Baby Box: evaluation

4. Perceived impacts

Key findings

• The benefits of the box most commonly identified by parents and health professionals were financial or material – saving money on things they needed for their baby and providing useful things they would not otherwise have bought. However, parents did also recognise other benefits, around learning and support.
• Nine in ten (91%) parents agreed that 'Getting a baby box has saved me money on things I would otherwise have had to buy', while 76% of health professionals agreed that the scheme is an effective way of ensuring that every family has access to newborn essentials. Midwives were more like to agree with this than were health visitors / family nurses.
• 37% of parents felt they had learned about bonding with their baby through playing, talking and reading as a result of receiving the box. This figure was higher among younger, first-time, and lower income parents.
• Most (84%) said they had read the books included in the box with their baby. Over half (60%) of parents felt the inclusion of books in the baby box had encouraged them to start reading with their baby earlier – again, younger, first-time and lower income parents were particularly likely to say this.
• 84% of parents surveyed said they had found the leaflet on safe sleeping useful. Findings from the qualitative research provided evidence of parents learning about safe sleeping from the leaflet in the box and/or being empowered to challenge inappropriate views among family members around safe sleeping, even when they had not used the box itself as a sleep space.
• Health professionals also gave positive examples of the potential impact of the box on safe sleeping even where it was not actually being used as a sleep space – for example, where they felt that the baby box had helped support conversations around safe sleeping, and therefore helped to increase or reinforce parents' understanding of this topic.
• A quarter (26%) of parents surveyed felt the box had helped support breastfeeding, but higher numbers (66%) said they found the leaflet on breastfeeding useful. A similar proportion (68%) said they had found the leaflet on post-natal depression useful – younger parents and those on lower incomes were more likely to say it had been 'very' useful.
• Other things parents reported learning from the box included: 'monitoring my baby's health or temperature' (50%), 'how my baby can sleep safely in the box' (42%) and about sources of support for new parents (35%). Again, younger and first-time parents were more likely to say they had learned about each of these areas.
• 47% of parents surveyed had signed up for Parent Club emails, most commonly (64%) at the same time as registering for a baby box. Most parents (79%) who read the emails reported they were useful. However, younger parents were less likely than older parents to read Parent Club emails.
• Parents and health professionals were both divided on the impact of the box on facilitating professional/parent engagement. 35% of parents agreed that 'Getting a baby box encouraged me to talk more to my midwife, health visitor or family nurse about things I wasn't sure about', while 23% disagreed and 41% neither agreed nor disagreed. 45% of health professionals agreed that the box was a useful tool in supporting conversations with parents in general, while 18% disagreed and 33% neither agreed nor disagreed.
• Younger parents and first time parents were more likely to agree that the box had encouraged them to talk more to their midwife, health visitor or family nurse. There was also some evidence from health professionals that the box had supported conversations with parents experiencing particularly challenging circumstances.

As described in Chapter 1, the main aim of the Baby Box scheme is to contribute to improved outcomes for children and families in Scotland, both by supporting new families financially (providing essentials that they would otherwise have to buy) and including items intended to support positive parenting behaviours and early child development. It was also hoped that the scheme would help support opportunities for midwives and health visitors to engage with parents, including those families that services may typically find more difficult to engage. This, in turn, could help support positive outcomes for parents and children. A central aim of the evaluation was to explore the potential impacts of the scheme on each of these areas.

In considering the implications of the quantitative and qualitative findings, it is important to keep in mind that, as discussed in Chapter 1, without a control group, it is not possible to establish definitive impacts. There is also potential for perceived impacts to be either over or under-stated, or misattributed. However, the findings highlight the areas where the scheme is potentially having an impact, as well as any areas where it is less clear that the scheme is having an impact. Where possible, findings from different sources are also triangulated, to reduce the risk of perceived impacts being over- or under-stated based on evidence from one source alone.

Outcomes

Parental knowledge and behaviour:

• Uptake of, and engagement with Parent Club emails
• Increased understanding of risk and positive behaviours
• Increased positive behaviours and reduced risk behaviours

Engagement between parents and health professionals:

• Attempts to engage with wider services (parents and workforce)
• Sustained engagement with wider services (parents)

Financial impacts:

• Reduced expenditure on newborn essentials
• Reduced inequalities in access to newborn essentials

Research Questions

• What has been the most important perceived benefit of the Baby Box scheme to families?
• How has parents' understanding of what is important for their baby been influenced by the baby box?
• Has the Baby Box scheme contributed to improving parents' understanding of positive and risk behaviours, such as breastfeeding and safe sleeping practice?
• Is there evidence that the Baby Box scheme is encouraging parents to engage in positive behaviours and reduce risk behaviours?
• How does the Baby Box scheme impact on workforce interaction and communication with parents?
• Is the Baby Box scheme offering new opportunities to identify families who are unlikely to engage with services?
• Do health professionals feel that the box provides an opportunity to engage parents with other services?
• Has receiving the baby box affected parents' spending decisions on newborn essentials?

