How volunteers can work with parents to improve early childhood outcomes: A review of the evidence

A 2015 review carried out in the UK explored whether and how volunteering and peer support can contribute to improving key child development outcomes...

Jenny McLeish 
Research Associate, Institute for Voluntary Action Research

Leila Baker 
Head of Research, Institute for Voluntary Action Research

Celia Suppiah
CEO, Parents 1st

A 2015 review carried out in the UK explored whether and how volunteering and peer support can contribute to improving key child development outcomes for children aged 0-3: social and emotional development, communication and language development, and diet and nutrition. It found evidence that volunteers can have a positive impact on all three outcomes, both directly and indirectly. This article summarises the strengths and weaknesses of different models of volunteering, how volunteers can engage with families who are ‘hard to reach’ for professionals, the key features of successful volunteer programmes, and the importance of volunteers working alongside professionals.

A Better Start (ABS) is a ‘test and learn’ programme in England, funded by the Big Lottery Fund which gives grants to organisations in the UK to help improve their communities. 
It aims to facilitate system change locally and to improve outcomes in pregnancy and for children aged 0-3. It brings together public services, the voluntary and community sector, and communities, to co-produce and deliver more joined-up services for all families living in the area. The programme is running in five partnership areas (Bradford and Blackpool in the north of England; Lambeth in London; Nottingham in the east of England and Southend-on-Sea, east of London), each of which will receive an investment of £36-£49 million during 2015-25. ABS is particularly aiming to improve outcomes in three key developmental areas:

1. Social and emotional development: preventing harm before it happens as well as promoting good attachment.
2. Communication and language development: developing skills in parents to talk, sing, read to, and particularly to praise their babies and toddlers and to ensure local childcare services emphasise language development.
3. Diet and nutrition: encouraging breastfeeding and promoting good nutritional practices, giving practical advice on healthier meals for young children and portion sizes.
To support the development of ABS services, in 2015 an evidence review was commissioned to explore whether and how volunteering and peer support could contribute to improving these child development outcomes. The ABS partnerships had asked for evidence of ‘what works, when, for whom and in what circumstances’. The review was led by social enterprise, Parents 1st,  and carried out by researchers from the Institute for Voluntary Action Research.

The evidence review had two components: a rapid review of peer reviewed literature, and a call for additional evidence that was put out to professional and practitioner networks. For the rapid review, we searched bibliographic databases (ASSIA, CINAHL, Cochrane Library, International Bibliography of the Social Sciences, MEDLINE, PSYCHINFO, PUBMED, Social Services Abstracts and SCOPUS) for research published in English since 1990, carried out in the UK or countries with some cultural, social or health service similarities to the UK. Studies were included if they described a volunteering or peer support intervention that directly affected one of the three chosen outcomes, or affected another outcome where there was a plausible causal pathway to improving one of the chosen outcomes (we describe these as ‘indirect’ impacts). We included studies using both quantitative and qualitative methodologies, and studies where the target age group included 0-3, even if older children were also included.
The call for evidence was sent out electronically via email to over 120 practitioner and professional organisations, requesting that they send us any published or unpublished material that was relevant to our research questions.
Because this was a rapid evidence review with a very broad scope and limited resources, we worked pragmatically with abbreviated filters and processes for quality appraisal, built around the relevance and transparency of the evidence, its methodological robustness and data confidence.

After screening over 25,000 documents, our search strategy returned a total of 267 papers that were relevant to the review, including 34 reports received through the call for evidence. Authors used a broad range of terminology to describe the activities of those helping parents, including ‘buddies’, ‘befrienders’, ‘mentors’, ‘parent champions’, ‘community champions’, ‘community parents’, ‘supporters’ and ‘peer supporters’. We therefore developed a simple typology to group similar interventions together, dividing them into ‘one-to-one support’ where an individual volunteer is paired with an individual parent; ‘group support’ where one or more volunteers lead a regular group for parents, and ‘community champions’ who spread health or parenting messages within their community. The identified strengths and weaknesses of these different models are shown in Table 1. We use the term ‘volunteer’ to refer to those helping parents (although in a small number of studies they received some payment), ‘parent’ to include pregnant women, and ‘professional’ to describe individuals who have completed specific qualifications and are registered with a professional body.

