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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
If Sure Start Continues, Why Not Do Something Exciting?
- Stella M O'Brien (16 June 2006)
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Letter to Editor - concerns about report on Sure Start Local Programmes
- Gordon Marsden (21 June 2006)
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Need for randomisation
- Carole J Torgerson (21 June 2006)
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Inequality may account for difference
- Benjamin R Barr (18 December 2006)
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Stella M O'Brien, Researcher CM20 1PD
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Both Sure Start and this evaluation are disappointing on this showing. The evaluation concludes with the assertion that the study indicates thatimproving parenting is one of the mechanisms by which SSLPs promote child wellbeing.I accept that this sentiment is part of the theoretical basis for Sure Start but I'm not at all sure that this evaluation has demonstrated that it is happening. Except, of course, in those "relatively less socially deprived" groups who may be depriving others of "access to services" that they may experience as "stressful and instrusive". I would like to have seen more discussion about whether it is the 'stress and intrusion' that is responsible for the 'harm' or the putative "less access to services": there is a case for saying that this paper has presented these two explanations without an acknowledgement that they may be mutually exclusive. A long-term follow-up study of the children of depressed parents reports that: The risks for anxiety disorders, major depression, and substance dependence were approximately three times as high in the offspring of depressed parents as in the offspring of nondepressed parents. Social impairment was also greater.There is a growing body of evidence to suggest that environmental exposure to hostility or aggression (whether physical or verbal) is linked to poorer lung function and an increased number of asthma exacerbations in children: and the environment may be the home, school or neighbourhood. These findings may be relevant to this programme and the interpretation of its results. It would have been useful if this evaluation had attempted to cost the advantages of supporting "relatively less socially deprived families" who may be benefiting by increasing their resilience, with all the improved physical, cognitive, social and emotional benefits that that confers for the family and the reduced costs for society. Interviewed for the New York Times, leading psychiatrist and resilience expert Sir Michael Rutter said: We now have well-replicated findings showing that genes play a major role in influencing people's responses to adverse environments. But the genes don't do anything much on their own.If Sure Start has to continue, why not sort out the civil liberties issues and do something exciting and useful like collect genetic material and test for the so-called resilience gene? Collecting data on this scale would be a valuable contribution to the work of researchers looking at the tandem effect of genetics and environment. In 2003 Avshalom Caspi and his colleagues published a fascinating paper in Science that discussed the relationship between the gene, 5-HTT, and childhood maltreatment in causing depression. Current theories say that 5-HTT is crucial for the regulation of serotonin to the brain; and that the proper regulation of serotonin protects us against depression in response to trauma or stress. In humans, each 5-HTT gene has two alleles, and each allele occurs in either a short or a long version. Scientists are still figuring out how the short allele affects serotonin delivery, but it seems that people with at least one short 5-HTT allele are more prone to depression. And since depression is associated with unemployment, struggling relationships, poor health and substance abuse, the short allele could contribute to a life going awry. A Question of Resilience New York TimesIf we insist on experimenting with social engineering, let's gather more data and look at the tandem effects of genetics, environment and life experiences. Competing interests: None declared |
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Gordon Marsden, Member of Parliament (Blackpool South) House of Commons, London SW1A 0AA
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Dear Ms Godlee As a Member of Parliament whose constituency contains significant pockets of social deprivation (like many seaside and coastal towns) and which now has three Sure Start projects (two of them estate-based) operating as part of the Government’s strategy to combat this, I was naturally concerned to see media reports that the report you published in your June 16 issue of the British Medical Journal by Jay Belsky and his colleagues was suggesting that Sure Start projects were making things worse, not better, for some of those who used them. I have therefore now read carefully the piece that you carried, which seems to be very far from substantiating the way in which it has been treated in the non-specialist media. Unfortunately it also seems to me that the conclusions Jay Belsky and his colleagues draw from what they themselves describe as ‘early findings from a quasi-experimental cross sectional study’ have also been too sweeping and have contributed, however unwittingly, to the distorted headlines and intros that appear in, for example, the Daily Mail of June 16: ‘Flagship project to help deprived children and families is making crime and truancy worse, not better, an alarming investigation revealed.’ I accept as a layman that others may be better placed than I to critique some of the details and protocols that this study used. But apart from my constituency interest – which has given me close contact with the Sure Start centres and meetings with staff, support workers and parents using them – I have followed these issues closely as a member of the Commons Education Select Committee and national vice-president of Early Education. I also – in a previous existence – spent nearly five years working as a public relations adviser on medical and related subjects, followed by twelve years as a magazine editor, which gave me a crash-course on the complexities and sensitivities of interpreting research presentations to a non-specialist audience and the pitfalls that lie in wait for the unwary. In the case of the assertions in the Belsky report that ‘children from relatively more socially deprived families…were adversely affected by living in SSLP’ – the assertion leapt on by the Daily Mail and others – there appears to be little substantial material elsewhere in the report to back it up. We are told that children of teenage mothers, like those who lived in workless or lone parent households, ‘scored lower on tested verbal ability’ – hardly surprising given that such mothers often have themselves had schooling and family difficulties. But the crucial question – how does this compare with their skills before they entered the Sure Start programme – does not appear to have been asked. Sure Start programmes have come in successive waves – some of those interviewed may have been in them for two to three years, some for much less. Again, no allowance appears to have been made for this in the evidence presented. It is surely a fundamental principle that in order to make valid or worthwhile judgements about how well the Sure Start programmes have performed – either overall or for particular groups – you have to look at the participants before and after entering the programmes to measure the progress – or non-progress – between A and B. The Belsky article does not appear to do this. We are told that ‘mothers of children aged 36 months (but not 9 months) living in SSLP areas rated their communities a little less favourably than mothers in comparison areas.’ Again, this is hardly surprising, given that pre- and continuing publicity for such Sure Start projects – as here in Blackpool – would rightly have highlighted they were being set up to help families in areas with elements of deprivation and social exclusion. It is not an evidential basis on which to judge their effectiveness. I would add that the ability of the non-specialist – and possibly many of the specialist – readers to penetrate and assess the Belsky paper is not helped by linguistic monstrosities such as on page 2: ‘the findings presented are based on multiple imputed data sets in which missing values of all independent and dependent variables were estimated based on standard multiple imputation procedures.’ I would hope that contributors to the BMJ, as a long-established journal of record with an impressive pedigree in communicating to a broader public as well as to the specialist, could do better than that! Jay Belsky and his colleagues have reported positively elsewhere in their article on other aspects of the Sure Start programme and, to be fair, issue their own health warning about the paper: ‘because this evaluation was quasi-experimental, cross sectional, and evaluated the impact of a programme that had been in place for only a few years, the detected effects of SSLPs and the conclusions much be treated with caution.’ Wise words, but the presentation of the paper’s conclusions did not follow them – and the broadsheet coverage which exploited them certainly did not. This is not just a specialist issue about academics’ findings which can cheerfully be discussed and argued over at learned symposia and conferences. The impact on the morale and self-esteem of the people using and involved with Sure Starts countrywide – including my constituents – will be affected by the coverage of papers such as this. I do believe that academics and researchers have a public responsibility to consider how they present such material – and to be acutely aware of how it may be misinterpreted or abused. It is hardly as if in taking on the Sure Start project the authors of your paper would have been unaware of the high- profile and public sensitivities of what they wrote. I hope they will reflect on how their study has been presented and make some effort to address the distortions and the issues I have raised here. Yours sincerely Gordon Marsden Competing interests: None declared |
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Carole J Torgerson, Senior Research Fellow Department of Educational Studies, University of York, York YO10 5DD
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Editor Belsky and colleagues reported that Sure Start programmes only had a limited effect on children and their families1. It is a pity that the Government refused to consider using a randomised trial to evaluate this important initiative. Initial non-randomised evaluations of the ‘Head Start’ programme in the USA found little or no benefit of that initiative2. Because of this lack of effectiveness evidence senior US policy makers, quite rightly, called for it to be stopped. However, evaluations using randomised controlled trials were commissioned instead and these found that Head Start did have a significant beneficial impact on outcomes. In the acknowledgments section of the Sure Start evaluation the authors claim that the Department for Education and Skills (DfES), did not consider a randomised design because the programme was delivered to entire communities. There is quite a bit of evidence from Table 3 that the two groups were not similar at baseline and the lack of a major impact may, as in the early Head Start evaluations, be due to confounding. Although an individually randomised trial may have been inappropriate, a cluster design could have been used. Had the DfES had the foresight to commission a RCT of this initiative then we would have been clearer as to whether it worked or not. Would the Government allow major pharmaceutical companies to market new products on non-randomised data? If not, why should they ‘market’ their own products on the community without using RCTs? 1 Belsky J, Melhuish E, Barnes J, Leyland AH, Romaniuk H. Effects of sure start local programmes on children and families: early findings from a quasi-experimental, cross sectional study. BMJ 2006. 2 Wortman PM. An exemplary evaluation of a program the worked: The High/Scope Perry Preschool Project. Evaluation Practice 1995;16:257-65. Dr Carole Torgerson
Competing interests: None declared |
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Benjamin R Barr, Specialist Trainee in Public Health Central Lancashire PCT,
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Dear editor Belsky and colleagues state that children from relatively more socially deprived families were adversely affected by living in areas where there were Sure Start Local Programs. As the authors acknowledge the cross sectional design and lack of randomisation mean that these conclusions need to be treated with caution. It is clear from the data that there are significant differences between Sure Start and comparison populations, most notably there are marked differences in the level of income and ethnicity of the populations. Although the authors claim to adjust for area characteristics it is not clear which of these are used in the analysis. It seems that it is possible that the differing outcomes experienced by the most deprived families are due to other differences between the areas not related to the provision of Sure Start. One such difference that does not seem to have been taken into account by the authors is that there is greater income inequality in the Sure Start group than in the comparison group. Several authors most notably, Wilkinson(1) have pointed out that income inequality, has an impact on social capital and health outcomes, independent of mean income. Much of this work is based on larger geographical areas mainly in the United States although one ecological study found an association between mortality and income inequality in English local authority areas (2). One explanation therefore for these results could be that the children of the most deprived families fair better in areas were there is more equality in income. The potential for confounding in this study could have been minimised if intervention and comparison areas had been matched for some of these characteristics. Yours Sincerely Benjamin Barr, Specialist Trainee in Public Health, Central Lancashire PCT, Ben.barr@centrallancashire.nhs.uk 1. Wilkinson, R. The impact of Inequality. How to Make sick societies healthier. London: Routledge; 2005 2. Stanistreet, D., Scott-Samuel, A., Bellis, M. A. Income in inequality and mortality in England. Journal of Public Health. 1999;21:205 -207. Competing interests: None declared |
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