Main perceived benefits of the scheme

The parents' survey indicated that parents are most likely to view the baby box in terms of its financial benefits – when asked which, if any, of a list of potential benefits they felt they had gained from receiving a baby box, 81% said the box had saved them money on things they needed for their baby, while 70% said it provided useful things they would not otherwise have bought. However, although less commonly chosen than the financial benefits, parents did also recognise wider benefits from receiving the box such as alerting them to available support for new parents (45%) and learning about how to look after a new baby (34%). With the exception of saving money, younger parents (under 30, but particularly those under 25) were more likely to feel they had gained each of the benefits the survey asked about from the baby box (Table 5.1). More detailed views on the perceived financial benefits of the baby box are discussed at the end of this chapter.

Table 5.1: Perceived benefits of the baby box, by parental age (parent survey)

Which, if any, of the following have been benefits of receiving a baby box for you personally?	16-24	25-29	30-34	35+	All
I saved money on things I needed for my baby	83%	83%	81%	80%	81%
It provided useful things I would not otherwise have bought for my baby	77%	75%	67%	65%	70%
It encouraged me to play, talk and read earlier with my baby	67%	56%	51%	44%	52%
I learned about sources of support available to me	63%	48%	39%	41%	45%
I learned more about how to look after a new baby	57%	37%	29%	28%	34%
I learned more about post-natal depression	52%	31%	20%	18%	27%
It supported me with breastfeeding	45%	31%	20%	21%	26%
It encouraged me to speak more with my midwife or health visitor	50%	31%	19%	19%	26%
None of these	1%	3%	3%	5%	3%
Sample size (unweighted)	248	529	770	665	2236

Parents who participated in qualitative interviews also highlighted financial savings on newborn essentials as a key benefit of receiving the box. However, another key perceived benefit was the reassurance and convenience of having all the basics they needed for their newborn provided in one trustworthy package. For first time parents in particular, the scheme was seen as providing a good 'starter kit', alleviating the difficulty of having to work out what to buy for their new baby. These two main perceived benefits also overlapped; it was suggested that receiving a box of 'essentials' from the state helped prevent parents from spending unnecessarily on items that were not needed (a view that was echoed in interviews with health professionals):

"I suspect as well that you would probably get conned into paying more for things if you were choosing them yourself, because you think that everyone wants to cash [in] on new parent anxiety and tell them not only do you need a bathroom thermometer, but you need one that does this, that and the next thing. ... and your bath sponge needs to be this fancy thing... Just being provided with the things that are useful but not exploiting you wanting to do the best by your child, meant that we saved a lot of money."

Fife, 25-29, Income 4, First child

These views were largely echoed in interviews with health visitors and midwives. Three main positive impacts were described:

• the financial impact
• ensuring families have everything they need (including items they might not otherwise have thought of buying, such as the thermometer and sling), and
• making them feel valued and supported by receiving the box as a gift.

Perceived impacts on play, reading and attachment

Play

The baby box includes various items specifically designed to support play and interaction between parents and their baby. These include a cloth playmat, a comforter toy, a small selection of books, and information for downloading the free Royal Scottish National Orchestra (RSNO) Aster App. When asked which, if any, items from the baby box they had used for play, parents who took part in qualitative interviews also mentioned using the bath sponge for play during bath time and the muslins for games such as peekaboo.

The survey found that 37% of parents felt they had learned about bonding with their baby through playing, talking and reading as a result of getting a baby box. This figure was higher among young parents (57% of parents aged 16-24, compared with 29% of parents aged 35 or older), first time parents (46%, compared with 28% of parents with other children) and parents on lower incomes (42% of parents with a household income of £15,599 or less, compared with 32% of parents with a household income of £52,000 or more).

