsandairpollution.Thechallengeishowtocommunicatetheimportanceofthepreconceptionperiodandfirstthousanddaysandhowthelifestyleofpotentialparentscaninfluencethehealthoftheirchildren.Thismustbeconveyedinasensitiveway–whileparentsbearabigresponsibilityoverthistime,itwouldnotbeconstructiveiftheyendupbearingaburdenofblame.Who,therefore,shouldbetheprimarytarget?Adultsofchildbearingage,families,healthandsocialpractitioners,communityorganisations,policymakers?

5.3ChildrenagedtwotofiveyearsItisimportantthatpreschoolchildrenlearnhealthybehavioursfromthestart,thussettingdownahealthylifestyleforthefuture.Particularareasofconcernarepoordietandsedentarybehaviour(oftenlinkedtothetimespentonscreens).Maternalandfamilyrelationshipsplayacriticalroleduringthisperiod,andchildrenbroughtupinahouseholdbesetwithfamilyconflicthaveanincreasedriskofdevelopinghealthproblems.Thechallengeishowtoengagewithfamiliesatrisk(whichareoften‘hardtoreach’)andsupportthemindevelopingparentingskillsandunderstandinghowlifestylefactorscontributetothehealthoftheirchildren.

5.4Interventions

5.4.1Introduction

Alltheenvironmentalhealth-detractingfactorshighlightedinsection3are,intheoryatleast,potentiallymodifiable.Thereisgeneralconsensusthatearlyinterventionisimportantandthereisanenormousamountofinformationavailableonhealthylifestylesforpregnantwomenandparentsofyoungchildren,butitisnotclearhowmuchthisadviceistakenupandtheimportanceofthepreconceptionperiodtendstobeoverlooked.

Thefindingsfromresearchintointerventionsisconfusingandatbestthereseemtobemodestbenefits,althoughithasbeenarguedevensmallpositiveeffectscanhaveanimpactatpopulationlevel.ThegovernmenthasinvestedsignificantamountsininterventionssuchasSureStartandtheFamilyNursePartnership,whichareaimedatpreschoolchildrenfromdisadvantagedfamilies.Botharebeingevaluatedandsofartheoutcomeshavebeendisappointing,despitethefactthattheywereevidence-basedandthattheFamilyNursePartnershiphadbeensuccessfullyimplementedintheUnitedStates.TheParentingEarlyInterventionProgrammeseemsinitiallytobemorepromising.Onasmallerscalemanylocalauthoritiesofferrelativelyshort-terminterventionssuchastheHENRYprogrammeandtheHealthyEarlyYearsCourse,whichseemtohavepositivebenefitsintheshortterm.Whatisuncertainiswhethertheyhavealong-termimpactandhowsustainabletheyare.

5.4.2Theearlystagesofresearchintointerventions

Asindicatedinsection4.2,therearesomemajorscientificchallengesindemonstratingtheeffectivenessofinterventionstoaddresslifestyleandhealthbehaviours.Theseinclude:


• studydesign–the‘goldstandard’randomisedcontrolledtrialisdifficulttosetupinalifestylesituationandotherdesignsoftensufferfromlackofadequatecontrolgroups;

• difficultiesinrecruitmentandretentionofparticipants,leadingtosmallsamplesizesthatarepronetobias;

• shortdurationofthestudies;

• choiceofoutcomemeasures,whichareoftenproxiesforhealthoutcomes;and

• theeffectofconfoundingfactors(whichmaybeknownorunknown)ontheresults.

Thechallengeforresearchers(andfundersandpublishersofscientificjournals)istoensurethatpreliminaryinterventionresearchisrobust.Thechallengeforthosewhoarelookingforresearch-basedevidencetosupportimplementationofaninterventionistoknowwhattomakeofalltheconfusingandconflictingfindings!Thesechallengesholdtrueforalltheareascoveredinthesebriefingpapers.

5.4.3Implementingandevaluatinginterventionsinpractice

Asindicatedinsection4.3therearemajorchallengesinevaluatinginterventionsthathavebeenimplementedinpractice,andthebenefitsfromsomemajorinvestmentssuchasSureStartandtheFamilyNursePartnership,whichhadpositiveeffectsinothercountries,seemtobelessevidentintheUnitedKingdom.Thissuggeststhat,foreachintervention,thelocalcontext(social,culturalandeconomic)needstobetakenintoaccount.Thechallengeforpolicymakersandpractitionersistoknowhowtoadaptevidence-basedinterventionstotheirlocalsituationandhowtoevaluateimpactinthefaceofacontinuallychangingenvironment,whichincludesparallelrelevantinterventions.

