Although randomized interventions trials have been shown to reduce the incidence of disorganized attachment, no studies to date have identified the mechanisms of change responsible for such reductions. Maternal sensitivity has been assessed in various studies and shown to change with intervention, but in the only study to formally assess mediation, changes in maternal sensitivity did not mediate changes in infant security of attachment (Cicchetti, Rogosch, & Toth, 2006). Primary aims of the current randomized controlled intervention trial in a high-risk population were to fill gaps in the literature by assessing whether the intervention (a) reduced disorganization, (b) reduced disrupted maternal communication, and (c) whether reductions in disrupted maternal communication mediated changes in infant disorganization. The results indicated that, compared to controls (n = 52), both infant disorganization and disrupted maternal communication were significantly reduced in the intervention group (n = 65) that received regular home-visiting during pregnancy and the first year of life. Furthermore, reductions in disrupted maternal communication partially accounted for the observed reductions in infant disorganization compared to randomized controls. The results are discussed in relation to the societal cost effectiveness of early attachment-informed interventions for mothers and infants, as well as the importance of formally assessing underlying mechanisms of change in order to improve and appropriately target preventive interventions.

Assessing a change mechanism in a randomized home-visiting trial: Reducing disrupted maternal communication decreases infant disorganization.

Resumo O puerperio trata-se de um periodo de significativa morbimortalidade para as mulheres, e a Atencao Primaria a saude (APS) e importante no desenvolvimento de acoes para atender as necessidades de saude das mulheres. Objetivou-se sistematizar o conhecimento produzido sobre as acoes de programas de atencao pos-parto no âmbito da APS, tanto em nivel nacional, como internacional. Utilizou-se revisao integrativa de literatura de artigos junto as bases Lilacs (Literatura Latino-Americana e do Caribe em Ciencias da Saude), BDENF (Base de dados em Enfermagem), SciELO (Scientific Electronic Library Online) e PubMed (Biblioteca Nacional de Medicina dos Estados Unidos). A busca ocorreu de abril a maio de 2017. Atenderam aos criterios de selecao 43 artigos. Os resultados apontam que: a APS possui estrutura fisica para atencao a puerpera, porem com deficit em recursos humanos e materiais; ha baixa cobertura de consulta pos-parto e visita domiciliar; boa avaliacao do incentivo ao aleitamento materno, porem com foco na crianca; rastreamento da Depressao Pos-Parto internacionalmente por meio da “Edimburgh Post-Natal Depression Scale”, e deficit na atencao a esse agravo no Brasil. A atencao pos-parto ainda tem como foco o cuidado ao recem-nascido e sao restritos, em sua maioria, ao puerperio imediato e tardio.

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Postpartum program actions in primary health care: an integrative review

Context: Postnatal maternal depression (PND) is a significant risk factor for infant mental health. Although often targeted alongside other factors in perinatal home-visiting programs with vulnerable families, little impact on PND has been observed. Objective: This study evaluates the impact on PND symptomatology of a multifocal perinatal home-visiting intervention using psychologists in a sample of women presenting risk factors associated with infant mental health difficulties. Methods: 440 primiparous women were recruited at their seventh month of pregnancy. All were future first-time mothers, under 26, with at least one of three additional psychosocial risk factors: low educational level, low income, or planning to raise the child without the father. The intervention consisted of intensive multifocal home visits through to the child’s second birthday. The control group received care as usual. PND symptomatology was assessed at baseline and three months after birth using the Edinburgh Postnatal Depression Scale (EPDS). Results: At three months postpartum, mean (SD) EPDS scores were 9.4 (5.4) for the control group and 8.6 (5.4) for the intervention group (p=0.18). The difference between the mean EPDS scores was 0.85 (95% CI: 0.35; 1.34). The intervention group had significantly lower EPDS scores than controls in certain subgroups: women with few depressive symptoms at inclusion (EPDS ,8): difference=1.66 (95%CI: 0.17; 3.15), p=0.05, adjusted for baseline EPDS score), women who were planning to raise the child with the child’s father: difference=1.45 (95%CI: 0.27; 2.62), p=0.04 (adjusted); women with a higher educational level: difference=1.59 (95%CI: 0.50; 2.68) p=0.05 (adjusted). Conclusion: CAPEDP failed to demonstrate an overall impact on PND. However, post-hoc analysis reveals the intervention was effective in terms of primary prevention and in subgroups of women without certain risk factors. Effective overall reduction of PND symptomatology for young, first-time mothers presenting additional psychosocial risk factors may require more tailored interventions. Trial registration: ClinicalTrials.gov NCT00392847 Promoting Parental Skills and Enhancing Attachment in Early Childhood (CAPEDP)

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Impact of a manualized multifocal perinatal home-visiting program using psychologists on postnatal depression: the CAPEDP randomized controlled trial.