v4i2 table6

Evidence of direct impact on the three outcomes 
Outcome 1: Social and emotional development
A randomised controlled trial of the Empowering Parents, Empowering Communities parenting programme, delivered to groups of parents by highly trained peer facilitators, found significantly greater improvements in positive parenting practices and reduction in child problems for parents (almost all mothers) who attended the group, compared with parents on the waiting list (Day, 2012). The evidence of direct impact on social and emotional development from one-to-one support is mixed. Much of the evidence comes from Home Start, one of the leading family support charities in the UK, which offers unstructured one-to-one trained volunteer social support to families with young children. Parents who receive Home Start in the UK consistently report that it helps them parent better, manage their children’s behaviour better, and be more involved in child development (Kenkre, 2011; McAuley, 2004). A cluster randomised study and a quasi-experimental study in the UK (Barnes, 2006a; McAuley, 2004) did not find any impact on child outcomes, but a randomised controlled trial of the same model in the Netherlands found that Home Start families had more responsive parenting and fewer child behaviour problems (Hermanns, 2013) and these improvements were sustained to age 10 (van Aar, 2015). This suggests that measuring impact may be partially dependent on the precise outcome indicators that are chosen and how they are assessed.

Outcome 2: Communication and language
There is evidence that volunteers delivering the Early Words Together language and literacy intervention with parents in small groups can improve children’s understanding of spoken language (measured using a standardised vocabulary test). Parents reported that it also improved their children’s enjoyment of sharing books and joining in with songs and rhymes, increased the amount of parent-child talk, and increased the parents’ awareness of the importance of talking and sharing books with their children (Wood, 2015). In a randomised controlled trial of one-to-one home visiting by volunteers, mothers who received the intervention were more likely to report that their children were read to daily and were exposed to more nursery rhymes (Johnson, 1993). In a comparison study, preschool children (aged 2-5) who received one-to-one support from a teenage volunteer had significantly increased communication and language skills (Humphrey, 2014).

Outcome 3: Diet and nutrition
The evidence for the impact of breastfeeding peer supporters is contested. Systematic review evidence has found that although peer support can increase the length of exclusive breastfeeding in high income countries, there is no randomised controlled trial evidence of impact in the UK (where all mothers have access to some breastfeeding support from midwives and health visitors) (Jolly, 2012; Ingram, 2010). On the other hand, some individual projects report that peer support does have an impact on breastfeeding rates in their local area (including in very deprived communities), particularly when delivered in combination with effective health professional support (e.g. Brown, 2011; Alexander, 2003). Moreover, breastfeeding mothers who receive peer support often say that it was the peer support that enabled them to continue breastfeeding, either through moral support and encouragement, having breastfeeding role models, or through specific help to overcome problems; and additional benefits such as improved family diet and maternal mental health and parenting skills have been reported by mothers attending breastfeeding peer support groups (Fox, 2015; Glass, 2015; Thomson, 2015; Whitmore, 2015; Ingram, 2013; Brown, 2011; Hoddinott, 2011; Muller, 2009; Wade, 2009; Briant, 2005; Ingram, 2005;  Alexander, 2003; Raine, 2003; Scott, 2003; Battersby, 2002; McInnes, 2001).
One challenge with this evidence is that there are many different models of breastfeeding peer support and it appears that there is no ‘one size fits all’ for all communities or individuals. For example, some mothers value the social support and ‘normalisation’ provided by breastfeeding groups over the potential ‘intrusion’ of one-to-one support at home; but other mothers value individual support (e.g. Thomson, 2015; Ingram, 2013;  Alexander, 2003; McInnes, 2001). 
Looking beyond projects focused on breastfeeding peer support, there is evidence that one-to-one support from trained volunteer doulas (who give mothers one-to-one support during pregnancy, at birth and postnatally for six to twelve weeks) can significantly affect both the number of women who start breastfeeding and the number who continue for at least six to eight weeks (Spiby, 2015). Monthly one-to-one home visiting was found to improve the diets of children in a randomised controlled trial in Ireland (Johnson, 1993), and a UK randomised controlled trial of volunteer support focused on healthy diet found some limited aspects of children’s diets improved in the intervention group, but with no significant impact on vitamin C intake or (when followed up four years later) on Body Mass Index (Scheiwe, 2010; Watt, 2009).

