Questions/Answers

Under the motto “Equity from the Start for a Healthy Future,” the Healthy First Step Project (HFSP) was launched in 2012 in an attempt to support women with young children and improve the health and development of babies, which is one of the three key areas in which health policy research has indicated that the health gap needs to be reduced. By introducing a prenatal and postnatal home visitation program that has been proven effective in advanced countries, this project has successfully developed a highly competitive model for mother and child health services in Korea. The HFSP uses universal risk assessments for pregnant mothers, universal and sustained visitations, mothers’ groups, and community service linkage system to address the social and psychological difficulties experienced by women before and after childbirth and strengthen parenting abilities with the aim of ensuring that all children are able to enjoy the highest level of health and development possible. The HFSP features universal components (universal risk assessments of mothers and universal home visitations) and selective components (sustained home visitations, mothers’ groups, and community service linkage system) and thus takes a proportionate universalism approach. By taking such an approach, the project aims to guarantee equity for all children from the very beginning of their lives by conducting universal assessments before birth and universal visitations within four weeks after birth. For high-risk families, social networks are enhanced, efforts are made to alleviate mothers’ distress, and tiered community services are provided to address/solve the diverse range of problems that families face (social, economic, medical, psychological, etc.). In addition, efforts are made to find and identify problems (prenatal and postpartum depression, intimate partner violence , poverty, lack of social networks, suicidal thoughts, child abuse, problems specific to multicultural families and single mothers, etc.) in a timely manner, and child health nurses (nurses specifically trained to conduct home visitations for families with young children) are made available to provide integrated services that help mothers and their infants avoid undue difficulties. The HFSP is a combination of diverse programs, systems, services, and resources, including training programs for nurses and social workers, clinical supervision by independent academic supervisors from nursing schools, satisfaction monitoring system, data system, child development program, parent education, and local community resources, and ultimately aims to enhance the parenting capabilities of families raising infants and create a tightly knit safety network to ensure the healthy development of all children.

This project aims to guarantee a healthy and fair start in life for all children by addressing diverse health and development issues at both the individual and community levels that pregnant women, children, and families face, through partnerships between families and service providers. The fundamental goal of the project is to enable all children to have a fair start in life in all aspects of development (physical health and wellbeing, social competence, emotional development, language and cognitive development, and communication skills) through universal assessments of pregnant women, postpartum home visitations, sustained visitations for high-risk families, mothers’ groups, and community services. More specifically, the project ascertains the social, economic, psychological, and environmental problems experienced by pregnant women and uses this information to inform its selection of families that require sustained visitations and/or linkage with community services. By supporting mothers from pregnancy, the project prepares women to become mothers and helps them create and prepare for positive parent-infant relationships, thereby enhancing the ability of mothers to raise their children effectively.

In 2012, when this project was in the policy design stage, it was discovered that socioeconomic inequality is at the root of many of the factors that influence child health and development, from pregnancy to infancy. A focus group survey of pregnant women confirmed the need for the development of a home visitation project that focuses on the needs of pregnant women and young children. By offering this project as a public service, we are working toward several goals. 1) We are promoting gender equality. By hiring 141 child health nurses who themselves have experience with childbirth and childrearing, the project creates jobs and helps increase women’s economic participation. As the biggest cause of career discontinuity among Korean women is childbirth and parenting in the infancy years, parenting support programs such as the HFSP are crucial to increasing women’s economic participation. 2) By creating an environment in which well-trained and highly experienced child health nurses have regular work, we are fostering a culture of healthy parenting that compliments parenting-related public services and gives more women opportunities to work outside the home. 3) The “mothers’ group” system involves regular gatherings of new mothers through which women can exchange information, build close bonds with one another, and work together to create a community environment in which their children can grow up healthy. A satisfaction survey of mothers’ group members is conducted on a regular basis, allowing all complaints to be addressed promptly. There is also a project monitoring system that was established based on parenting skills assessments.

