A needs and resource assessment to inform the design and development of an antenatal support and parent support programme

A report prepared for youngballymun

Dr. Anne Matthews

Dr. Pamela Gallagher

Ms. Muriel Redmond

Mr. Simon Dunne

Mr. Liam MacGabhann

Prof. Anthony Staines

Prof. Chris Stevenson

School of Nursing, Dublin City University

November 2007

Table of Contents

Section 1: Introduction...... 3 Section 2: Audit...... 4 2.1 Aim ...... 4 2.2 Method...... 4 2.3 Findings...... 4 2.3.1. Identification of organisations ...... 4 2.3.2. Audit of existing pre-birth and early (0-2 years) parent support services and resources in Ballymun ...... 6 2.3.3. Mapping of existing pre-birth and early (0-2 years) parent support services and resources in Ballymun ...... 14 Section 3: Needs Assessment ...... 15 3.1 Aim ...... 15 3.2 Literature Review...... 16 3.2.1 Method...... 16 3.2.2 Findings...... 16 3.2.2.1 Antenatal needs of mother and child...... 16 3.2.2.2 Antenatal education ...... 17 3.2.2.3 Needs of children 0-2 ...... 19 3.2.2.4 Fathers’ needs ...... 20 3.2.2.5 Mothers’ needs...... 21 3.2.2.6 Post-natal depression ...... 22 3.2.2.7 Mothers and children in disadvantaged areas ...... 23 3.2.2.8 Adolescent mothers ...... 25 3.2.2.9 Home visitation from nurses...... 27 3.2.2.10 Group-based parenting programmes...... 28 3.2.2.11 Community-based parenting programmes ...... 30 3.3 Review of available birth-related and maternal health data in Ballymun...... 33 3.3.1 Method...... 33 3.3.2 Findings...... 34 3.3.2.1 Population ...... 34 3.3.2.2 Proportion within age-groups of population ...... 34 3.3.2.3 Household size ...... 35

1 3.3.2.4 Ethnic minority groups ...... 35 3.4 Priority Needs Identified Via Individual Structured Interview ...... 37 3.4.1 Method...... 37 3.4.2 Findings...... 37 3.4.2.1 Antenatal needs ...... 37 3.4.2.2 Child’s needs (0-2) ...... 37 3.4.2.3 Parents’ needs (0-2)...... 37 3.5 Participatory Open Forum ...... 39 3.5.1 Method...... 39 3.5.2 Questions for group-work ...... 39 3.5.3 Findings of forum ...... 39 3.5.3.1 Ante-natal needs ...... 40 3.5.3.2 Child Needs (0-2) ...... 41 3.5.3.3 Parents’ Needs ...... 42 3.5.3.4 What would it look like if these needs were met?...... 42 Section 4: Summary of key findings...... 44 Section 5: References ...... 45

2 Section 1 – Introduction

Youngballymun is a ten-year strategy to improve mental well-being and learning outcomes for children and young people in Ballymun. Youngballymun will have 3 strands of work – each characterised by the themes of integration, innovation and evaluation - to improve the education and mental well-being outcomes for children and young people in Ballymun:

• Systemic and integrated change processes within and across existing children’s service provision including the spheres of education, health, and community spanning the pre- birth – 18 year age group

• 6 new services: 2 services dedicated to pre-birth and early childhood; one pre-school service; 2 services providing primary school age literacy and well-being supports and a youth mental well-being service

• Rigorous evaluation of services and of the youngballymun change project and communication of learning

Youngballymun is currently in its service design stage of the Antenatal Support and Parent Support programmes – a clear, outcomes focused, sequential process involving the facilitation of multidisciplinary teams, informed - by a needs and resource assessment, consideration of the national policy context, models of best practice - and following a logic model approach to project planning. This report is informing the design of the youngballymun antenatal support and parent support programmes, based on the following objectives:

1) An audit of existing services – both statutory and non-statutory – that target children from pre-birth to age 2 years and their parents in Ballymun

2) An assessment of needs of children from pre-birth to age 2 years and their parents as identified by local service providers and as identified through existing research

The specific research questions to be addressed are:

1. What statutory and non-statutory antenatal and parent support services currently exist in Ballymun and how are they resourced?

2. What are the needs for antenatal and parent support services as perceived by local service providers in Ballymun and as identified by previous research?

The first question is addressed in Section 2 of the report which includes a listing of relevant organisations in the Ballymun area, the findings of the audit of the services provided and a mapping of these services along the ante-natal to age 2 continuum. The second question is addressed in Section 3 of the report which incorporates a review of the literature and existing data, and service providers’ views of needs which have emerged from structured interviews and a participatory open forum. Section 4 provides a synthesis of the findings and concluding comments.

3 Section 2 - Audit

2.1 Aim To conduct an audit of existing services – both statutory and non-statutory – that target children from pre-birth to age 2 years and their parents in Ballymun

2.2 Method To successfully complete the audit of existing services, the following steps were undertaken:

(1) All organisations targeting children from pre-birth to 2 years of age and their parents living in Ballymun were identified by working closely with youngballymun in reviewing documentation and listings of statutory and non-statutory organisations in Ballymun and collating a list of potentially relevant services. Each organisation was subsequently contacted by telephone to establish their relevance to the overall aim of the audit and needs assessment (see Table 1 below).

(2) Descriptions of the service(s) provided by the relevant organisations to children from pre-birth to 2 years of age and their parents living in Ballymun were achieved by developing a structured interview to gather data on the specific relevant services provided by each of the identified organisations. Details of their aim, focus, client coverage, spatial spread of services, extent, intensity, mode of delivery and the personnel, facilities and materials involved in the planning and delivery of the services were sought. Any available evaluation data on the impact of their services was also sought. Each organisation providing a relevant service was contacted by letter and e-mail and informed that a member of the research team would be in contact to arrange a face-to-face or telephone meeting. Letters outlining the background to and purpose of this study and explaining what was required and would be covered by the structured interview were sent to confirm the date and time of interview.

(3) These services and associated resources were mapped across the antenatal to age 2 continuum of care.

2.3 Findings

2.3.1 Identification of Organisations

Within a specified timeframe, contact was attempted with the 29 organisations listed in Table 1, as these organisations were identified as providing or potentially providing relevant services. Table 1 documents whether a member of the research team was able to make direct contact with a person within the organisation, whether the organisation considered themselves relevant for the interview stage, that is, whether they provided an antenatal service or a service relevant for children aged 0-2 and their parents, and finally whether the organisation was interviewed. Of the 29 organisations identified, 10 (34%) did not consider themselves relevant to the focus of the audit, 5 (17%) organisations were not contactable or were potentially relevant but were unable to be interviewed, and 14 (49%) organisations considered themselves relevant for the audit and were interviewed.

4 Table 1: Sample of Organisations Contacted and/or Interviewed

Organisation Direct Contact Relevant Interviewed (Y es /N o) (Y es /N o/M aybe ) (Y es/ No) Community and Family Training Agency (CAFTA) Y Y Y Community Mothers’ Programme Y Y Y Dublin City Council, Social Inclusion Unit Y Y Y Drop In Well Centre Y Y Y Geraldstown House Y Y Y Lifestart Y Y Y Mater Child and Adolescent Mental Health Service Y Y Y (CAMHS) Primary Care Team, HSE, Ballymun Y Y Y Psychology Service Y Y Y Public Health Nursing Service Y Y Y Rotunda Hospital- Medical Social Work Service Y Y Y Rotunda Hospital- Teen Clinic Y Y Y Trinity Comprehensive School services Y Y Y Women’s Resource Centre Y Y Y Ballymun Regional Youth Resource (BRYR) Y M N STAR project Ballymun Y M N Ballymun Youthreach Centre N Sophia housing association N YAP- Ballymun Youth Action Project N Axis Ballymun Arts and Community Resource Centre Y N N/A Ballymun Community Law centre- outreach clinic Y N N/A Ballymun Community Organisations Network Y N N/A Ballymun Job Centre Y N N/A Ballymun Library- Toddler playtime Y N N/A Drugs Task Force Y N** N/A Intercultural Group Y N N/A Men's Group Y N N/A St Margaret’s Travellers’ pre-school Y N* N/A St Michael’s House Y N N/A

*It was suggested that Community Health Workers employed by St. Margarets would be useful and were invited to the forum ** Not directly relevant but link in with LifeStart where appropriate.

5 2.3.2 Audit of existing Pre-birth and early (0-2 years) parent support services and resources in Ballymun

Organisation Aim How long Brief description of Client group (details- How service is Resources used: Evaluation- details running services age, gender, place) accessed and (e.g. people, facilities, advertised equipment and materials) Primary Care • To provide Since March • Antenatal classes: 8 • Pregnant women and • By word of mouth- People • Informal feedback is Team, HSE, antenatal 2007 classes per programme, their partners. 5- 9 per also in GP • Primary care team requested at end of each Ballymun education and runs weekly. To date, 3 group. Smaller practices, members- physiotherapist, session; a questionnaire is preparation for programmes have run numbers than in hospitals, chemists, dietician, psychologist, also disseminated. Although birth and (with an additional 3 hospital classes. post office public health nurses, it is recognised that it is parenthood. To week course during the • Open to all. Some Community Mothers’ difficult to measure meet gap as summer). They are younger women Programme Coordinator outcomes, to date, there few women facilitative rather than attend. It is recognised (Family Development are positive responses with attending imparting information. that the group format Nurse). potential for long-term antenatal Participants are asked to may not suit all. benefits. Currently, classes specify what they need • As the programme Facilities consideration is being given (Rotunda etc) and medical terms develops, it could be • Hosted in health centre. to best outcomes (e.g. (verbal and written) are breastfeeding rates etc) and provided at specific introduced. Classes locations (e.g. St the development of a 5 year have a flat structure, Margaret’s). strategy. and are participative. Participants share knowledge with each other and develop friendships. Trigger cards, pictures and games are used throughout. Public health • To provide Statutory • Provide mandatory visit • All new mothers • State service- People None available nursing service population basis when return home (80% notified by • Public health nurses health-based mothers in Dublin North maternity hospitals (providing this service services Central HSE receive visit within their overall role) , postnatally to within 48 hours). all mothers in • Needs assessment- a Facilities catchment care plan is developed if • Health centre, area. people have additional

needs. Materials • Developmental • Health promotion leaflets screening at 3, 7 and 18 and booklets months- developmental check-up by Doctor at 9 months. • Home visits or open clinics- 4 afternoons per week (60-70% attend). Prioritise child welfare, but fewer home visits possible.

6 Organisation Aim How long Brief description of Client group (details- How service is Resources used: Evaluation- details running services age, gender, place) accessed and (e.g. people, facilities, advertised equipment and materials) Community • To provide non- 1988 • A monthly visit for one • All first time mothers • All birth People • Randomised Controlled Trial Mothers’ professional hour from a Community offered service where notifications • Programme Coordinator in 1989 (Johnson et al, EHB Programme support to Mother (CM) until the there is a Community passed from PHN (Family Development unpublished 1992; BMJ develop the child is 2 years old to Mother in that area. service. Nurse) HSE-funded; 22 1993). N= 232, randomized latent self- enable discussion and About 25% first time • CMs referred by volunteer Community to CMP or usual care by FDN esteem and information-giving. Focus mothers decline existing CMs or Mothers, visiting 200 (and FDN measured results). skills of new on 3 tasks (e.g. service- contacted 3 PHNs or used families. 99 CMs trained Significant positive results for parents. behavioural or practical) times. service themselves over past 15 years. High children and mothers in • To provide a to achieve by next visit- • Second time mothers (qualities: good turnover as CMs move on intervention group - model of to suit mother. Queries are also offered but listener, interested to education and work, immunizations, reading, parent are referred to Family most decline. in the community which is encouraged. On diet/nutrition, positive empowerment. development Nurse • 50% mothers using the and good rapport average CMs stay for 4.5 maternal results. Significant (FDN). Only one visit per programme in 2005 with own children). years, with the longest difference in employment month, unless following were single parents; being 14 years. level (higher in intervention up a query. 10% were teenagers • Expenses paid (€8.50 per group) controlled for that • If the mother is (CMP Annual Report hour) and reanalyzed- no effect. expecting another child 2006 p19) • One CM has additional • 7 year follow-up (Johnson et during the 2 years, training for antenatal al, Jnl PH Medicine, 2000). 76 antenatal support is support. mothers (38/38) re- possible but otherwise it interviewed. No comment re employment status is not offered. Facilities • Breastfeeding group is matching original group. • Based in community Results: sustained beneficial led by 2 CMs, 2 setting in Geraldstown Wednesdays per month. effects. House. This can include • Ongoing evaluation- at one

weighing the child and and 3 years old- how the guest speakers. There Materials mother feels. • are approx 5-8 in a Antenatal pack. • Visit from UNESCO group. CMP Coordinator Programme Manual (with delegation in 2006 (included visits all breastfeeding Illustrated Sheets to lead a visit to Ballymun) CMP mothers herself. sessions). Breastfeeding Annual Report 2006. support materials- booklets • Parent and toddler • Have been involved in lots of and videos (e.g. nursery group meets weekly for other studies- breastfeeding, rhyme book). Specific 2 hours and is facilitated family planning. CMP materials- accessible. by 2 CMs. There are 3 • Benefits to Community sessions- social part, Mothers (Molloy 2007): a children minded, all play pathway to lifelong learning together, go around (survey n=82 CMs 2004/5). parent and child individually to promote appropriate play etc. There are approx 12-15 people, mostly mothers. • St Margaret’s FDN and CM visit (5-6 births per year).