Evidence of indirect impact
We described a programme as having an indirect impact when it had an effect from which there was a plausible causal pathway to one of the three chosen outcomes. In this way the volunteers could be seen as having an impact on an intermediary step in the process of change. For example, early years education is likely to promote children’s language and social development, and there is evidence that community champions can be effective in promoting uptake of the free childcare available to two year olds in disadvantaged families (Family and Childcare Trust, 2016). Parents’ attendance at a healthy lifestyle group course is likely to improve their ability to offer a healthy family diet, and community champions have been successful at recruiting parents of young children to such a course (Ives, 2015).
An important factor disrupting children’s social and emotional development is the mother’s poor mental health in pregnancy and after birth (National Institute for Health and Care Excellence (NICE), 2014). It is therefore likely that interventions supporting the mother’s emotional wellbeing will have an indirect impact on her parenting and on her children’s social and emotional development. There are a number of models of one-to-one volunteer support that offer needs-led social and emotional support, often combined with mentoring activities, information about parenting, and support to access services such as children’s centres. Although the limited randomised controlled trial evidence demonstrated that receiving unstructured volunteer home visits did not affect the onset of diagnosable maternal depression, mothers consistently report that one-to-one volunteer and peer support (structured and unstructured) reduces their stress and increases their self-esteem, parenting confidence and emotional wellbeing, including reducing feelings of anxiety and depression (Spiby, 2015; Bhavnani, 2014b; Barlow, 2012; Granville, 2012; Akister, 2011; Kenkre, 2011; Barnes, 2009; Suppiah, 2008; McAuley, 2004).
It has been suggested that in some communities there may be social factors inhibiting breastfeeding that need to be addressed at a community rather than individual level, and it has been argued that breastfeeding peer supporters may contribute to longer-term change in the local infant feeding culture by championing and normalising breastfeeding as a feeding choice (Fox, 2015; Glass, 2015; Thomson, 2015a; Whitmore, 2015; Ingram, 2013; Brown, 2011; Hoddinott, 2011; Muller, 2009; Wade, 2009; Hoddinott, 2006; Briant, 2005; Ingram, 2005; Alexander, 2003; Raine, 2003; Scott, 2003; Battersby, 2002; McInnes, 2001).

Reaching families who are ‘hard to reach’ for services
It has been theorised that volunteers from a specific community may be trusted over outsiders and are therefore able to reach those who are ‘hard-to-reach’ for services (e.g. McInnes, 2001), and the core rationale of peer support is the trust and empathetic understanding engendered by common experiences (e.g. Harris, 2015; Jones, 2014; Briant, 2005). The evidence shows that offering peer support from people with ‘lived experience’ of the parents’ own issues gave vulnerable parents the assurance they would be understood and not judged, enabled them to talk honestly in a way they could not do with professionals, and gave information from the volunteers more credibility (Fox, 2015; McLeish, 2015; Marden, 2014; Turner, 2012; Murphy, 2008; McInnes, 2001).
Disadvantaged parents were less likely to engage with volunteers than more advantaged parents but, once engaged, disadvantaged parents were least likely to disengage (Suppiah, 2008; Barnes, 2006b; Cox 1991). Both group support (e.g. Day, 2012) and one-to-one support (e.g. McLeish, 2015; Bhanvani, 2014a; Lederer, 2009) have been found to be acceptable and effective for parents from Black, Asian and minority ethnic (BME) communities, although the evidence does not distinguish between different BME groups. Although some parents from BME communities accessed support more readily when it was offered by someone from their own cultural and language background, support was more acceptable to others if the volunteer was not from the same minority community because this was felt to reduce the risk of gossip and stigma (McLeish, 2015; Prosman, 2014; Summerbell, 2014; South, 2012; Lederer, 2009; Muller, 2009). One-to-one support has also been shown to be acceptable to and to benefit very vulnerable families such as asylum seekers and refugees (Bhavani, 2014b; James, 2013), Travellers (Fitzpatrick, 1997), families without recourse to public funds (Lederer, 2009), mothers experiencing domestic abuse and families whose children were at risk of neglect or abuse (Prosman, 2014; Tunstill, 2012; Akister, 2011; Taggart, 2000). 
It is important to note that figures for take-up by parents were not always reported, and where they were, projects had variable degrees of success at engagement. For example, home visiting projects reported take up by 64−80% of parents referred (Barlow, 2012; Cupples, 2011; Lederer, 2009), but in a cluster randomised trial of Home Start home visiting, only 41% of parents referred for support received it, largely due to administrative and capacity issues (Barnes 2006b). Reported barriers to initial engagement included parents being uninterested in, or not understanding, the support offered; feeling that they already had enough support from friends and family; being concerned at taking on a stressful social obligation; feeling suspicious about the motivation and purpose of the volunteer; or experiencing opposition from family members (McLeish, 2015; Spiby, 2015; MacPherson, 2010; Murphy, 2008; Barnes, 2006b).
Although there were occasional contacts with fathers reported and sometimes particular efforts to reach fathers (e.g. Thomson, 2015; Day, 2012; Lederer, 2009), in almost all cases the volunteers were working overwhelmingly with mothers. There was no UK evidence of any volunteer projects set up specifically to work with fathers towards the three outcomes.