In the qualitative interviews, while parents described various positive ways they had used items from the box to support play and interaction with their baby, they also stated that they did not necessarily feel that they had played more or done things differently because of the items included in the box – rather, they felt that it had simply been useful to have additional 'tools' to hand. For example, although the playmat was well used by parents we spoke to during in-depth interviews, they did not typically feel it had affected the way in which they had played with their baby. Indeed, it was not always used as a space where they played with their baby, with some parents using it more often as a clean, comfortable and safe place to put their baby down. Had they not received a playmat in the box, parents suggested that they would have used something else in its place, such as a baby gym, foam floor tiles, or a rug or towel on the floor, or that they would have bought a playmat themselves.

However, although parents felt they would have accessed alternative items to play and read with their baby, the findings indicate that having such items available from birth may have made it easier for them to engage with these activities at an earlier stage. The parents' survey found that around half (52%) cited the baby box encouraging them to play, talk and read earlier with their baby as a benefit of receiving the box, with one in ten (13%) saying this was the most important benefit. Younger, first-time and low income parents were more likely to say that encouraging them to play, talk and read earlier with their baby was a benefit of receiving the box: 67% of parents aged 16-24 said this, compared with 44% of parents aged 35 or older; 58% of first-time parents, compared with 46% of parents with other children; and 60% of parents with a household income of £15,599 or less, compared with 45% of parents with a household income of £52,000 or more.

In the qualitative interviews, there were examples where parents indicated that, if they had not received the toys in the baby box, they would not otherwise have thought to buy any toys until their baby was a bit older. First time parents also suggested that the toys included in the box helped them to learn what kind of toys were appropriate for very young babies, providing inspiration for other toys they could buy. Thus even in cases where parents did not feel the baby box had had a major impact on when or how they played with their babies, there was some evidence to suggest that it may encourage parents to try different kinds of toys and/or support play from a younger age.

A similar view of the impact of the box on play, attachment and child development was apparent from interviews with midwives and health visitors. On the one hand, there was a clear view that they would be having conversations with parents about attachment, play and child development regardless of the baby box, which made judging its impact in this regard difficult. However, the inclusion of items such as the toys and playmat, wrap, and books was viewed by some as helping support these conversations and also reinforcing their importance. Having something they knew most parents would have to refer to when discussing these topics was considered helpful – for example, being able to point to the playmat when discussing tummy time or the importance of face-to-face interaction. Professionals also felt the inclusion of such items in the box provided parents with the opportunity to engage in positive parenting behaviours without needing to financially invest in items which they may not use long term.

Reading

The baby box includes two books aimed at young babies – a cloth book and a black and white baby book. Most parents (84%) who responded to the survey said they had read the books included in the box with their baby, with 14% saying they had not read them yet but planned to do so, and just 1% saying they did not intend to read them. Sixty per cent said they felt getting the books in their baby box had encouraged them to start reading with their baby earlier. Again, younger parents, parents on lower incomes, and first-time parents were all more likely to say that receiving books in the baby box had encouraged them to start reading to their baby earlier. Two thirds (66%) of parents aged 16-24 said it had encouraged them to read earlier, compared with 55% of parents aged 35 or over; 65% of parents with a household income of £15,999 compared with 51% with an income of £52,000 or more; and 65% of first-time parents compared with 54% of those with other children.

Parents we spoke to during in-depth interviews varied in whether they felt the inclusion of these books had influenced their decisions and behaviour around reading to their baby. Among those who felt it had not had any impact, this was primarily because they said they had always intended to read to their baby from an early age. However, these parents still generally said they valued the books included in the box. One view was that the black and white newborn book had helped highlight the importance of sensory stimulation and bold patterns for babies.

The qualitative interviews also highlighted the potential benefits of the books in encouraging earlier reading with babies by younger and first-time parents – there were examples of parents in these groups indicating that, prior to receiving the baby box, they had assumed young babies would not benefit from being read to. As such, they had planned to begin reading to their baby when they were a few months old, instead of starting from birth to a few weeks. Having books specifically for new-borns to hand had encouraged them to try reading to their baby earlier than they had planned.

Similarly, professionals felt that the books had been helpful in terms of explaining and validating the benefits of reading to young babies, and that having them available in the box from day one did encourage parents to try reading to their baby.

"… we always promote the books, the books you've got in your baby box: 'Have you got them out yet? Your baby is only a couple of weeks old, but you can always read to the baby and show the baby the pictures and, yes, help develop vision and closeness, yes, bonding.'"