Thereare,therefore,somemajorchallengesinfulfillingthethreeMarmotthemes–togiveeverychildthebeststartinlife,toenableallchildren,youngpeopleandadultstomaximisetheircapacitiesandhavecontrolovertheirlives,andtostrengthentheroleandimpactofill-healthprevention.Inparticular:

• identifyingandengagingwithchildrenandfamiliesatrisk,manyofwhomarelikelytobe‘hardtoreach’;

• findingthebestwaytocommunicatethemessageoftheimportanceofthefirstthousanddaysoflife;

• identifyingthemostappropriatewaytointervene–thismayvary,dependingontheindividualcontext;

• assessingtheevidencebasefromeconomicandpracticalaswellasscientificstandpoints.

6.Talkingpoints• Preconceptionand/orthefirstthousanddays–arethesethemostimportantpointstointervene?

• Howdowemakesenseoftheconfusingandconflicting‘evidence’aroundinterventions?

• Areinterventionswherethereisevidenceforsmallpositiveoutcomesworthpursuingbecause,assumingtheseoutcomesarethesameatthepopulationlevel,therewillbepositiveeffectsonrelativelylargenumbersofparticipants?

• Whatisthebeststrategytoreachthe‘hard-to-reach’families?


Annex1:KeyplayersThereisahostoforganisationswhocommissionand/orfundresearchandevaluationintothehealthofyoungchildren.Theresourceslistedbelowareselectedfromthelargenumberavailable,andashortdescription,URLand(whereappropriate)importantpublicationsoftheorganisationsappearintheDebateGraphmappingthataccompaniesthisscopingproject.([email protected].)

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• AmericanAcademyofChildandAdolescentPsychiatry

• ASH–ActiononSmokingandHealth

• Barnado's

• BigLotteryFund

• BillandMelindaGatesFoundation

• BritishAssociationforEarlyChildhoodEducation

• BritishHeartFoundation

• BritishNutritionFoundation

• Bromley-by-BowCentre

• CEDAR–CentreforDietandActivityResearch

• CentreforLongitudinalStudies

• ChildhoodDevelopmentInitiative

• ChildrenandYoungPeopleScrutinyCommittee

• ChildrenandYoungPeople’sHealthOutcomesForum

• ChildrenandYoungPeople’sServicesCommittees

• Children'sSociety

• CommunityHealthandLearningFoundation

• DanoneNutriciaEarlyLifeNutrition

• DepartmentforCommunitiesandLocalGovernment

• DepartmentforEducation

• DepartmentofHealth

• EarlyInterventionFoundation

• EconomicandSocialResearchCouncil

• EPODE

• FacultyofPublicHealth

• FamilyNursePartnership

• HealthandSocialCareInformationCentre

• HealthComplexityGroup

• HealthyChildProgramme(DepartmentofHealth)

• HENRY–HealthExerciseandNutritionfortheReallyYoung

• HEY–HealthyEarlyYears

• InclusiveChange

• InclusiveNeighbourhoods

• InstituteofAlcoholStudies

• InstituteofChildHealth(UCL)

• InternationalDiabetesFederation

• InternationalSocietyforDevelopmentalOriginsofHealthandDisease

• JosephRowntreeFoundation

• LEAP–LambethEarlyActionPartnerships

• LGAKnowledgeHub

• LocalGovernmentImprovementandDevelopment

• MedicalResearchCouncil

• MentalHealthFoundation

• MIND

• MyTimeActiveUK

• NationalCentreforHealthandClinicalExcellence

• NationalChildMeasurementProgramme(HealthandSocialCareInformationCentre)

• NationalChildbirthTrust

• NationalChildren'sBureau

• NationalFoundationforEducationalResearch

• NationalInstituteofMentalHealth

• Nesta

• NHSAlliance

• NuffieldTrust

• NutritionSociety

• PreventionandEarlyInterventionNetwork

• PROMISE–PaediatricResearchinObesityMulti-modalInterventionandServiceEvaluationprogramme

