Supporting parents is central to the current government's approach to improving children's lives. However, little is as yet known about the effectiveness and cost-effectiveness of family support services. Home-Start is currently one of the largest family support organisations in the UK. Established over thirty years ago, it offers volunteer home visiting support to families with children under five years of age. This study, by Colette McAuley, Martin Knapp, Jennifer Beecham, Nyree McCurry and Michelle Sleed, evaluates the outcomes and costs of Home-Start support to 80 young families under stress compared with 82 similar families who did not receive this kind of support. The study found that:

• At the start of the study, the majority of mothers from both groups were experiencing a high level of parenting stress at the outset and high levels of depressive symptoms. Problems with the social and emotional development of their children were also evident.
• The mothers appeared to have little social support, and for the families using Home-Start, this was often the only non-statutory service available.
• Mothers who received the support of a Home-Start volunteer valued the service and considered that it had made a positive difference to their lives.
• At the eleven-month follow-up, the mothers in both groups had improved in well-being. This appeared to be due to changes over time and to experience.
• The results did not support the view that Home-Start had made a significant difference to the mothers over the eleven-month period of the research, relative to the experiences of the families in the comparison group. Interviews with the mothers suggested that the intensity and type of support may have contributed to this.
• Although many families were not accessing the services they clearly needed, the costs of supporting young families experiencing stress are still quite high, with the costs spread across a number of agencies.
• The receipt of Home-Start services nevertheless pushed costs for the study group to a higher level relative to the comparison group. Combined with the outcome results, the evidence did not therefore point to a cost-effectiveness advantage for Home-Start.

Background
The recent Green Paper Every Child Matters (Stationery Office, 2003) indicates the Government's intention to place support for parents and carers at the centre of its approach to improving children's lives. This builds upon the stronger mandate given to family support in recent child care legislation in England and Wales and Northern Ireland. It has been recognised for some time, though, that family support services should be offered where needs have been assessed, and where there is a likelihood of beneficial outcomes for children and families. More recently, there is an expectation that such services should also be seen to be cost-effective.

Home-Start is one of the largest family support providers in the United Kingdom. Established over thirty years ago, there are now 330 Home-Start schemes in England, Scotland, Wales and Northern Ireland (Home-Start, 2003). It offers volunteer home visiting support to families under stress where there is at least one child under five years of age. The aim of this study was to evaluate the outcomes and costs of Home-Start support to young families in the community who were experiencing stress.

For this study of effectiveness, the researchers recruited and followed the progress of 162 families from Northern Ireland and South England over an eleven month period. The study group (80) of young families received Home-Start support whilst the comparison group (82) did not. The families in both groups were well matched (see 'About the project' for details).

Needs of the families at outset
The research found that the needs of the majority of mothers in both groups were high. The mothers were experiencing a high level of parenting stress and were exhibiting a high level of depressive symptoms. Problems with the emotional and social development of their children were also evident.

The initial interviews with the mothers confirmed that the stresses they were facing were multiple and interconnected and affected their capacity to parent. Many of the mothers had experienced considerable trauma related to pregnancy and birth and the transition to parenthood generally had not been a smooth one. The prevalence of depressive symptoms amongst the mothers was high, with many indicating that they had moderate to severe symptoms.

"All I do is cry. I'm short-tempered with the kids, I wouldn't harm them but I snap at them. And ... I also snap at my husband as well."

Almost three-quarters of the mothers had concerns about the health or development of their children. Needs ranged broadly from childhood asthma and behaviour problems to autism.

"He's been having a lot of tantrums ... he's been biting and he's been violent to me and his sister ... It makes it very stressful when we go out because he has tantrums and is badly behaved."

Whilst most of the mothers were not lone parents, their husbands/partners were at work and the daily responsibility for caring for the children appeared to fall upon the mothers. There was a strong sense of these mothers being overwhelmed at times by the intensity of the demands being placed upon them, particularly when trying to care for several children on their own. What seemed to make the situation particularly stressful was the lack of respite.

"You don't have much time for yourself ... so after a while you just feel that you're not coping ... that just gradually gets you down."

"I haven't really got anyone down here that I can speak to. I love my kids to bits and I wouldn't be without them, but I need a break at the same time ... I just feel so alone."

Another major source of stress for these mothers was finance. Many were finding it difficult to decide whether to return to work and were highly critical of the lack of affordable childcare facilities to make this feasible. Many mothers were worried about their family's financial situation and several were in debt.