(Health Visitor)

Attachment

Many of the items in the baby box could in principle support parent-child attachment – including the toys and books discussed above. However, the wrap included in the box is perhaps the item most obviously intended to support physical attachment between parent and child in the early months. The baby wrap is a single piece of material that can be used as a 'sling' to help carry the baby on the parent's body ('baby wearing'). As mentioned in Chapter 3, 42% of parents picked the wrap as one of the 5 most useful items included in the box.

During in-depth interviews, parents who had used the wrap described two main perceived benefits. The first was less about attachment and more around convenience and enabling parents to do other things while also keeping their baby close. Parents reported that using the wrap inside and outside the house enabled them to be more mobile and kept their hands free for other tasks. This was useful for keeping on top of household chores and for looking after older children. The second set of perceived benefits were more directly related to parent-child attachment. Parents described using the wrap:

• to settle their baby, particularly when they did not like to be put down or had issues such as colic
• to help their baby feel safe and secure, and
• to support breastfeeding.

"… it meant you could just sort of pop her in. It was good fun and it was lovely having her close, I think it was really helpful just while we were trying to establish breastfeeding and just having her close all the time."

Fife, 25-29, Income group 4, First child

The 'one size fits all' nature of the baby wrap was also seen as a benefit of the wrap over a more structured baby carrier. This meant it could be used with premature babies and by fathers.

Only one in five (20%) parents who responded to the survey reported owning a baby wrap before they received the box. During in-depth interviews it was clear that, for some parents, the inclusion of the wrap in the box had encouraged parents who might not otherwise have done so to try baby wearing. It prompted them to 'have a go', when they either would not have thought about buying one otherwise or were unsure it was worth the investment.

However, not all parents in the qualitative research who had tried the wrap went on to use it. In the main, this was because they had found it complicated to use, despite reading the instructions included in the box. These parents reported a lack of confidence in how to ensure the wrap was tight enough to securely hold their baby, but not so tight that it would be a suffocation risk. In some cases, they had ended up buying a more structured baby carrier with straps instead. It was suggested that the instructions could be improved and supplemented with an official video showing parents how to tie the wrap securely. A small number of the parents interviewed had been shown how to use the wrap by professionals, such as in hospital, at a sling library or a breastfeeding group. This had imparted confidence in how to use the wrap properly, with these parents suggesting such demonstrations should be more widely available. Midwives and health visitors also commented that they would be better able to encourage parents to use the sling properly if they themselves had training on how to use it properly.

Questions for consideration: Could the instructions that come with the wrap be improved or enhanced with links to video demonstrations? Are there opportunities for health professionals to take a more active role in demonstrating safe use of the wrap to parents (supported by further training/guidance for them on safe use)?

Perceived impacts on safe sleeping

As described in Chapter 3, the baby box itself is intended to provide a safe sleeping option for the early months. It also includes a leaflet about safe sleeping when using the box and has visual guidance on the lid of the box on how to use the box safely.

Although only a minority (39%) of parents surveyed said they had actually used the box for their baby to sleep in, around eight in ten (84%) said they had found the leaflet on how to use the box for safe sleeping useful (a figure which did not vary significantly by age, income or whether or not they were a first time parent). Parents who took part in qualitative interviews gave examples of what they felt they had learned from the leaflet on safe sleeping, including:

• not putting items such as toys or cot bumpers in the sleep space with their baby
• ensuring their baby is not too warm
• keeping their baby's feet to the bottom of their sleep space, and
• the importance of not falling asleep on the sofa with their baby in their arms.

In other cases, although parents did not feel they had personally learnt anything about safe sleeping from the box, they said that the leaflet had helped them to explain safe sleeping practices to family members, and to challenge inappropriate gift offers or advice (for example, offers of cot bumpers, or advice to put their baby to sleep on their stomach).

Even parents who felt that the leaflet did not provide any information that they had not already covered in antenatal classes welcomed its inclusion in the baby box. It was suggested that it reinforced what parents had learned from other sources, and helped them to stay up to date, since guidance on safe sleeping can change.

Qualitative interviews with health professionals for this study identified a belief that the box was not used for sleep as often as it could be – something they felt limited its potential impact on safe sleep. However, professionals nonetheless gave positive examples where they felt that the baby box had helped support conversations around safe sleeping even when it was not actually being used by parents as a sleep space. Having the box available in parents' houses meant professionals could use it to demonstrate safe sleeping practices (such as feet to foot). They also mentioned showing parents the cellular blanket from the box, as an example of the kind of blanket they needed to ensure their baby is the right temperature and is not at risk of suffocation. Having these items physically to hand was seen as particularly useful when families did not have a high level of English and it was more difficult to explain things verbally. There were also a number of positive reports from professionals working with families on very low incomes who they felt had benefited directly from having the box as a safe sleep option, and of cases where they had been able to encourage families to use the box in preference to another, unsafe sleep option (e.g. a car seat or bouncy chair they saw being used as a nap space for a young baby).