7 Organisation Aim How long Brief description of Client group (details- How service is Resources used: Evaluation- details running services age, gender, place) accessed and (e.g. people, facilities, advertised equipment and materials) Geraldstown • To provide a Open since • HSE-funded. • All parents including • Self referral Geraldstown House is a None available House range of family 1987 • Provide parent support, young mothers. through word of HSE service and the support e.g. a weekly mother Consideration is mouth- social work relevant services are services (e.g. and toddler group which currently being given referrals, other provided by HSE and personal provides an opportunity to the best way to agencies, Community Employment development, to meet socially. As part provide services (e.g. Community staff, including local staff. work with of this group, children should there be a Mothers’ teenagers with can be minded in a separate group for Programme challenging crèche while parent can teen mothers?). behavior, discuss relevant issues • Currently 6-10 in a relaxation such as child group. The crèche classes) development. As part of can cater for up to 10 this group, there is also children. the possibility of a joint session with parents and children. Then a joint session with parents and children. Rotunda • To support all • Support to any mother • All mothers- those who • Self-referred or Facilities None available Hospital- mothers who who requires social work are drug users (special referrals from • Social work department, Medical Social need social services, particular focus team, with social maternity care Rotunda Hospital, Dublin. Work Service work service, on child protection, drug worker), with child professionals; link with a variety using mothers, younger protection needs, with others, e.g. Materials of mothers younger mothers Drug Liaison • Leaflets, information circumstances (liaise with Community Midwife in the booklets. and needs Care Social Worker) Rotunda, community drugs services, and family support services. Rotunda • To provide • Clinic-based antenatal • Less than 18 at time of • Referred from People • Currently evaluating using a Hospital- Teen antenatal care, care and education with booking visit. Partners antenatal clinic to • Specialist midwife, questionnaire- poor Clinic education and dedicated classes (e.g. (or sibling, mother or teen clinic. It is consultant and registrar. response rate- 30 responses. support to 3 in programme, and friend) are welcome promoted as an Clients are saying that they pregnant girls participants choosing to classes and usually additional service. Facilities would like a postnatal class. who are less areas to cover). do come • Clinic facilities. Also perceive a need for a than 18 years Reminder texts are sent young parents’ room before old. the day before. There is clinic for peer support. also ongoing continuity of care through mobile phone contact with midwife who also visits most on ward after birth and 6 week check-up.

8 Organisation Aim How long Brief description of Client group (details- How service is Resources used: Evaluation- details running services age, gender, place) accessed and (e.g. people, facilities, advertised equipment and materials) Trinity • To support and An evolving • Currently an information • Pregnant school • Referred within People None available Comprehensive provide a service over and support service but students. Do not school. • Full-time chaplain and School services pastoral role to the past few developing a more provide a direct counselor. school- years. formal service. There are service to fathers in attending girls weekly meetings but the school, but may Facilities who are with poor attendance. provide support in an • Office on school premises pregnant and Practical advice is given informal way.

in motherhood. (e.g. applying to crèche, Aim is to filling out forms, applying encourage girls for Home Tuition Scheme to continue (9 weeks). Guest education speakers are also (balanced with brought in. Currently attachment compiling a directory of needs) crèches- waiting lists etc. and peer support facilitated. Psychology • To provide • The PCT • Contributes to PCT Ante- • The client group • Service is People • No specific programmes for Service -PCT psychological ante-natal natal programme. The attending the ante- advertised through • In terms of Ballymun area, antenatal or support of support in programme psychologist gives natal programme are leaflets, GP, self- 2 FTEs (translates into 2 parents of 0-2 year olds and North Dublin has only approximately 2 sessions predominantly mid- referral people who work half time therefore no evaluation. City Centre been running (about 20 minutes each) late 20s, local to the in the Ballymun area and this year. It out of approximately 6-8 Ballymun area the Psychology Manager) has already sessions. Content been run focuses on expectations Facilities twice and is of motherhood, • Health Care Facility, currently developing a bond with Ballymun being run a the baby.

third time • Individual sessions are Materials (see above). also given, for example • with women who are Leaflets experiencing anxiety while pregnant but are unable to take medication, and with women experiencing post-natal depression. Lifestart • To educate Ballymun • Lifestart is a universal • Clients come from all • Referral, usually Facilities In 2002, the pilot stage was parents of project programme, open to all over Ballymun and it is through other • Currently located in internally evaluated by the children 0-5 started in parents. However, in open to all parents. community groups converted flats, which are Foundation. Findings were years of age. 1999. Lifestart Ballymun, participants • 20% of places are (e.g. Youthreach, due to be knocked down positive at that stage. • To provide Foundation generally tend to be allocated to/targeted Star Project). before Christmas, so are Recently completed an early going since from disadvantaged at vulnerable groups • Staff give moving to another flat evaluation in the summer of intervention 1989 families. including people using presentations on complex. Long term 2007. Results are imminent. and primary • Lifestart does not drugs. Lifestart to other premises plan is uncertain. Currently involved in a five intervention discriminate, and • ‘A few’ settled parents groups. year longitudinal

9 Organisation Aim How long Brief description of Client group (details- How service is Resources used: Evaluation- details running services age, gender, place) accessed and (e.g. people, facilities, advertised equipment and materials) promotes the from the travelling • Word of mouth. Materials randomised control trial to uniqueness of every community attend. It • Newsletter • Main programme (i.e. evaluate the programme child was noted that a • Leaflet drop but home visits) is written in and its outcomes. This is just • One home visit per presentation was have not done chapters that changes starting now. month made at St. Margarets one this year every month. • Provides information on but it did not get a • Have library with books, development of child on great reception and toys, art supplies, DVD’s a monthly basis. The unsure of reasons why. etc. This operates as a information pack • Over the past 3 years lending library but a lot of ‘Growing Child’ is some foreign nationals time do not get materials tailored to each stage of have been involved back the child’s development. but tend to be short They have 60 monthly term as a lot are People issues that are age moved on from • Only employ volunteers for appropriate (0-5) and temporary housing one off event, Christmas and could be placed tailored for each month parties, days out etc. elsewhere. of a child’s • 5 part-time staff development • 1 full time staff

• 1 staff on community employment schemes (20 hours) Dublin City • To provide • Since 2000. • Family support • Vulnerable families • Get referrals from • This is the only service of its • No evaluation as yet but did Council Social Social Service programmes. Two visits their own agency kind across the city. an internal review which Inclusion Unit. Support to per week to a family for (DCC) and from found that a lot of people in vulnerable a period of two years. other local People the community were not families. Tailored made for agencies, from the • 3 full time members of aware of this service so had individual family needs. neighbourhood staff, from social work and to get organised in terms of Provide general support, wardens and psychology background. networking and helping out in the home, project estate • No volunteers but communication. • listening, advising on management, HSE. sometimes work with the Ongoing struggle with the family life, for example, They also accept neighbourhood wardens issue that this is a service finance, diet, nutrition, self-referrals. • Monday to Friday, 9am- provided by Dublin City parenting support, Council so local people are 5pm linking people in with wary and worried about

other agencies like issues of confidentiality. For CAFTA who run a lot of example, if they were co- courses on parenting habiting or using drugs etc, etc. HSE, Mabs (financial would the council be made advice centre) etc. aware of this. There is a • Tenants support need to build up trust with programme. Work with service users as Dublin City families who may be Council do not have the under threat of eviction best image. They are not because of ‘anti-social’ seen as community behaviour, rent arrears, development but rather as or going through a crisis the ‘council’.

10 Organisation Aim How long Brief description of Client group (details- How service is Resources used: Evaluation- details running services age, gender, place) accessed and (e.g. people, facilities, advertised equipment and materials) and provide support in gaining employment, training, and education. • Second chance programme. Support for those who have been evicted, mainly for anti- social behaviour, drug abuse etc, and are returning to the community • Shortly starting in the neighbourhood centre an informal drop in service providing information on housing, financial advice, & other support services. Mater Child • Child and Operating • Multidisciplinary services • Children and • Get referrals from People None available. and adolescent since 1974 for children and Adolescents doctors, nurses, • 1 part-time psychiatrist Adolescent mental health adolescents • Occasionally, community • 1 full time psychiatric Mental Health experiencing difficulties, members of the services, schools. registrar Service behavioural and travelling community • Direct referrals • 1 and a half social workers (CAMHS) emotional problems, attend. However, it from parents are • 2 psychologists whose needs cannot be was noted that this not taken. • 1 speech and language met at primary care group can encounter therapist level. difficulties in engaging • Occupational therapist for • CAMHS run a parenting with the service as half day. course, twice a year, they can be more once a week for 7 or 8 consumed with basic weeks. At moment they needs than additional Materials have a small group. services, feeling • Use a broad range of • Use Marte-meo method. stigmatised, and lack standardised assessment This involves looking at of support. tools for cognitive and the caregiver (parent, • A ‘handful’ of African emotional assessment. foster parent, residential and Eastern European care giver etc) and how clients attend. It was Facilities they relate and noted that while • Located in Civic Centre, communicate to the African clients have Ballymun. person with need. The good English, it is interaction is filmed in generally necessary to own home situation. work through an Therapist analyses the interpreter with film and gives feedback families from Eastern to caregiver on what is Europe. Furthermore, working well and how the different cultural

11 Organisation Aim How long Brief description of Client group (details- How service is Resources used: Evaluation- details running services age, gender, place) accessed and (e.g. people, facilities, advertised equipment and materials) they could improve in child-rearing practices some areas. Available in provide interesting Ireland for past 10 years. discussions. However, HSE provides training in it can be difficult for the unit in Richmond Rd. them if they are the They have two sessions only minority in the of Marte Meo, 2 days a group. week, which can take place in clients home or in their offices. They have one half day art therapy per week run in their offices. Drop In Well • Provide local Since 1991, • Non threatening informal • Work mostly with older • Do an open day at Facilities None available Centre service to has only environment clients 40 -60 age beginning of the • Work out of a three break isolation been funded • Beauty therapy, group school term. bedroom flat provided by since 2002 personal development, • Word of mouth, DCC meditation, arts and get referrals from crafts other community People • Pass It On: people who groups • 1 full time staff member have completed these • 1 part time development courses now pass this worker information on. • Part time volunteers • Open 9am-5pm, drop in centre • Get tutors and hours from VEC and DCC. Work during term time, set activities (e.g. do ‘Angel Cards’)

Community • A community 1979 • FETAC Parenting • Open to all in • Referral: People • An external evaluation took and Family development Courses: To create a Ballymun. CAFTA also progression from • 8 people on board of place a few years ago with Training programme to learning space for work with Finglas/ other courses, management positive results. Agency support and parents to support each Cabra partnership. other community • 3 paid staff on Community • Internal evaluations for every (CAFTA) empower other, to develop and CAFTA work with St. groups, self Development Programme programme individuals and grow, share experiences Margaret’s and some referral. • 8 funded by Ballymun • Reports not available families to and acknowledge their members of the • Posters in Regeneration Ltd. make choices achievements. Eight travelling community community • 18 part-time and 1 full time as part of the programmes a year over attend. Few people • Active link website, as part of FAS community regeneration 11 weeks. Attendees are from ‘new other community scheme programme in offered a childcare communities’ attend development • 3 from An Pobal funding the community. allowance or are offered and it was noted that programmes. a free crèche place. it is difficult to target Facilities

12 Organisation Aim How long Brief description of Client group (details- How service is Resources used: Evaluation- details running services age, gender, place) accessed and (e.g. people, facilities, advertised equipment and materials) • Magic 123 Programme: this group. • Most courses run in training A 4 week programme on centres. discipline that is gentle and effective leading to Materials a more peaceful • Use various teaching household, fewer angry resources moments, higher self- esteem and confidence, more time for fun and affection and stopping repetitive bad behaviour. • Teen Programme: a yearly 6 week programme for teens that cover many issues such as sexual health, drug and alcohol issues. • Has community crèche in the flats Women’s • Very large 1995 • FETAC Education • Women only, all ages. • Advertisement is Facilities • Different programmes have Resource centre programmes, full At the moment they not required. • Centre works out of 5 flats been evaluated at different Centre providing childcare facilities, peer have no women from Referrals through phases. Furthermore, services and education, youth the travelling word of mouth, Materials because they use peer programmes support, young mums community or other public health • Use TV’s, videos, a variety education they do have an for women working with other ethnic groups. nurse, or local of training materials ongoing evaluation as part only. young mums. Support school might refer of the ethos of the centre.

and information service young women. • Evaluations have been People for young mothers. Drop mainly positive. One • in youth service. There 3 youth workers and 1 negative is the location of are services for older senior child care worker. the centre as it is perceived mothers but not on a Also they have tutors who to be sometimes unsafe, regular basis. deliver the courses. especially for young women • Provide a 10-week coming in on their own. programme pre-birth People hanging round the and after birth, 3 times a flats may intimidate and year for all mothers. stop women from using • Run a young mothers centre. programme twice a week for 10 weeks that includes parenting skills, household budgets, childcare, rest and relaxation, and daily living skills.

13 2.3.3 Mapping of existing pre-birth and early (0-2 years) parent support services and resources

Based on the informed gathered during the structured interviews for the audit of existing pre-birth and early (0-2) parent support services in Ballymun, the available services were grouped and mapped as in Figure 1. The services were grouped into structured programmes (e.g. a series of classes or organised meetings/visits) and general services and supports (e.g. information and support or services within which support may be offered to parents either pre-birth or at the early parenting stage). These two groups were subsequently sub-divided into services that were not age specific, those that were specific to the 0-2 age group and pre-birth.