This project is significant in that it has fundamentally changed the paradigm of Korea’s mother and child healthcare programs, which were established in accordance with the Mother and Child Health Act of 1973. The HFSP moves away from projects based on a “giveaway approach” (providing material or cash benefits) to instead strengthen parenting capabilities and improve children’s health by providing substantive services. In other words, it is a shift toward a service-based system that is in line with the changes occurring in the social environment (e.g. providing folic acid/iron supplements during pregnancy as well as postpartum). The project’s most prominent feature is its integration of diverse projects that were previously focused on individual problems (single motherhood, premature births, postpartum depression, etc.), which enables the HFSP to address all issues surrounding pregnancy and parenting. Another important aspect of the HFSP is that it breaks from the path dependence of local healthcare programs in Korea, which have focused on the rapid expansion of less-intensive and center-based services rather than outreach services. The sustained visitation service for high-risk mother-baby families aims to provide at least 25 visits per family over a two and half-year period (at least three prenatal and 22 postnatal visits). The universal visitation service is also a quality service that focuses on providing substantive assistance; rather than providing routine visits or delivering materials, it offers visits that last for approximately 1.5 hours each, during which time the specialist provides services that cater specifically to that family’s needs, including services related to breastfeeding and bottle feeding, how to cope with crying babies, psychosocial issues of mothers, physical and growth assessments of babies, assessments of mothers’ physical and mental health, and parent education. The HFSP is not path dependent, in that it aims to increase the quality of the services provided in Korea rather than the quantity (which is typical of most existing projects).

The HFSP works to increase the number of registered pregnant women by conducting diverse activities at local public health centers (provision of folic acid/iron supplements, encouragement of voluntary participation, PR campaigns, cooperation with private institutions, etc.). Based on the list of pregnant women created through these activities, the HFSP identifies those who require universal visitation service and selects candidates for sustained visitations as well. Universal visitations, which are provided within four weeks of childbirth, offer services related to: mother’s health (perineum care, nutrition/meals, cigarette smoking, alcohol consumption, contraception/sexual intercourse, postpartum depression, parenting-related stress, etc.), newborn health (breastfeeding, bottle feeding, jaundice, skincare, umbilical cord care, weight change, vaccinations, hearing, etc.), and improvement of parenting capabilities (newborn care ability, including breastfeeding, soothing a crying baby, and sleep issues, as well as mother-baby attachment, parental roles, participation of fathers, provision of educational materials and materials related to public health center programs, etc.). Sustained visitations require the formation of a trusting relationship and partnership between the child health nurse and the family, based on which services are provided according to the baby’s stage of development and the specific problems faced by each family. Mothers’ groups are made up of those who have received visitations and their operation is facilitated by the child health nurses. Also, by promoting group activities catering to specific types of families (single parent, multicultural, postpartum depression, etc.) and interests (breastfeeding, play groups, etc.), the HFSP fosters relationships among community members and helps participants improve their ability to interact with others in a community.

Over the past four years, the HFSP has paid 53,300 visits to 31,800 families with babies. It increased the coverage rate (for newborn babies and pregnant women) from 13.8 percent in 2013 to 21.4 percent in 2016 in Seoul Metropolitan City. By drastically increasing the number of child health nurses it employs from 69 in 2017 to 141 in 2018, the HFSP expects to increase the coverage rate to 50 percent. With a service-providing staff that is entirely female, the HFSP is making a significant contribution to the effort to increase the employment of service personnel. While increasing its staff from nine in 2013 to 141 in 2018, the HFSP has provided stable employment (unlimited-term contract), over 320 hours of high-quality education and training, compensation and incentives for outstanding employees, and acknowledgement of similar career experience at other public institutions. By creating an atmosphere in which women can work consistently without having to worry about contract periods, the HFSP is increasing women’s participation in the economy. Through universal and sustained visitations, mothers’ groups, and the community service linkage system, the HFSP aims to address the social and psychological difficulties experienced by women before and after childbirth and strengthen the parenting capabilities of mothers to ensure the healthy development of all children. To achieve this aim, the HFSP staff conduct universal prenatal assessments and postpartum visits within four weeks of childbirth and at least 25 prenatal and postpartum sustained visitations for high-risk mothers and babies to strengthen the parenting capabilities of mothers. Mothers’ groups serve to bolster the social networks of mothers who are caring for babies or very young children and help them resolve any psychological problems they may have through bonding with and supporting one another. Through instrumental and psycho-social support activities, we are working to resolve the diverse problems and needs of families—including single-mother and multicultural families—that are struggling with postpartum depression, intimate partner violence, financial difficulties, lack of social networks, suicidal thoughts, and/or child abuse.

One important point regarding the innovativeness of the HFSP is that, while most public health programs implemented via public health centers in Korea thus far have involved expanding less-intensive programs, the HFSP provides intensive, high-quality programs for high-risk mothers and families based on proportionate universalism with the goal of narrowing the health gap (provides focused and consistent support services through maternal and child health experts, monitoring of children’s growth and development, and education on parenting and parental roles from birth until the child turns two years old). To achieve this goal, Seoul Metropolitan Government decided to introduce relevant foreign sustained visitation programs (Australia’s Maternal and Early Childhood Sustained Home-Visiting Program) whose effectiveness has been proven through randomized controlled trials—an unprecedented administrative decision in Korea. In addition, the HFSP is based on an innovative approach that emphasizes partnership and empowerment, as opposed to the “problem identification and prescription” approach of most public services in Korea. The HFSP strives to enhance the capabilities of both service providers (staff) and recipients by offering high-quality services based on clinical supervision, operating an assessment system, and providing at least 320 hours of training/education for service providers (mainly child health nurses).