Exceptionally, a more negative view on the potential impact of the box on safe sleeping was expressed by one health visitor who had observed the box being used potentially unsafely by a family who did not speak English. It is worth noting in this regard that the box does include a diagram on the lid showing how it should be used, as well as written instructions. However, this finding suggests there may be a need to work with health visitors and midwives to ensure these instructions are highlighted to families who may not read English, and to consider alternative ways of communicating how the box should be used (such as videos) to ensure the instructions are not overlooked.

Perceived impacts on breastfeeding

In order to support parents with breastfeeding, the baby box contains nursing pads and a leaflet on breastfeeding. A quarter (26%) of parents felt the box had helped support breastfeeding, and 21% that it had informed them about it. Higher numbers of respondents were positive about the inclusion of the leaflet on breastfeeding, with 66% stating they found the leaflet very or fairly useful. This figure did not vary significantly by parental age or whether they were first time parents.

During in-depth interviews, parents generally indicated that the breastfeeding leaflet had served to remind or reinforce things they already knew, either from raising older children or from other sources, such as their midwife, antenatal classes or their own research, rather than teaching them anything completely new. This applied to both first-time parents and those who already had children. Despite this, some parents were nonetheless keen to stress the usefulness of the breastfeeding leaflet in providing handy hints and tips to refer back to when they were struggling with breastfeeding at home, including useful information about latching on and how often their baby might want to feed. Parents of older children also suggested that the leaflet had provided a useful refresher on breastfeeding for their new baby.

In contrast, professionals interviewed for the evaluation did not generally consider the Baby Box scheme to have had any significant impact on breastfeeding. It was noted that it was very challenging to increase breastfeeding rates, particularly in deprived areas. However, it was suggested that including the sling in the box had helped facilitate conversations about breastfeeding in some cases – midwives and health visitors could discuss to use a sling to support feeding, as well as the benefits of keeping your baby close for attachment and bonding in general.

Perceived impacts on understanding of Post Natal Depression

According to the Royal College of Psychiatrists, about 10-15 in every 100 women experience depression after having a baby^[31]. While the cause of post-natal depression is not completely clear, evidence suggests it can be associated with a history of mental health problems, a lack of social support, and recent stressful life events, such as a bereavement.^[32]

Around two-thirds of parents (68%) who responded to the survey said they had found the leaflet on post-natal depression included in the baby box very or fairly useful. Younger parents and those on lower incomes were particularly likely to say the leaflet on postnatal depression had been 'very' useful – 52% of 18-24 year-olds, compared with 27-28% of parents in their 30s or older, and 49% of those with annual household incomes under £15,599 compared with 20% of those on £52,000 or more.

The leaflet on post-natal depression tended to be discussed in less detail than the breastfeeding leaflet in qualitative interviews with parents. However, where parents expressed a view, the leaflet was seen as a useful and reassuring guide, helping to destigmatise the illness and reinforce the message that parents can, and should, seek help straight away should they be concerned about their mental health.

There was low awareness of the inclusion of the post-natal depression leaflet in the box amongst professionals interviewed for the evaluation. Unsurprisingly, therefore, when asked they did not perceive any particular impacts from the box on post-natal depression.

Other perceived learnings from the baby box

The parent survey asked which, if any, of a number of areas they felt they had learned about as a result of getting a baby box. The most commonly mentioned area was 'monitoring my baby's health or temperature', mentioned by half of parents (50%), followed by how my baby can sleep safely in the box (42%). Around a third (35%) said they had learned about sources of support for new parents from the box.

Younger and first-time parents were significantly more likely to feel they had learned about each of the areas asked about as a result of getting the box (Table 5.2). Parents aged 30 or older were more likely to say they did not feel they had learned anything new from getting a baby box (24-26%, compared with 8% of parents age 16-24 and 17% of those aged 25-29).