Figure 1: Map of existing pre-birth and parent support services

General Services & Supports Structured Programmes

CAMHS Trinity Comprehensive: Parenting programmes (7/8 weeks x 2 p.a.) Chaplaincy CAFTA Women ’s Resource Centre: Parenting courses (11 weeks x 8 p.a.) Structured General Support & Information, Youth Drop in Magic 123 Programme (discipline) (4 weeks) Programmes services Service across all age across all age Women ’s Resource Centre: groups group Hospital and Community Social Work Young Mothers Programme (10 weeks) services DCC Social Inclusion Unit: HSE Psychology Services Family Support Programme (2 visits per week for two years)

Geraldstown House Parent & Toddler Group Lifestart Programme (0 -5 years) Home visit (monthly from 0-5) General Structured programmes Community Mothers ’ Programme (0 -2 Community Mothers ’ Programme (0 -2 years): programmes for 0-2 age years): Parent & Toddler Group Home visits (monthly for two years); for 0-2 age group group PHN service Women ’s Resource Centre: Mandatory home visit on after birth Pre & Post-Birth Parenting Programmes (10 Developmental screening at 3, 7 & 18 weeks x 3 p.a.) months- at home or in clinic Birth Rotunda Teen clinic & classes Structured pre-birth Primary Care Team programmes Ante-natal classes (8 weeks x 3 p.a.)

14 Section 3 – Needs Assessment

3.1 Aim To assess the needs of children from pre-birth to age 2 years and their parents as identified by local service providers and as identified through existing research.

To successfully complete the assessment of need, the following steps were undertaken:

a) A review of all existing data / research covering needs of children from pre-birth to 2 years of age and their parents.

b) Local and national data sources were accessed to identify and retrieve all available birth-related and maternal health data for Ballymun.

c) An analysis of need as identified by service providers that target children from pre-birth to 2 years of age and their parents. This was a two-step process:

o Local service providers were asked to prioritise the pre-birth support needs of women and their partners in Ballymun and the support needs of parents of 0-2 year olds in Ballymun as part of their individual structured interviews.

o A participatory open forum to which all current local service providers were invited was organised and facilitated.

15 3.2 Literature Review

3.2.1 Method

Desk research methods were used to source local, national and international literature. Policy documents developed by local, national and international agencies and advocacy groups were sought and reviewed. Online research databases such as CINAHL, Nursing and Allied Health Collection, PsycLit, Social Science Citation Index, Cochrane Database of Systematic Reviews, and MedLine were searched. Contact was also made with researchers and reviews of Internet resources developed by advocacy groups, service providers, and Government bodies in Ireland and internationally were undertaken. Our goal was to collect sufficient material, within the allowable timeframe, to form a soundly based view of the needs of children from pre-birth to 2 years of age and their parents.

3.2.2 Findings

3.2.2.1 Antenatal needs of mother and child

Important basic needs that are required for the developing foetus to remain healthy include quality nutrition and an environment that is both comfortable and free from toxins. When these needs are not met, there are many negative health outcomes that can result, including obstetric complications, preterm delivery and low birth weight. Exposure to tobacco, alcohol and illicit drugs can prevent the foetus from developing properly and can be a cause of preterm delivery (Kramer, 1987). Excessive alcohol during pregnancy has been associated with an increased risk of m iscarriage (Doggett, Burrett & Osborn, 2005). Prenatal tobacco exposure has been found to be a unique risk for the development of conduct disorder and later delinquency (Olds, 2002). Women who inject drugs during pregnancy can increase the likelihood of vertical transmission of infections like hepatitis C and HIV to the infant and can also increase the risk of infant sudden death syndrome (Doggett et al., 2005). Domestic violence inflicted on the mother has been taken as an indicator of low birth weight (Souza & Garcia, 2004).

In addition to these needs for the developing foetus, there are some important needs to be met for the pregnant mother if she is to remain in good physical and mental health. Material resources like adequate housing and financial security are important basic needs for pregnant women (Prilleltensky, Nelson & Peirson, 2001). Physical, emotional and social needs like reassurance and confirmation in relation to labour and childbirth concerns and information about key pregnancy issues (e.g. nutrition information and sexual activity during pregnancy) have also been found to be important for women during this time (Turan, Nalbant, Bulut, & Sahip, 2001; Luyben & Fleming, 2005) in order to alleviate stress and anxiety related to the approaching birth. Maternal stress and anxiety during pregnancy is more likely to lead to premature birth and irregular contractions during labour, the latter of which can cause irregularities in the baby’s oxygen supply or irregularities after birth (Santrock, 2002).

Summary Box 1: Antenatal Needs of Mother and Child • Attenuation of the basic needs of food, safety and lack of toxins for the developing foetus can lead to obstetric complications, preterm delivery and low birthweight. • Exposure to alcohol, tobacco and illicit drugs can lead to increased risk of miscarriage, infant sudden death syndrome and later delinquency. • Basic needs for the mother’s physical and mental health antenatally include adequate housing and financial security in an economic sense and reassurance and information about pregnancy in a psychological sense.

16 3.2.2.2 Antenatal Education

Antenatal education can range from routine antenatal care from midwifes and nurse home visits to specific antenatal parental programmes. Antenatal care typically involves a midwife or nurse performing a routine medical check-up on the mother-to-be and supplying them with information on healthy pregnancy behaviours and how to prepare for childbirth. There is some evidence from qualitative studies to suggest that these antenatal care visits may assist first-time mothers in feeling more at ease and confident about the approaching pregnancy. Luyben & Fleming (2005) interviewed 23 women from Scotland, Switzerland and the Netherlands who were using routine antenatal care to find out their views on the importance of this type of care and why they were using it. Findings indicated that responsibility for themselves and their babies was the central reason that accounted for these mothers’ use of antenatal services and important aspects of this dimension of responsibility were that the mother experienced “feeling confident” and “feeling autonomous” in relation to the approaching birth. These feelings of confidence and autonomy may be extremely important for mothers-to-be in alleviating feelings of stress and anxiety about childbirth.

Antenatal education classes have been strongly recommended by healthcare professionals around the world to increase education in relation to pregnancy, childbirth and parenting. These classes are often aimed at influencing parental health behaviours, preparing women and their partners for childbirth and parenting, alleviating the fears and anxieties associated with pregnancy and delivery and promoting confidence in parents-to-be (Gagnon and Sandall, 2007). Gagnon & Waghorn (1995) have posited that the main reasons why mothers attend child- birth classes are to reduce anxiety about labour and birth, whereas men do it to support their partner and learn about infant care.

There is some evidence to suggest that antenatal classes may not be very helpful to parents in preparing women for childbirth and later parenting. Cronin (2002) interviewed 13 Irish women aged 20 years or less who varied in their degree of attendance to routine antenatal education classes and found that the majority of those who did attend felt that the breathing exercises and techniques that they had been taught during these classes were completely forgotten once the experiences of shock and pain from labour were encountered. In a study of 1197 women from Sweden, Fabian, Radestad & Waldenstrom (2005) found no significant differences in parental skills, labour pains or duration of breastfeeding between those who attended group-based antenatal classes (where partners discussed topics such as the approaching birth, breastfeeding and new parenthood with other couples and a midwife) and those who did not attend these classes.

Gagnon and Sandall (2007) reviewed 9 trials (Carter-Jessop, 1981; Corwin, 1998; Corwin, 1999; Davis & Akridge, 1987; Fraser, Maunsell, Hodnett & Moutquin, 1997; Hamilton-Dodd, Kawamoto, Clark, Burke, & Fanchiang, 1989; Klerman, Ramey, Goldenberg, Marbury, Hou, & Clirer, 2001; Mehdizadeh, Roosta, Chaichian, & Alaghehbandan, 2005; Pfannenstiel & Honig, 1991; Westney, Cole & Munford, 1988) involving 2,284 women in order to assess the effects of antenatal classes on anxiety, knowledge, maternal sense of control, labour pain, partner birth involvement, breast- feeding success, parents’ infant care abilities, social support and psychological and social adjustment to parenthood. These trials were unable to be combined into a meta-analysis as each study was testing the effect of a different intervention on one or more different outcomes. In addition, the trials were of small-to-moderate size and of uncertain methodological quality,

17 making it difficult to identify whether or not antenatal classes are an effective means of parental education. Despite these concerns, a number of the studies showed beneficial effects of antenatal education on specific issues like reducing labour length (Mehdizadeh et al., 2005), increasing satisfaction with maternal role preparation (Hamilton-Dodd et al., 1989) and lowering the prevalence of unhealthy attachment behaviours (Carter-Jessop, 1981; Davis & Akridge, 1987).

Austin (2003) investigated the efficacy of five additional antenatal group intervention studies (Stamp, Williams & Crowther, 1995; Buist, Westley & Hill, 1998; Brugha, Wheatley & Hill, 1998; Elliott, Leverton, Sanjack et al., 2000; Zlotnick, Johnson, Miller, Pearlstein, & Howard, 2001) that were aimed at reducing Post-Natal Depression in women by assessing their methodology and effectiveness. In all studies, the women were screened with questionnaires that touched on issues like past history of depression and amount of social support in order to identify those women who were “at risk” for developing depressive symptoms in the postpartum period. As with Gagnon and Sandall’s (2007) review, a meta-analysis was not possible and the results were inconclusive as to whether or not antenatal group interventions are sufficient at reducing Post- Natal Depression because three out of the five studies reported a lack of a significant difference between the intervention and control group depression scores. However, the studies that reported a lack of effect had substantial limitations such as high participant attrition rates, small study numbers and a systematic approach in identifying those “at risk”. Interestingly, the most methodologically rigorous study (Zlotnick et al., 2001) using interpersonal therapy demonstrated a significant reduction of Post-Natal Depression symptoms in the intervention group compared to the control group. Nonetheless, this study needs further replication with a larger sample, as the sample size was very small (containing only 35 women in total).

Inclusion of fathers in antenatal education classes may increase the likelihood of them providing a caring and supporting role for the mother (Richards, Papworth, Corbett, & Good, 2007). Pregnant mothers often express the wish to be accompanied to antenatal education by their partners in order that they may receive more emotional support and understanding from them (Turan et al., 2001). Partner involvement may facilitate the maternal role if the involvement is supportive in nature and degree (Richards et al., 2007). Increasing father involvement in antenatal education may also have positive outcomes on later child development as children with supportive fathers who provide a playful learning environment have been found to achieve better academically, avoid antisocial and delinquent behaviours such as drug use and criminal behaviours and exhibit more empathy (Buckelew, Pierrie & Chabra, 2006).

A study by Doherty, Erickson & LaRossa (2006) underlines some of the potential benefits of getting fathers involved in antenatal education classes. The intervention in this study consisted of a relatively brief couple-oriented parenting programme of 8 sessions that was targeted at 165 American couples, which began in the second trimester of pregnancy and ended at 5 months postpartum. The programme sessions were group-based and contained much group discussion, where couples got a chance to discuss their concerns about childbirth and parenting, interact with infant participants to learn different parenting skills and specifically address the barriers that exist in co-parenting and father involvement. The researchers found that the intervention had significant positive effects on fathers’ skills in interacting with their infants (as measured by the Parent Behaviour Rating Scale) and on their involvement with their infant on work days (as measured by the Interaction/Accessibility Time Chart). This study underlines some of the potential benefits of getting fathers involved in both antenatal and postnatal education classes.

18 Summary Box 2: Antenatal Programmes • Designed to promote healthy practices for mothers in pregnancy and prepare parents-to-be for childbirth and parenting. • There is some evidence that antenatal classes can help first-time mothers to feel more confident about the approaching pregnancy • Limited evidence exists to support the effectiveness of these programmes in improving parental health practices and increasing parental knowledge and skills during pregnancy and post-partum. • Involving fathers in antenatal programmes may increase their support for the mother and their involvement with the infant.

3.2.2.3 Needs of children 0-2

The first few months of a child’s life are important for establishing patterns of emotional, social and cognitive functioning (Barlow & Parson, 2003). In addition to the basic needs of a child such as nutrition, shelter, a toxin-free environment, there are several psychosocial needs that must be met for a child in the early stages of life in order to assist his or her developmental capacity. Interactions between parents and their infants in the early years of life can provide the necessary scaffolding for the child’s socio-emotional and cognitive development (Puura, Guedeney, Mantymaa, & Tamminen, 2007).

Attachment and responsive parenting

Attachment can be defined as a close emotional bond between the infant and caregiver (Bowlby, 1969). Infants tend to adapt their attachment behaviour in response to the responsiveness and sensitivity of their primary caregiver (typically the mother). Secure attachment comes from consistently responsive caregivers providing a secure base for the child’s exploration of his or her environment (Coyl, Roggman & Newland, 2002). Children who are securely attached tend to move freely away from the caregiver while processing her location and react positively towards encounters with strangers (Ainsworth, 1979). Insecurely attached infants are often the result of inconsistent responsiveness or hostile, insensitive and indifferent responses to their child’s interactions with them (Coyl, Roggman & Newland, 2002; Berlin, Brady-Smith & Brooks-Gunn, 2002). They may be avoiding of their mother (“Insecure avoidant”) when she is present or they may cling to her and then resist her closeness (“Insecure resistant”) while displaying distress when she leaves the room (Ainsworth, 1979). Disorganised attachment behaviour may be recognised by irregular interruptions in behaviour, contradictory behaviour patterns or signs of disorientation and apprehension towards the caregiver (Pauli-Pott et al., 2007) when she is present.

