The Evaluation of the Family Nurse Partnership Programme in Scotland: Phase 1 Report – Intake and Early Pregnancy

6 EARLY CLIENT IMPACTS

This chapter explores information from the monitoring data about clients' knowledge and behaviours at (or shortly after) enrolment. ¹⁴ It also uses the qualitative interviews to consider clients' and Nurses' perceptions of the early impacts of the Family Nurse on specific health behaviours, knowledge and understanding and on clients' wide social and economic situation.

6.1 Smoking, alcohol and drug use

Data about smoking, alcohol and drug use were collected at the third or fourth visit after clients enrolled with the programme. Almost two-thirds (62%) of clients in the FNP Edinburgh programme had smoked at some point in their pregnancy. This was somewhat higher than the figure at enrolment into the programme reported for the first 10 pilot sites in England of those reporting smoking in past 48 hours at intake to the programme (40%) and those reporting at intake to the programme that they had ever smoked in pregnancy which was 45% (Barnes et al, 2008). This figure is also considerably higher than the rates for smoking in pregnancy in Scotland. Although, as the FNP clients are specifically a group of younger pregnant women, this may reflect the evidence that smoking amongst young women is much higher than in the population as a whole, hence one of the explanations for much higher levels. Provisional figures for 2009 indicate that less than 1 in 5 (18%) pregnant women smoked during pregnancy in Scotland (Scottish Government, 2011). However, several studies have identified a tendency for women in general to underreport smoking during pregnancy, perhaps due to the social stigma associated with smoking while pregnant (e.g. Boyd et al, 1998). It is therefore possible that the higher reported smoking rates among FNP clients in part reflect a greater willingness to acknowledge smoking to their Family Nurses than might be the case where they asked by another health professional (see discussion in section 5.4). Of the clients that had smoked at some point during pregnancy, 69% had smoked at least one cigarette in the previous 48 hours, with a mean of 15.5 cigarettes for that period. Of those who reported smoking during pregnancy, approximately a third had not yet been referred to a smoking cessation service, a third had accepted smoking cessation support and the remaining third had declined a referral.

Six percent of clients reported to their Family Nurse that they had consumed alcohol in the previous 14 days - a much lower figure than the 14% reported for the first 10 pilot sites in England (Barnes et al, 2008). The number of days range from one to two, and the number of units consumed on any day ranged from one to six, with a mean of two units.

Recorded use of illicit drugs was low: five clients (3.4%) had used marijuana in the previous 14 days, using this drug on between 1 and 14 days. In addition, fewer than five clients reported using any other form of street drugs. These figures are very similar to those reported by Barnes et al for England.

All clients interviewed as part of the qualitative panel reported that they had spoken to their Family Nurse at some point during their pregnancy and to varying degrees about smoking, alcohol and drugs, although this obviously varied according to their current use of any of these substances. Where substance use had been discussed in more detail, clients said that they had learned from their Family Nurse about the effects of the substances during pregnancy and on the baby after birth.

I probably knew some bits from school, but, apart from that, I never really thought about the after effects after the baby's born. I just thought the effects obviously during pregnancy. I never really thought after … when the baby's born what kinda effects it would have.

[Pregnancy Interview, Client 1]

Well I, to be honest I already knew about like drinking alcohol and taking drugs but I never knew about the smoking thing because my gran smoked with all her three kids while she was pregnant and my gran keeps on saying that later on they were fine.

[Pregnancy Interview, Client 13]

Clients reported that talking to Family Nurses had had an impact on their and their family's behaviour. Although clients may have tried to cut down smoking before speaking to the Family Nurse, they reported that they tried to cut down even more afterwards. There were reports of family members who had also tried to stop smoking around the client after she filled in a form about how much smoke she was exposed to. Family members would now leave the room when smoking, open a window or limit smoking to one room in the house.

I smoke maybe about two or three a day but it's because of what I got told fae the Family Nurse that I tried tae cut doon.

[Pregnancy Interview, Client 11]

Clients reported that they had not started drinking again after the first trimester as they had planned. The Family Nurses' advice that they needed to make a good home for the baby and that the baby was depending on them appears to have had an impact on clients.

Clients were happy to discuss these issues with their Nurse, reporting that they felt comfortable doing so as she never judged them and did not ask direct personal questions, such as "do you take drugs? How much do you take? Do you drink loads?" From the clients' perspective, everything they talked about with their Nurse was relevant.

