gms | German Medical Science

The early support programme (Frühe Hilfen), which was first introduced in Germany in 2009, supports parents and their children from early pregnancy up to the third year of the child’s life. The National Centre for Early Support (NZFH) offers tailored help for parents and children and also fills gaps in the local social and health care services [13]. These programmes incorporate various professionals and institutions offering pregnancy counselling, social and health care, as well as children and youth health services [21]. The National Centre for Early Support originates from the Youth Welfare Office, which is responsible for child protection services. For this reason, early support networks and the Youth Welfare Office are generally in close contact. Various health professionals are involved in early support programmes because of their high acceptance rate in the community [17].

Starting a family affects the life of all family members and their social networks. Vulnerable parents and parents with a low socioeconomic status require additional information and tailored support during this time [16]. This is where the early support programme comes in. However, vulnerable parents often use these services less than parents in better circumstances [20]. It is assumed that vulnerable parents often come up against more barriers to accessing this support. The negative impact on children’s living conditions of inequality in health literacy and uptake of healthcare is exacerbated by the differences in access to early support [11]. In light of this, vulnerable parents in particular should be introduced to early support programmes [19]. The way in which contact is established is crucial for motivating parents to engage with early support. Contact can be initiated in a universal or selective manner [7]. There are only a few areas of Germany where a systematic and universal approach is taken to contacting families after the birth of a child to introduce them to early support [17]. Local authorities use a variety of different ways to approach families. A total of 70 percent of the local departments for youth and health care use written information to establish contact with families. In addition, two-thirds of the local Youth Welfare Offices and about half of the local health departments offer drop-in and referral services for parents.

About 50 percent of the local authorities have implemented a service whereby staff from the Children and Youth Health Service (KJGD) make home visits soon after birth. The aim is to identify vulnerable families and introduce them to the services they can access through early support [22]. International research has shown that home visits to this target group are particularly well suited to initiate contact and reduce barriers to the care and support offers of the early support scheme [16], [19]. Universal prevention approaches that include a home visit after birth allow for large-scale screening of parents regarding their need for help and offer them further information about early support measures.

In Germany, as well as in other countries, there is a lack of scientific evidence about how best to approach vulnerable families and the families’ perception of how contact is made. In response to this, the Berlin Senate Department for Education, Youth and Science commissioned an explorative study which was conducted in four Berlin districts over the course of three months.

In order to provide a systematic and effective analysis of how parents were approached and how this can be improved, both parents and professionals were asked how contact was established. To approach the subject from different perspectives, a mixed methods study design was chosen [4].

The qualitative part of the study comprised semi-structured interviews with users of early support measures. The aim was to gain an insight into parents’ experience of their first contact with early support programmes and determine the factors which influenced their decision to participate in early support measures.

Data protection rules prevented the research team from contacting parents directly. Therefore, contact with users was established through professionals offering early support measures. Inclusion criteria for participants were adequate knowledge of the German language and enrolment in one of the early support programmes. Establishing contact with service users proved difficult. Theoretical sampling [9], which would have assured the inclusion of participants with different educational and socioeconomic backgrounds, was therefore not feasible. In total, nine service users were recruited to participate in the study.

All interview participants received information about the background and aim of the study and gave informed consent. The consent form assured anonymity and provided participants with the option to leave the study at any time, as well as the deletion of all data upon completion of the study. Semi-structured telephone interviews with open-ended questions, lasting about 15 minutes (min 10.5 minutes; max 20 minutes), were conducted. All interviews were recorded digitally and transcribed verbatim. The interviews were analysed using structured qualitative content analysis to identify central themes concerning the establishment of contact with parents and their uptake of early support offers [10].

In the quantitative part of the study, professionals working within early support programmes were asked to complete a standardised online questionnaire. Inclusion criteria for these individuals were that they are actively involved in establishing contact with families and/or play a coordinating role within the network. These experts were reached through lists of staff email addresses provided by early support projects. They received the same information about the study, regarding the background and aim, as the participants in the qualitative part.