Families' use of services
Overall, these mothers had little available informal support. There were a variety of reasons for this. Some mothers lived some distance away from family, and the families of some others could not offer support owing to their own circumstances. Occasionally the relationships with family were fractured. There was little evidence of shared responsibility for parenting with estranged spouses.

The families used a range of services. Contact with mental health services, A&E and GPs was quite high relative to typical levels for the population. Again, there were very few differences between the groups in the services being received prior to the start of the research.

Home-Start support
Home-Start offered volunteer home visiting support to the study families, on average for 21/2 hours per week. The volunteers generally offered a combination of emotional support, practical assistance and help with outings. They tended to provide more emotional support at the beginning and more help with outings in the latter months. Practical assistance remained fairly constant throughout. The average length of support was nine months, although the number of visits per month diminished over time.

Outcomes and costs of Home-Start support at follow-up
Approximately eleven months after they were first interviewed, the majority of the mothers in both the study and comparison groups had much improved situations. They were experiencing less parenting stress and exhibiting fewer depressive symptoms. They had higher self-esteem and there was evidence of improvement in the emotional and social development of their children. They also had more social support. The progress was evident not only from the improvement on all the outcome measures but also from the content of the interviews with the mothers. However, mothers in both groups showed similar levels of improvement, even though there was no evidence of any other comparable family support service being received by the comparison group during the intervening period.

The follow-up interviews with the mothers suggested that these improvements were due to a number of factors. Many of the issues relating to the transition to parenthood were resolved through time and experience. Many of the short-term health problems of the mothers and babies were no longer present. There was evidence of the mothers gaining in confidence as parents. They had established routines to manage competing demands and had made decisions about their priorities. In many ways, they seemed to have regained control over their lives. Some had returned to work which resulted in regaining their work status, an improved financial situation and more equitable sharing of parental responsibilities. An important change for many mothers was that their children were older, more independent and often attending playgroups or schools, giving the mothers some respite from the daily demands of family life. Furthermore, those who had been experiencing fraught relationships with ex-husbands/partners stated that the issues were largely resolved following court decisions about contact and financial support.

Four-fifths of the mothers using Home-Start stated that it had made a difference to the stresses they had been experiencing. The service helped to provide a sense of relief from overwhelming pressure and most mothers clearly valued the support and friendship offered by the volunteers. However, many mothers felt that the intensity of the service was insufficient to make a significant difference to the stresses they were experiencing.

"I think I got more than I expected out of it because I have been pleasantly surprised at the family outings ... I've enjoyed that."

"I think practically it is a great idea. The two hours were great but to make a difference, it needs to be a bit more intense."

Many of the families were using quite a number of health, education and other services before the research started. Most of these service contacts continued during the research period. Overall, the receipt of Home-Start did not alter the costs of formal service use. At follow-up, there were no significant differences in formal service costs between the study and comparison groups. However, the total costs for the study group were higher due to the additional costs of the Home-Start support (see Figure 1).

Research issues
Our understanding about support services for children and families and how best to evaluate their effectiveness is clearly at an early stage in the UK. There is also very little empirical work in the UK on the cost-effectiveness of interventions, and the calculation of service costs is still at a rudimentary stage.

This study has provided an evaluation of the effectiveness of Home-Start support eleven months after the service was initially offered. This provides a solid starting point to consider its impact over time. However, the evaluation of most early years' services usually involves examination of impact over longer periods. With a community-based initiative such as Home-Start, which does not aim to provide a structured, intensive programme, a follow-up study after a number of years might well prove valuable.

About the project
The study followed 162 families with young children over an eleven-month period. Eighty of these families received Home-Start volunteer home visiting support during that period whilst the remainder did not. All of the mothers were interviewed at baseline and follow-up and they completed standardised measures on parenting stress, mental health, self-esteem, social support and the emotional and social development of their children at both time points. They also completed a questionnaire on service use and their economic circumstances at outset and follow-up.

The families were well matched on demographic variables and on maternal needs at outset. Other services being used prior to the start of the research were also similar for both groups.

How to get further information
The full report, Young families under stress: Outcomes and costs of Home-Start support by Colette McAuley, Martin Knapp, Jennifer Beecham, Nyree McCurry and Michelle Sleed, is published by the Joseph Rowntree Foundation (ISBN 1 85935 217 0, price £14.95).

Click on the 'order report' icon in the left margin to order online.

Click on the 'report .pdf' icon in the left margin to download a pdf of the full report free of charge. (File size is 0.43MB).