6.2 Maternal mental health

Maternal mental health was measured at enrolment using the Hospital Anxiety and Depression Score ( HADS). HADS was used alongside the Edinburgh Post-natal Depression Scale ( EPDS) which is routinely administered in Scotland to all mothers in the postpartum period. Although higher scores are associated with low mood and potential depression or stress and adjustment disorder, there is no agreed cut-off score for HADS (Walker et al, 2006, Herrmann, 1997). However, the tests authors suggest scores of 8-10 suggest mild cases of anxiety and depression, scores of 11-15 moderate cases, and 16+ severe cases (see discussion Crawford et al, 2001). A systematic review of studies assessing depression during pregnancy which had used a range of assessment tools found that rates of depression ranged from 7.4% in the first trimester to 12.8% and 12% in the second and third trimesters of pregnancy (Bennett et al, 2004). A quarter (26%) of FNP clients were reported to have scores of 15+, with a further 18% scoring 11-14. Thus if HADS scores of 11 or more are taken as indicating moderate to severe anxiety and depression, then the HADS data for FNP appear to indicate that the enrolled clients had higher rates than other populations of pregnant women.

Percentage of clients scoring in each HADS score category

HADS Score	Clients at Intake (%)
Below 8	32
8-10	24
11-14	18
15+	26
Base	136

Clients who spoke to their Family Nurse early on about negative emotions could find this difficult at first, primarily because they did not want to speak to anyone about how they were feeling. However, those clients who had spoken to the Family Nurse about such feelings said that acknowledging their stress or distress to the Nurse who they trusted was helpful and reassuring. Clients contrasted the Nurses' concern with their emotions with midwives and GPs, who were perceived to have little regard for their feelings. Clients who had more serious emotional health difficulties reported that they were referred by their Family Nurse (or were offered a referral) to counselling services and were given advice about how to "get into a routine" and "give yourself something to do in order to feel better". This was appreciated by these clients.

6.3 Domestic abuse

Data on domestic abuse is derived from the FNP monitoring data gathered shortly after their enrolment (base=134 ¹⁵). It was agreed that this topic should not be included in the first evaluation interview, but will be explored in future interviews.

Almost a third (31%) of clients reported having experienced emotional or physical abuse at some point in their lives, including almost 1 in 4 (23%) who had been abused by a partner or someone important to them. 1 in 5 (19%) clients reported being physically abused in the year prior to enrolment, of whom almost half (46%) were abused by their current/ex-partner, more than a third (39%) by a friend/acquaintance/family member and almost a quarter (23%) by a stranger ¹⁶. The majority of these clients (69%) had been physically abused once or twice, with the remainder having been abused more often. The forms of abuse reported were a slap or push (73%), a kick or cut (54%), a burn, bruise or broken bone (31%), a head, internal or permanent injury, or being abused with a weapon ¹⁷. In addition, a small minority of clients reported being forced by either an ex-partner or a stranger to have sexual relations in the last year.

Since becoming pregnant, 1 in 20 (5%) of all clients reported being hit, slapped, kicked or otherwise physically hurt by someone else. There were no new events of physical abuse against clients who had not already experienced abuse before becoming pregnant and, apart from one incident, the perpetrators appeared to be the same people (reported as same category of perpetrator). Fourteen percent of clients reported being afraid of a current or previous partner, of which around a third were afraid of their current partner.

These figures are similar to those reported for the pregnancy period in the first 10 pilot sites in England - although the reported abuse rate for the previous 12 month period appears to be slightly lower for Scotland (19% in Scotland vs. 24% in England), this difference is not statistically significant. The figure for abuse since becoming pregnant was, however, slightly but significantly lower in Scotland than that reported for England (5% vs. 11%). ¹⁸

6.4 Accessing ante-natal care

All clients in the qualitative panel had seen their midwife during their pregnancy, but had also talked to their Family Nurse about aspects of their ante-natal care. This included asking for advice if there was anything concerning them or if they had forgotten to ask the midwife something. They might also ask the Family Nurse to explain their notes to them if they did not understand the "lingo" or to explain blood tests and scans. The Family Nurse was able to explain the purpose of tests and - on occasion - prepare the client for potentially bad news. Clients valued this support.

Clients reported mixed relationships with their midwife, either saying they felt pretty lucky to have a really nice midwife as well as a Family Nurse or reporting that they did not know their midwife and did not have enough time with them to get to know them as well as the Family Nurse. Where clients felt that they did not have a relationship with their midwife, they were reluctant to ask her questions and felt that they were "shooed back out" as soon as the check up was over [Pregnancy Interview, Client 3]. This was contrasted with the Family Nurse, who they perceived would sit and talk to them and answer questions for as long as needed.

All clients were made aware of possible ante-natal classes they might attend through their Family Nurse, midwife or both. There were clients who did not want to attend ante-natal classes, either because they felt that they lacked of confidence or the times of classes were not convenient. Of those clients who did in fact attend classes, there was a view that the information given was similar to that which they received from their Nurse, but that the information received from the Family Nurse was much more detailed. Clients particularly praised classes they were referred to for young mothers, as they felt they "fitted right in", because they were designed for younger women. However, it is worth noting that the FNP team in Lothian had some reservations about the content of the ante-natal support provided through some classes geared specifically at teenagers. While they recognised the benefit clients may have gained from the social aspects of attending such services, there were some concerns that the messages clients received about breastfeeding, for example, did not always chime with the messages the FNP team were hoping to convey. Moreover, these classes were not available to all FNP clients, as the main service offering ante-natal services specifically geared to young expectant mothers in Edinburgh stopped delivering relatively early in the recruitment period of FNP.