By adapting advanced programs from other countries to meet domestic needs, the HFSP has created a new type of mother and child health project that is specific to Seoul. While some developed countries, such as Australia and the UK, have operated postpartum universal home visitation programs for over 100 years, Korea had never had such a program. The sustained visitation program is based on Australia’s Maternal Early Childhood Sustained Home-Visiting Program (MECSH), while the universal visitation program, mothers’ groups, and community service linkage system were independently developed based on the particular circumstances of Seoul residents. It is absolutely remarkable that Seoul was able to develop its own nurse-administered maternal early childhood home visitation program in only five years, when it took countries such as England and Australia more than 100 years to do the same. In Australia, there is a university-level educational program designed to cultivate “child and family health nurses.” Until the HFSP, however, there had been no program for educating nurses to visit homes with babies in Korea. Through an independently developed human resource education program, which is based on the Australian model, Seoul Metropolitan Government is cultivating a type of healthcare personnel that has never existed in Korea before. With the administration of the Family Partnership Model Training, one of the key components of the educational program, being conducted entirely by Korean educators, the HFSP is now complete.

The HFSP was founded in 2012 as an early childhood health development program to reduce the “health gap” that Seoul Metropolitan Government mentioned in its “Health Policy Research Report for Reducing Health Gaps in Seoul.” The project continues to be funded entirely by Seoul Metropolitan Government. The core strategy of the HFSP is to provide home visitation services through a registered nurse from pregnancy until the baby is 24 months old. As this kind of project was unprecedented in Korea, there were no qualified healthcare personnel to carry it out. Thus, the HFSP, with the support of academic institutions (nursing and medical schools) in Korea, trained child health nurses to conduct quality prenatal and postpartum visits. This training is equivalent to the one-year education program for child and family health nurses conducted at nursing schools in Australia. In 2018, a budget of KRW 5 billion will be used to station and operate 141 child health (home visit) nurses throughout Seoul. Currently, we are providing a wide range of facilities and equipment that the HFSP personnel need to adequately manage the health of pregnant women and infants, including: vehicles for the exclusive use of HFSP staff, a data system, offices for baby nurses, computers, devices for measuring the height/weight of infants, personal tablet PCs, and digital cameras.

Yes

The HFSP is offered in all of Seoul’s autonomous districts and is currently being expanded nationwide as a project model with guaranteed quality control. The HFSP was designated as a model case of the Mother and Child Health Service’s home visitation health management model for pregnant women and infants and has since been benchmarked by other cities and provinces in Korea (Jeju-do, Busan, etc.). Efforts are also being made to expand the HFSP to other regions and develop the project further by holding discussion sessions among stakeholders (experts and policy beneficiaries).

The poor socioeconomic conditions of parents leads directly to the deterioration of the childrearing environment (as experienced by the child) and ultimately results in social inequalities in childhood cognitive and non-cognitive skills, which significantly contribute to social and health inequalities later in life. Therefore, providing assistance for mothers who are experiencing significant difficulties with parenting and creating a protective social safety net are crucial tasks. Recently, postpartum distress caused by childrearing difficulties has become a serious social problem in Korean society, as evidenced by the rise in instances of suicide, infanticide, and child abuse. Furthermore, postpartum distress is only one of many problems. The number of high-risk families with newborn babies and/or very young children that are struggling with various other difficulties (smoking, alcoholism, poverty, multicultural family-related issues, etc.) is gradually increasing. This makes the establishment of an integrated service provision system capable of addressing this multitude of intertwined problems all the more important. Through its health management service that is tailored to the needs of pregnant women/infants in socially vulnerable or extremely destitute families, the HFSP provides at least 25 meaningful sustained home visitation sessions, spanning the period from pregnancy until the baby is 24 months old. The service intervenes constructively in various ways during the prenatal and postpartum stages, including in relation to maternal health, children’s growth and development, and parent education. Investment in the prenatal and early childhood stages is already widely regarded as both efficient and equitable. Many economists, including James Heckman (co-recipient of the 2000 Nobel Memorial Prize in Economic Sciences), argue that, from a long-term perspective, investing in low-income children is a highly recommended policy that involves no equity-efficiency tradeoff. Therefore, this type of prenatal/early childhood program has a high degree of sustainability in terms of alleviating health inequality toward making society fairer and the lives of all citizens healthier.