Table 5.2: Perceived learning from the baby box, by parental age (parent survey)

Which, if any, of the following areas do you feel you have learned about as a result of getting a baby box?	16-24	25-29	30-34	35+	All
Monitoring my baby's health or temperature	70%	56%	43%	42%	50%
How my baby can sleep safely in the baby box	55%	44%	37%	40%	42%
Bonding with my baby through playing, talking and reading	57%	42%	32%	29%	37%
Sources of support for new parents	50%	40%	30%	29%	35%
My baby's development	53%	33%	21%	19%	28%
Postnatal depression	44%	24%	16%	15%	22%
Breastfeeding	38%	26%	15%	16%	21%
How to dress my baby	32%	20%	14%	11%	17%
I didn't learn anything new as a result of getting a baby box	8%	17%	24%	26%	21%
Sample size (unweighted)	248	529	770	665	2236

With respect to learning how to monitor their baby's temperature, parents who took part in the qualitative research described how they had learned about the healthy temperature range for young babies from the instructions that came with the in-ear thermometer, and safe bath and bedroom temperatures from the bath and room thermometer. Both thermometers provided parents with the reassurance of being able to monitor these aspects of their baby's health and safety. Parents felt that they might not have thought to buy these items otherwise (or, in the case of the ear thermometer, not before their baby was ill). However, they reported using them frequently.

"The wee duck thermometer for the bath was brilliant, especially when she was first home and being new parents and stuff, do you know, it was quite daunting to give her her first bath anyway, and that sort of does give you a bit of peace of mind. And again it's something I probably wouldn't have got myself."

Lothian, 25-29, Income group 2, first child

Parents who took part in the qualitative interviews generally felt the information provided with the baby box was sufficient and comprehensive. One view was even that there was an overwhelming amount of information, when combined with all other sources they had received. However, when prompted during qualitative interviews, a few improvements or topics for additional information were suggested by parents, including:

• Improved instructions on using the wrap (as discussed above)
• Further information on feeding - while one view was that parents receive enough (or too much) information on breastfeeding already, another was that the baby box could include more information on this, including guidance on expressing milk, information about cluster feeding and signposting to healthcare professionals for further breastfeeding support. It was also suggested that the box could include information on bottle feeding as an alternative, particularly since some new parents may find themselves unable to breastfeed, despite having planned to do so.
• Information and signposting to support specifically for fathers, including information about male Post-Natal Depression
• Information on money and benefits, including how to claim Child Benefit and shared parental leave
• Information about local support and local parent and baby groups
• What to expect during the first few weeks after their babies' birth, including how to bathe a new baby, general information on how they might feel as new mothers, information aimed at new fathers, and what their baby might do during this time, for example, newborn sleeping patterns
• Information on weaning, including what is and is not safe for babies during the weaning process, as well as recipes and ideas of foods to try
• Information on when it is medically safe for new mothers to have sex after birth (since the box contains condoms), including information for mothers who had had their baby by caesarean section.

Midwives and health visitors who took part in qualitative interviews also felt that there was a risk of overwhelming new parents with information. However, they did raise a few additional areas which they thought could possibly be covered in the information provided with the baby box:

• Enhanced information about safe sleeping (the professional who made this suggestion was unable to say exactly what additional information they would like to see included, but nonetheless felt it could be covered in more detail)
• Baby first aid
• Information on all types of feeding options (not only breastfeeding), and
• Information on what to expect from the Universal Health Visiting Pathway in Scotland.

It was also suggested that information could be pulled together in one booklet, to prevent individual leaflets being discarded.

Question for consideration: Is the information included in the box sufficient, or are there opportunities to include additional information that parents might find useful?

Parent Club emails

Parent Club is a dedicated website for new parents in Scotland. Parents can also sign up to receive regular emails – there is an option to sign up on the baby box registration form, or they can sign up on the website. An additional objective for this evaluation was to examine parental uptake and views of Parent Club, in order to inform its future development.

Just under half (47%) of parents who responded to the survey had signed up for Parent Club emails, with the majority (64% of those who had signed up) doing so when registering for a baby box. No particular groups of parents stood out as more or less likely to sign up for the emails. During in-depth interviews with parents, the main reasons parents gave for not having signed up were either that they had never heard of Parent Club, or that they preferred to get information from other sources (including Google searches, looking at the Bounty or NHS Inform websites, or Facebook groups for parents).

Of those who had signed up, 20% of survey respondents said they always read the emails, 24% that they often did so and 34% that they sometimes did. One in five (19%) rarely or never read them. Younger parents were less likely to say they read Parent Club emails – 31% of 16-24 year-olds read them 'always' or 'often', compared with 52% of those aged 35 or older. Parents who took part in the in-depth interviews and had signed up but not read the emails said they had either been too busy after the birth of their new baby, or that they did not feel the need to read them, as they got the information they needed from elsewhere (from their midwife, family members, books, and other parent mailing lists).

