The process evaluation showed that delivery of the gFNP programme was variable in terms of the number of sessions delivered, but was relatively consistent with the balance of content that is recommended for the one-to-one FNP programme and the extent of involvement and understanding of clients, although site comparisons in infancy indicated that the strategy of agenda matching to some or all group members was likely to lead to differences in the focus of sessions. This was particularly evident with respect to time spent on environmental health, and on links with/referrals to other agencies. In a group programme it may be
DISCUSSION AND CONCLUSIONS
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challenging to match all the agendas, but neither of these two domains should have a specific impact in terms of the main outcomes of the study, parental attitudes and maternal sensitivity, unless issues such as depression are not identified and supported with suitable referrals and advice.
There were several reasons why some sites were not able to deliver the recommended number of sessions, the primary one relating to the slow recruitment that led to smaller than ideal numbers in most groups. Some clients reported that they liked the group to be small, but very small groups are not sustainable from a cost-effectiveness or commissioning standpoint and may also lose some of the dynamic interaction that is likely with a larger number of parents holding varying views. In addition, as was the case in one location, a small group with one or two members who are outspoken and dominant may lead to high attrition as others stop attending, whereas in a larger group they do not have such an impact. It is clear that recruitment pathways will need to be very efficient in any future delivery of gFNP,86to ensure that all
potential participants are identified in a timely fashion.
Staffing issues also had an impact on programme delivery. To avoid taking resources away from the home-based FNP programme the residential training for gFNP was offered to the FNs in each site who had been identified to deliver gFNP, and their supervisors. In some instances additional FNs were able to attend, but not for all sites. This meant that, if the trained FN was not available, through sickness or for other reasons, then it was not easy to deliver the programme and in one case led to gFNP not being delivered, although clients had been enrolled. In addition, even if a trained FN was available, the lack of continuity was perceived as somewhat disruptive to the group process. Any future delivery might consider rotating programme delivery between three FNs so that the group members will be comfortable with whichever two deliver a particular session.
Many positive comments were made by gFNP clients about receiving the service and they linked participating in the programme with increased confidence and increased capacity to manage parenting challenges, such as weaning. However, they also noted that transport or timing factors could mean that they were not able to attend. The ideal model in the feasibility work57,67was that travel would not be
an issue, with the groups taking place in a local children’s centre or health clinic. Not only should this enable easy‘pram pushing’access, it should also help to join gFNP up with other services for children and families. However, even in the feasibility work it was a challenge to identify and recruit sufficient numbers of pregnant women with similar EDDs living close to a centre. For the trial, double the number needed to be identified so that a control group could be formed. This led many of the trial sites to locate the programme in a more central spot, which was likely to be able to draw in women from around the area with bus routes generally radiating in to town or city centres. This meant that almost all participants had some kind of journey to make rather than being able to‘walk around the corner’. If that model is used in the future, then funds to reimburse clients’travel as were provided in the trial would need to be factored in to delivery costs as they have been in the cost estimates inChapter 4.
Overall, the process evaluation identified many themes that mirrored the implementation evaluations of both FNP36,39,40and gFNP.57,67Those who attended regularly appeared to really like the programme,
believing that it had reduced their isolation, improved their mental health and enhanced their capacity to parent. The FNs found it rewarding to work with them and also identified gains. However, the lack of evidence of effectiveness for most outcomes compared with those for women in the control arm would suggest that other families are similarly supported, although both groups would appear to be likely to benefit from more support. Potentially, the group context, and the presence of both peers and medical practitioners able to explain scientifically the benefits, is particularly relevant to supporting breastfeeding where there was evidence of an improvement in the gFNP group, but differing strategies may be needed to make change for parents potentially at risk for abuse or child neglect.