For the past several years, the general fertility rate in Korea has remained about 1 birth per 1,000, and the low general fertility rate is increasingly becoming a deeply entrenched social problem. In Seoul, the general fertility rate in 2016 was 0.94 births per 1,000. This means that the average number of babies born in Korea is decreasing by 3,200 annually. Number of babies born in Seoul: 91,526 (2011) → 75,536 (2016) The low birthrate problem in Korea is a sociocultural phenomenon that is caused by a complex and diverse array of factors. A fundamental solution, therefore, requires changing the social perception of and taking a new approach toward the issue. Korea’s birthrate is expected to remain low, at least in the short-term if not the long-term. Now, more than ever before, an individual’s decision to marry, conceive, and give birth must be respected, all newborn babies must be regarded as invaluable human resources for the future, and a social caretaking system that guarantees high-quality childrearing services must be established. In particular, public health services during infancy (pregnancy to 24 months of age), a period where there exists a large health gap due to socioeconomic differences, is an important human resource investment that promotes lifelong health and is a key strategy for addressing the low birthrate problem. Considering the lack of information on and experience with parenting and child development caused by the rise of the nuclear family and increasing number of women working outside the home, it is crucial to create a foundational resource that can strengthen the parenting capabilities of mothers and fathers. By doing so, this project has the potential to increase the possibility of families having a second child. In addition, the creation of a local community environment that is conducive to childrearing can help married couples make the decision to have children. Considering the fact that countries with high birthrates have a well-established social perception of gender equality and largely view childrearing not as a burden but a major accomplishment, it is very important to create a social environment in which the responsibility of pregnancy and childrearing does not lie entirely with the parents but is shared between the family and the society by breaking away from the stereotypical gender roles (childrearing done entirely by the mother) and creating an environment in which men participate much more actively in childrearing.

Yes

In 2013, the HFSP received the Metropolitan Grand Prize at the Community Welfare Service Awards, which was hosted by the Hankyoreh Social Policy Institute (a policy institute of the Hankyoreh, a major newspaper in Korea), Korea Institute for Health and Social Affairs (the Korean government’s health and social welfare research institute), and Korea Association of Community Welfare (an academic society focused on community welfare). The HFSP received high scores from the evaluation committee for its locality, originality, effectiveness, and sustainability and was evaluated as a project with great potential in terms of the care it provides for new mothers and infants as well as from a family welfare perspective. It was evaluated as a project that is capable of reducing health inequality in Korea. In 2017, the HFSP was designated by Korea’s Ministry of the Interior and Safety as an outstanding policy of an autonomous government for overcoming the low birthrate problem. With this designation, it received a ministerial citation and cash prize of KRW 50 million as an incentive. Every year, an external organization (The Seoul Institute) is commissioned to conduct a performance management assessment of the HFSP. The HFSP conducts satisfaction surveys of universal and sustained visitation service recipients and a monthly survey of mothers who receive universal visitation services in order to get feedback on project activities. An overwhelming majority of mothers provide useful feedback. Most feedback is complimentary, but there are also suggestions for ways of improving the HFSP’s services (e.g. increasing the number of universal visitations). The survey of universal visitation recipients involves sending smartphone messages within one month after the visitation. The surveys on sustained visitation services (satisfaction survey and parenting skills instrument survey) are conducted at 6 to 8 weeks, 12 months, and 24 months postpartum as well as after service termination.

The results of the 2016 performance assessment conducted by an external organization (The Seoul Institute) show that 93 percent of HFSP service recipients were satisfied with the home visitation services. The HFSP was also designated as the service that recipients most want to inform others about, thus proving its effectiveness, according to the results of the external performance assessment. The HFSP has also established a quality assessment/monitoring system. With each successive year, the project is gaining significant momentum in terms of recipient satisfaction with the universal/sustained visitation services and the confidence of mothers in themselves and their childrearing capabilities. ※ Satisfaction with universal/sustained visitation services (on a 10-point scale) 8.92/9.20 (2014) → 8.94/9.25 (2015) → 9.05/9.25 (2016) → 9.08/9.42 (2017) ※ Parenting skills instrument (on a 12-point scale, with a score of six meaning “better than average/before”) 7.22 (2014) → 7.25 (2015) → 7.36 (2016) → 7.40 (2017) To ensure its sustainability, the HFSP conducts comparative studies on program effectiveness (currently using an intervention/control comparison study with observational follow-up design but planning to use an experimental design) to accumulate scientific evidence regarding its effectiveness. In addition, mothers who have received HFSP services are given the opportunity to participate in assessment meetings and symposiums and provide feedback on Seoul Metropolitan Government’s policies regarding prenatal and early childhood care. On August 8, 2017, over 100 families (including mothers who have received HFSP services) took part in the HFSP “Nanumteo” event (an event for sharing experiences with parenting and the program), where they offered their opinions on the activities of Seoul Metropolitan Government (which were then used to improve projects). The event was attended by Mayor Park Won-soon and the chairperson of Seoul City Council, who showed that high-ranking policymakers are interested in the HFSP and promised that it would continue to be executed.