• PublicHealthEngland

• RANDEurope

• RobertWoodsJohnsonFoundation

• RoyalCollegeofMidwives

• RoyalCollegeofNursing

• RoyalCollegeofObstetriciansandGynaecologists

• RoyalCollegeofPaediatricsandChildHealth

• RoyalCollegeofPhysicians

• RoyalCollegeofPsychiatrists

• RoyalSocietyforPublicHealth

• SavetheChildren

• SEED–StudyofEarlyEducationandDevelopment

• SHINEHIT–SupportingHealthyInclusiveNeighbourhoodEnvironments

• SureStart

• TrimTots

• TrussellTrust

• UKHealthForum

• UnderstandingSociety

• UNICEF

• WellcomeTrust

• WorldHealthOrganization

• WorldObesityFederation

18 www.c3health.org

Annex2:EvidencetablesTable1:Summariesoftheevidencebaseforearly-yearsinterventions

Title Reference Interventions Findings

Rapidreviewtoupdateevidence

fortheHealthyChildProgramme

0to5

PHE2015 Rapidreviewupdatingtheevidencebasethat

underpinsthecurrentHealthyChildProgrammefor0–

5s(thepreviousupdatewasin2009).Itfocuseson

interventionsthatworkacrosskeyareas:parental

health(smoking,alcohol/drugmisuse,intimatepartner

violence);preparationandsupportforchildbirthand

transitiontoparenthood;attachment;parenting

support;unintentionalinjuryinthehome;safetyfrom

abuseandneglect;nutritionandobesityprevention;

speech,languageandcommunication.

Someofthenewevidenceidentifiedcomesfromthe18piecesof

guidancepublishedbyNICEsincethepreviousreview.For

example,newrecommendationsonhelpingpregnantwomento

stopsmokingbasedonevidencethatsomehealth-care

professionalshavenegativeperceptionsaboutintervention

efficacy.

Thebeststartathome Early

Intervention

Foundation

2015

ThisisthefirstWhatWorksreviewcommissionedby

theEarlyInterventionFoundationonUK-basedearly

interventionsforchildrenfromconceptiontothestart

ofprimaryschool.Itconsidersinterventionsthat

enhanceparent–childinteractionwithaviewto

improvingthreeimportantoutcomes:attachmentand

parentalsensitivity;socialandemotionaldevelopment;

andlanguageandcommunication.

Thereviewfound100programmesaroundtheUKthatmetits

criteria,allincludedinanannextothereport.Theseprojectsare

tobereviewedingreaterdetailsothatrecommendationsabout

efficacyandcosteffectivenesscanbemade.32ofthe

programmesarelookedatinmoredetailinthereport.

EarlyIntervention:Informing

LocalPractice

Eastonand

Gee2012

Reviewofearlyinterventionapproachestoinformthe

practiceoflocalauthorities.Examinestheimpactof

theHealthyChildProgramme,FamilyNurse

Partnerships,andParentingEarlyIntervention

Programme.

Overall,theevidencereviewedshowsthatthecaseforinvestingin

earlyinterventionapproachestoimproveoutcomesforchildren,

youngpeopleandfamiliesandtobringaboutcostsavingsinthe

longertermiswidelyacceptedandsupported.Investingearlyin

thelifeofaproblem,orwhenchildrenareyounger,canhave

greaterbenefitsinthelongtermandisthereforelikelytobemost

costeffective.Itistheextentofpotentialcostsavingsthat

increasinglyneedstobeidentifiedandevidencedtoenable

policymakersandlocalcommissionerstomakeinformed

decisions.


Table2:Smoking–systematicreviews


Effectofsmoke-freelegislation

onperinatalandchildhealth:a

systematicreviewandmeta-

analysis

Legislativesmokingbansfor

reducingharmsfromsecond-

handsmokeexposure,smoking

prevalenceandtobacco

consumption

Beenetal.2014;

Frazeretal.2016

Thefirstreview(2014)analysestheimpactof

smoke-freelegislationlocally(fivestudiesin

NorthAmerica)ornationally(sixEuropean

countries).Togethertheycover2.5million

birthsand247,168asthmaexacerbations.Risk

ofbiaswashighforonestudy,moderateforsix

andlowforfour.Thesecondreview(2016)

covers21countries.