The online questionnaire included 18 items. Three items focused on the participant’s work (i.e. healthcare, youth welfare or social care). Five items asked how contact to vulnerable families is made, and another five items asked the participants to evaluate the effectiveness of these contact options. The participants were asked through open-ended questions how they would optimise the methods used to access families. Lastly, four items gathered sociodemographic information about the participants (age, gender, professional experience with early intervention programmes and professional qualification). Data was analysed using descriptive statistics with IBM SPSS Statistics 24. Due to the short duration of the study, only a limited number of participants could be recruited in the two study strands. This and the regional reference of the study do not allow for a generalisation of the results.

Nine women who had participated in early support measures were interviewed. The women were aged between 21 and 38 years (mean 31). Six of the women had one child, two had two children and one had three children. Four of the women reported that they had completed their A levels, three had completed upper secondary education and two had completed secondary school/GCSEs (see Table 1 [Tab. 1]).

One woman had contacted early support professionals during pregnancy. Two women made contact after the birth of their children. Six women became aware of the early support scheme through a leaflet sent out by the local health authority or a home visit by the Children and Youth Health Service.

Home visits by the Children and Youth Health Service were brought up as a topic in several of the interviews. Parents expressed that they had been surprised to receive a letter announcing a home visit by the Children and Youth Health Service. It became clear that they had been unsure of the origin of this letter. Several of the participants thought this would be a visit from child protection services. This left the participants feeling watched and monitored. One mother reported:

It became clear that the home visit was seen as having a monitoring purpose. The participant accepted the home visit, since she felt that she had nothing to hide and feared that cancelling it would attract the attention of the child protection authorities. Another participant perceived the visit primarily as being for monitoring and only secondarily as an information service offered by the local authorities, as illustrated by this statement:

One interviewee suggested that information about the home visit should be distributed at the hospital after the birth to avoid these concerns, so that parents “(…) aren’t thrown in at the deep end (…)” (E.30). She herself was not surprised by the visit because she works at the district office and so knew about the home visit by the Children and Youth Health Service. Had this not been the case, she would have wondered:

On the other hand, one woman who was informed by her midwife in advance valued the visit as something positive. It can clearly be deduced from the interviews that the Children and Youth Health Service needs to emphasise the visit as an opportunity rather than a risk for families. The purpose of the visit was undoubtedly to ensure “the welfare of the child". One participant said that it is important:

In summary, before the home visit by the Children and Youth Health Service takes place, it is perceived by the service users interviewed as being to identify children at risk. It was clear that the written notification of the visit by local health authorities led to ambivalent feelings. Although they first perceived it as a form of monitoring, those interviewed accepted the visit, saying that the welfare of children should come first.

The participants’ experience of their actual home visits by Children and Youth Health Service was positive and they deemed it a family-friendly initiative by the authorities. It represented an opportunity to relay information and signalled the willingness of this institution to look after young families. One interviewee perceived the home visit by a social worker as helpful. She initially thought that she would not benefit from it. In the end, though, she confirmed that she had received some useful information. She also said the social worker was very nice, and that they had a “nice conversation” (E.06). Another participant reported that, during the visit, she received a voucher to participate in an early support measure for free. Overall, she rated the visit as follows:

She further described the home visit as nice and helpful regarding information about the local care infrastructure. According to this interviewee, families who are less well informed or those with language difficulties, in particular, can benefit from the visit. Another participant expressed a similar view on the visit by the Children and Youth Health Service. She said that it is:

Apart from the informational aspect of the visit, this participant also acknowledged the authorities’ efforts to check on the wellbeing of the family. Another participant also confirmed the potential of the visit to support and monitor parents who are not being looked after by a midwife in the postnatal period. She herself did have a midwife, but the social worker could also have checked where the child was sleeping and observe how the parents were caring for the child and “(…) maybe have them do a nappy change” (C.78).

The women who were interviewed made specific suggestions on how to improve the flow of information regarding early support measures. They mainly identified professionals or institutions with whom young parents come into contact almost as a matter of course: obstetricians, midwives, paediatricians, health insurance funds and the registry office. Obstetricians’ ambulatory practices were suggested numerous times as a place where pregnant women could be provided with information. “I mean, all pregnant women see an obstetrician. I think this would be the best place to reach them.” (A.40).