The index used for the Outstanding Policy assessment was the presence of a comprehensive administrative framework encompassing effectiveness, originality, perception improvement, applicability and expandability, and life stage appropriateness. “Effectiveness” evaluated the effectiveness, necessity, timeliness, and administrative/structural stability of the HFSP in overcoming the low birthrate, while “applicability and expandability” evaluated the possibility of further developing and expanding the HFSP to other self-governing bodies and whether the HFSP reflects the characteristics of its locale. “Perception improvement” was evaluated based on whether the HFSP includes aspects that aim to improve social perception, has a network that aims to overcome the low birthrate problem, and is making efforts to promote a healthy perception of the project’s aims. Other assessment criteria included the existence of a comprehensive administrative structure that encompasses all stages of life, the willingness of the local government to conduct the project, and the project’s sustainability.

In 2012, when the HFSP was in the planning phase, discussions were held with academics in Australia and the United States on developing a health equality project addressing the prenatal to early childhood stages. Meetings were also held with government officials in charge of child and family health services at South Australia’s state government, and discussions were held with nursing and midwifery faculty members of University of Technology Sydney and Flinders University (Adelaide) regarding educating nurses in Korea. Based on statistical analyses on the Panel Study on Korean Children, the HFSP discovered that socioeconomic inequality has a clear effect on the health and development of young children from pregnancy to early childhood. Focus group interviews conducted with new mothers in Seoul revealed the necessity of home visitations focused on the prenatal and postnatal stages. The HFSP’s wide-ranging activities are based on partnership and cooperation among Seoul Metropolitan Government, the autonomous governments of the districts where the HFSP is being implemented in public health centers, and academic institutions (nursing and medical schools of Seoul National University and other universities in Korea). Seoul Metropolitan Government sets the direction, plans the budget, and settles the accounts of the HFSP and helps with project assessments. Autonomous governments conduct the major HFSP activities (e.g. universal/sustained visitation) and provide community services in cooperation with local communities to raise the quality of HFSP services. Academic institutions introduce evidence-based programs of other developed countries, provide the necessary technology to operate the programs, and develop/execute training programs for HFSP service providers. They also create multi-disciplinary teams to provide a community service linkage system for maternal mental health, child abuse, and intimate partner violence. Caring for the health of pregnant women and infants is primarily provided by the child health nurses. However, for families in complicated circumstances or that need additional professional assistance (psychological problems, intimate partner violence, child abuse, housing problems, etc.), a service delivery system is established for comprehensive case management purposes. Through local consultative groups that draw on various local professional resources, a governance system is created through which individual needs are addressed based on a recipient-centered problem-solving approach.

In only four years, the HFSP has successfully adapted an evidence-based licensed sustained home visitation program for domestic use and newly developed a universal risk assessment system for public health centers, a universal home visitation program, mothers’ group programs for mothers receiving universal or sustained visitation services, and community service linkage systems in Seoul. With the aim of establishing a comprehensive service system to address the diverse and complex problems experienced by pregnant/postpartum families, child health nurses are dispatched to all districts where the HFSP is being implemented. The HFSP’s signature family visitation program focuses on enhancing the parenting capabilities of mothers and fathers so that they can play active roles in resolving the diverse problems they face before and after childbirth. By shifting the focus of its services from the supplier to the recipient, the HFSP has increased the satisfaction of new mothers and strengthened parenting capabilities and the mental health of mothers before and after childbirth. In addition, by developing new mother and child health care models that reflect the current social atmosphere (e.g. strengthening social support for high-risk pregnancies and births), the HFSP has reduced health inequality by providing high-risk families with high-quality professional services. Going forward, the HFSP will continue developing resources with the aim of improving the quality of its services, monitoring service satisfaction levels and the consistency of services, and engaging in academic research to secure objective proof of the effectiveness of its services (e.g. universal/sustained visitation services and mothers’ groups)—all for the purpose of ensuring that the HFSP remains sustainable for as long as possible.