• By Dartington SRU
  • Posted on Tuesday 16th February, 2010

For better prevention maybe don't do that

For every handful of family support programs known to work, there are many more in circulation that just as certainly do not, and, as evaluation methods improve, so the argument against throwing good money after bad becomes more potent.The case was put plainly enough in these pages two years ago by the Director of Research at the UK National Academy for Parenting Practitioners, Stephen Scott.He acknowledged that decommissioning was a painful prospect. "People grow very attached to the interventions they are delivering," he wrote. "They want to feel justified in what they do. But in future the emphasis must be on delivering what is right for children and their parents, rather than on permitting an organization to carry on doing the same old thing even if when it doesn't work."The public spending climate was already changing, and it has changed more dramatically since. Weeding out bad services has necessarily become a more palatable prospect.The case for "disinvestment" is still a relative novelty in a research report, even so. As the Early Years Task Group whose work has just been published as part of the UK Strategic Review of Health Inequalities explains, research conclusions more normally include recommendations for new spending."Practitioners are increasingly told what to add to their 'to do' lists without being told what might be left off."Alan Dyson, Jane Tunstill, Helen Roberts, Clyde Hertzman and Ziba Vagheri focus on disconcerting evidence from three fronts: the value of mentoring to prevent antisocial behavior in childhood, public health campaigns that assail parents with leaflets and educational materials, and area-based regeneration initiatives. They give shortest shrift to leafleting: "Nostrums on what to do, or what not to do, without having the resources to turn these into a reality can be debilitating for parents," they write. Anxieties about regeneration initiatives center on the knock-on effects. So, while a UK review of their performance showed improvements in average employment rates, educational achievements, household income and housing quality – all of which, the researchers say, may contribute to a reduction in inequalities in health – the associated surge in housing costs, had the effect of rendering residents poorer. They were driving out of the neighborhood the very people they were intended to help. The researchers conclude: "It is important to monitor the outcomes of social and public health policies, not only for their overall impact, but also for their potentially differential effects on socio-economic groups and the possibility of actual harm for some groups."The reservations about mentoring programs for vulnerable young people focus on the damage too often done when mentor-mentee relationships break down:

    Worryingly, a ten year follow-up study of one well designed scheme found that a sub-group of mentored young people, some of whom had previously had been arrested for minor offenses, were unexpectedly found to be more likely to be arrested after the project than those not mentored.
    On the basis of findings such as these, and on the evidence available at the time, it was concluded that non-directive mentoring programs delivered by volunteers cannot be recommended as an effective intervention for young people at risk for, or already involved in anti-social behavior or criminal activities.
It did not mean mentoring was ineffective – just that meta-analysis had uncovered a big variation in the findings associated with different schemes. Mentoring was non-invasive and medication-free. It was easy to see why it might work, and why it was attractive to politicians and policy makers. Robust research indicated benefits from mentoring for some young people, for some programs, in some circumstances, in relation to some outcomes.The state of knowledge made its status similar to that of a new drug that was showing promise, but was in need of further research and development:
    There was no equivalent of the National Institute for Health and Clinical Evidence (NICE) or Food and Drug Administration (FDA) for mentoring. If there were, no more than a handful of programs might have realistic hopes of qualifying. And even then, it would have to be acknowledged that a full understanding of the safeguards needed to ensure that young people were not harmed by participation was lacking.
• The Strategic Review of Health Inequalities in England was commissioned to advise the UK Secretary of State for Health on the future development of a health inequalities strategy, by taking into account the best global evidence from the WHO Commission on the Social Determinants of Health, and the work of the last ten years. Documents and launch conference proceedings are available online.See also: Time to start stopping what we know doesn't work?

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