Amongst those who had read the emails (even if only rarely), most parents reported finding them useful (21% said they found them very useful and 58% fairly useful). However, during in-depth interviews with parents, they generally described them as more of a 'nice to have' than something that had taught them anything new – indeed, it was suggested that some of the content was repetitive of other information they had already received. In spite of this, parents were typically positive about the coverage and tone of the emails and reported finding them reassuring.

Suggestions for improving the Parent Club emails included: sending information prior to birth; including ideas about games parents could play with their baby; and adding more information about weaning.

Question for consideration: Can anything can be done to improve the appeal of Parent Club emails to younger parents, and to encourage them to read them more often?

Perceived impact on engagement with health professionals

There are a number of policies and initiatives in Scotland aimed at improving engagement between health professionals and families, including notably reforms to the Health Visiting Pathway, which aims to increase and enhance the contact that families have with health visitors in their child's early years. While the impact of the Baby Box scheme cannot be seen in isolation from wider policies and activities to support engagement, it was envisaged during its design that the scheme would act as a mechanism for supporting and encouraging parental engagement with services.

Overall, a third of parents (35%) agreed that 'Getting a baby box encouraged me to talk more to my midwife, health visitor or family nurse about things I wasn't sure about'. A further 23% disagreed with this statement and 41% neither agreed nor disagreed or were not sure.

Health professionals were similarly divided as to whether the box was a useful tool in supporting conversations with parents – while 45% agreed that the box was a useful tool in supporting conversations with parents in general, 18% disagreed and 33% neither agreed nor disagreed with this statement. Similarly, while 50% of midwives, health visitors and family nurses said that the Baby Box scheme was having a positive impact on their interactions with parents, 44% said it was having no impact one way or another (the remainder were unsure – less than 1% said it was having a negative impact). Midwives were more likely to feel it was having a positive impact (61%, compared with 45% of health visitors / family nurses).

Midwives and health visitors interviewed for the qualitative research fell into three main groups with respect to views of the impact of the baby box scheme on supporting their engagement with parents:

• Those who felt it had made no difference – they felt they were already able to engage well with families (or not), and the box had no impact on this.
• Those who felt the baby box had an impact as a 'talking point' or 'conversation starter', which could help the conversation to flow more naturally, or to introduce more difficult topics such as cot death. One view was that it could be particularly useful in this regard in discussions with younger mothers or those who are unlikely to come to antenatal classes.

"It does help, [the box is] part of the whole parent education system, you know, you can tie it in with that. You can say 'there is stuff in the box that you can use'. People ask about their baby's long fingernails and that and you can say 'there is an emery board in the baby box, you can use that'."

Midwife

• Those who felt the scheme had a significant impact in supporting them to engage families in challenging circumstances – specific examples included: those who had low levels of English (where they could physically demonstrate things using the box and its contents); a low income family with a very premature baby where their midwife was able to support and engage them by getting the box for them; and a mother with significant mental health problems, where the midwife was able to discuss using the box as a safe place to put her baby if she started to feel unwell, before calling for help.

The finding that the box can be useful in helping health professionals engage with specific groups of parents also finds some support from the surveys of both health professionals and parents. Thirty-seven per cent of midwives, health visitors and family nurses felt the box had a positive impact on opportunities to engage families who might be less likely to engage with healthcare services, although 53% felt it had no impact in this regard. (There were no significant differences between the views of midwives and those of health visitors or family nurses on whether it was supporting opportunities to engage with families who may be less likely to engage with health services.)

Meanwhile, the parent survey indicated that younger parents were more likely to agree that getting a baby box had encouraged them to talk to a health professional about things they were unsure about (57% of those aged 18-24, compared with 28% of parents aged 35 of older). Similarly, first-time parents were also more likely than those with older children to agree that the box had encouraged them to talk to health professionals (39% of first-time parents compared with 31% of those with one to three other children under 18).

The findings therefore highlight both the potential scope for the baby box to support conversations with parents – including those in challenging circumstances or who are less likely to engage with health services – and the fact that health professionals are divided on whether it has any impact in this regard. Qualitative interviews with health professionals also found that professionals felt there was scope for them to have a greater role in promoting and discussing the purpose and use of the box and its content, and that this could be supported by further training and information about the scheme. There may, therefore, be a link here with the finding (discussed in Chapter 6) that only a minority of professionals felt they had received enough training or information about the Baby Box scheme.