Attachment behaviour may be a predictor of later outcomes for the developing child. Pauli-Pott, Haverkock, Pott, & Beckmann (2007) found 64 healthy firstborn children and their caregivers to have attachment security. They found disorganisation in the Strange Situation procedure to be significantly negatively related to serious behaviour problems (using the clinical Mannheim Parent Interview). Negative infant emotionality {assessed using the “Infant Emotion Scale” by Esser, Scheven, Petrova, Laucht and Schmidt (1989) to rate the positivity or negativity of infants’ vocal and facial emotional expression} was also found to amplify the strength of association between attachment disorganisation and later behaviour problems.

Reactive and sensitive caregiving may have positive effects on a child’s tolerance and emotional regulation patterns (Pauli-Pott et al., 2007) and may be central in the development of

19 secure attachment in children. Responsive parenting is thought to play a critically important role in children’s socio-emotional, cognitive and language outcomes (Landry, Smith & Swank, 2006) whereas harsher practices can often lead to attachment problems that may manifest themselves in delinquency and substance abuse in later years (Barlow & Parson, 2003; Coyl, Roggman & Newland, 2002).

Landry Smith & Swank (2006) suggest that there are at least four aspects of responsive parenting; contingent responding, emotional-affective support, support for the infant foci of attention and conversations with infants. “Contingent responding” refers to prompt parental responses to signals from the infant (e.g. that they are hungry) and may assist the infant’s ability to cope with stress and novelty while fostering a bond of trust with the caregiver. Emotional-affective support involves praise, encouragement and affection toward the child (often called “positive pro- active parenting”) and is often associated with high child self-esteem and higher social and academic confidence in later life (Barlow & Parson, 2003). “Support for the infant foci of attention” utilises dyadic (two-way) interactions between the child and caregiver in order to facilitate the child’s active learning and development. “Conversations with infants” are the contingent responses to infant vocal noises and can be extremely helpful in early infant language development. A lack of awareness of the infants’ responsivity to verbal stimulation may hinder the healthy language development of the young infant (Berlin, Brady-Smith & Brooks- Gunn, 2002).

Summary Box 3: Childs’ Needs Post-partum • The emotional bond between infant and caregiver can greatly assist a child’s socio-emotional and cognitive development. • Securely attached infants are less likely to develop serious negative behaviour patterns and tend to have mothers who are consistently responsive. • Insecure attachment can result from negative and hostile parenting or inconsistent parental responses and often leads to later delinquency and substance abuse. • Positive responsive parenting can assist the child’s cognitive and language development and foster secure attachment behaviour patterns. This can include prompt responses to infant signals, affective support for child behaviours and play interactions with child and the contingent verbal responses to infant vocal noises.

3.2.2.4 Fathers’ needs

There is relatively little literature surrounding the needs of fathers throughout pregnancy and parenting. This may be partly due to the fact that fathers are not physiologically linked to the child in the same sense that the mother is. In this way, fathers are generally thought to be the providers of care and support in an emotional and financial sense (although the latter is generally regarded as more important; Richards et al., 2007; Turan et al., 2001) rather than people in need of support for parenting.

One study that has looked at the issue of fathers’ needs was carried out by the Fatherhood Collaborative of San Mateo County in California. The researchers in this study (Buckelew, Pierrie & Chabra, 2006) asked 204 fathers of children aged 0-5 to complete a 35-item questionnaire related to their general and healthcare needs, availability of community support services and their identification as fathers. Nine focus groups of 80 fathers were also used to expand on this quantitative data. The picture that emerged from this study was that fathers felt that finances, healthcare and housing were the most important needs to be met for the family, that father- child activities could be improved in the community (e.g. by improving recreational facilities and

20 promoting father-child activities by a series of community-based initiatives) and that they felt that there was a negative view of non-custodial fathers by legal services and child support services. This study underlines the fact that it is important for health, community and legal services to maintain a positive relationship with fathers in order to foster positive father-child interactions.

3.2.2.5 Mothers’ Needs

The transition into parenthood marks many changes in the lives of mothers. This transition often requires new skills for mothers to learn, like how to care for themselves and their infant simultaneously. The period is also often marked by significant changes in the lifestyle of mothers as a large amount of time and effort needs to be devoted to the infant. This extra focus of time and effort is often reflected in the mother’s own concerns in the early post-partum period. Graham & Oakley (1981) suggest that new mothers want a healthy infant, satisfaction in pregnancy, positive interactions with the infant and their new lifestyle to be good. Kaitz (2007) investigated the concerns that are most common for 366 first-time Israeli mothers at 3 and 6 months post-partum with their Mother’s Concern Questionnaire. This questionnaire contains 30 items referring to issues of concern for the mother (operationally defined as sources of uneasiness and worry), which are rated on a scale of 1 (not concerned at all) to 7 (extremely concerned). Results indicated that returning to work and family health were the factors of greatest concern to the new mother out of the five factors identified by the questionnaire, which also included Caregiving and Spouse, Mother’s well-being and relationships and support. Additionally, separation from the infant and quality day-care were the most common concerns that were identified among these factors, demonstrating a shift in focus towards the needs of the young infant. How the mother copes with these concerns and with her new lifestyle requires several psychosocial needs to be met.

The presence of social support is important at this stage in reducing stress and increasing mothers’ self-image and parenting skills (Herrmann, Van Cleve & Levison, 1998). Social support involves interpersonal transactions that can increase self-esteem, reduce stress and provide emotional support and can be a big factor in reducing the stress associated with the transition into motherhood (Haslam, Pakenham & Smith, 2006). Advice and emotional support, especially from the maternal mother, can help to ease nervousness associated with early motherhood and assistance with household chores can give the new mother greater time to adapt to her new role (Cronin, 2002; Warren, 2005).

Warren (2005) has posited that the self-esteem of the new mother is extremely important in this period in order to facilitate positive feelings of motherhood and competence in the ability to care for the child. Women who have unhealthy negative core beliefs in relation to their autonomy and performance (characterised by feelings of failure, dependence and incompetence) may be more likely to extrapolate these negative cognitions onto their perceived role as caregiver, which can lower their self-esteem (Farrow & Blissett 2007). For example, mothers who feel they lack certain parenting skills may give up in their efforts to calm an infant more easily, which can lead to the perception of confirming their low self-efficacy beliefs (Haslam, Pakenham & Smith, 2006).

21 Low levels of self-esteem of the mother and lack of social support are also key factors in the development of postnatal depression in new mothers. In a study of 246 Australian first-time mothers from a Sydney public hospital, Matthey, Kavanagh, Howie, Barnett, & Charles (2002) found that women with low self-esteem (measured by the self-report Coopersmith Self-Esteem Inventory) had significantly higher levels of postnatal depression on the Edinburgh Postnatal Depression Scale and the Profile of Mood States-Total Distress Scale than those with higher self- esteem. Cooper, Murray, Hooper & West (1996) underscored the importance of a social support network for new mothers in a study where several thousand women lacking social support were almost twice as likely to develop postnatal depression.

In order to assess the relationship that social support and feelings of self-efficacy have on maternal adjustment, Haslam, Pakenham & Smith (2006) asked 192 first-time mothers from Queensland in Australia to complete questionnaires during their last trimester and 4 weeks postpartum. A questionnaire contained measures of depression (the Edinburgh Postnatal Depression scale and the Beck Depression Inventory), a measure of social support and a measure of maternal self-efficacy. Women with higher levels of parental support and maternal self-efficacy had significantly lower depressive symptoms. However, partner support did not have any significant effects on depressive symptoms. This may demonstrate that parents may be a more helpful form of social support to primiparous women as they may be able to provide more informational or practical support and encouragement to new mothers based on their own experiences.

Summary Box 4: Mothers’ Needs Post-partum • Social support from the maternal mother and partner can reduce stress and anxiety for new mother and ease nervousness associated with the transition to parenthood. • The maternal mother in particular can provide practical support and information to the new mother based on her own personal experiences. • High levels of self-esteem are also important for a new mother to facilitate feelings of competence in her caregiving role and to prevent them giving up on efforts to provide emotional support to the child. • Low levels of self-esteem and social support are significant factors for the onset of postnatal depression.

3.2.2.6 Postnatal depression

Failure to meet a mother’s psychosocial needs can often result in depressive symptoms emerging. These symptoms often result from low self-esteem, lack of confidence and unrealistic expectations of motherhood (Matthey et al., 2002; Dennis & Hodnett, 2007). Although depression in this period is normally mild and transitive in nature, postnatal depression is estimated to prevail in 10-15% of new mothers and often goes undetected by primary healthcare professionals (Barlow, Coren & Stewart-Brown, 2003). Postnatal depression can be defined as a non-psychotic depressive episode beginning or extending into the first year post-partum with symptoms such as; uneasiness, irritability, confusion and forgetfulness, anhedonia, fatigue, insomnia, anxiety, guilt, inability to cope and thoughts of suicide (Dennis & Hodnett, 2007).

Maternal depression can lead to many significantly negative outcomes for the child. Children of depressed mothers can have significantly impaired cognitive skills, expressive language development and are two to five times more likely to develop long-term behavioural problems (Dennis & Hodnett, 2007). They are also more likely to develop insecure attachment behaviour patterns, engage less with objects and exhibit social interactive difficulties and increased negative affect (Dunne et al., 2007).

22 There are some unique stressors for new mothers that have been linked to maternal depression. Poor marital relationship quality and stress associated with transition to parenthood are often contextual stressors that can influence the onset of depressive symptoms (Coyl, Roggman & Newland, 2002). Mothers who feel significant stress or depression may be unprepared to handle toddler’s emerging desire to do more things by themselves and may therefore employ inappropriate or harsh disciplining strategies to counter these emerging behavioural tendencies. Coyl, Roggman & Newland (2002) assessed 169 mainly European-American mothers and infants from a Utah Early Head Start Program by interview and self-report measures on contextual stress (on a 20-item rating scale), depressive symptoms (on the Center for Epidemiological Studies Depression Scale), parent-child negative interactions (using a subscale of the Parenting Stress Index/Short Form) and amount of spanking on a measure from the HOME Inventory. Contextual stressors such as economic and relationship stress were found to have significant negative effects on the mother’s depression level, her interactions with her child and the amount of spanking.

Another factor that may influence the onset of depressive symptoms is the temperament of the child. In a study of Australian mothers, Austin, Hadzi-Pavlovic, Leader, Saint, & Parker (2005) found a significant correlation between infant temperament as measured by the Short Infant Temperament Questionnaire (a 30-item parental report) and Postnatal Depression in the mother as measured by the Edinburgh Postnatal Depression Scale. These results suggested that mothers who reported a more “difficult” temperament in their child were more likely to have significantly higher depression scores than those mothers who reported their child’s temperament as being milder.

Summary Box 5: Postnatal Depression • Postnatal depression usually occurs in the first year postpartum and is characterised by anxiety, guilt, fatigue, uneasiness, irritability and often thoughts of suicide. • It often results from low self-esteem, lack of confidence in maternal role, unrealistic expectations of motherhood and stresses associated with the transition to motherhood. • “Difficult” infant temperament may also contribute to postnatal depression symptoms. • Mothers with postnatal depression tend to employ harsher discipline and have less interaction with the child. • Negative outcomes for the child that can result from this type of depression include impaired language and cognitive development, insecure attachment and long-term behavioural problems.

3.2.2.7 Mothers & children in disadvantaged areas

Mothers and children from areas of social and economic disadvantage constitute a population that is at risk for many negative outcomes. Psychiatric illness and domestic violence are both major concerns for mothers from disadvantaged areas (Souza & Garcia, 2004; Quinlivan, Box & Evans, 2003; Lieberman, 2007). Socio-economic disadvantage leaves women at increased risk for postpartum depression due to chronic stressors and inadequate social support (Sword & Watt, 2005; Coyl, Roggman & Newland, 2002). Domestic violence is also common in these areas and may be related to negative later outcomes such as depression, alcoholism and suicide attempts (Lieberman, 2007). These negative outcomes tend to emerge from the trauma experienced by increased exposure to a dangerous and often hostile living environment.

23 In addition, children from economically and socially disadvantaged areas may be at greatest risk with respect to their physical and mental health. Carpenter (2007) points out that clear evidence exists to demonstrate that negative child outcomes are a result of key factors such as homelessness, parental unemployment, poor education opportunities and being brought up in low-income families. These factors are generally associated with families from disadvantaged areas and tend to be comorbid with other key indicators of negative child outcomes such as poor parenting, parental substance abuse, parental mental health problems (such as post-natal depression), low birth weight, premature birth and infant mortality (Hodnett & Fredericks, 2007; McNaughton, 2004; Izzo, Eckenrode, Smith, Henderson, Cole, Kitzman & Olds, 2005; Olds, 2002; Souza & Garcia, 2004).

