Assessing community readiness for early intervention programmes to promote social and emotional health in children

Abstract Objective Evidence for early intervention and prevention‐based approaches for improving social and emotional health in young children is robust. However, rates of participation in programmes are low. We explored the dynamics which affect levels of community readiness to address the issues of social and emotional health for pregnant women, young children (0‐4 years) and their mothers. Setting A deprived inner‐city housing estate in the north of England. The estate falls within the catchment area of a project that has been awarded long‐term funding to address social and emotional health during pregnancy and early childhood. Methods We interviewed key respondents using the Community Readiness Model. This approach applies a mixed methodology, incorporating readiness scores and qualitative data. A mean community readiness score was calculated enabling the placement of the community in one of nine possible stages of readiness. Interview transcripts were analysed using a qualitative framework approach to generate contextual information to augment the numerical scores. Results An overall score consistent with vague awareness was achieved, indicating a low level of community readiness for social and emotional health interventions. This score suggests that there will be a low likelihood of participation in programmes that address these issues. Conclusion Gauging community readiness offers a way of predicting how willing and prepared a community is to address an issue. Modifying implementation plans so that they first address community readiness may improve participation rates.

course trajectory well into adulthood. [6][7][8] In consequence, early intervention policies and programmes which enable parents to help children achieve the best start in life are promoted as a blueprint for a healthy and happy society. [9][10][11][12][13] Social and emotional health is a multifaceted concept encompassing the development of self-control, building relationships and learning skills and abilities to help children succeed in school and broader society. 14 NICE guidance makes a point that-"good social, emotional and psychological health helps protect children against emotional and behavioural problems, violence and crime, teenage pregnancy and the misuse of drugs and alcohol". 14 Subsequent guidance concurs and adds "happiness and confidence" as outcomes of positive social and emotional well-being which can act as protective factors against depression. 15 Early intervention is vital as the optimum time to influence developmental trajectories recedes with age. 16 Perinatal depression provides a lucid example; mothers experiencing perinatal depression can adversely impact on children's emotional and cognitive health because this type of depression "coincides with a period of substantial baby brain development during which infants are entirely dependent on their primary caregivers for physical care, security, and emotional regulation" 17 (p608). Missed opportunities during the formative years of a child's life could contribute to a disadvantaged adulthood, [17][18][19] something personally damaging and distressing as well as costly for government and society. [20][21][22] This is a context that has given rise to a wide range of approaches including family support services, parenting programmes and one-to-one support for expectant and new parents during pregnancy and the first years of a child's life.The extant literature broadly supports EIP approaches to address issues relating to children's social and emotional health. 9,23,24 Particularly in contexts of social disadvantage, parenting courses can contribute to positive child outcomes such as improved school readiness and enhanced rates of academic success. 25 Moreover, the social and developmental benefits can be felt as much as 20 years after attendance. 8 Parents support the principle of early intervention to enhance social and emotional health development, especially parents in lower socio-economic groups. 26,27 But across all socio-economic groups, there appears to be a difference between expressed favourable support which is high, and uptake, which is often low. For example, Cullen and colleagues 28 asked parents of young children how likely they were to participate in parenting classes and found that 33% said they might participate and 10% said they were likely to participate; however, when take-up data were examined at the end of a pilot of free parenting classes, only 6% of eligible parents had Whilst research has been predominantly concerned with individual and family influences, parenting and children's social and emotional health are also impacted by neighbourhood factors.
Neighbourhood poverty can impede the quality of parenting. 29 Issues that stem from living in a highly deprived neighbourhood include increased stress [30][31][32] and higher numbers of lone parent households with subsequent pressures on parental time. 33,34 Areas with high rates of ethnic diversity may experience higher inequities as research has shown women from minority ethnic backgrounds can be twice as likely as White British women to miss detection of common mental disorders. 35 This omission is a risk factor in terms of identified socio-emotional and behavioural difficulties in their young children. 32 Given research evidence of effectiveness and parental enthusiasm for EIP but recurring challenges in recruitment to programmes, the aim of this study was to examine levels of community readiness amongst residents living in a deprived neighbourhood to participate in a programme which aims to enhance and address issues related to social and emotional well-being for young children. We report our findings after the application of the community readiness model (CRM); a key principle of the CRM is "that unless a community was ready, initiation of a prevention programme was unlikely, and if a program started despite the fact the community was not ready, initiation was likely to lead only to failure" 36 (p.293). To our knowledge, the CRM has not hitherto been applied and findings published after gauging readiness for social and emotional health issues.