Question for consideration: Is there scope to encourage greater use of the box and its contents by health professionals in support of conversations about positive parenting practices?

Perceived financial impacts

As discussed in Chapter 1, a key aim of the Baby Box scheme is to ensure that every family in Scotland has the essentials they need for their newborn baby. The contents of the baby box (including the box itself) would cost an estimated £298 to buy new.^[33] Interviews with parents explored their perceptions of the financial impact receiving the box had on them, and whether it had affected their spending decisions on newborn essentials.

The parent survey found that 91% agreed (72% strongly) that 'Getting a baby box has saved me money on things I would otherwise have had to buy'. Those on lower incomes were more likely to agree strongly with this statement – 77-78% of those with household incomes under £26,000 agreed strongly, compared with 62% of those on £52,000 or more.

Participants on lower incomes who took part in the in-depth interviews said that receiving the baby box meant they had access to everything they needed for their new baby, without having to go without particular items. This included both high value items they considered essential, such as the thermometers, and other items they were keen to try but felt were prohibitively expensive, such as reusable nappies or the wrap.

"We would have gone without the thermometers probably and they have been essential. [We] would have gone without the reusable nappies as well because unless you have got something there to gauge it on to know it [would work] … [the] initial expense would be too much of a risk for something we wouldn't have liked."

Highland, 30-34, Income 2, Not first child

They also reported that the cost savings from receiving the box had meant they had more money for other items for their baby, such as nappies and formula. It had also helped parents (particularly those on lower incomes) feel less restricted in terms of their finances in two main ways:

• Parents had newborn essentials to hand from birth, instead of having to spread purchases across a longer period of time to help them manage financially
• Parents had more freedom to buy non-essentials for their new baby, such as family days out.

For parents on higher incomes, although the box was less likely to be seen as essential to them financially, they nonetheless felt it had saved them money that could be spent on other things for their family, such as buggies, childcare, baby groups or general expenses. Other higher earning families noted that their current circumstances (including having recently moved house, being on maternity leave, or having twins) meant that, although they could manage, they had less disposable income than usual, so the financial savings from the box were very welcome.

Health professionals were also very positive about the impact of the scheme in ensuring equal access to newborn essentials. Three quarters (76%) agreed that the scheme is an effective way of ensuring that every family has access to newborn essentials. Midwives were more like to agree with this statement than were health visitors/ family nurses (81%, compared with 74%). Midwives were also more likely than health visitors / family nurses to be positive about the impact of the Baby Box scheme overall – 73% of midwives, compared with 63% of health visitors / family nurses, agreed that the scheme is 'making a useful contribution to supporting families with new babies in Scotland'. This may reflect the fact that midwives are more directly involved with registering families for their baby box, and are also more likely to say they have received information or training on the scheme (see Chapter 6), so may feel clearer on how it is intended to contribute to family support.

Qualitative interviews with midwives and health visitors indicated that their views on the extent to which the Baby Box scheme was fulfilling the aim of promoting equality varied with both whether or not they believed it was being well used, and whether or not they felt a universal scheme was the best way of delivering this outcome. In relation to perceived use, one view was that the fact that take-up was high alone meant the scheme had succeeded: 'in public health, it's rare to get people wanting what you're giving them, so this is a success' (Health Visiting Team Lead). However, different opinions were expressed on the extent to which the box and its contents are well used in practice, particularly among families on low incomes. One view was that the scheme has been particularly helpful for the most vulnerable families – professionals gave examples of families in homeless units, asylum seekers, and families on the very low incomes who they felt had benefited hugely from receiving the box when they had very limited resources. However, another view was that the box and its contents were less well used by those on low incomes, who might be expected to benefit most. It was suggested that stigma (around using a box for sleep, and around dressing their babies in the same clothes as others, for example) was contributing to this:

"We have a very large Syrian community and a lot of the women have come over with nothing or very little and some have come over pregnant. I think the baby box makes a big difference for them, and we actually see a lot of them using the box as somewhere for the baby to sleep safely"

Midwife

"I think the people who most need the boxes tend to be the ones who don't use them. I live and work in quite a socially deprived area"

Midwife

The survey and qualitative interviews with parents do provide some support for the view that parents on lower incomes are less likely to use the box itself for their baby to sleep their baby in (see Chapter 3). However, the findings above indicate that parents on low incomes are nonetheless more likely to feel the box has saved them money and provided essential items for their newborn which they might otherwise have struggled to buy.