Title: Evaluating the real-world implementation of the Family Nurse Partnership: a data linkage study
Funder: Department of Health and Social Care

Abstract: More than 20,000 babies are born to teenage mothers in England each year (around 1 in every 25 births). Teenage mothers face a number of challenges in pregnancy, including lower levels of education, less stable careers and lower income than older mothers. Whilst teenage motherhood is a positive experience for some, it is also linked to domestic violence, unhealthy behaviours during pregnancy (e.g. smoking) and lower levels of prenatal care. These challenges mean that children born to teenage mothers are more likely to have worse health and do worse at school and employment than those born to older mothers. They are also more likely to suffer child abuse and neglect, and poorer physical and mental health throughout childhood and adulthood. _x000D_ _x000D_ Pregnancy and the period after birth are a chance to provide more support for teenage mothers and their children. In the US, a home visiting service has been shown to help mothers and their children. It was linked to better health during pregnancy, improved school readiness, better maternal employment, and fewer child injuries. In England, the Family Nurse Partnership (FNP) home visiting service was introduced in 2007, aimed at first time teenage mothers. A research study of 1600 families in England found that those who were visited by nurses as part of FNP did no better than those who received usual care, in terms of birth weight, maternal smoking, repeat pregnancies and A&E attendances. However, the study suggested that those in the FNP group had better language development at age 2. There is strong support for the programme locally, and FNP is still offered to teenage mothers in areas across the UK. By 2016, 25,000 mothers had taken part in FNP across 125 Local Authorities (covering around 25% of eligible mothers). The service is evolving and adapting over time. We now need to understand the the factors that affect how well the programme works (e.g. the local setting, and the types of families receiving FNP), in order to know how best to help familes who are in need of support. _x000D_ _x000D_ This study aims to add to results from the earlier study, by providing more detailed information about how the FNP differs in areas across England. We will work out whether there are particular settings in which FNP works well. To do this, we will use electronic records that are routinely collected as part of health, education, and social care services to compare outcomes for FNP participants with similar families who did not take part in FNP. We discussed our proposal with mothers participating in FNP, and they were supportive of the study. _x000D_ _x000D_ We will look at outcomes for children (e.g. emergency hospital admissions for possible neglect or abuse, development at school-age, referrals to social services) and mothers (e.g. continuing education after birth, subsequent pregnancies, hospital admissions due to violence or injuries). We will work out whether FNP works better for some families (e.g. the youngest teenagers) than others. This information will help those in charge of services decide which mothers are in most need of additional support, who might benefit most from FNP, and who might need alternative support. The study will help policy-makers decide whether FNP should be offered to families in their local setting.

Lay abstract: Background_x000D_ _x000D_ The Family Nurse Partnership (FNP) is a home visiting programme to improve outcomes of teenage pregnancies. Understanding the context in which FNP is currently delivered and the factors that influence results is key to understanding who might benefit most from FNP and how service delivery may be improved. Our proposal addresses variation in delivery and targeting of FNP by using longitudinal observational data for the whole population eligible for FNP to generate evidence on the real-world implementation of FNP, and the factors that may influence effectiveness (e.g. setting, provider, participants and programme delivery)._x000D_ _x000D_ Research question / Aims and objectives_x000D_ _x000D_ Aim: Generate evidence on the real-world ongoing implementation of FNP in England_x000D_ _x000D_ Research questions_x000D_ _x000D_ 1 Are mothers who are most in need of support receiving FNP?_x000D_ _x000D_ Objectives_x000D_ • Describe variation in delivery of FNP and usual care across LAs_x000D_ • Describe variation in health, education and social care characteristics of families participating in FNP over time and by LA_x000D_ _x000D_ 2 Which families does the real-world implementation of FNP benefit?_x000D_ _x000D_ Objectives_x000D_ • Evaluate the effectiveness of FNP on health, education and social care outcomes for both children and mothers_x000D_ • Determine which families benefit most from FNP_x000D_ • Evaluate outcomes for groups now eligible for FNP but excluded from BB (e.g. mothers up to age 24)_x000D_ _x000D_ 3 What are the contextual factors associated with benefiting from FNP?_x000D_ _x000D_ Objectives_x000D_ • Explore the effect of contextual factors e.g. usual care, nurse characteristics, programme fidelity_x000D_ • Explore individual and LA-level predictors of programme engagement_x000D_ • Determine how FNP differs between LAs and compared with the BB population_x000D_ _x000D_ Methods_x000D_ _x000D_ Design_x000D_ _x000D_ Linked hospital, education and social care records for all mothers aged =24 years, and their children born in England between 2010-2017, plus FNP programme data._x000D_ _x000D_ Outcomes_x000D_ _x000D_ Children up to age 6:_x000D_ _x000D_ • Child abuse or neglect_x000D_ • Unplanned admissions;A&E visits_x000D_ • Outpatient department referrals_x000D_ • A “good level of development”_x000D_ • Child in care_x000D_ • Child in need status_x000D_ _x000D_ Mothers: _x000D_ • Unplanned admissions;A&E visits_x000D_ • Subsequent pregnancies_x000D_ • Qualifications before versus after birth _x000D_ _x000D_ Analysis_x000D_ _x000D_ We will compare outcomes for mothers ever enrolled in FNP versus those who were never enrolled. Multiple analysis strategies will be used to take account of measured confounders related to both participation in FNP and outcomes, and to explore maternal and programme variables associated with benefiting from FNP. _x000D_ _x000D_ Timeline (months)_x000D_ Pre-award: Finalise data access approvals and recruit study staff_x000D_ 0-6: Data cleaning / preparation for analyses_x000D_ 6-12: Analyses and write up: research question 1_x000D_ 13-18: Analyses and write up: research question 2_x000D_ 19-24: Analyses and write up: research question 3_x000D_ 25-30: Finalise outputs; dissemination._x000D_ _x000D_ Impact / dissemination_x000D_ We will work with the FNP National Unit (NU) to disseminate results to LAs, policy makers, commissioners, parents and nurses. We will work with parents to co-produce a range of outputs suitable for FNP families and to identify relevant streams of communication. We will publish peer review journal articles and present at conferences. Findings will provide commissioners and policy makers with detailed and up-to-date evidence to aid decision making about the roll out and targeting of FNP. Our findings will inform ongoing adaptations of FNP.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH