Effectiveness and cost-effectiveness of a universal parenting skills programme in deprived communities: multicentre randomised controlled trial

"All Children in Focus": Effects of a Universal Parenting Program at a 6-Month Follow-Up in a Randomized Controlled Trial in Sweden

Parenting programs have been shown to empower parents and prevent mental health problems in children. However, few programs are designed to promote wellbeing, which led to the development of the Swedish-promotive universal program, "All Children in Focus" (ACF). This study aimed to understand the effects of parents' participation in the ACF program on parents' emotion regulation and parenting practices over a 6-month follow-up and if intervention-produced changes predict child wellbeing (CW). Parental self-efficacy (PSE) was also included to assess the relation with parental outcomes and CW. This is an evaluation of a multicenter randomized waitlisted control trial conducted in Stockholm County, Sweden, with parents of children aged 3 to 12 years (n = 621) in 2012. Parents were randomized 1:1 to enter the program or to a waitlist. Questionnaires were completed by parents at baseline, post-intervention, and 6 months post-baseline. We used generalized mixed modeling to test effects on parental outcomes over time and regression analyses to study the predictive role of parental outcomes on CW. From baseline to the post- and to the 6-month follow-ups, parents in the intervention group reported greater levels of emotion regulation skills, cognitive reappraisal, and positive parenting than did parents in the control group. A decrease in negative and harsh parenting was evident in both groups, although it was greater in the intervention group. An increase in PSE was associated with high negative parenting at baseline in the intervention group. Child gender moderated positive parenting, suggesting that parents of girls in the intervention group had more favorable development of positive strategies. The findings indicate that a change in PSE predicts a change in CW at 6 months. The ACF program can be used to strengthen and develop parenting. This study advances our knowledge about the potential advantages of using a health-promoting approach to strengthen the wellbeing of families in the general population. Clinical trial registration: ISRCTN70202532 Current Controlled Trials.

A cost-effectiveness analysis of a universal, preventative-focused, parent and infant programme

BACKGROUND

This study assessed whether a relatively newly developed Parent and Infant (PIN) parenting support programme was cost-effective when compared to services as usual (SAU).

METHODS

The cost-effectiveness of the PIN programme versus SAU was assessed from an Irish health and social care perspective over a 24-month timeframe and within the context of a non-randomised, controlled before-and-after trial. In total, 163 parent-infant dyads were included in the study (86 intervention, 77 control). The primary outcome measure for the economic evaluation was the Parenting Sense of Competence Scale (PSOC).

RESULTS

The average cost of the PIN programme was €647 per dyad. The mean (SE) cost (including programme costs) was €7,027 (SE €1,345) compared to €4,811 (SE €593) in the control arm, generating a (non-significant) mean cost difference of €2,216 (bootstrap 95% CI -€665 to €5,096; p = 0.14). The mean incremental cost-effectiveness of the PIN service was €614 per PSOC unit gained (bootstrap 95% CI €54 to €1,481). The probability that the PIN programme was cost-effective, was 87% at a willingness-to-pay of €1,000 per one unit change in the PSOC.

CONCLUSIONS

Our findings suggest that the PIN programme was cost-effective at a relatively low willingness-to-pay threshold when compared to SAU. This study addresses a significant knowledge gap in the field of early intervention by providing important real world evidence on the implementation costs and cost-effectiveness of a universal early years parenting programme. The challenges involved in assessing the cost-effectiveness of preventative interventions for very young children and their parents are also discussed.

TRIAL REGISTRATION

ISRCTN17488830 (Date of registration: 27/11/15). This trial was retrospectively registered.

Evidence for investing in parenting interventions aiming to improve child health: a systematic review of economic evaluations

A comprehensive review of the economic evidence on parenting interventions targeting different aspects of child health is lacking to support decision-making. The aim of this review is to provide an up to date synthesis of the available health economic evidence for parenting interventions aiming to improve child health. A systematic review was conducted with articles identified through Econlit, Medline, PsychINFO, and ERIC databases. Only full economic evaluations comparing two or more options, considering both costs and outcomes were included. We assessed the quality of the studies using the Drummond checklist. We identified 44 studies of varying quality that met inclusion criteria; 22 targeting externalizing behaviors, five targeting internalizing problems, and five targeting other mental health problems including autism and alcohol abuse. The remaining studies targeted child abuse (n = 5), obesity (n = 3), and general health (n = 4). Studies varied considerably and many suffered from methodological limitations, such as limited costing perspectives, challenges with outcome measurement and short-time horizons. Parenting interventions showed good value for money in particular for preventing child externalizing and internalizing behaviors. For the prevention of child abuse, some programs had the potential of being cost-saving over the longer-term. Interventions were not cost-effective for the treatment of autism and obesity. Future research should include a broader spectrum of societal costs and quality-of-life impacts on both children and their caregivers.

Early parenting interventions to prevent internalising problems in children and adolescents: a global systematic review and network meta-analysis

QUESTION

We compared the effectiveness of different types of parenting interventions based on an a priori taxonomy, and the impact of waitlists versus treatment as usual (TAU), in reducing child internalising problems.

STUDY SELECTION AND ANALYSIS

We conducted a systematic review and network meta-analysis of published and unpublished randomised controlled trials (RCTs) until 1 October 2022 that investigated parenting interventions with children younger than 4 years.

EXCLUSION CRITERIA

studies with children born preterm, with intellectual disabilities, or families receiving support for current abuse, neglect, and substance misuse. We assessed the certainty of evidence using the Confidence in Network Meta-Analysis framework. We used random-effects network meta-analysis to estimate standardised mean differences (SMDs) with 95% credible intervals (CrIs).

FINDINGS

Of 20 520 citations identified, 59 RCTs (18 349 participants) were eligible for the network meta-analysis. Parenting interventions focusing on the dyadic relationship (SMD: -0.26, 95% CrI: -0.43 to -0.08) and those with mixed focus (-0.09, -0.17 to -0.02) were more effective in reducing internalising problems than TAU at the first time point available. All interventions were more effective than waitlist, which increased the risk of internalising problems compared with TAU (0.36, 0.19 to 0.52). All effects attenuated at later follow-ups. Most studies were rated as with 'high risk' or 'some concerns' using the Risk of Bias Assessment Tool V.2. There was no strong evidence of effect modification by theoretically informed components or modifiers.

CONCLUSIONS

We found preliminary evidence that relationship-focused and mixed parenting interventions were effective in reducing child internalising problems, and the waitlist comparator increased internalising problems with implications for waiting times between referral and support. Considering the high risk of bias of most studies included, the findings from this meta-analysis should be interpreted with caution. PROSPERO registration number CRD42020172251.

Methods of assessing value for money of UK-based early childhood public health interventions: a systematic literature review

INTRODUCTION

Economic evaluation has an important role to play in the demonstration of value for money of early childhood public health interventions; however, concerns have been raised regarding their consistent application and relevance to commissioners. This systematic review of the literature therefore aims to collate the breadth of the existing economic evaluation evidence of these interventions and to identify the approaches adopted in the assessment of value.

SOURCE OF DATA

Recently published literature in Medline, EMBASE, EconLit, Health Management Information Consortium, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, Health Technology Assessment, NHS EED and Web of Science.

AREAS OF AGREEMENT

The importance of the early childhood period on future health and well-being as well as the potential to impact health inequalities making for a strong narrative case for expenditure in early childhood public health.

AREAS OF CONTROVERSY

The most appropriate approaches to evaluating value for money of such preventative interventions relevant for UK decision-makers given the evident challenges.

GROWING POINTS

The presented review considered inconsistencies across methodological approaches used to demonstrate value for money. The results showed a mixed picture in terms of demonstrating value for money.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future resource allocations decisions regarding early childhood public health interventions may benefit from consistency in the evaluative frameworks and health outcomes captured, as well as consistency in approaches to incorporating non-health costs and outcomes, incorporating equity concerns and the use of appropriate time horizons.

What Works to Improve Wellbeing? A Rapid Systematic Review of 223 Interventions Evaluated with the Warwick-Edinburgh Mental Well-Being Scales

INTRODUCTION

The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) is a commonly used scale of mental wellbeing focusing entirely on the positive aspect of mental health. It has been widely used in a broad range of clinical and research settings, including to evaluate if interventions, programmes or pilots improve wellbeing. We aimed to systematically review all interventions that used WEMWBS and evaluate which interventions are the most effective at improving wellbeing.

METHODS

Eligible populations included children and adults, with no health or age restrictions. Any intervention study was eligible if the wellbeing outcome was measured using the 7 or 14-item WEMWBS scale assessed both pre- and post-intervention. We identified eligible intervention studies using three approaches: a database search (Medline, EMBASE, CINAHL, PyschInfo and Web of Science from January 2007 to present), grey literature search, and by issuing a call for evidence. Narrative synthesis and random-effects meta-analysis of standardised mean differences in the intervention group were used to summarise intervention effects on WEMWBS score.

RESULTS

We identified 223 interventions across 209 studies, with a total of 53,834 participants across all studies. Five main themes of interventions were synthesised: psychological (n = 80); social (n = 54); arts, culture and environment (n = 29); physical health promotion (n = 18); and other (n = 28). Psychological interventions based on resilience, wellbeing or self-management techniques had the strongest effect on wellbeing. A broad range of other interventions were effective at improving mental wellbeing, including other psychological interventions such as cognitive behavioural therapy, psychoeducation and mindfulness. Medium to strong effects were also seen for person-centred support/advice (social), arts-based, parenting (social) and social prescribing interventions. However, a major limitation of the evidence was that only 75 (36%) of studies included a control group.

CONCLUSIONS

WEMWBS has been widely used to assess wellbeing across a diverse range of interventions, settings and samples. Despite substantial heterogeneity in individual intervention design, delivery and groups targeted, results indicate that a broad range of intervention types can successfully improve wellbeing. Methodological changes, such as greater use of control groups in intervention evaluation, can help future researchers and policy makers further understand what works for mental wellbeing.

A systematic review and meta-analysis of psychological interventions to improve mental wellbeing

Our current understanding of the efficacy of psychological interventions in improving mental states of wellbeing is incomplete. This study aimed to overcome limitations of previous reviews by examining the efficacy of distinct types of psychological interventions, irrespective of their theoretical underpinning, and the impact of various moderators, in a unified systematic review and meta-analysis. Four-hundred-and-nineteen randomized controlled trials from clinical and non-clinical populations (n = 53,288) were identified for inclusion. Mindfulness-based and multi-component positive psychological interventions demonstrated the greatest efficacy in both clinical and non-clinical populations. Meta-analyses also found that singular positive psychological interventions, cognitive and behavioural therapy-based, acceptance and commitment therapy-based, and reminiscence interventions were impactful. Effect sizes were moderate at best, but differed according to target population and moderator, most notably intervention intensity. The evidence quality was generally low to moderate. While the evidence requires further advancement, the review provides insight into how psychological interventions can be designed to improve mental wellbeing.

'Every day is hard, being outside, but you have to do it for your child': Mixed-methods formative evaluation of a peer-led parenting intervention for homeless families

We conducted a mixed-methods, formative evaluation of a peer-led parenting intervention for homeless families. Participants were parents living in temporary accommodation with self-identified difficulties related to parenting an index child aged 2-11 years. An evidence-based programme ('Empowering Parents, Empowering Communities') was adapted for delivery with the target population in London, UK. We assessed feasibility in terms of session attendance rate, intervention completion rate and potential for impact on a range of parent-reported outcomes measures. Acceptability and appropriateness were examined by a user satisfaction measure and qualitative interviews. The intervention was delivered across three group cohorts (N = 15). Thirteen parents completed the programme (including one parent who required two attempts). We found improvements in child behavioural difficulties, parenting knowledge and practices, while parental well-being and social support were unchanged. Participants were highly satisfied overall, with indications that the peer-led model mitigated negative expectancies of services and normalized experiences of parenting in challenging conditions. Parental self-care and 'the good enough parent' were strongly endorsed topics, although some content (e.g. timeout) was deemed impractical. These promising findings warrant further testing under controlled conditions.

Problematic cost-utility analysis of interventions for behavior problems in children and adolescents

Cost–utility analyses are slowly becoming part of randomized control trials evaluating physical and mental health treatments and (preventive) interventions in child and adolescent development. The British National Institute of Health and Care Excellence, for example, insists on the use of gains in Quality Adjusted Life Years (QALYs) to compute the “value for money” of interventions. But what counts as a gain in quality of life? For one of the most widely used instruments, the EuroQol 5 Dimensions scale (EQ‐5D), QALYs are estimated by healthy individuals who provide utility scores for specific health states, assuming that the best life is a life without self‐experienced problems in five domains: mobility, self‐care, usual activities, pain/discomfort, and anxiety/depression. The worst imaginable outcome is defined as “a lot of problems” in each of these five domains. The impact of the individual's problems on the social network is not weighted, and important social–developmental domains (externalizing problems, social competence) are missing. Current cost–utility computations based on EQ‐5D favor physical health over mental health, and they rely on adult weights for child and adolescent quality of life. Thus, a level playing field is absent, and developmental expertise is sorely missing.

Promoting Learning from Null or Negative Results in Prevention Science Trials

There can be a tendency for investigators to disregard or explain away null or negative results in prevention science trials. Examples include not publicizing findings, conducting spurious subgroup analyses, or attributing the outcome post hoc to real or perceived weaknesses in trial design or intervention implementation. This is unhelpful for several reasons, not least that it skews the evidence base, contributes to research “waste”, undermines respect for science, and stifles creativity in intervention development. In this paper, we identify possible policy and practice responses when interventions have null (ineffective) or negative (harmful) results, and argue that these are influenced by: the intervention itself (e.g., stage of gestation, perceived importance); trial design, conduct, and results (e.g., pattern of null/negative effects, internal and external validity); context (e.g., wider evidence base, state of policy); and individual perspectives and interests (e.g., stake in the intervention). We advance several strategies to promote more informative null or negative effect trials and enable learning from such results, focusing on changes to culture, process, intervention design, trial design, and environment.

Randomized cluster trial of a parenting program in Chile: Key mediators in the decrease in behavior problems in preschool children

BACKGROUND

Parenting training is a proven strategy for the promotion of positive parenting practices and for the prevention and treatment of behavior problems in children. The processes that explain this efficacy are less clear. The aim of this study was to assess the mediating role of parenting practice modification, encouraged through the implementation of a universal parenting training program, for the decrease of behavior problems in 3- to 6-year-old children.

METHOD

A cluster randomized trial was carried out in 19 educational centers in low and middle socioeconomic areas. A total of 178 families received the program and 154 of them were the control group. The following parenting practices were assessed: positive reinforcement, involvement, inconsistency, unsuitable treatment behaviors and physical punishment, as well as hostility and humiliation behaviors. Parent-child interaction was also assessed using an observational instrument. A multiple mediation analysis was carried out, identifying the indirect effects.

RESULTS

Reduction of harsh discipline and physical punishment, and parental inconsistency mediated the effects observed in the reduction of child behavior problems during the program.

CONCLUSION

Within Chilean families, harsh discipline, physical punishment, and parental inconsistency are important aspects to be considered in the implementation of universal parenting training programs.

Effectiveness of a Positive Parental Practices Training Program for Chilean Preschoolers' Families: A Randomized Controlled Trial

Background: Evidence for the effectiveness of parental training as a strategy for promotion of positive parental practices and prevention of child behavior problems in low and middle income countries is not conclusive. This study aims to assess the effectiveness of a universal positive parental training program designed for this context, “Día a Día” UdeC © (“Day by Day” University of Concepción), in Chilean preschoolers’ families (3–6 years old children).

Methods: A cluster randomized controlled trial (cRCT) was carried out in 19 preschool education centers. There were two treatment arms: 10 centers (including 178 families) were randomly assigned to the intervention group and nine centers (including 154 families) were assigned to the waiting list control condition. Intervention groups received Day by Day UdeC, a six group sessions program for parents, including two group sessions for preschool educators, focused in affective communication; daily and child-directed play; directed attention; routines and transitions; reinforcement and incentive programs; planned inattention-ignore and time out; and logical consequences. Parental practices, parental satisfaction, and presence of children behavioral problems were examined at two-time points: T1 (4 weeks before intervention) and T2 (5–6 weeks after intervention).

Results: Intention-to-treat analysis shows a reduction in physical punishment and an increase in parental involvement, as well as a reduction in children behavioral problems. A per-protocol analysis revealed an additional effect: increase in observed parental practices.

Conclusion: This cRCT provided evidence for the effectiveness of a parental training program for the promotion of positive parental practices in low and middle income countries. The observed effects of the program in decreasing physical punishment and children’s behavioral problems make it a promising strategy for prevention purposes.

Trial Registration: This study was registered under ISRCTN.com (ISRCTN90762146; https://doi.org/10.1186/ISRCTN90762146).

Enhancing first-time parents' self-efficacy: A systematic review and meta-analysis of universal parent education interventions' efficacy

BACKGROUND

Poor adjustment during early parenthood often leads to low feelings of parental self-efficacy, which influences parents' behaviours towards their infants. The long-term consequences on infant development warrant the need for more attention on the efficacy of universal parent education interventions to empower parents and enhance their self-efficacy.

OBJECTIVES

To synthesise available evidence and explore the efficacy of universal parent education interventions on the parental self-efficacy of first-time parents.

DESIGN

A systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

A literature search of 10 databases was conducted to identify randomised controlled trials from each database's point of inception to November 2016.

METHODS

Based on the inclusion criteria, 24,062 articles were screened for their titles and abstracts. Two hundred and eighty articles were identified for full-text screening. Risks of bias posed by the selected articles were assessed using Cochrane's Risk of Bias instrument. Meta-analyses were conducted using RevMan 5.3. The overall intervention effect was evaluated using z tests at p < 0.05, while I² and Cochran Q tests were used to measure heterogeneity.

RESULTS

Ten randomised controlled trials were selected; eight trials were combined in meta-analyses and two trials were synthesised narratively. A meta-analysis revealed that universal parent education interventions significantly enhanced parental self-efficacy (p < 0.001) among first-time parents and these effects were also maintained over time (p < 0.001). The extent of improvement in parental self-efficacy was affected by the duration of the interventions.

CONCLUSION

This review provides sufficient evidence to support the use of universal interventions to enhance new parents' self-efficacy. While intervention effects were sustained at the two-month follow-up, further research using randomised controlled trials and longitudinal studies are needed to determine long-term effects. The findings serve as an impetus for hospitals and healthcare professionals to integrate universal interventions in perinatal care to guide first-time parents' transition into parenthood.

Randomised controlled trial evaluating the effectiveness and cost-effectiveness of 'Families for Health', a family-based childhood obesity treatment intervention delivered in a community setting for ages 6 to 11 years

BACKGROUND

Effective programmes to help children manage their weight are required. 'Families for Health' focuses on a parenting approach, designed to help parents develop their parenting skills to support lifestyle change within the family. Families for Health version 1 showed sustained reductions in mean body mass index (BMI) z-score after 2 years in a pilot project.

OBJECTIVE

The aim was to evaluate its effectiveness and cost-effectiveness in a randomised controlled trial (RCT).

DESIGN

The trial was a multicentre, investigator-blind RCT, with a parallel economic and process evaluation, with follow-up at 3 and 12 months. Randomisation was by family unit, using a 1 : 1 allocation by telephone registration, stratified by three sites, with a target of 120 families.

SETTING

Three sites in the West Midlands, England, UK.

PARTICIPANTS

Children aged 6-11 years who were overweight (≥ 91st centile BMI) or obese (≥ 98th centile BMI), and their parents/carers. Recruitment was via referral or self-referral.

INTERVENTIONS

Families for Health version 2 is a 10-week, family-based community programme with parallel groups for parents and children, addressing parenting, lifestyle, social and emotional development. Usual care was the treatment for childhood obesity provided within each locality.

MAIN OUTCOME MEASURES

Joint primary outcome measures were change in children's BMI z-score and incremental cost per quality-adjusted life-year (QALY) gained at 12 months' follow-up (QALYs were calculated using the European Quality of Life-5 Dimensions Youth version). Secondary outcome measures included changes in children's waist circumference, percentage body fat, physical activity, fruit/vegetable consumption and quality of life. Parents' BMI and mental well-being, family eating/activity, parent-child relationships and parenting style were also assessed. The process evaluation documented recruitment, reach, dose delivered, dose received and fidelity, using mixed methods.

RESULTS

The study recruited 115 families (128 children; 63 boys and 65 girls), with 56 families randomised to the Families for Health arm and 59 to the 'usual-care' control arm. There was 80% retention of families at 3 months (Families for Health, 46 families; usual care, 46 families) and 72% retention at 12 months (Families for Health, 44 families; usual care, 39 families). The change in BMI z-score at 12 months was not significantly different in the Families for Health arm and the usual-care arm [0.114, 95% confidence interval (CI) -0.001 to 0.229; p = 0.053]. However, within-group analysis showed that the BMI z-score was significantly reduced in the usual-care arm (-0.118, 95% CI -0.203 to -0.034; p = 0.007), but not in the Families for Health arm (-0.005, 95% CI -0.085 to 0.078; p = 0.907). There was only one significant difference between groups for secondary outcomes. The economic evaluation, taking a NHS and Personal Social Services perspective, showed that mean costs 12 months post randomisation were significantly higher for Families for Health than for usual care (£998 vs. £548; p < 0.001). The mean incremental cost-effectiveness of Families for Health was estimated at £552,175 per QALY gained. The probability that the Families for Health programme is cost-effective did not exceed 40% across a range of thresholds. The process evaluation demonstrated that the programme was implemented, as planned, to the intended population and any adjustments did not deviate widely from the handbook. Many families waited more than 3 months to receive the intervention. Facilitators', parents' and children's experiences of Families for Health were largely positive and there were no adverse events. Further analysis could explore why some children show a clinically significant benefit while others have a worse outcome.

CONCLUSIONS

Families for Health was neither effective nor cost-effective for the management of obesity in children aged 6-11 years, in comparison with usual care. Further exploration of the wide range of responses in BMI z-score in children following the Families for Health and usual-care interventions is warranted, focusing on children who had a clinically significant benefit and those who showed a worse outcome with treatment. Further research could focus on the role of parents in the prevention of obesity, rather than treatment.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN45032201.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 1. See the NIHR Journals Library website for further project information.

Could scale-up of parenting programmes improve child disruptive behaviour and reduce social inequalities? Using individual participant data meta-analysis to establish for whom programmes are effective and cost-effective

Background

Child disruptive behavioural problems are a large and costly public health problem. The Incredible Years®(IY) parenting programme has been disseminated across the UK to prevent this problem and shown to be effective in several trials. It is vital for policy to know for which families IY is most effective, to be sure that it helps reduce, rather than widen, socioeconomic inequalities. Individual trials lack power and generalisability to examine differential effects; conventional meta-analysis lacks information about within-trial variability in effects.

Objectives

To overcome these limitations by pooling individual-level data from the IY parenting trials in Europe to examine to what extent it benefits socially disadvantaged families. Secondary objectives examine (1) additional moderators of effects on child behaviour, (2) wider health benefits and potential harms and (3) costs, cost-effectiveness and potential long-term savings.

Design

Individual participant data meta-analysis of 14 randomised trials of the IY parenting intervention.

Settings

UK (eight trials), the Netherlands, Ireland, Norway, Sweden and Portugal.

Participants

Data were from 1799 families, with children aged 2–10 years (mean 5.1 years; 63% boys).

Interventions

IY Basic parenting programme.

Main outcome measures

Primary outcome was disruptive child behaviour, determined by the Eyberg Child Behavior Inventory Intensity scale (ECBI-I). Secondary outcomes included self-reported parenting practices, parenting stress, mental health, children’s attention deficit hyperactivity disorder (ADHD) and emotional symptoms.

Results

There were no differential effects of IY on disruptive behaviour in families with different levels of social/socioeconomic disadvantage or differential effects for ethnic minority families, families with different parenting styles, or for children with comorbid ADHD or emotional problems or of different ages. Some moderators were found: intervention effects were strongest in children with more severe baseline disruptive behaviour, in boys, and in children with parents who were more depressed. Wider health benefits included reduced child ADHD symptoms, greater parental use of praise, and reduced harsh and inconsistent discipline. The intervention did not improve parental depression, stress, self-efficacy or children’s emotional problems. Economic data were available for five UK and Ireland trials (maximumn = 608). The average cost per person of the IY intervention was £2414. The probability that the IY intervention is considered cost-effective is 99% at a willingness to pay of £145 per 1-point improvement on the ECBI-I. Estimated longer-term savings over 20 years range from £1000 to £8400 per child, probably offsetting the cost of the intervention.

Limitations

Limitations include a focus on one parenting programme; the need to make assumptions in harmonising data; and the fact that data addressed equalities in the effectiveness of, not access to, the intervention.

Conclusions

There is no evidence that the benefits of the IY parenting intervention are reduced in disadvantaged or minority families; benefits are greater in the most distressed families, including parents who are depressed. Thus, the intervention is unlikely to widen socioeconomic inequalities in disruptive behaviour and may have effects in narrowing inequalities due to parent depression. It was as likely to be effective for older as for younger children. It has wider benefits for ADHD and parenting and is likely to be considered to be cost-effective. Researchers/funders should encourage data sharing to test equity and other moderator questions for other interventions; further research is needed on enhancing equality of access to interventions.

Funding

The National Institute for Health Research Public Health Research programme.

Costs and savings of parenting interventions: results of a systematic review

BACKGROUND

This systematic review of economic evaluations of universal preventative or targeted treatment parenting interventions that aim to enhance parent-infant interaction is primarily intended to inform decision makers who have to make difficult spending decisions, especially at a time of reduced spending allocations. A synthesis of available costs and savings about parenting interventions that set out to enhance parent-infant interaction is presented. This topic is important specifically in view of the UK Governments' emphasis on the equalities agenda and the early years. The benefits of positive early life experiences, which include good parent-infant interaction, are far reaching and may be positively correlated with improved educational, health and well-being outcomes and reduced criminality.

METHODS

A literature search was undertaken using on-line indexing databases between 2004 and 2014 that included the search terms 'parent', 'infant', 'interaction', 'cost benefit analysis' and their synonyms.

RESULTS

Despite existing economic studies generally focusing upon targeted short-run outcomes, significant savings were observed in the included studies. Parenting interventions could save the health service around £2.5k per family over 25 years and could save the criminal justice system over £145k per person over the life course. In light of the escalating costs of remedial services, these potential savings may provide the UK and other governments with a robust incentive to invest in early years parenting interventions.

CONCLUSIONS

Parenting interventions can be economically efficient and return savings on investment. Moreover, and one might argue as a moral imperative of democratic societies, population health can be improved and health inequalities reduced. An important debate is needed about early years policy, to include acknowledgement of the differences between UK and international healthcare systems and the potential savings from the synergistic and spin-off effects of early years interventions to inform decision-making to fund and implement appropriate action.

Randomised controlled trial and economic evaluation of the 'Families for Health' programme to reduce obesity in children

OBJECTIVE

Evaluating effectiveness and cost-effectiveness of 'Families for Health V2' (FFH) compared with usual care (UC).

DESIGN

Multicentre randomised controlled trial (RCT) (investigators blinded, families unblinded) and economic evaluation. Stratified randomisation by family; target of 120 families.

SETTING

Three National Health Service Primary Care Trusts in West Midlands, England.

PARTICIPANTS

Overweight or obese (≥91st or ≥98th centile body mass index (BMI)) children aged 6-11 years and their parents/carers, recruited March 2012-February 2014.

INTERVENTIONS

FFH; a 10-week community-based family programme addressing parenting, lifestyle change and social and emotional development. UC; usual support for childhood obesity at each site.

MAIN OUTCOME MEASURES

Primary outcomes were 12-months change in children's BMI z-score and incremental cost per quality-adjusted life-year gained (QALY). Secondary outcomes included changes in children's physical activity, fruit and vegetable consumption and quality of life, parents' BMI and mental well-being, family eating/activity, parent-child relationships and parenting style.

RESULTS

115 families (128 children) were randomised to FFH (n=56) or UC (n=59). There was no significant difference in BMI z-score 12-months change (0.114, 95% CI -0.001 to 0.229, p=0.053; p=0.026 in favour of UC with missing value multiple imputation). One secondary outcome, change in children's waist z-score, was significantly different between groups in favour of UC (0.15, 95% CI 0.00 to 0.29). Economic evaluation showed that mean costs were significantly higher for FFH than UC (£998 vs £548, p<0.001). Mean incremental cost-effectiveness of FFH was estimated at £552 175 per QALY.

CONCLUSIONS

FFH was neither effective nor cost-effective for the management of obesity compared with UC.

TRIAL REGISTRATION NUMBER

ISRCTN45032201.

Group-based parent training programmes for improving emotional and behavioural adjustment in young children

BACKGROUND

Emotional and behavioural problems in children are common. Research suggests that parenting has an important role to play in helping children to become well-adjusted, and that the first few months and years are especially important. Parenting programmes may have a role to play in improving the emotional and behavioural adjustment of infants and toddlers, and this review examined their effectiveness with parents and carers of young children.

OBJECTIVES

1. To establish whether group-based parenting programmes are effective in improving the emotional and behavioural adjustment of young children (maximum mean age of three years and 11 months); and2. To assess whether parenting programmes are effective in the primary prevention of emotional and behavioural problems.

SEARCH METHODS

In July 2015 we searched CENTRAL (the Cochrane Library), Ovid MEDLINE, Embase (Ovid), and 10 other databases. We also searched two trial registers and handsearched reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

Two reviewers independently assessed the records retrieved by the search. We included randomised controlled trials (RCTs) and quasi-RCTs of group-based parenting programmes that had used at least one standardised instrument to measure emotional and behavioural adjustment in children.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data and a second reviewer checked the extracted data. We presented the results for each outcome in each study as standardised mean differences (SMDs) with 95% confidence intervals (CIs). Where appropriate, we combined the results in a meta-analysis using a random-effects model. We used the GRADE (Grades of Recommendations, Assessment, Development, and Evaluation) approach to assess the overall quality of the body of evidence for each outcome.

MAIN RESULTS

We identified 22 RCTs and two quasi-RCTs evaluating the effectiveness of group-based parenting programmes in improving the emotional and behavioural adjustment of children aged up to three years and 11 months (maximum mean age three years 11 months).The total number of participants in the studies were 3161 parents and their young children. Eight studies were conducted in the USA, five in the UK, four in Canada, five in Australia, one in Mexico, and one in Peru. All of the included studies were of behavioural, cognitive-behavioural or videotape modelling parenting programmes.We judged 50% (or more) of the included studies to be at low risk for selection bias, detection bias (observer-reported outcomes), attrition bias, selective reporting bias, and other bias. As it is not possible to blind participants and personnel to the type of intervention in these trials, we judged all studies to have high risk of performance bias. Also, there was a high risk of detection bias in the 20 studies that included parent-reported outcomes.The results provide evidence that group-based parenting programmes reduce overall emotional and behavioural problems (SMD -0.81, 95% CI -1.37 to -0.25; 5 studies, 280 participants, low quality evidence) based on total parent-reported data assessed at postintervention. This result was not, however, maintained when two quasi-RCTs were removed as part of a sensitivity analysis (SMD -0.67, 95% CI -1.43 to 0.09; 3 studies, 221 participants). The results of data from subscales show evidence of reduced total externalising problems (SMD -0.23, 95% CI -0.46 to -0.01; 8 studies, 989 participants, moderate quality evidence). Single study results show very low quality evidence of reductions in externalising problems hyperactivity-inattention subscale (SMD -1.34; 95% CI -2.37 to -0.31; 19 participants), low quality evidence of no effect on total internalising problems (SMD 0.34; 95% CI -0.12 to 0.81; 73 participants), and very low quality evidence of an increase in social skills (SMD 3.59; 95% CI 2.42 to 4.76; 32 participants), based on parent-reported data assessed at postintervention. Results for secondary outcomes, which were also measured using subscales, show an impact on parent-child interaction in terms of reduced negative behaviour (SMD -0.22, 95% CI -0.39 to -0.06; 7 studies, 941 participants, moderate quality evidence), and improved positive behaviour (SMD 0.48, 95% CI 0.17 to 0.79; 4 studies, 173 participants, moderate quality evidence) as rated by independent observers postintervention. No further meta-analyses were possible. Results of subgroup analyses show no evidence for treatment duration (seven weeks or less versus more than eight weeks) and inconclusive evidence for prevention versus treatment interventions.

AUTHORS' CONCLUSIONS

The findings of this review, which relate to the broad group of universal and at-risk (targeted) children and parents, provide tentative support for the use of group-based parenting programmes to improve the overall emotional and behavioural adjustment of children with a maximum mean age of three years and 11 months, in the short-term. There is, however, a need for more research regarding the role that these programmes might play in the primary prevention of both emotional and behavioural problems, and their long-term effectiveness.

The HAPPY (Healthy and Active Parenting Programmme for early Years) feasibility randomised control trial: acceptability and feasibility of an intervention to reduce infant obesity

BACKGROUND

The prevalence of infant obesity is increasing, but there is a lack of evidence-based approaches to prevent obesity at this age. This study tested the acceptability and feasibility of evaluating a theory-based intervention aimed at reducing risk of obesity in infants of overweight/obese women during and after pregnancy: the Healthy and Active Parenting Programme for Early Years (HAPPY).

METHODS

A feasibility randomised controlled trial was conducted in Bradford, England. One hundred twenty overweight/obese pregnant women (Body Mass Index [BMI] ≥25 kg/m(2)) were recruited between 10-26 weeks gestation. Consenting women were randomly allocated to HAPPY (6 antenatal, 6 postnatal sessions: N = 59) or usual care (N = 61). Appropriate outcome measures for a full trial were explored, including: infant's length and weight, woman's BMI, physical activity and dietary intake of the women and infants. Health economic data were collected. Measurement occurred before randomisation and when the infant was aged 6 months and 12 months. Feasibility outcomes were: recruitment/attrition rates, and acceptability of: randomisation, measurement, and intervention. Intra-class correlations for infant weight were calculated. Fidelity was assessed through observations and facilitator feedback. Focus groups and semi-structured interviews explored acceptability of methods, implementation, and intervention content.

RESULTS

Recruitment targets were met (~20 women/month) with a recruitment rate of 30 % of eligible women (120/396). There was 30 % attrition at 12 months; 66 % of recruited women failed to attend intervention sessions, but those who attended the first session were likely to continue to attend (mean 9.4/12 sessions, range 1-12). Reaction to intervention content was positive, and fidelity was high. Group clustering was minimal; an adjusted effect size of -0.25 standard deviation scores for infant weight at 12 months (95 % CI: -0.16-0.65) favouring the intervention was observed using intention to treat analyses. No adverse events were reported.

CONCLUSIONS

The HAPPY intervention appeared feasible and acceptable to participants who attended and those delivering it, however attendance was low; adaptations to increase initial attendance are recommended. Whilst the study was not powered to detect a definitive effect, our results suggest a potential to reduce risk of infant obesity. The evidence reported provides valuable lessons to inform progression to a definitive trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN56735429.

A Cost-Effectiveness Analysis of the Swedish Universal Parenting Program All Children in Focus

OBJECTIVE

There are few health economic evaluations of parenting programs with quality-adjusted life-years (QALYs) as the outcome measure. The objective of this study was, therefore, to conduct a cost-effectiveness analysis of the universal parenting program All Children in Focus (ABC). The goals were to estimate the costs of program implementation, investigate the health effects of the program, and examine its cost-effectiveness.

METHODS

A cost-effectiveness analysis was conducted. Costs included setup costs and operating costs. A parent proxy Visual Analog Scale was used to measure QALYs in children, whereas the General Health Questionnaire-12 was used for parents. A societal perspective was adopted, and the incremental cost-effectiveness ratio was calculated. To account for uncertainty in the estimate, the probability of cost-effectiveness was investigated, and sensitivity analyses were used to account for the uncertainty in cost data.

RESULTS

The cost was € 326.3 per parent, of which € 53.7 represented setup costs under the assumption that group leaders on average run 10 groups, and € 272.6 was the operating costs. For health effects, the QALY gain was 0.0042 per child and 0.0027 per parent. These gains resulted in an incremental cost-effectiveness ratio for the base case of € 47 290 per gained QALY. The sensitivity analyses resulted in ratios from € 41 739 to € 55 072. With the common Swedish threshold value of € 55 000 per QALY, the probability of the ABC program being cost-effective was 50.8 percent.

CONCLUSION

Our analysis of the ABC program demonstrates cost-effectiveness ratios below or just above the QALY threshold in Sweden. However, due to great uncertainty about the data, the health economic rationale for implementation should be further studied considering a longer time perspective, effects on siblings, and validated measuring techniques, before full scale implementation.

Looking After Me Looking After You: using positive cognitive behavioural techniques to improve emotional well-being

Stress and anxiety have been identified as among the most common reasons for sickness absence. Therefore, timely work-based well-being interventions are needed. Strengths-based Cognitive-Behaviour Therapy (CBT) approaches are of benefit therapeutically. Guided imagery approaches enable individuals utilize previous positive experiences and construct positive future templates potentially increasing the likelihood of better outcomes. One hundred and seventeen participants from a health service clinical/corporate environment participated in the Looking After Me Looking After You (LAMLAY) programme. It comprised three 3-hour or four 2-hour sessions weekly. Positive imagery and strengths-based cognitive-behavioural approaches were delivered via participant exercises and didactically. Completion rate was 77.8%; seventy-five participants (83% of completers) completed the Warwick–Edinburgh Mental Well-Being Scale (WEMWBS) pre-course (mean 46.4) and post-course (mean 52.4). Significant improvements in well-being were obtained (t = 9.32, d.f. = 74, p<0.0001, d = 0.82). An online follow-up survey demonstrated sustained improved scores on the WEMWBS (F2,223 = 17.04, p<0.001, η = 0.13). Satisfaction ratings indicated high approval levels. Participants’ well-being improved at the end of the LAMLAY programme and was sustained at follow-up. The potential impact of LAMLAY and the potential to deliver cost-effective benefits is discussed. Further development work is required including more systematic investigation over a longer term.

Effectiveness of a universal health-promoting parenting program: a randomized waitlist-controlled trial of All Children in Focus

BACKGROUND

Parenting programs have been highlighted as a way of supporting and empowering parents. As programs designed to promote children's health and well-being are scarce, a new health-promotion program, All Children in Focus, has been developed. The purpose of this trial was to evaluate the potential effectiveness of the program in promoting parental self-efficacy and child health and development, as well as to investigate possible moderators of these outcomes.

METHODS

A multicenter randomized waitlist-controlled trial was conducted. The trial included 621 parents with children aged 3-12 years. Parents were randomized to receive the intervention directly or to join a waitlist control group. Parents completed questionnaires at baseline, 2 weeks after the intervention, and 6 months post-baseline. To evaluate potential effects of the program, as well as any moderating variables, multilevel modeling with a repeated-measures design was applied.

RESULTS

Parents in the intervention group reported that their self-efficacy (p < .001), as well as their perceptions of children's health and development (p < .05), increased 6 months post-baseline when compared with parents in the control group. One variable was found to moderate both outcomes: parents' positive mental health. Furthermore, parents' educational level and number of children moderated parental self-efficacy, while the children's age moderated child health and development. Having a poor positive mental health, a university-level education, more than one child in the family, and older children, made the families benefit more.

CONCLUSIONS

In the first randomized controlled trial of All Children in Focus, we found that the program appears to promote both parental self-efficacy and children's health and development in a general population. Additionally, we found that families may benefit differently depending on their baseline characteristics. This contributes to an existing understanding of the advantages of offering universal parenting programs as a public health approach to strengthening families. However, further research is needed to investigate long-term effects and mediating variables, as well as the potential cost-effectiveness of the program.

TRIAL REGISTRATION

Current Controlled Trials: ISRCTN70202532. November 7th 2012.