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, 10-11 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 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.
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
Group
Number of families
Visit Group
467
Leaflet Group
825
Control Group
3281
Total
4573
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
Group
Original
set of
families
Found on New users
Final set
e-start
of of families
SureStart
included
Visit Group
467
85
19
363
Leaflet Group
825
176
24
625
Control Group
3281
689
136
2456
Total
4573
950
179
3444
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
Control
Group
9.7 mths
Visit
Group
9.6 mths
Leaflet
Group
9.5 mths
51.7%
52.6%
49.9%
38.1%
38.4%
34.9%
- Greater Manchester
5.5%
6.1%
6.7%
- Rest of UK
13.1
12.5
13.3
- Europe
9.2%
9.8%
9.7%
34.1%
33.2%
35.4%
2456
363
625
Mean age (months)
Proportion of Male
Children
Mother born in
- Manchester
- Outside Europe
TOTAL N
Outcome measure - attendance
• Sure Start centres monitored attendance by families
over a five-week period in October – November
2010.
• Computer records and written attendance sheets.
• Using these attendance records, we were able to
compare attendance between the visit, leaflet and
control groups.
Sure Start RCT – Flow Diagram
CHILD 0-18 MTHS, NOT
REGISTERED ON E-START
4,573 households
CONTROL GRP
3,281
households
VISIT GRP
467 households
LEAFLET GRP
825 households
Ineligible = 825
Ineligible = 104
Not treated = 195
Ineligible = 200
Not treated = 19
Included in
analysis = 2456
Included in
analysis = 363
Included in
analysis = 625
Results
The effect of visits and leaflets on attendance at Sure Start
Control Visit
Group Group
Leaflet Total
Group
Attended Sure
Start
7.9%
195
8.5%
31
9.8%
61
8.3%
287
Total
2,456
363
625
3,444
• 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.
References
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