| ME THODOLOGY
The CRM is a practical toolkit which seeks to provide some approximation of the likelihood that a community will engage and participate in a programme designed to address a specific issue. The model was originally developed in the United States for assessing a community's readiness to address alcohol and drug abuse and has subsequently been applied to cover a broad range of issues including obesity prevention, HIV prevention and deforestation issues. 37,38

| The CRM tool
The CRM is a mixed method approach which incorporates a qualitative component 39,40 and a numerical score. The CRM comprises of 36 questions spread across six dimensions of readiness, these are as follows: community efforts, community knowledge of the efforts, leadership, community climate, community knowledge of the issue and resources for prevention (see below for examples of questions).
The model identifies nine stages of readiness that range from "no awareness" of the issue to "high level of community ownership" (see Table 1). Once a community's stage of readiness is identified, plans can be formulated to raise levels of community readiness through engagement and communication exercises appropriate at each level and barriers that may impede community participation can be addressed.

| Ethics
Ethical approval for this study was granted by the University of Bradford Ethics Committee on 22 December 2016 (EC2435).

| Setting
We applied the CRM to a housing estate which, according to the Big Lottery funded initiative to deliver interventions to address a range of health and social disparities affecting children's development. 10,42 The interventions delivered to support the development of social and emotional health for children include support for teenage mothers, a befriender scheme for all mothers affected by or at risk of post-natal depression, healthy lifestyle advice and a range of targeted and universal parenting programmes.

| Recruitment and consent
A date and venue were arranged for each interview during the invitation telephone call with participants. All participants were asked to provide informed consent prior to any data collection.

| Participants
The CRM relies on interviewing between four and six local key respondents who understand the community in an esoteric way, 36,43 for example community leaders or community activists. Purposive sampling was used to identify potential respondents through discus- Community Research Advisory Group members were able to identify key respondents who were well placed to answer the questions listed in the CRM for the aforementioned issues and area. On the subject of sampling, the CRM handbook advises-"try and find people who represent different segments of your community" 43 (p10) and then offers a list of who could be included. With this in mind and with the advice taken from CRAG, we aimed to recruit a minimum of six community leaders/key stakeholders. Eight individuals were invited to take part via telephone. However, two potential participants were not eligible; both represented faith organizations (Mosque and Church) but informed us that most worshippers came from outside the eligible area. This notwithstanding, we were able to recruit six key respondents. This is an acceptable number of participants necessary to complete the assessment 43  Our sample included key respondents from a diverse range of backgrounds including Rohail and Laura who were, respectively, employed and volunteered with non-profit organizations to support and engender community activism through a range of methods including community clean-ups, residents associations and liaison with schools. We had three local authority employed professionals who were highly active in the neighbourhood and contracted by different statutory organizations: the children's centre (Fazal), the primary school (Jason) and the neighbourhoods team (Katrin). Our final key respondent was a ward councillor who represented the ward in which the estate is located on the city council (Ali). All names used in this paper are pseudonyms.

