1. Encouraging families to attend Sure Start: a field experiment Sarah Cotterill, University of Manchester (with Laura Humber, Peter John, Alice Moseley and James Rees) The Manchester Women’s Conference. Evidence into Practice: Promoting mental health and wellbeing for mothers and families, 23 rd June 2011

2. Contents Manchester Sure Start. How families find out about Sure Start. Who attends Sure Start? Recent research with Manchester City Council: can doorstep visits or leaflets encourage families to attend?

3. Manchester Sure Start Services for all Manchester families, pre-birth and up to age 5. Emphasis on early engagement. 40 Sure Start centres. Sure Start services in libraries, community centres, schools, health, private nurseries. Variety of provision, tailored to local needs. Services for all, combined with targeted support for vulnerable families.

4. Manchester Sure Start - activities Services vary from centre to centre, but can include ….. Day nursery; creche. Child Health – antenatal care, baby clinics, parent preparation classes, health checks, immunisations… Play sessions – various, for variety of ages. Adult education – e.g. numeracy, English as a second language.

5. Manchester Sure Start - activities Babies – new baby group, rhyme & sign, baby massage, breast is best. Toddlers – busy bodies. 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.

6. How do families find out about Sure Start in Manchester? 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.

7. Manchester Sure Start – Who attends? Register of births: 8,347 children born in Manchester during the 18 months up to September 2010. 4,903 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.

8. Manchester Sure Start – Who attends? Mother’s place of birth Registered with Sure Start Not registered with Sure Start Total families Manchester38%37%3,121 Outside Europe34% 2,840 Rest of UK16%13%1,204 Gtr Manchester6% 486 Europe – non UK6%9%593 Total families4,9033,444 (Mother’s place of birth missing for 103 families)

9. Research Study Randomised Controlled Trial in partnership with Manchester City Council.

10. Objectives The primary research objective is to test the randomised controlled trial method as a tool to evaluate local authority interventions and services. The second objective is to evaluate the effectiveness of home visits and leaflets on the take up of Sure Start services: Is a visit from an outreach worker providing verbal and written information about Sure Start more effective than written information alone or the usual service in encouraging attendance at Sure Start?

11. Background Doorstep visits have been shown to be effective in Get Out the Vote campaigns (John & Brannan 2008; Gerber & Green 2008). Leaflets can also be effective. Doorstep visits found to raise household recycling rates (Cotterill et al 2009); Can visits and leaflets raise take-up of a local service?

12. Study Methods The research took place in Manchester in October 2010 It included all households with a child aged 0-18 months that were not already using Sure Start services. Manchester City Council researchers identified families from the register of births and checked against the Sure Start e-Start database. 3,444 families took part in the study. (Ardwick, Hulme and West Didsbury excluded).

13. 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.

14. Randomisation and Power Visit group 363 families. Leaflet group 625 families. Control Group 2,456 families. Total 3,444 families. Adequate statistical power to detect a difference of 5% between visit and control, and a difference of 3% between leaflet and control group. After randomisation, the characteristics of the three groups were similar. Randomisation done by York Trials Unit.

15. Study implementation Families in the treatment groups received the usual service plus either a leaflet or a visit. The usual service comprises all the ways families might find out about Sure Start centres, including word of mouth, invitations to health sessions, birth registration, referrals from professionals, and promotional activity. The usual service varies between Sure Start Centres and between families. Sure Start centres monitored attendance by families over a five-week period in October – November 2010. Using these attendance records, we were able to compare attendance between the visit, leaflet and control groups.

16. CHILD 0-18 MTHS, NOT REGISTERED ON E-START 3,444 households CONTROL GRP 2,456 households VISIT GRP 363 households CONTROL 168 VISITS (46% visited) ATTENDANCE 31 (8.5%) ATTENDANCE 195 (7.9%) LEAFLET GRP 625 households 19 leaflets returned (97% received) ATTENDANCE 61 (9.8%) Sure Start RCT – Flow Diagram

17. Results The effect of the treatments on attendance at Sure Start Control Group Visit Group Leaflet Group Total Attended Sure Start 7.9% 195 8.5% 31 9.8% 61 8.3% 287 Total Number of Families 2,4863636253,444

18. Findings Visits: The treatment effect for visits is 0.6%, with a 95% confidence interval from -2.5% to 3.7%. The study indicates that home visits, of the type conducted in this study, are not an effective way of promoting Sure Start to families who are not already engaged: the effect of the visits was not significantly different to the effect of the usual service.

19. Findings Leaflets: The treatment effect for leaflets is 1.8, with a 95% confidence interval of -0.74 to 4.38 (p < 0.1). Results suggest leaflets have a small effect on attendance at Sure Start. We used a A5 leaflet with simple design and generic message – addressed, but without the family name.

20. Summary Sure Start in Manchester attracts a cross section of families in terms of child’s age & sex and mother’s place of birth. It attracts more families from deprived areas. Register of births can be used to identify families to target for Sure Start. Brief doorstep visits not shown to be an effective way to promote Sure Start. Leaflets have a small effect in raising attendance.