Obstetricians are not expected to advise on topics other than medical care. Since their waiting rooms are stacked with various flyers and brochures, they are seen as a platform for information exchange. Hospitals were also mentioned as information platforms since most families can be reached there. The respondents suggested handing out information leaflets about the early support programme during routine antenatal checks. Lastly, respondents also referred to health insurance funds and registry offices, since the chance of reaching almost all parents is highest there.

Another suggestion that was made was to increase public awareness of early support measures. One participant specifically mentioned the leaflet entitled Wegweiser aktuell, which lists the services offered in each district. These leaflets can be a useful reference for parents over a longer period as shown in this statement: “I keep it and look through it once in a while.” (B.62). The respondents were also in favour of using public advertising material, such as billboards. Furthermore, the results of the survey showed that the way children benefit from early support measures should be more strongly emphasised. The users of early support measures also believed that testimonials from parents could help draw attention to the scheme and increase its outreach.

A total of 48 professionals from early support programmes took part in the quantitative study. The statistical analysis included 26 completed questionnaires. All study participants were female and aged between 33 and 63 years (mean 48.8 years). Their professional experience varied from 2 to 40 years (mean 10.92 years). Among the study participants were 14 social workers and 4 professionals from various other professions (e.g. psychotherapist or public health midwife). Furthermore, 13 study participants had coordinating roles, 11 were in direct contact with families and 2 had roles in team management and counselling.

A total of 19 study participants reported that they used a systematic set of guidelines for establishing first contact with vulnerable parents, while 6 participants reported that their organisations had no such guidelines. One participant was unsure whether or not they had guidelines at her workplace. Of those workplaces that had guidelines in place, 12 kept written guidelines and 3 relied on verbal agreements. Four participants selected “other” in response to the question about the type of guidelines at their workplace.

A total of 22 study participants answered the question on how the first contact with parents was made. According to the answers, the first contact was initiated either by the parents themselves or by third-party institutions (see Table 2 [Tab. 2]).

Almost all study participants [20] considered the methods used to initiate contact with families to be advantageous, while one did not. Another question asked whether the institution evaluated the effectiveness of its access methods. A total of 11 study participants reported regular evaluation, another 11 reported none, while 3 participants did not know whether or not a regular evaluation took place.

The parents who were interviewed regarded the home visit by an employee from the Children and Youth Health Service as a routine administrative process for all families after the birth of a child. However, many parents were surprised by the visit because they were not familiar with the process and its purpose. Even though they were not informed about the visit beforehand, the parents still allowed access to their homes. Not knowing that the visit was optional, they worried that it would attract the attention of the Youth Welfare Office if they cancelled the visit. Those parents who were already familiar with this process had randomly obtained the information about it through their social networks. They perceived it as legitimate and plausible. They understood the authorities’ concern for the children’s welfare and their living conditions. However, the parents criticised that the home visit seemed to be mandatory, and that it was left up to them to cancel. Hence, to them, the visit by the authorities appeared to be for monitoring purposes. At the same time, the visit was retrospectively classified as helpful, and the Children and Youth Health Service staff were described as friendly and respectful.

Since only a few questionnaires could be evaluated in the quantitative part of the study, these results should rather be understood as background information to the qualitative part. Almost three-quarters of the experts reported that there is a written procedure for establishing first contact with families. The experts generally perceived the establishment of contact with the parents as successful. Surprisingly, only four of the respondents referred to the Children and Youth Health Service as an institution which establishes contact with parents, whereas this method of contact was often mentioned in the interviews. The experts reported that, while some contacts are initiated through the home visit by staff from the Children and Youth Health Service, parents often establish contact themselves. However, the data does not provide any information about how parents find out about the early support programme. The experts also mentioned the possibility of third-party institutions flagging up vulnerable families as a relevant way of establishing first contact. This was also evidenced by the interviews, where some mothers reported having already been contacted by early support professionals during their stay in hospital after the birth of their child. In these cases, hospital staff put the families in touch with a public health midwife, for example.