TheanalysisintheBeenetal.reviewsuggeststhatsmoke-free

legislationisassociatedwithsubstantialreductionsinpreterm

birthsandhospitalattendancesforasthma.Therewasno

significanteffectonlowbirthweight.However,theFrazeretal.

review,whichcovers21countries,concludedthattheresultson

prematurebirthswereinconclusive,althoughitdidfindapositive

effectoncardiovascularhealthoutcomesatthepopulationlevel.

Smokingcessationinpregnancy:

psychosocialinterventionsand

patient-focusedperspectives.

Miyazakietal.2015 Smokersmayhavepsychosocialaswellas

healthproblems.Thisreviewinvestigatedthe

evidencethatpsychosocialinterventionsfor

smokingcessationareeffectiveduring

pregnancy.35articles,coveringstudiesinhigh-

,middle-andlow-incomecountriesmetthe

searchcriteria.

Interventionprogrammesincludedhealth

education,face-to-facecounselling,telephone

counselling,websites,textmessaging,other

self-helpmaterials,andmulti-component

interventionprogrammes.

Therewereconsiderablevariationsintheprevalenceofsmoking

duringpregnancyacrossthecountriesstudied,reflecting

differencesinsocial,culturalandethnicbackgrounds.However,as

ageneralrule,womenwhoexperiencedsocioeconomic

disadvantages,problemswithinterpersonalrelationships,higher

stress,depression,lesssocialsupport,andwhoengagedinhealth-

riskbehavioursweremorepronetosmokingduringpregnancy.

Theauthorsconcludedthatpsychosocialinterventions,suchas

counselling,canbeeffectivemethodsforincreasingsmoking

cessationandshouldbefocusedontheneedsandcharacteristics

oftheindividual.

Interventionstoreduceharm

fromsmokingwithfamiliesin

infancyandearlychildhood:a

systematicreview

Brownetal.2015

Reviewsinterventionsdesignedtopromote

smoke-freehomeenvironmentsforinfantsand

youngchildren.Mostfocusedon

reduction/cessationofparentalsmokingand

reducingenvironmentaltobaccosmokeinthe

home.Theapproachesincludedmotivational

interviewingandcounselling.Primaryoutcome

measureswerebasedonself-reportingof

smokingstatus.

Mostofthestudieswereratedasfairqualityandonlyfour

reportedstatisticallysignificantpositiveeffects.However,the

reportsuggeststhatinterventionstoreducesecond-handsmoke

exposuremaybemoresuccessfulinfamilieswithyoungchildren

thaninterventionsaimedatstoppingfamilymemberssmokingor

relapsing.Italsosuggeststhatthereisaneedforarangeof

interventions(includingtargetingthesocialandpsychodynamics

ofthefamily)tosupportfamiliesincreatingasmoke-freehome

environment,andthattheyshouldbetailoredandtargetedto

specificpopulations.Theyalsohighlightedissuesaround

stigmatisationoffamilymemberswhosmoke.


Table3:Dietandobesity–systematicreviews


Impactofinterventionsto

preventobesityorimprove

obesity-relatedbehavioursin

children(0–5years)from

socioeconomicallydisadvantaged

and/orindigenousfamilies:a

systematicreview

Lawsetal.2014 Reviewsevidenceforinterventionstargetingprevention

ofunhealthyweightgainand/orobesity-related

behavioursindisadvantagedchildren.Moststudies

useda(cluster)RCTdesign.Deliverywasinthehome,

primaryhealthcaresettings,atpreschoolorinthe

community,mainlybytrainedvolunteersorhealth

professionals.Primaryoutcomesincluded

anthropometricmeasures,child/familydietandphysical

activity.

Theinterventionsinitiatedininfancy(undertwoyears)

hadapositiveimpactonobesityrelatedbehaviours(e.g.

dietquality)buttheirlonger-termimpactonweightis

unknown.Forchildrenaged3–5,thefindingsweremixed,

butthemoresuccessfulinterventionsrequiredhighlevels

ofparentalengagement,useofbehaviour-change

techniques,orafocusonskillbuildingratherthanjust

knowledgeacquisitionandlinkstocommunityresources.

Lessthan10percentofstudieswerehighquality.

Asystematicreviewoftypesof

healthy-eatinginterventionsin

preschools

Mikkelsenetal.