Background Home visiting programs are implemented in high income countries to improve outcomes for families with young children. Significant resources are invested in such programs and high quality evaluations are important. In the context of research trials, implementation quality is often poorly reported and, when reported, is variable. This paper presents the quality of implementation of the right@home program, a sustained nurse home visiting intervention trialled in Australia, and delivered in a 'real world' context through usual child and family health services. right@home is structured around the core Maternal Early Childhood Sustained Home-visiting (MECSH) program, which is a salutogenic, child focused prevention model. Method At each visit right@home practitioners completed a checklist detailing the client unique identifier, date of contact and activities undertaken. These checklists were collated to provide data on intervention dose, retention to program completion at child age 2 years, and visit content, which were compared with the program schedule. Quality of family-provider relationship was measured using the Session Rating Scale. Exploratory factor analysis was conducted to identify clusters of activities and allow qualitative assessment of concordance between program aims and program delivery. Results Of 363 intervention families offered the program, 352 (97·0%) commenced the program and 304 (87·3%) completed the program to child age 2 years. 253 of 352 (71·9%) families who commenced the program received more than 75 percent of scheduled visits including at least one antenatal visit. Families rated the participant-practitioner relationship highly (mean 39.4/40). The factor analysis identified six antenatal and six postnatal components which were concordant with the program aims. Conclusions The right@home program was delivered with higher adherence to program dose, schedule and content, and retention than usually reported in other home visiting research. Program compliance may have resulted from program design (visit schedule, dose, content and delivery flexibility) that was consistent with family aims.

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Quality of delivery of "right@home": Implementation evaluation of an Australian sustained nurse home visiting intervention to improve parenting and the home learning environment.

Health inequities among children in Sweden persist despite the country’s well-developed welfare system and near universal access to the national child health care programme. A multisectoral extended home visiting intervention, based on the principles of proportionate universalism, has been carried out in a disadvantaged area since 2013. The present study investigates the content of the meetings between families and professionals during the home visits to gain a deeper understanding of how it relates to a health equity perspective on early childhood development. Three child health care nurses documented 501 visits to the families of 98 children between 2013 and 2016. A qualitative data-driven conventional content analysis was performed on all data from the cycle of six visits per child, and a general content model was developed. Additional content analysis was carried out on the data from visits to families who experienced adverse situations or greater needs. The analysis revealed that the home visits covered three main categories of content related to the health, care and development of the child; the strengthening of roles and relations within the new family unit; and the influence and support located in the broader external context around the family. The model of categories and sub-categories proved stable over all six visits. Families with extra needs received continuous attention to their additional issues during the visits, as well as the standard content described in the content model. This study on home visiting implementation indicates that the participating families received programme content which covered all the domains of nurturing care as recommended by the WHO Commission on Social Determinants of Health and recent research. The content of the home visits can be understood to create enabling conditions for health equity effects. The intervention can be seen to represent a practical example of proportionate universalism.

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A better start for health equity? Qualitative content analysis of implementation of extended postnatal home visiting in a disadvantaged area in Sweden

Objective
Implementation fidelity is a key issue in home-visiting programs as it determines a program’s effectiveness in accomplishing its original goals. This paper seeks to evaluate fidelity in a 27-month program addressing maternal and child health which took place in France between 2006 and 2011.

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Evaluating fidelity in home-visiting programs a qualitative analysis of 1058 home visit case notes from 105 families.

La psychologie du developpement constitue un champ en developpement depuis le milieu du XXe siecle. La genetique, l’epistemologie, les sciences cognitives, la psychologie clinique et la psychologie sociale l’ont enrichie de leurs modeles et theories. Cet article synthetise les principales conceptions et applications de la psychologie du developpement. A travers l’approche clinique, cognitive ou sociale, les auteurs ont developpe des methodes et outils pour leur pratique aupres de bebes et de jeunes enfants, conduisant a une approche contemporaine reposant sur l’integration des modeles.

Eléonore Pintaux

Papers

Evaluating fidelity in home-visiting programs a qualitative analysis of 1058 home visit case notes from 105 families.

Le développement précoce de l'enfant : évolutions et révolutions

Les interventions préventives en santé mentale du jeune enfant vues par leurs bénéficiaires : l’exemple du projet CAPEDP

Interventions préventives en périnatalité : illustrations de terrain