The parents saw the potential to optimise the way that families are contacted. They felt the information provided about the home visit by the Children and Youth Health Service was insufficient. They suggested preparing new parents by providing them with transparent and comprehensive information during pregnancy. Obstetricians’ and midwives’ ambulatory practices could be suitable places to provide this information.

This study confirms that home visits by the Children and Youth Health Service have the potential to establish systematic access to vulnerable families [23]. For those parents who established contact themselves, it was not known how they obtained the information about the support measures. Furthermore, third-party reporting mechanisms also seemed relevant for establishing the first contact.

Initially, parents saw the home visit less as an offer of early support and more as a monitoring mechanism used by the authorities, with no option to cancel the visit. Sarminski [18] pointed out that, due to its similarity with the usual approach taken by child protection services, this way of establishing contact instils fear in parents that they are being monitored and stigmatised [18]. Since the Children and Youth Health Service is part of the health service authorities, it was deemed the right institution to carry out these home visits. This should be explained in detail to parents, since any similarity with child protection services can have a negative impact on parents’ motivation to participate in the visit and acceptance of it.

However, the role of early support professionals also includes recognising threats to a child’s welfare and acting on these, as well as organising ongoing care and support measures [7]. Therefore, early support schemes require multidisciplinary cooperation. In an American study, parents also reported feeling that the visit was of a monitoring nature. At the same time, they criticised formalised screening, which they felt did not reflect their individual situation [16]. These results correspond with the statements made by the respondents of this study, who welcomed the visit by the Children and Youth Health Service particularly because of the approachable manner of the professionals and the fact that they did not give the impression they were monitoring the parents. However, no non-users of early support programmes could be surveyed due to the short duration of the study, which indicates the need for more research.

Some families were not aware of the home visit by the Children and Youth Health Service and the early support measures initiated by hospital staff, for example, after preterm birth or twin birth. These findings confirm the results of Woolfenden et al. [24] and Lakes et al. [8]. According to these studies, parents mainly obtained information about options for support from relatives and friends. Professionals they were familiar with and who were part of daily life (i.e. professionals in medical practices) also played an important role as a source of information. Parents explained that the reason they did not take up support offers was the lack of information [12]. Clauß et al. also see doctors’ ambulatory practices as an important referral point to early support services [2]. Belzer et al. [1] and Clauß et al. [2] also emphasise the positive role that hospitals can play in screening families to ascertain who may need help and in referring them to early support services. Especially with the large number of families requiring support due to medical factors (e.g. premature or twin birth), medical facilities can take on a referring role.

The educational background of parents has been shown to be an important predictor of their knowledge about prevention programmes [3]. Neumann and Renner [15] hypothesised that the linguistic and aesthetic design of the information material for primary prevention programmes was not appealing to parents with a lower level of education. At the same time, these parents were less satisfied with primary prevention measures, which could result in them being less interested in participating in further activities [15]. The participants in this study mainly had a high level of education, yet they still reported a lack of information regarding early support offers. This suggests that the information provided would be unlikely to reach less educated parents.

Providing better and earlier information could be helpful in improving transparency and clarifying the aim of the support measures. Therefore, information material about early support measures should be made available to the public and particularly to women during pregnancy. The respondents suggested distributing information material via obstetricians’ ambulatory practices, for example. Although the announcement of the home visit worried parents, they recognised the purpose behind the visit. A broad-based information campaign has the potential to enhance this method of establishing first contact with parents. In terms of public relations and how support offers are communicated, the provision of information addressing parents can help optimise the way they are contacted [14]. However, there is evidence (in the literature) that information only encourages participation if it is tailored and individualised, while standardised information material is less appealing [16].

In conclusion, if contact was established through a home visit by the Children and Youth Health Service, parents were initially concerned because this was sometimes perceived as a monitoring mechanism used by child protection services. However, the study also showed that early support has a high acceptance rate among parents. Then again, the professionals were not aware of the parents’ concerns and considered the ways in which they established contact to be advantageous. That said, many of them reported that regular evaluation was missing. By uncovering this contradiction, this study reveals the lack of research in this area.

The research project was funded by the Senate Department for Education, Youth and Science of the State of Berlin.

The authors declare that they have no competing interests.