6.5 Intentions to breastfeed

Monitoring data from shortly after enrolment ¹⁹ shows that a third (32%) of the clients definitely intended to breastfeed, 42% said that they would possibly breastfeed but were not certain, and a quarter (26%) were definitely not intending to breastfeed.

The Growing Up in Scotland data (Sweep 1) indicate that 40% of mothers aged under 20 had intended to breast feed and that 75% (30% of all teen mothers) of those went on to breastfeed at all (Scottish Executive, 2007). At this point, the intended breast feeding rates (combining definite plus possible breast feeders) for the FNP clients appears to be higher than the figure for GUS. ²⁰ Once the post-natal data are available, it will be possible to assess whether the FNP clients have elevated breast feeding rates compared with all teen mothers in Scotland.

Unless clients expressed a strong preference for one feeding method and requested not to talk about alternatives, Family Nurses were praised by clients for being unbiased and non- judgemental about infant feeding. Clients' perceptions were that their Nurse explained the advantages and disadvantages of each feeding method, but would never say that one method was bad. This was contrasted with a view of midwives, who were perceived as putting pressure on clients to breastfeed:

…[the Midwife] just keep going on and on about breastfeeding and how good it was, but with [Family Nurse] she was just like 'I'm not going to say you should be doing this, it's totally up to you, I'm never going to judge you in any way and I'm not going to pressure you and say breastfeeding's got all these benefits'. We sat and went over like the pros and cons of bottle-feeding and breastfeeding, so I dinnae feel like the pressure that normally got from my midwife about it, so it was really good.

[Pregnancy Interview, Client 9]

Clients reported being told everything they needed to know, including making up bottles and sterilising bottles, attaching the baby, and how to know if the baby has had enough breast milk. There was a view that it was useful to know the benefits of each method. In terms of breastfeeding, clients found it helpful to talk about it with the Family Nurse as there were a lot of things they found that they had not known and hoped that having had all the information beforehand, they knew what to expect. Clients were reassured that bottle feeding would not be detrimental to their baby and nor would it affect bonding with the baby. After speaking to their Family Nurses, qualitative panel clients were almost equally split between those who intended to breast feed and those who intended to bottle feed.

The fact that clients' reported that their Nurses gave balanced advice and did not say one method of feeding was good and one bad should not necessarily be interpreted as implying that Family Nurses were not working with clients to encourage them to breastfeed. Rather, the specific approach FNP takes to working with clients may mean that, particularly at the stage at which the evaluation interviewed clients during pregnancy, clients do not recognise this directly. FNP emphasises working with clients' own feelings and potential resistance to behaviour change, but using motivational interviewing to try and support them over time to make healthier choices for themselves and their babies. Subsequent evaluation reports will provide further evidence on the impact which this approach appears to have had on eventual breastfeeding rates among clients.

6.6 Housing and finance

Monitoring data shows that at enrolment, a fifth (21%) of clients lived with their husband or partner only and 1 in 10 (11%) lived alone. The remainder lived with some combination or husband/partner, family and friends/others. In addition, 10% of clients were classed as homeless.

Family Nurses talked to clients about various aspects of housing, benefits and money management. In terms of housing, Family Nurses were perceived to have helped clients in several different ways: they talked through situations and scenarios, they helped clients through the process of securing new accommodation, they told clients how to get and fill in forms for housing benefit and council tax benefit, answering questions and writing letters in support of applications to the council. Clients reported being grateful and finding it helpful to have this support, particularly as for some obtaining housing benefits was perceived as causing more problems during pregnancy than anything else.

There were clients who had not yet discussed money management with their Family Nurse. For those who had, Nurses gave information about the benefits clients may be entitled to and clients were given a money management sheet on which they could fill in their incomings and outgoings. While there were clients who found this "silly" at first, the idea was deemed more helpful with time. Until their Family Nurse asked how they were going to manage, clients had not necessarily thought about money, just about the pregnancy and baby. Certainly, clients were aware of the impact of the Family Nurse on their spending and saving. There was also appreciation of advice about benefits with clients not always knowing what they might be entitled to, where to go for help and what forms to complete.

At this early stage, the impact of the programme on the clients in the qualitative panel's lives as a whole varied. While there were clients who could not identify specific impacts, others felt that the Family Nurse had made things more manageable in different ways. Family Nurses provided advice and information about a wide range of topics - infant feeding, smoking and alcohol and their impact on the unborn and newborn baby, money management, benefits and how to seek help with housing. Family Nurses were thought to have made clients' lives more manageable by being there if the client needed to talk, was worried or required extra support or information.