There are a number of reasons why areas of disadvantage can lead to negative outcomes for children. Poverty can lead to the attenuation of many of a child’s basic material needs by leading to malnutrition, unsafe living environments and increased risk of infection (Hodnett & Fredericks, 2007). “Failure-to-thrive”, which can develop as a result of poor nutrition and is often found in areas of poverty, is a categorisation for children whose weight, height, head circumference and psychosocial development indicators are significantly below normal for their age and has been taken as a key indicator of long-term consequences such as developmental delay, personality problems, abuse, attachment problems and disturbed behaviour (Dunne, Sneddon, Iwaniec, & Stewart, 2007). Children from these areas are also at a high risk of injury, abuse, neglect, infant health problems and are less likely to receive child health service care on a regular basis (Bennett, Macdonald, Dennis, Coren, Patterson, & Abott, 2007; Macdonald, Bennett, Dennis, Coren, Patterson, Astin, & Abbott, 2007; Attree, 2005). There have also been consistent findings of, often as a result of the use of illicit drugs, alcohol or tobacco.

Women from areas that are at an economic disadvantage can experience many problems in raising their children. There can be major difficulties experienced by these women in terms of obtaining information about child healthcare or social support from their family and friends. They often have restricted social networks and experience conflict in their family relationships, limiting their ability to acquire information and support from family and friends or professional sources (Sword & Watt, 2005; Attree, 2005). Souza & Garcia (2004) have also highlighted the fact that there are wide differences between high-income and low-income groups in access to and uptake of community health services and satisfaction with these services. Problems of access to these services can be a result of a lack of knowledge about what support is available or a lack of material resources such as transport (Attree, 2005). This is a potentially problematic situation as the higher prevalence of poor breastfeeding rates, pregnant smokers, teenage pregnancy and poor mental health among mothers from low income-groups indicates that they are the population most in need of these services.

Unmet learning needs in relation to pregnancy and parenting can often result from a lack of uptake of these health services. In a study from Ontario in Canada, Sword & Watt (2005) got 1250 women to complete a questionnaire before being discharged from hospital after giving birth to their child, which focused on concerns about health-related topics such as breastfeeding, bottle-feeding, infant care, emotional changes, sexual changes and family care. Of the 890 women who completed a structured telephone interview 4 weeks postpartum, 17% were of low socio-economic status and were found to have significantly more unmet learning needs in relation to signs of infant illness, infant care and behaviour, physical changes and self-care, emotional changes and community supports and services.

24 Summary Box 6: Mothers and Children in Disadvantaged Areas. • Economic and social disadvantage increases the risk of postnatal depression. • Poverty increases the risk of parental and child malnutrition, unsafe living environments and increased risk of infection, all of which can lead to lower birth weight, premature birth and infant mortality. • Women from disadvantaged areas can experience problems in accessing quality healthcare, often resulting in lack of information on infant illness, infant care and available community services. This can be a problem as children from these areas are at a high risk of injury, abuse, neglect and infant health problems.

3.2.2.8 Adolescent Mothers

Pregnant and parenting adolescent mothers are at increased risk for more negative child health outcomes and parenting inadequacies. Poor birth outcomes for children, child abuse and neglect and diminished economic self-sufficiency of parents are problems that are most prevalent in populations of low-income and adolescent mothers (Olds, Sadler & Kitzman, 2007). Teen mothers have a higher incidence of stillbirths, premature births and children with significantly lower birth weights (Flynn, 1999; Koniak-Griffin, Mathenge, Anderson, & Verzemnieks, 1999; Quinlivan, Box & Evans, 2003). Reported cases of child abuse and neglect are substantially higher for teenage mothers (Flynn, 1999; Thomas & Looney, 2004; Quinlivan, Box & Evans, 2003). Koniak-Griffin et al. (1999) identified common risk behaviours associated with young mothers, including; poor nutritional habits, tobacco or substance dependence, high alcohol intake and unsafe sex practices. Additionally, early pregnancy is generally associated with unemployment, lower educational status and lack of opportunities (Cronin, 2002; Quinlivan, Box & Evans, 2003; Berlin, Brady-Smith & Brooks-Gunn, 2002). Adolescent mothers are less likely to complete secondary education, marry or find stable employment and these women are also most likely to be dependent on social welfare as a means of supporting their infant (Herrmann, VanCleve, & Levisen, 1998; Quinlivan, Box & Evans, 2003; Richards et al., 2007). Children of teenage mothers are more likely to exhibit more social and academic problems and are also more likely to become teenage parents themselves (Berlin, Brady-Smith & Brooks-Gunn, 2002).

Teenage mothers’ cognitive and emotional immaturity can lead to lower parental sensitivity in response to their children, leading to insecurely attached infants (Berlin, Brady-Smith & Brooks- Gunn, 2002). The demands of teenage mothers own developmental transitions may impact negatively on their resources to attend sensitively to their children’s needs in a contingently- responsive way. Adolescent mothers have been found to be less patient and emotionally- responsive to their children, less verbally and interactively responsive and more likely to exhibit harsh or hostile responses to child behavioural patterns (Florsheim & Smith, 2005). Using 1702 low- income mother-child dyads from a population drawn from the Early Head Start Research and Evaluation Project, Berlin, Brady-Smith & Brooks-Gunn (2002) videotaped mothers and children during 10 minutes of free play using the “Three Bag” free play assessment measure. Teenage mothers were found to be significantly less supportive, more detached and more intrusive towards their infants than older mothers during free play. These elevated levels of intrusiveness may reflect the emotional and cognitive immaturity of these mothers; they may be directing play to make themselves the focus of attention.

The relationship between adolescent mothers and the child’s father can also be an important aspect of healthy later development. Adolescent couples are at greatest risk for relationship difficulties. A poor relationship or infrequent contact with the child’s father can lead to problems like limited financial assistance (Richards et al., 2007). Florsheim & Smith (2005) got 36 expectant

25 couples from Utah to self-report on their perceived partner relations using the Quality of Relationship Inventory and were videotaped for observational data on couple and parent-child interactions (behaviours for this measure were coded using the Structural Analysis of Social Behaviour observational coding scheme). A follow-up study of 27 of the mothers and 20 of the fathers at 2 years postpartum collected further observational data. Hostile controlling behaviour between partners significantly predicted more hostile controlling behaviours for both mothers and fathers towards their children. Expectant mothers tended to engage in higher rates of hostile controlling towards their partners than fathers-to-be. In addition, fathers tended to treat their children in the manner in which their partner (often resulting in harsh or hostile parenting practices) had treated them. These results demonstrate that a turbulent relationship can result in negative consequences for the child.

One characteristic of adolescent mothers that may have a significant effect on later child outcomes is the sense of autonomy that the adolescent mother has attained. In a study of 71 Australian mother-child dyads, Aiello & Lancaster (2007) showed that adolescent mothers with higher separation-individuation scores (i.e. those adolescents who had developed a more autonomous sense of self), as measured by the Separation-Individuation Process Inventory, tended to have infants with more optimal mental development on the Bayley Scales of Infant Development. Conversely, adolescents who were found to have less-resolved separation- individuation (i.e. those with greater childlike-attachments to their parents) had infants with poorer scores on the Bayley Scales. Aiello & Lancaster suggest that this might result from mothers with less resolved separation-individuation viewing the infant as a part of themselves and therefore discouraging their early explorations, thus potentially compromising their cognitive development.

Herrmann, VanCleve & Levisen(1998) have posited that teen mothers need parenting and development knowledge skills before they can feel competent as parents. They note that after education (involving diet instruction, family planning, monitoring of both mother and infant for health and social problems and teaching the teens about childcare and health concerns), many adolescent mothers have been found to improve their environments and give more appropriate responses to behaviours. Quinlivan, Box & Evans (2003) got 139 adolescent mothers to complete an antenatal questionnaire assessing contraception knowledge, infant vaccination and breastfeeding. Half of the participants were then assigned to receive 5 structured postnatal home visits by nurse-midwives and half received standard routine postnatal care. Postnatal home visits were found to significantly reduce adverse neonatal outcomes and significantly increase contraception knowledge but to have no significant impacts on breastfeeding or infant vaccination rates.

Summary Box 7: Adolescent Mothers. • Teen mothers are at increased risk for poor nutritional habits and risky behaviours like substance use, leading to a higher incidence of stillbirths, premature births and low birthweight. • The cognitive and emotional immaturity of adolescence can lower a mother’s sensitivity to a child’s needs and increase the use of harsh discipline methods. • Adolescent couples are at greater risk for relationship problems, which can be a cause of more hostile paternal parenting practices. • Young mothers who do not have a clear sense of autonomy may inhibit infants’ early explorations from viewing them as a part of themselves, thereby restricting their cognitive development.

26

3.2.2.9 Home-visitation from Nurses

Home visitation by nurses to adolescent mothers and mothers in disadvantaged areas has been traditionally advocated as a means of improving the health of their children by promoting child development and preventing childhood accidents. McNaughton (2004), Izzo et al (2005) and Olds (2002) have all reported that home-visitation tends to have positive effects on improving physical health in the children, encouraging a positive rearing environment in the home, decreasing harsh punishment given by parents and fostering an environment with less incidence of reported abuse.

In particular, studies of the Nursing Family Partnership (NFP) have shown that the children of parents who have received home-visits by registered nurses tend to have fewer reported accidents or injuries, fewer respiratory problems and a higher birth weight (Izzo et al., 2005; Olds, 2002, Olds, 2006). Nurses in this program are focused on improving mothers prenatal health- related behaviours, providing more competent care to the children, improving their economic self-sufficiency and planning for future pregnancies (Olds, Sadler & Kitzman, 2007). McNaughton (2004) reviewed 13 home-visitation studies (Armstrong, Fraser, Dadds & Morris, 1999; Barnes-Boyd, 1995; Black, Nair, Kight, Wachtel, Roby & Schuler, 1994; Booth, Mitchell, Barnard & Spieker, 1989; Braveman, Miller, Egerter, Bennett, English, Katz & Showstack, 1996; Bryce, Stanley & Garner, 1996; Cappleman, Thompson, DeRemer-Sullivan, King & Sturn, 1982; Chen, 1993; Hall, 1980; Kitzman, Olds, Henderson, Hanks, Cole, Tatelbaum, McConnochie, Sidora, Luckey, Shaver, Engelhardt, James & Barnard, 1997; Koniak-Griffin, Anderson, Verzemnieks & Brecht, 2000; Norbeck, DeJoseph & Smith, 1996; Olds, Henderson, Tatelbaum & Chamberlin, 1986) and confirmed these physical health benefits.

In spite of these potentially positive findings, no significant replicable effects have been reported from these studies on improving maternal mental health, child motor/cognitive/language development, breast-feeding behaviours or parenting knowledge using standardised instruments. Additionally, it has been noted by Bennett et al (2007), McDonald et al (2007) and McNaughton (2004) that the sample sizes in these studies have all been very low and replication of results has been difficult. Failed attempts at meta-analysis {e.g. in McDonald et al (2007), where data from two or more studies could not be combined} have illustrated the varying quality and clarity of results in nurse home-visitation studies. The recent Cochrane reports on home- visitation studies (Bennett et al, 2007; McDonald et al, 2007) have also criticised the way that the results have been presented in the NFP reports to reflect positive outcomes and downplay insignificant or negative results. These reports have also commented on the difficulties in accurately assessing child abuse and accidents/injuries as no standard measurement instruments can capture them fully.

On the other hand, there appears to be long-term benefits on life outcomes for children of teenage mothers in disadvantaged areas who receive NFP home visits (particularly in relation to delinquent behaviour). In particular, the Elmira study (Olds, Henderson, Chamberlin, & Tatelbaum, 1986; Olds, Henderson, Tatelbaum & Chamberlin, 1986) of the NFP contained a 15- year follow-up study, where the children of nurse-visited women had significantly fewer arrests, convictions, violations of probation and fewer lifetime sex-partners. Nevertheless, the bulk of evidence from the literature suggests that home visitation from nurses has very limited

27 demonstrated benefits and may need to be combined with other interventions that provide facilities to cater for the learning and childcare needs of young children or community health care advice in order to be effective (as in the community-based programmes detailed further on).

Combining home visitation with reflective consultation with a mentor may be one way of increasing its effectiveness as an intervention. Summers, Funk, Twombly, Waddell, & Squires (2007) have highlighted the usefulness in reflective consultation sessions between home visitors and mentors trained in clinical psychology or social work to assist them in delivering infant mental health services. In their study, videotapes of caregiver-child and visitor-caregiver interactions were made during home visits and analysed by the home visitors and mentors at the reflective consultation sessions. These sessions were reported by the home visitors to be extremely helpful in recognising the areas in which they could assist the infants’ mental health and socio-emotional well-being.

Summary Box 8: Home visitation from Nurses • Home visits by nurses to young mothers antenatally can assist them in feeling competent about parenting and reduce adverse neonatal outcomes. • The Nurse Family Partnership have demonstrated the beneficial effects home visits can have in reducing accident and injury in children, increasing their birthweight and leading to a lower incidence of later delinquent behaviour. • Visits by nurses appear to have little significant effects on improving maternal mental health, breastfeeding behaviours, parental knowledge and the child’s motor, cognitive and language development. • The use of reflective consultation between the home visitor and a mentor trained in psychology or social work can aid the home visitor in identifying areas in which he/she can assist the infant and parents’ mental health.

3.2.2.10 Group-based Parenting Programmes

Group-Based Parenting Programmes have been around since the 1960s, taking many forms (from Cognitive-Behavioural to Rational-Emotive Therapy) and offered in a variety of settings. They have consistently shown to improve short-term maternal psychosocial health and behavioural problems in 3-10 year olds (Barlow & Parson, 2003). More recent studies have also been carried out to assess the potential value of these programmes in developing 0-2 year olds.

