Does mobilization increase family engagement with Sure Start? Sarah Cotterill, University of Manchester Peter John, University College London Alice Moseley, University of Exeter Research funded by Association of Greater Manchester Authorities. Thank you to Laura Humber and James Rees UK Society for Behavioural Medicine 8th Annual Scientific Meeting New Developments in the Theory and application of Behavioural Medicine Manchester, December 2012

Contents Background: Mobilization & engaging families Sure Start Randomised controlled trial: can doorstep visits or leaflets persuade families to attend Sure Start? Findings Discussion

Mobilization Doorstep visits and leaflets have been shown to be effective in Get Out the Vote campaigns (John & Brannan 2008; Green & Gerber 2008). Doorstep visits can raise household recycling rates (Cotterill John Liu Nomura 2009) Direct mail can raise charitable donations (Huck & Rasul 2011; Cotterill John Richardson 2010 “The messenger matters” (Green & Gerber 2008) Effective mobilisation requires: a motivated canvasser; a comfortable canvasser; receptive householders (Michelson 2006). Can visits and leaflets raise take-up of a local service?

Barriers to families attending early years services Sure Start caters for conflicting interests (Clarke 2010). Logistic barriers & Interpersonal barriers (Winslow et al 2009). “Not for me”. Service provider role in problem solving. Attendance is higher with: trusted signposting; clear benefit; child behavioural problems; quality of service.

Sure Start Services for all local families, pre-birth and up to age 5. Emphasis on early engagement. 40 Sure Start centres plus services in libraries, community centres, schools, health, private nurseries. Services for all, combined with targeted support for vulnerable families. Sure Start nationally shown to benefit families (Melhuish et al 2010; Churchill & Williams 2006)

Sure Start - activities Day nursery; creche. Child Health – antenatal care, baby clinics, health checks, immunisations… Play sessions – for variety of ages. Adult education – e.g. numeracy, English as a 2nd language. Babies – new baby group, rhyme & sign, breast is best. Toddlers. Pre-school preparation. Parenting – e.g. early years survival course, dads and dudes, young parents group. Childminder drop-in. Adult health – counselling, smoking cessation, self esteem.

How do families find out about Sure Start? Family and friends - word of mouth. NHS appointments - antenatal, baby clinics, health checks etc. Midwives, health visitors, other professionals. Birth registration. Day care enquiries. Promotion & outreach. Publicity & web pages.

Local Sure Start – Who attends? Register of births: 8,347 children born in local area during the 18 months up to September ,903 families (59%) already registered. 3,444 families (41%) not registered with Sure Start. We find only small differences between registered and non-registered families: No difference in mean age or sex of child; Families from deprived neighbourhoods are more likely to register.

Research Objectives To evaluate the effectiveness of home visits and leaflets on the take up of Sure Start services: To test the randomised controlled trial method as a tool to evaluate local authority interventions and services.

Data and Randomisation The research took place in October 2010 Includes all households with a child aged 0-18 months not already using Sure Start services. Local Council researchers identified families from the register of births and checked against the Sure Start database. 3,444 families took part in the study (3 wards excluded). Randomisation done by York Trials Unit, using Stata. Block randomisation, stratified by Sure Start centre (37 centres)

Experimental Design Households were randomly assigned to one of three groups: Visit Group - Outreach staff from the local Sure Start Centre undertook short doorstep visits to provide information about local Sure Start services and encourage families to attend. Contact rate = 168 out of 363 families (46.3%). Leaflet Group - The A5 sized leaflet encouraged families to call into a Sure Start Centre and find out about the range of opportunities available. Control Group - Families in the control group received the usual service.

Randomisation and Power GroupNumber of families Visit Group467 Leaflet Group825 Control Group3281 Total4573 Over 93% of statistical power to detect a difference of: 5% between visit and control group 3% between leaflet and control group 8% between visit and leaflet group

The final numbers GroupOriginal set of families Found on e-start New users of SureStart Final set of families included Visit Group Leaflet Group Control Group Total Retain 90% of statistical power to detect a difference of: 5% between visit and control group 3% between leaflet and control group 8% between visit and leaflet group

Baseline characteristics of the groups

Outcome measure - attendance Sure Start centres monitored attendance by families over a five-week period in October – November Computer records and written attendance sheets. Using these attendance records, we were able to compare attendance between the visit, leaflet and control groups.

CHILD 0-18 MTHS, NOT REGISTERED ON E-START 4,573 households CONTROL GRP 3,281 households VISIT GRP 467 households Ineligible = 825 Ineligible = 104 Not treated = 195 Included in analysis = 363 Included in analysis = 2456 LEAFLET GRP 825 households Ineligible = 200 Not treated = 19 Included in analysis = 625 Sure Start RCT – Flow Diagram

Results The effect of visits and leaflets on attendance at Sure Start Control Group Visit Group Leaflet Group Total Attended Sure Start 7.9% % % % 287 Total2, ,444 Included all families, whether or not they received intervention. Excluded families who were ineligible due to recent registration. In all groups, families with younger children more likely to attend.

Findings Visits: The difference in attendance between control group and visit group was 0.6%, with a 95% confidence interval from -2.5% to 3.7%. Leaflets: The treatment effect for leaflets is 1.8, with a 95% confidence interval of -0.7 to 4.4 (p = 1.4, two-tailed test). The study found no evidence that home visits or leaflets, of the type conducted in this study, are an effective way of promoting Sure Start to families who are not already engaged.

Discussion - visits Sure Start implies more on-going engagement, compared to voting or recycling. Research was with those families (41% of total) who have not responded to usual methods. – Don’t need the service? – Isolated and vulnerable, with “logistic and interpersonal barriers” (Winslow et al 2009), so need special methods? Families of young children most likely to attend. Other types of visit and visitors.

Discussion - leaflets We used a A5 leaflet with simple design and generic message – addressed, but without the family name. Not tailored to the child’s age or family circumstances. No attempt at framing or use of persuasive “nudge” techniques.

Conclusions Sure Start in Manchester attracts a cross section of families in terms of child’s age and sex and mother’s place of birth. It attracts more families from deprived areas. A successful pilot of a RCT for the council - Register of births can be used to identify families to target for Sure Start. Neither leaflets nor visits shown to be more effective than usual service.

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