No awareness
Issue is not generally recognized by the community or leaders as a problem (or it may truly not be an issue)

Denial/resistance
At least some community members recognize that it is a concern, but there is little recognition that it might be occurring locally

Vague awareness
Most feel that there is a local concern, but there is no immediate motivation to do anything about it 4. Pre-planning There is clear recognition that something must be done, and there may even be a group addressing it. However, efforts are not focused or detailed

Preparation
Active leaders begin planning in earnest. Community offers modest support of efforts

| Data collection
Interviews were conducted by the first author in community locations which were most convenient for respondents and took place during a four-month period from February to May 2017. Interviews began with a discussion to clarify the meaning of the term "social and emotional health." To facilitate this discussion, key points relating to social and emotional health, as defined by NICE guidance, 15 were explained to the respondent. The subsequent discussion varied because levels of familiarity and awareness about this issue differed between key respondents. We sought to ensure a commonly agreed meaning of this term existed across all respondents.

| Topic guide
Interviews used the topic guide found in the handbook of CRM. 43 This included 36 questions relating to the six dimensions of the tool. By way of example, the open-ended questions included the following: What type of information is available in your community regarding this issue?
What does the community know about these efforts or activities?
How are these leaders involved in efforts regarding this issue?
Please explain?

| Analysis
Interviews lasted between 34 and 68 minutes and were audio-recorded and transcribed verbatim. Respondent's transcripts were given a pseudonym to ensure confidentiality, and their job roles removed to reduce the risk of identification. Interview transcripts were independently scored by two authors (NH and SB) trained in using the anchored rating scales of the community readiness model to assign scores ranging from one to nine for each of the six dimensions.
Following the guidance for completing a community readiness assessment, 43 both scorers independently rated each of the six interviews and then agreed a consensus score for each interview after discussing and resolving differences in scores they had independently reached.
The consensus scores were then summed across each dimension and divided by the number of interviews to generate a mean stage score for each of the six dimensions. The scores ranged from one (no awareness) to nine (community ownership). The dimension scores and the overall mean community score are rounded down, as per the guidance. 43 Some commentators (notably Kesten and colleagues 40 ) highlight the importance of using the qualitative data generated through the application of CRM to understand context and score as, they argue, these are inextricably linked. We therefore analysed the qualitative data through NVIVO 11 software using framework analysis. 44,45 This was completed by the first author (SI) with supervision and support provided by the second author (NS). Since the purpose of this study was to produce a useful categorization scheme for community readiness using questions organized around the six dimensions, we then arranged these a priori dimensions into analytical themes. These were indexed systematically, a process which entailed comparison within and between the themes. As the analysis evolved, it became necessary to chart and rearrange segments of the data to ensure contents were placed under the heading of the theme that was most appropriate. For example, when issues discussed under the theme of knowledge about efforts seamlessly segued into discussions about community climate then these were appropriately relocated.

| Data validation
The qualitative analysis was validated through discussion with two authors (NH and SB) who were familiar with the transcripts and findings. Data interpretations were also discussed within the wider research team who were able to provide guidance about the emergent findings. After completion, key respondents were emailed a short report which included the numerical scores along with a summary of key findings. This email was accompanied with an invitation to contact two members of the research team in case further clarification would be helpful (NH and SB). This process served two purposes. Firstly, closing the feedback loop through debriefing is an important part of conducting ethical research, 46 and second, a useful yardstick, according to Greenhalgh, 47 by which to measure validity from qualitative research findings is to ask "how comprehensible would this be to a thoughtful participant in the setting?"(p.176). We followed these steps and key respondents let us know they were thankful for receiving the findings, though no queries were returned.

| FINDING S
Topical points and verbatim quotes presented below will draw on the salient issues raised during interviews to help us comprehend the numerical scores achieved across the dimensions. As there were several areas of overlap between the dimensions (eg between attitude of leaders to the issue and how this affects resources available for prevention), it has been necessary to present the results in an aggregated way rather than treating each dimension as an independent unit.

| Overall CRM score
The mean overall CRM score was three (SD = 1.17), corresponding with vague awareness stage of readiness for social and emotional health. The mean scores for each dimension (Table 2) varied, ranging from two to five which suggests that, for this community, some dimensions displayed more readiness than others. The overall score of three is described in the following way by the authors of the CRM: There is a general feeling amongst some in the community that there is a local problem and that something ought to be done about it, but there is no immediate motivation to do anything. There may be stories and anecdotes about the problem, but ideas about why the problem occurs and who has the problem tend to be stereotyped and/or vague. No identifiable leadership exists or leadership lacks energy or motivation for dealing with this problem. Community climate does not serve to motivate leaders 36 (p.298)

| Community efforts and Knowledge about efforts
The highest score was found in the Community effort dimension (five SD 1.95) which indicates that it was believed efforts had been made to improve issues around social and emotional health, but these did not necessarily translate into the community attaining sufficient knowledge about these efforts as that dimension scored three (SD   Despite these epistemic differences and varying levels of familiarity with the issues, respondents converged on two crucial points that may explain a lower level of awareness, and perhaps, a lower likelihood of uptake in projects. Firstly, social and emotional health problems in children may not be immediately apparent in terms of behavioural changes. This could make it difficult for parents to know whether help should be sought early. Problems whose origins are in early childhood may become manifest as a concern some years later.

| Community knowledge about issues
Secondly, for mothers, there is not a direct relationship between experiencing mental health problems and the decision to seek help.

| Community climate
The interview with Jason allowed us to segue from the above topics into the theme of community climate as he saw the issue in a nuanced and dynamic way: Later in the interview he told us: "There's a lot of volunteering that goes on in the area, you know, there's a lot of civicness that happens, that goes un-noted" (Rohail).

| Leadership and resources
These points are of crucial importance to the dimensions of This quote illustrates that whilst leaders wish to achieve more for the neighbourhood, they are equally reluctant to translate this ambition into any meaningful action because this may take more resource and effort than what is currently available. Relative deprivation theory predicts that a disadvantaged neighbourhood may be more supportive for low-income residents than a mixed neighbourhood 48 and evidence to support this theory was found in responses to our question-who do people turn to for help and support with issues related to social and emotional health? Consider the following: "Initially they probably start with, or start off with, their friends and families I reckon".

| D ISCUSS I ON
Based on the collective dimension scores using the Community Readiness Model, our neighbourhood was deemed to be at a stage of vague awareness (three) and, as such, showed low levels of community readiness to address issues related to social and emotional health. We saw the availability of services did not match awareness about those services, and we identified a gap in scores between community efforts (five) and knowledge about the issues (two). Making services available does not mean people will access them.
Research from the early 1980s 49 highlighted that mothers in high-density support networks were more likely to refuse parenting services than mothers with fewer social supports. Similar findings were noted by research which highlighted that people from working-class backgrounds and ethnic minority groups were more likely to turn to people in their social networks for help with parenting support and therefore less likely to access services compared to families in affluent areas. 50   Similar impediments help us understand why it might be problematic today for families living in poor neighbourhoods to attend programmes even though they offer hope for children to achieve positive social and emotional development.

| CON CLUS ION
This paper shows that applying the CRM methodology to an important issue in a dynamic community can provide insight on why a community may not embrace a programme despite its robust evidence base and potential to improve children's social and emotional wellbeing. The CRM is able to identify, at a granular level, the domains that can be addressed to enhance levels of community readiness.
This approach can enable policymakers and service providers to work in harmony with the level of community readiness, thus maximizing chances of successful implementation.

INFORMATIVE
Early intervention programmes targeted at families with young children to improve social and emotional health are promoted widely especially in neighbourhoods with high levels of deprivation. Evidence shows that whilst rates of promotion are high, participation is generally low. This study explores what impact community readiness may have on levels of preparedness amongst residents living on a local authority council estate.

ACK N OWLED G EM ENTS
We are very grateful to Better Start Bradford for funding this research. We would like to pay special thanks to the Community Research Advisory Group (CRAG) for guiding us during the planning phase and to our key respondents for participating in this research.