There are a number of different Group-Based Parenting Programmes that are commonly in use. Behavioural programmes teach parents how to use behavioural modification strategies to manage a child’s behaviour (Barlow, Coren and Stewart-Brown, 2003). Cognitive-Behavioural Therapy combines behavioural methods with an element that identifies and corrects erroneous negative beliefs in order to improve parental self-efficacy (Dennis & Hoddnett, 2007). Parent- Child Interaction Therapy programmes focuses on parental motivation and incorporates clinic- based individual parent-child dyad sessions that focus on enhancing positive parent-child interactions and discipline-giving methods for parents (Barlow, Johnston, Kendrick, Polnay and Stewart-Brown, 2006). Rational-Emotive Therapy involves the disputation of irrational parental beliefs and reinforcement of rational beliefs surrounding parenting (Barlow, Coren and Stewart- Brown, 2003). Finally, humanistic videotape modelling programmes like the Webster-Stratton “Parent and Children” Series and the “Incredible Years” Series focus on the parent-child interaction through modelling positive parental caregiving techniques (Jones, Daley, Hutchings, Bywater, & Eames, 2007).

28 Barlow, Coren and Stewart-Brown (2003) reviewed 26 Randomised Control Trial studies from the UK, USA, Republic of Ireland, Canada and Australia (Anastopolous, Shelton & Guevremont, 1993; Blakemore, Shindler & Conte, 1993; Cunningham, Bremner & Boyle, 1995; Gammon & Rose, 1991; Greaves, 1997; Gross, Fogg & Tucker, 1995; Irvine, Biglan, Smolkowski, Metzler, & Ary, 1999; Joyce, 1995; McGillicuddy, Rychtarik, Duquette & Morsheimer, 2001; Mullin, Quigley & Glanville, 1994; Nicholson, Anderson, Fox & Brenner, 2002; Odom, 1996; Patterson, Barlow, Mockford, Klimes, Pyper & Stewart-Brown, 2002; Pisterman, Firestone, McGrath, Goodman, Webster, Mallory, & Goffin, 1992a; Pisterman, Firestone, McGrath, Goodman, Webster, Mallory, & Goffin, 1992b; Schultz, Bruce & Carey, 1993; Scott & Stradling, 1987; Sheeber & Johnson, 1994; Sirbu, Cotler & Jason, 1978; Spaccarelli, Cottler & Penman, 1992; Taylor, Schmidt, Pepler & Hodgins, 1998; Van Wyk, Eloff & Heyns, 1983; Webster-Stratton, Kolpacoff & Hollinsworth, 1988; Wolfson, Lacks & Futterman, 1992; Zimmerman, Jacobsen, MacIntyre & Watson, 1996) that used a group-based parenting programme in order to assess the potential impact that these programmes can have on improving maternal psycho-social health. Five outcomes (depression, anxiety, self-esteem, social support and marital adjustment) from these studies were combined in a meta-analysis and results indicated that these parenting programmes are effective in improving maternal depression, anxiety, self-esteem and marital adjustment irrespective of type (including Behavioural Therapy, Cognitive-Behavioural Therapy, The Webster-Stratton Parent and Children Series and Rational-Emotive Therapy). For example, Taylor et al. (1998) examined the effectiveness of the Parent and Child Series in reducing depression (as measured by the Beck Depression Inventory) and found that those parents in the intervention group had significantly lower depression scores. Anastopolous et al., (1993) found a Behavioural-parenting programme had a significantly positive impact on parents’ marital adjustment scores (as measured by the Marital Adjustment Test). Another study by Joyce (1995) found that a Rational-Emotive Therapy could have significant beneficial effects in decreasing parental irrational beliefs and levels of parental guilt (both measured by the Bergers’ Feeling Scale).

Despite these beneficial effects, attrition rates were high in many of these studies and drop-outs from these group-based programmes tended to be less-educated, have children with more child behaviour problems and came from socially disadvantaged or ethnic minority backgrounds. This is potentially problematic as these particular populations represent parents and children who are most at risk for negative outcomes (Olds, 2002; Olds, Sadler & Kitzman, 2007; Koniak-Griffin et al., 1999; Quinlivan, Box & Evans, 2003; Sword & Watt, 2005; Coyl, Roggman & Newland, 2002).

Barlow & Parson (2003) examined five Random Controlled Trials of group-based parenting programmes (Gross, Fogg, & Tucker, 1995; Gross, Fogg, Webster-Stratton, Garvey, Julion, & Grady, 2003; Sutton, 1992; Nicholson, Janz, & Fox, 1998; Nicholson, Anderson, Fox, & Brenner, 2002) to establish if group-based parenting programmes are effective in improving emotional and behavioural adjustment in 0-3 year old children. A meta-analysis of the five studies revealed no significant differences between control and intervention groups for parental reports on measures like the Eyberg Child Behaviour Inventory. However, a meta-analysis of the three studies that contained independent observation measures (Gross et al., 2003; Gross et al., 1995; Nicholson et al., 2002) revealed significant improvements in emotional and behavioural adjustment. For example, Gross et al. (2003) found significantly lower teacher-reported child behaviour problems on the Dyadic Parent-Child Interactive Coding System-Revised in an intervention that used the Webster-Stratton “Incredible Years” video series. Additionally, parents

29 in Nicholson et al.’s (2002) study reported less verbal and physical punishment in the intervention group (a Cognitive-Behavioural Therapy parenting programme), suggesting that group-based parenting programmes may be effective in the prevention of child abuse.

A recent Cochrane Review (Barlow, Johnston, Kendrick, Polnay and Stewart-Brown, 2006) examined the efficacy of group-based and one-to-one parenting programmes in the prevention and treatment of child abuse through the evaluation of seven parent programme studies (Chaffin, Silovsky, Funderburk, Beverly, 2004; Hughes & Gottlieb, 2004; Terao, 1999; Kolko, 1996; Brunk, Henlegger, & Whelan, 1987; Egan, 1983; Wolfe, Sandler & Kaufman, 1981) that contained randomised control trials and at least one indicator of abuse, neglect or maltreatment. It was not possible to conduct a meta-analysis of these studies as the outcome variables were too different but the results of the different studies indicated that there were no significant effects of the parenting programmes on treating physical abuse directly. In addition, the quality of the included studies is variable (e.g. four of the studies contained no control group) and most of the studies contained small samples.

In spite of these shortcomings, this review provided limited evidence that group-based parenting programmes such as Cognitive-Behavioural Therapy, Parent-Child Interaction Therapy and the Webster-Stratton Social Learning Programmes are effective in reducing abusive parenting. For example, Terao (1999) found significantly lower scores on the Child Abuse Potential Inventory for parents in their study who used a Parent-Child Interaction Therapy programme. Kolko (1996) found significantly fewer reports of force and parental anger for those parents who received a Cognitive-Behavioural Therapy parental programme. The reviewers outline the fact that while much of the evidence from this review is inconclusive, there are few other interventions with better-established levels of empirical support than group-based parenting interventions. They also suggest that parent programmes incorporating additional components aimed specifically at addressing problems associated with abusive parenting, like parental anger and stress, may be more effective than those without such components.

Summary Box 9: Group-Based Parenting Programmes • Group-Based Parenting Programmes range from behaviour modification programmes to the elimination of erroneous negative beliefs to improve parental self-efficacy and the use of video modelling to improve parental practices. • These programmes can significantly reduce parental anxiety and depression and can increase self-esteem and marital adjustment through the interaction of couples with others in similar circumstances. • These programmes can also be effective in improving infant emotional and behavioural adjustment (thereby decreasing the prevalence of conduct problems later on). • Rational Emotive Therapy and Cognitive Behavioural Therapy are effective means of reducing irrational and erroneous negative beliefs that can lead to poor parenting practices. • Cognitive Behavioural Therapy and video-based modelling can reduce harsh punishment strategies and parental anger, leading to more positive parenting practices. • A major problem with these types of programmes is that attrition rates tend to be high, particularly with disadvantaged and young parents.

3.2.2.11 Community-Based Parenting Programmes

Recent community-based parenting programmes have focused on involving the community residents for whom the programme is intended in the construction and implementation of the programme (Prilleltensky, Nelson & Peirson, 2001). There are many benefits of involving members of the community in this way. Collaborations between researchers and community members

30 can increase the capacity of researchers to identify, understand and address key issues in the community (McAllister, Green, Terry, Herman & Mulvey, 2003). Social support from a woman who is a community member trained as a home visitor may have significant benefits over a normal healthcare professional as these women often share the same socio-economic background and life concerns (Hodnett & Fredericks, 2007). This can lead to a shared empathy between the community worker and target mother, which can increase the impact that the community worker has on the target mother’s life (Rowe, 2006).

Comprehensive Community Initiatives were initially set up in the USA from a growing need of partnership between families, the government, child welfare services, health and educational services in order to tackle target outcomes like teen pregnancy, youth employment and crime, with an emphasis on promoting responsibility and planning in the community (Melhuish, Belsky, Anning, Ball, Barnes, Romaniuk, Leyland, & the National Evaluation of Sure Start Research Team, 2007). The most predominant of these initiatives in the USA was the Early Head Start Programme. This programme was initiated in 1994 in order to make it possible for disadvantaged children to begin formal schooling on a par with their peers and has been found to have significant positive impacts on key developmental indicators in children from low-income areas (Gray & Francis, 2007). The programme has also been found to have some significant positive effects in reducing maternal depression (Chazan-Cohen, Ayoub, Pan, Roggman, Raikes, McKelvey, Whiteside- Mansell & Hart, 2007; Gray & Francis, 2007).

Sure Start, the UK-based equivalent of this programme was set up by the English government in 1999 in order to tackle poverty and disadvantage in young children. The Sure Start programme has been administered to families in geographically-defined deprived areas in what have become known as “Sure Start Local Programmes” (SSLPs). It has been set up in this way based on the assumption that the characteristics of communities can adversely affect parental behaviour and child development and that these areas can be identified (Barnes, Belsky, Broomfield, Dave, Frost, Melhuish & the National Evaluation of Sure Start Research Team, 2005). Each SSLP was set up to be comprehensively community-based and in this way to focus on the local needs of the community. This approach has been adopted in order to recognise the autonomy of different areas and to make the programme in this way more responsive to local needs and priorities (Gray & Francis, 2007). In this way it is less prescriptive than its American counterpart. The SSLPs are expected to provide outreach and home-visiting support for families and parents, good quality play, learning and childcare needs for children, community health care advice and special needs support for families (Melhuish et al., 2007).

The National Evaluation of Sure-Start has focused on 150 of the 260 first SSLPs and found significant small positive overall impacts on a number of measures (e.g. Melhuish et al., 2007; Barnes et al., 2005; Belsky, Melhuish, Barnes, Leyland, Romanuik, & the National Evaluation of Sure Start Research Team, 2006). Melhuish et al. (2007) reported that 12, 575 mothers of nine month- old children involved in the SSLPs have reported significantly lower levels of household chaos on the confusion, hubbub and order scale (derived from Matheny, Wachs, Ludwig & Philips, 1995). Additionally, non-teenage mothers of children aged 36 months were found to have significantly less negative parenting practices and their children were found to exhibit fewer behavioural problems and to have greater social competence than comparison mothers (Belsky et al., 2006).

Barnes et al. (2005) have demonstrated that an area-based approach like the SSLPs is well placed in trying to deal with local issues surrounding child poverty. In their study, demographic,

31 family structure, economic deprivation and adult health problem information was collected from administrative databases for two hundred and fifty seven SSLP areas in England. Cluster analysis allowed them to identify five distinct “types” of SSLP areas, which were found to differ in community measures of child health, academic achievement and use of child welfare services. For example, the 28 “Indian Subcontinent” communities (where a large population originating from the Indian subcontinent dwell) were found to use prenatal services less and to have relatively poor child health. This research highlights the value of targeting the differential and individual needs of particular communities.

The use of community members as trained professionals may also have an increased benefit in these types of programmes. Rowe (2006) demonstrated the potential value of having community residents assist in the running of a Sure Start programme. These “lay researchers” were able to design a research tool questionnaire where sensitive questions were asked in an acceptable way for local community members. They tended to have high attendance rates at the research seminars and commented that being from the local community tended to have an increased impact on respondents. However, Rowe also identified some potential problems with this approach. Community residents tended to dislike the controlled linear research process of agreeing the focus of a study, identifying and collecting data and analysing this data and making recommendations based upon it. They found this method to be too passive, not dynamic enough and not focused enough on the immediate needs of community members. As described above, in an Irish context the Community Mothers’ Programme has been positively evaluated using a Randomised Controlled Trial in 1989 and a follow-up study 7 years later (see Section 2.3.2, page 6 above).

Summary Box 10: Community-Based Parenting Programmes • Community-based Parenting Programmes involve community members in the design and implementation in all stages of an intervention that typically involves nurse home visits, community healthcare facilities and quality learning and recreational resources for children. • These programmes tend to use community members as trained nurses in order to increase empathic relations between the home visitors and mothers and as researchers in order that they may identify local needs more readily and design research instruments that are sensitive to local needs. • They were initially set up in the U.S. (e.g. the Head Start Programme) to deal with target issues like teen pregnancy and have been found to have significant positive impacts on child development and in the reduction of maternal depression. • Sure Start was set up in 1999 in the U.K. in order to tackle poverty and disadvantage in geographically-defined deprived areas in order to cater for local needs and priorities and involves nurse home visits, provision of good quality learning and play facilities, community healthcare advice and special needs support for families. • The National Evaluation of Sure Start (NESS) has found that mothers of nine month-old children in Sure Start areas have lower levels of household chaos and mothers of thirty-six month-old children have less behaviour problems and greater social competence. • The NESS have also demonstrated the differing needs of different disadvantaged communities in terms of healthcare services, suggesting the importance of community-based programmes that focus on local needs. • The Community Mothers’ Programme (which also runs n Ballymun) has been positively evaluated by an RCT in 1989 and a follow-up study 7 years later.

32 3.3. Review of available birth-related and maternal health data for Ballymun

3.3.1 Method

The objective in relation to data on births and maternal health was to

• Access local and national data primary and secondary sources to identify and retrieve all available birth-related and maternal health data for Ballymun.

The data that was identified as being required was as follows: • Population-related data (overall population, trends, age-group breakdown, household patterns) • Births (number annually, age of mother, marital status) • Child (0-2 years) health data (immunization rates, illness rates, accident rates) • Maternal health data (for example, postnatal depression, anaemia, also prevalence of smoking, alcohol consumption, drug use) • Paternal health data (for example, cancers, lung disease, cardiovascular disease and prevalence of smoking, alcohol consumption, drug use)

The following sources were identified and access sought: • The Central statistics Office. The CSO allows for searches by Small Area (District Electoral Divisions) and presents data in 5 year age bands (0-4 etc). The DEDs Ballymun A-D comprise the study area (social housing), i.e. it does not include Ballymun E. • The Department of Health and Children (Health Information Section, Public Health Department). No information is available at small area level. • The Health Service Executive, (health information by region- not locally), including the Immunisation data ( www.immunisation.ie ) (vaccination data is only currently a test file and no current information is publicly available). • The Economic and Social Research Institute (www.esri.ie). A query was submitted regarding access to Ballymun level data within the Hospital In Patient Enquiry (HIPE) database, for access to data on illnesses requiring in-patient hospital stays. This is available only at HSE Regional level or else postcode level (e.g. Dublin 9 or Dublin 11) which would not be exclusive to Ballymun. • Health atlas. (www.healthatlas.ie). This is the key HSE information system. It provides access to census data, mapping, the calculation of rates and counts, and a range of health data. At the moment the system includes mortality data, birth data, hospital admission records, cancer registry data, vaccination uptake records, and locations of HSE facilities. At a large scale the system is very useful, but it is severely limited in its application to a small area, such as Ballymun, by the absence of health data at a small scale. Most of the existing data is only available at county level. The only current data available at the Ballymun level is census, and the cancer data. While the census data is useful, effective service planning at small level requires more local data. There is no nationally available data at local level on GP and other primary care use, health status, drug use, smoking, alcohol intake and obesity.

These sources confirmed that there is a dearth of publicly available health information at DED level and only the CSO Census data provides usable population information. This is disappointing

33 as it was not possible to confirm the service providers’ perceptions about Ballymun residents’ health patterns.

3.3.2 Findings

3.3.2.1 Population

• The population of Ballymun was recorded as 15,495 in the 2006 Census, an increase of 1.7% since 2002 census. In comparison, the population of Ireland grew by 8.2% between 2002 and 2006. • Between 2002 and 2006, the total number of private households in Ballymun increased from 4,800 to 5,080. • The population density of Ballymun in 2006 was higher than in Dublin City (22 persons per acre compared to 18 persons per acre). • The past decade has seen movement out from Ballymun, in the context of uncertainty about housing replacement and also movement into Ballymun, as new housing options were made possible. There has been movement within the areas of Ballymun, with a wider geographical spread than previously the case.

3.2.2.2 Proportions within age-groups of population Females constitute 52.4% pf the population of Ballymun and the breakdown within this percentage for women of child-bearing age is shown in table 3.1.

Table 3.1 Percentage of population who are females by age group

Age group % females (of all population)

15-19 3.2

20-24 4.4

25-29 4.6

30-34 5.0

35-39 4.4

40-44 4.3

Total 25.9%

In addition, just below child-bearing age, there is 4.6% in the 10-14 years age group.

Ballymun’s population is younger than that of Dublin city and Ireland as a whole, with half of the female population aged between 15 and 44 years old.

There are 237 children aged less than 1, 221 children aged 1 and 261 children aged 2 recorded in the 2006 census, as per Table 3.2. This suggests that approximately 200 children are born in Ballymun each year, allowing for inward and outward movement.

34 Table 3.2: Number of children in Ballymun by age (Source: Census 2006, CSO)

Age of child Number 0 237 1 221 2 261

3.2.2.3 Household size

Almost 1,000 families in Ballymun had a child between 0-4 years (2006 Census), this number declined just slightly by 2.1% from 2002.

There are 969 one person households in Ballymun, an increase of 10.2% since 2002. In comparison, Ireland overall had an increase of 18.6%.

Table 3.3: Children in family units with mother and children only

All children aged less than 15 All children aged Total number of years old more than 15 years children old

Ballymun A 160 145 446

Ballymun B 339 225 841

Ballymun C 653 271 1376

Ballymun D 612 182 1066

The number of houses with 5 or more persons in Ballymun dropped by 9.3% since 2002, while this dropped by 4.5% nationally in the same period.

There were 1.75 children per family in Ballymun in the 2006 Census, compared to 1.24 children per family in Dublin City, and 1.41 children per family nationally.

The rate of single mother families with children aged both under and over fifteen is more than three times higher than Dublin, and more than four times the rates of Leinster and Ireland (no data for specific younger children age groups).

3.2.2.4 Ethnic minority groups

Information on the ethnicity and nationality can also assist in informing needs and service responses.

35 Table 3.4 Population of Ballymun (by DED) by ethnic group (Source: Census 2006, CSO)

White White Other Black or Asian or Not Other Total Irish Irish white black Asian stated Traveller Irish Irish Ballymun A 1,969 4 30 0 11 56 26 2,096 Ballymun B 3,144 272 231 33 41 178 22 3,921 Ballymun C 5,414 8 176 27 37 162 57 5,881 Ballymun D 2,942 11 288 31 43 124 34 3,473 Total 13,469 295 725 91 132 520 139 15,371

Table 3.5 Population of Ballymun (by DED) by nationality (Source: Census 2006, CSO)

Irish UK Polish Lithuanian Other Rest of Not Total EU 25 the stated world Ballymun A 1,975 27 6 10 5 31 42 2,096 Ballymun B 3,415 59 123 27 57 114 126 3,921 Ballymun C 5,473 73 48 17 81 74 115 5,881 Ballymun D 3,003 56 136 34 77 80 87 3,473

The Census also provides information on people with a disability. The figures for children and women aged 15-44 are shown in Table 3.6. This provides very limited information.

Table 3.6: People with a disability recorded in the Census by Ballymun DED (Source Census 2006, CSO)

Children Women age 0-14 15-24 25-44 Ballymun A 39 19 57 Ballymun B 56 55 110 Ballymun C 93 55 180 Ballymun D 53 27 119 Total 241 156 466

36 3.4 Priority Needs Identified Via Individual Structured Interview

3.4.1 Method

Each of the service providers who took part in the individual structured interview as part of the audit of existing pre-birth and early (0-2) parent support services in Ballymun (see section 2.2 & section 2.3.1), was asked to prioritise what they perceived to be the specific antenatal support needs of women and their partners in Ballymun and the support needs of parents of 0-2 year olds in Ballymun. The responses were subsequently thematically analysed and are summarized below.

3.4.2. Findings

3.4.2.1 Antenatal Needs Support There was a need identified for support and encouragement at what can be a difficult time for parents if a pregnancy was unplanned. Additional support is required for women where English is not their first language. Incentives to attend antenatal classes may be required. Overall a need was identified for an antenatal service that is non judgemental and sensitive to the particular needs of parents in Ballymun

Education and information A need was identified for education about pregnancy (especially nutrition), birth (including yoga classes, breathing exercises etc) and parenting. There was an emphasis on preparing parents as much as possible for life after the birth, with practical advice and information. Information needs to be provided in both verbal and written forms (for example on medical terms to be encountered in hospital). There is a need for Information on services available, their location, the professionals delivering them and how and where they are provided. For school-aged girls who are pregnant there is a need to support them to stay in education, including accessing home tuition.

3.4.2.2 The Child’s Needs The basic needs of the child for sleep, nutrition and safety were highlighted. Their cognitive and psychological development needs and emotional needs (regarding bonding, attachment) were also identified. There is also a need for the social development of the child through appropriate interaction.

3.4.2.3 Parent Needs (0-2 age group) Support Support was identified as having many forms for parents. It was acknowledged that home visiting services and community based services will both be needed. A need for peer support was identified. There is a need for early and ongoing assessment for nutritional and psychological issues. Specific needs were identified for teenagers, those who use drugs and older mothers. Overall there was a need for support services that go out and find parents and a need for services to work together.

Practically, there is a need for childcare facilities while parent is attending training/support.

37 There were suggestions made for the extension of specific programmes, such as Marte Meo, Parents Plus and Incredible Years. A need for a sleep clinic was also highlighted as this affects bonding and attachment.

Education Parents have a need for education about the child’s physical, cognitive, psychological development (e.g. development stages, object permanence, containing anxiety); practical issues (e.g. eating, bathing, sleeping, establishing routines, communication (e.g. turn taking, eye contact), and modelling behaviour. There is also a need to promote developmental checks.

38 3.5 Participatory Open Forum

3.5.1 Method To provide an opportunity for an in-depth exploration of the antenatal needs of women and their partners and the needs of children (pre-birth to 2 years) and their parents, a participatory open forum was held on 14 November 2007. All those with involvement or interest in antenatal and 0-2 years parenting services were invited to the Forum.

The Forum was opened with a brief background to the Forum, an outline of the aims of the audit and needs assessment and the methods that were being used and a brief introduction to the needs that were emerging from the literature review and the interviews (Section 3.4). Participants were then assigned to groups. There were three groups, comprising between 5 and 6 people each. Groups were constituted by assigning group numbers to participants. Research team members facilitated the discussions, recorded summary notes on flip-charts and fed back on behalf of the group to the full forum. Staff members from youngballymun took more detailed notes which were passed over to the research team. This was designed to facilitate full participation in the discussion by the forum participants.

Each group fed back their key points under the separate headings of antenatal needs, child needs (0-2 years) and parents’ needs (0-2), as well as a visual representation of what it would look like if all those needs were met.

Each group facilitator fed-back and checked with group members that their feedback was accurate and that nothing had been missed. After each group had presented, all participants were given the opportunity to add points that had not been sufficiently covered. The Forum facilitator then invited discussion about points raised across groups and a discussion took place. This concluded the Forum.

3.5.2 Questions for group-work 1. What are your perceptions of the needs of women and their partners ante-natally, and of children aged 0-2 years and their parents in Ballymun (each to be considered separately)? 2. What are the unmet needs at the moment? 3. What would it look like if all these needs were met? What are the desired parent/child outcomes?

3.5.3 Forum findings While the needs identified were focused on antenatal needs, child needs (0-2 years) and parents’ needs (0-2) separately, there were a number of principles found to have underpinned those needs across the time spans discussed.

• Fundamentally a need for continuity across the antenatal and parenting time periods was identified. It was very difficult for participants to discuss these periods separately, as each one affected the other. Although not within the scope of this project, this also included the pre-conceptual period, for optimum health and well-being when

39 pregnancy begins. This continuity also related to the need to build relationships over time, with peers and professionals, so that trust can develop.

• Linked with this was the symbiosis or overlap between the needs of the child and parents’ needs- whereby a child’s needs relied on parents’ needs being met, as the parent is the primary carer.

• There was a need for inclusiveness identified, with a focus on family-based needs, including extended families. It was stated that language can be exclusive, especially to fathers and younger parents. Child-friendly services permit the inclusion of those with other children.

• Linked with the last point was the need for accessibility , seen as a means for each individual’s needs to be met. This includes geographical and cultural aspects.

• The need for connectedness and streamlining between existing services, in terms of the seamless flow between services and even that service providers are aware of each other.

• The need to focus on the individuality of parents and their needs. All individuals are entitled to respect and a non-judgmental approach. Individuals’ needs should be appropriately acknowledged and recognised before they can be met.

• This last point slinks with the need for flexibility in the services offered, so that individual needs can be met.

• This was seen as compatible with also wanting comprehensiveness , so that all needs could be met. For example, some parents prefer home-based individual support over group-based support and these needs change over time for individuals too.

• The need for quality monitoring within an ongoing consultative process with service users and community members to evaluate whether needs are being met as services change and develop.

3.5.3.1 Antenatal needs The two key antenatal needs identified were support and education/information . These are closely inter-linked.

• Support Support was described in many ways, encompassing social, emotional and psychological support. This can be a lonely time, depending on the woman’s circumstances. In particular peer support (both informally and formally, with training) was seen as important, for example, for fathers and younger parents. Advocacy for younger mothers was seen as particularly important. Fear was identified as a big barrier to accessing existing services, so the need for trust and education was highlighted. Women and men have fears. Support to help men “fit in” was seen as vital and linked to how information is communicated.