Key features of successful volunteer projects
The models of volunteer support in this evidence review were very diverse and not always well described, so it was not possible to draw conclusions about whether any particular model was ‘better’ than another. Looking at the evidence as a whole we were, however, able to draw some key conclusions about the circumstances in which volunteers may have an impact on the three chosen outcomes in the UK (see Table 2).

v4i2 table7

We were also able to draw some conclusions about the key features that successful volunteer projects have in common (see Box 1).

Key features of successful volunteer 1:1 and group projects
1. The key role of the project coordinator is understood.
2. Projects are fully costed to provide a proper operational base and infrastructure.
3. They are realistic about timescales, allowing for a long lead-in time while relationships are built with the local community and professionals, and volunteers are recruited and trained.
4. They collect ‘just enough’ data.

Working with professionals
Good relationships with local professionals were key to the success and sustainability of volunteer projects. Many volunteer projects experienced tension with professionals, leading to restrictive ‘gatekeeping’, poor communication and a lack of referrals (e.g. Thomson, 2015; Aiken, 2013; Ingram, 2013; Suppiah, 2008; Curtis, 2007; Dykes, 2005). Other professionals were reported to see volunteers as a key resource, complementing and enhancing their professional support for families, and reaching families who were ‘hard-to-reach’ (e.g. Spiby, 2015; Thomson, 2015; Ingram, 2013; Tunstill, 2012; Curtis, 2007). Many projects found it challenging to publicise their work effectively to the wide range of professionals whose support they needed, and this required ongoing networking from project coordinators (e.g. Spiby, 2015; Bhavnani, 2014a; Barlow, 2012).
Successful strategies for promoting co-operation between volunteer projects and professionals have been described (Spiby, 2015; Thomson, 2015; Bhavani, 2014a; Barlow, 2012; Tunstill, 2012; Lederer, 2009; Curtis, 2007; Raine 2003): 
• Professionals were involved at the earliest stage of the development of the project.
• Projects demonstrated how the volunteers complemented professional support by contributing to the shared endeavour of improved outcomes for children.
• Projects articulated their clear boundaries, training and supervision. 
• Professionals were involved in volunteer training and sometimes volunteers became involved in professionals’ training. 
• Volunteers used training that was also used and/or understood by professionals (for example on breastfeeding). 
• There were clear referral guidelines and a simple referral process into the project.

This evidence review has found that volunteers can make a distinctive contribution to achieving the three chosen outcomes for children, but only when they are accepted by local professionals. Volunteers can initiate a different kind of relationship with parents based on trust and equality, and can reach and be accepted by parents who do not engage with professional services. We recommend that volunteer support should be commissioned as part of a ‘whole system’ approach to improving outcomes for children. The full evidence review, and an accompanying implementation framework, which includes evidence on running successful volunteer projects, can be found at http://abetterstart.org.uk/content/resources.

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