2014

Reviewsinterventionstopromotehealthyeatingin

preschools.26studies,mainlyfromNorthAmerica,

wereincluded.Eightinvolvedsingleinterventions(e.g.

promotingfruitorvegetableintake;generallylow

quality,withsmallnumbers),11wereeducational(i.e.

designedtoincreasethechildren’sknowledgeof

healthyeating;generallybetterqualitybutsomehad

seriouslimitationssuchaslackofacontrolgroupor

highdrop-out)andsevenweremulticomponent(i.e.

usedmorethanonestrategytoinfluenceeating

behaviour;thesewerethebestdesignedbutsomehad

highdrop-outrates).

Therewasevidencesuggestingthathealthy-eating

interventionsincreasedfruitandvegetableconsumption

andnutrition-relatedknowledgeamongthetarget

groups,indicatingthatpreschoolsarepotentiallyauseful

settingforinfluencingchildren’sfoodchoices.However,

thisreviewhighlightsthescarcityofproperlydesigned

healthy-eatinginterventionsusingclearindicatorsand

verifiableoutcomes.

Obesitypreventioninthe

preschoolyears

deSilva-Sanigorski

andCampbell2012

Analyseseightstudiesthatinvolvedobesity-prevention

interventionstargetedatchildrenunderfiveyearsold.

Theyweredeliveredindifferentways–athome,orin

health-careoreducationsettings.Fiveincorporated

bothdietandphysicalactivitystrategies,threejust

physicalactivity.TheprimaryoutcomewasBMI.

Overalltheimpactswerepositivebutmodest,withlarger

effectsinthehome-basedorhealth-caresettingsthanin

educationsettings.However,numbersweresmallandthe

qualityofthestudydesignswaslow.


Table4:Parenting–systematicreviews


Systematicreviewofparenting

interventionsinEuropean

countriesaimingtoreducesocial

inequalitiesinchildren'shealth

anddevelopment

Morrisonetal.

2014

Reviews23studies,mostlyfromtheUnitedKingdom

andRepublicofIreland,designedtoimprove

parentingskills.Studydesignsvaried–RCTs,

experimentalandquasi-experimentalstudies,before-

and-afterevaluations,andqualitativeresearch

assessments.Theyinvolvedofferingintensivesupport,

information/homevisits,psycho-educational

approaches,andsomehadadditionalcomponents

suchasday-careprovision,improvinghousing

conditionsandspeechorpsychologicaltherapies.

Outcomeswereparentingbehaviours,children’s

healthandcognitivefunctioning.

Interventionswiththebestoutcomescombinedactivities

suchasworkshopsandeducationalprogrammesforboth

parentsandchildren,beginningearlyinpregnancy,and

includinghomevisitsbytrainedstaff.Theauthorsnotedthat

somestudieshadsmallsamplesizes,whichmakethestudy

vulnerabletochancevariation.

Reviewofrelationship-based

interventionsforlowincome

familieswithinfantsand

toddlers:facilitatingsupportive

parent-childinteractions

Mortensenand

Mastergeorge

2014

Meta-analyticreviewexaminingtheeffectivenessof

19studiesaimedtoimproverelationshipsin

socioeconomicallydisadvantagedfamilieswithinfants

andtoddlers.Itfocusesontheeffectivenessof

interventionsinimprovingsupportiveparenting

behaviours,asmeasuredbyobservational

assessmentsofdyadicparent–childinteractions.

Randomisedandnon-randomisedstudydesignswere

included.

Interventioncharacteristicssuchasparticipant

randomisation,breadthofinterventionservicesoffered,

duration,childageatthestartoftheintervention,

professionalqualificationsoftheintervener,andtypeofplay

taskusedduringassessmentweretestedaspossible

moderatorsofeffectiveness.Significantdifferencesin

effectivenesswerefoundbetweenrandomizedandnon-

randomisedinterventions.Withinthesubsampleof

randomisedinterventions,programmesthatwereshorterin

duration,thatprovideddirectservicestotheparent–

childdyad,usedintervenerswithprofessionalqualifications,

andassessedparent–childinteractionswithfree-playtasks

werethemosteffective.Thereviewsuggeststhatthese

factorsshouldbeconsideredwhendesigningintervention

protocolstomeettheneedsofthishigh-riskpopulation.

22 www.c3health.org

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