40

• Education/Information Education and the provision of information were seen as key to antenatal well-being as well as preparation for birth and parenting. Some particular antenatal education needs were identified, including the need for: o Nutritional education- during pregnancy, and after birth, especially education about breastfeeding and infant feeding topics such as weaning. It was stressed that this information needs to be given antenatally so that parents are aware early of these areas. o Preparation for birth: breathing exercises, for time after birth as may have short hospital stay o Preparation for parenting • Play: its importance and appropriateness at different stages of the child’s development • the “reality” of parenting, which may involve negative experiences • emotional aspects – bonding and how its develops and is enhanced

There was a need for specific antenatal education/classes for younger parents, women who use drugs etc. specific classes for fathers, or communicate to reach fathers using appropriate styles, language. Childcare facilities are needed for those who have other children. The need for community based classes was emphasized.

The need to have available and up-to-date information on the full range of antenatal and parenting services available was identified. There also needs to be information on crèche facilities, especially for young babies, as there are long waiting lists. This may be particularly important for younger mothers who wish to return to school.

3.5.3.2 The child’s needs

The child needs identified can be viewed as being linked with their developmental stages and are described under the following categories:

• Socio-emotional and cognitive needs : Stability, parental well-being, play, care, routine; an environments where interaction needs can be met

• Physical needs for warmth, nutrition, accommodation, health promotion (e.g. immunizations)

The child’s future needs (for education etc.) also need to be acknowledged so they can be planned for.

These needs were not very deeply expanded upon in the groups or in subsequent discussion, and the discussion how to assist and support in parents meeting these needs was a more involved discussion.

3.5.3.3 Parents’ needs

41 Parents’ needs were linked to the child’s needs, in terms of supporting parents to meet the child’s needs. The needs of parents themselves were also highlighted, in terms of their personal development which will affect the family’s well-being.

Support Support again was seen to encompass many areas, spanning practical and psychological support. There was a need identified to facilitate parents to communicate their negative feelings. Breastfeeding support includes both encouragement and practical support and advice. Practical support needs included a need for childcare so that parents can move on in terms of their own education or work. Childcare workers were identified as a resource to educate and support parents. It was acknowledged that some parents need additional supports, for example, parents who use drugs. For parents from ethnic and minority groups there is a need to recognise cultural needs and diversity.

The means to meeting the need for support were said to include peer support and advocacy, especially for younger parents, drop-in facilities for both social and informational support. The need to expand current services was stated. These services included public health nurse visiting, Lifestart and Community Mothers’ Programmes. They were all said to be useful and valued but limited at the moment.

Wider social aspects were also seen as required to support parents, including adequate income, housing, space and a healthy and safe environment.

Personal development As well as meeting parents’ needs in relation to their child, parents’ own needs were highlighted. The need to think of the future in terms of education and/or work was identified, especially for younger parents. For younger parents the need to continue in education was thought to be critical to their subsequent well-being. There is also a need for younger parents to think longer term than currently, in the current economic context where construction and other jobs are available in the short-term.

Parents need time for themselves, facilitated by childcare. This links with the need for health promotion and self-esteem development; and the development of parental capacity.

Information/education The education needs for parenting identified in the antenatal section were reiterated here. There is a need for information and understanding about the child’s physical, psychological, emotional and cognitive development stages and how to parent within these stages. There is also a need for information about their own and their child’s nutritional needs and how to meet them.

3.5.3.4 What would it look like if these needs were met? Groups were also asked to examine the question of desired outcomes, or outcomes if the identified needs had been met. Group members visually represented this through drawings.

Groups represented children centrally within families, in two cases extended families. One group also highlighted the need for future thinking and planning and the need for information. Another

42 group emphasised the linking of informal and formal supports around the extended family as a means to meet needs favourably. All groups represented happy children and parents.

43 Section 4 – Summary of Key Findings

• The audit of existing services showed that there are some specific services for antenatal support and for parenting of 0-2 year old children, as well as other family and general support services. The specific antenatal services are the new Primary Care Team antenatal classes and the Rotunda Hospital’s Teen Clinic which includes antenatal classes (for all Rotunda catchment population, including Ballymun residents). Specific parenting support programmes include the Community Mothers’ Programme and Lifestart (which covers parents of children 0-5 years). There is little evaluative evidence rating to existing services, with some exceptions.

• The literature review on antenatal needs identified physical (nutrition, safety, absence of toxins) and psychological (support, knowledge, confidence) needs. Although antenatal programmes are aimed to meet these needs there is limited evidence of their value. Fathers’ involvement in such programmes may increase their value. The child’s (0-2 years) needs are physical, cognitive, psychological and socio-emotional, with a fundamental need for bonding and secure attachment. Mothers’ psychosocial and physical needs are also described in the literature. Social support is identified as facilitating the transition to motherhood. Maternal postnatal depression is linked to low self-esteem, high expectations and relationship stress and has negative effects on the child. Social disadvantage also places additional stresses on new mothers. Teenagers’ transitions to motherhood are also reported as involving additional stresses and challenges. The literature reports the effectiveness of home visits and group-based community parenting supports for parents to meet these needs.

• The review of relevant data confirmed a dearth of relevant health data available at local (Ballymun level). Data from the 2006 Census is available and this provides important demographic information on population ago-groups, household size and ethnicity. Future developments in area-based health information will assist in confirming local service providers’ perceptions about local health and illness patterns.

• The needs assessment identified the key needs of parents as support and education across the continuum of pre-birth to 2 years old (and after). Support was both psychological and practical. Antenatal education encompassed preparation for birth and parenting, with an emphasis on preparing for the psychological and emotional “realities” of parenting, rather than just focusing on medical and physical aspects. The child’s needs were described as being physical and psychosocial, reflecting universal understanding of these needs. The emphasis postnatally was on supporting parents to meet those child needs, again through support and education. The provision of appropriately communicated information throughout this pre-birth to age 2 continuum was stressed; in particular there was a need for information about the range of services available at each stage and about the stages and needs of a child’s development. Across all these needs, the key principles of continuity, comprehensiveness, flexibility, accessibility and streamlining were identified. Where available, existing programmes were perceived as meeting these needs but as programmes are limited, there is a need for further development and streamlining between services.

44 Section 5 - References

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52 Terao, S.Y. (1999). Treatment Effectiveness of Parent-Child Interaction Therapy with Physically Abusive Parent-Child Dyads [EdD]. Stockton, California: University of the Pacific. Thomas, D.V. & Looney, S.W. (2004). Effectiveness of a Comprehensive Psychoeducational Intervention with Pregnant and Parenting Adolescents: A Pilot Study. Journal of Child and Adolescent Psychiatric Nursing, 17 (2): 66-77. Turan, J.M., Nalbant, H., Bulut, A. & Sahip, Y. (2001). Including Expectant Fathers in Antenatal Education Programmes in Istanbul, Turkey. Reproductive Health Matters, 9 (18): 114-125. Van Wyck, J.D., Eloff, M.E. & Heyns, P.M. (1983). The Evaluation of an Integrated Parent-Training Program. The Journal of Social Psychology, 121: 273-281. Warren, P.L. (2005). First-time mothers: social support and confidence in infant care. Journal of Advanced Nursing, 50 (5): 479-488. Webster-Stratton, C., Kolpacoff, M., Hollinsworth, T. Self-Administered Videotape Therapy for Families with Conduct-Problem Children: Comparison with Two Cost-Effective Treatments and a Control Group. Journal of Consulting and Clinical Psychology, 56 (4): 558-566. Westney, O.E., Cole, O.J. & Munford, T. (1988). The effects of prenatal education intervention on unwed prospective adolescent fathers. Journal of Adolescent Health Care, 9 (3): 214-218. Wolfe, D.A., Sandler, J., Kaufman, K. A competency-based parent training program for child abusers. Journal of Consulting and Clinical Psychology, 49 (5): 633-640. Wolfson, A., Lacks, P. & Futterman, A. (1992). Effects of Parent Training on Infant Sleeping Patterns, Parents’ Stress, and Perceived Parental Competence. Journal of Consulting and Clinical Psychology, 60 (1): 41-48. Zimmerman, T.S., Jacobsen, R.B., MacIntyre, M. & Watson, C. (1996). Solution-Focused Parenting Groups: An Empirical Study. Journal of Systemic Therapies, 15 (4): 12-25. Zlotnick, C., Johnson, S.L., Miller, I.W., Pearlstein, T. & Howard, M. (2001). Postpartum depression in women receiving public assistance: pilot study of an interpersonal therapy oriented group intervention. American Journal of Psychiatry, 158: 638-640.

53 Appendix 1 - Key Systematic Reviews [In alphabetical order]

Study Austin (2003) Title Targeted group antenatal prevention of postnatal depression: a review. Participants Five studies using RCTs were included and contained 512 pregnant women from the U.S., England and Australia who received a group-based antenatal programme aimed at preventing postpartum depression or no intervention. Interventions All antenatal programmes contained a screening questionnaire to identify women who were “at risk” for depression. The programmes’ content was aimed at reducing the prevalence of depressive symptoms in the postpartum period through extending parents support network, giving pregnant women information about postpartum mood change and teaching pregnant women skills to cope with the transition to motherhood and conflicts that may arise as a result of this. Measures Four of the studies used the Edinburgh Postnatal Depression Scale (EPDS) to measure depressive symptomatology, one of which also contained the Depression Inventory of the General Health Questionnaire (GHQ). The fifth study used the Beck Depression Inventory (BDI) and a Structured Clinical Interview using the DSM-IV in order to assess depressive symptoms. Outcomes A meta-analysis was not possible due to the varying methodologies employed by the studies. Three of the five studies found a lack of significant effect in reducing depressive symptoms with antenatal programs but had methodological flaws such as a lack of an adequate standardised screening tool to identify women “at risk” for depression and high attrition rates. Two studies did find reductions in depressive symptoms after an antenatal program and one of these (Zlotnick et al., 2001) was particularly methodologically rigorous.

Study Barlow, Coren & Stewart-Brown (2003) Title Parent-training programmes for improving maternal psychosocial health. Participants Twenty-six RCTs were reviewed containing 1707 parents and their children from the UK, USA, Republic of Ireland, Canada and Australia. Interventions All studies contained group-based interventions that were structured, had a specific theoretical framework {Behavioural, Cognitive-Behavioural, “Multimodal” (combining behavioural, cognitive and additional components), Humanistic and Rational Emotive Therapy} and were developed with the intention of helping parents to manage their children’s behaviours. Each study contained a waiting-list or no-treatment control group in addition to the intervention group. Measures Measures of maternal psychosocial health included measures of depression (BDI, GHQ and Profile of Mood States), anxiety (STAI), stress (Parenting Stress Index), irritability (Irritability, Depression and Anxiety Scale), marital adjustment (Marital Adjustment Test), social support (Inventory of Socially Supportive Behaviors) and self-esteem (Parenting Sense of Competence Scale). Outcomes Results from a meta-analysis found that these parenting programmes are effective in significantly improving maternal depression, anxiety, self-esteem and marital adjustment irrespective of type. There was no evidence for the programmes providing increased levels of social support.

54

Study Barlow, Johnston, Kendrick, Polnay & Stewart-Brown (2006) Title Individual and group-based parenting programmes for the treatment of physical child abuse and neglect. Participants Seven studies with RCTs were included and contained 297 parents and their children from the U.S. and Canada. Interventions All of the studies included contained group-based interventions (Humanistic, Cognitive-Behavioural, Behavioural and Parent-Child Interaction Therapy) that were aimed at reducing physical abuse and neglect in at-risk families. Control groups either contained no treatment or an alternative treatment method. Measures Child abuse potential was measured using the Child Abuse Potential Inventory, parenting behaviours were measured with the Dyadic Parent- Child Interaction Coding System and the Parent-child Interaction form and reports of child abuse and injuries were taken from medical records. Outcomes It was not possible to conduct a meta-analysis of these studies as the outcome variables were too different but the results of the different studies indicated that there were no significant effects of the parenting programmes on reducing physical abuse or injuries in children.

Study Barlow & Parsons (2003) Title Group-based parent-training programmes for improving emotional and behavioural adjustment in 0-3 year old children. Participants Five RCTs with group-based parenting programmes were used in this review and contained 394 parents and their children from the U.S. Interventions Studies included contained group-based interventions (Humanistic, Cognitive-Behavioural and Behavioural) that were aimed at improving the emotional and behavioural adjustment in 0-3 year old children and each study contained a waiting-list or no-treatment control group. Measures Children’s’ Behavioural Adjustment was measured using the Eyberg Child Behaviour Inventory, the Child Behaviour Questionnaire, the Behaviour Screening Questionnaire, the Pediatric Symptoms Checklist and the Home Situations Questionnaire. Outcomes A meta-analysis found no significant parent reports of improved child behavioural adjustment but significant independent measures of improved child behavioural adjustment in the children of parents who were given group-based parent programmes. In the studies that contained follow-up data, there were no significant improvements in child behavioural adjustment on a more long-term basis.

Study Bennett, Macdonald, Dennis, Coren, Patterson & Abott (2007) Title Home-based support for disadvantaged adult mothers. Participants Eleven studies (each containing RCTs) with 4,751 disadvantaged mothers and their children from the U.S., the U.K., Australia, Canada and Ireland who were more than 19 years of age were included in the review. Interventions All participants were screened for social deprivation using established indices or data relating to their socioeconomic status. All studies contained a group who received home visits by professional or specially trained lay nurses that began antenatally and continued into the postpartum period and a group who received normal healthcare services.

55 Measures The studies contained measures of maternal depression (EPDS), maternal anxiety (the State-Trait Anxiety Inventory {STAI}), parenting Stress (Parenting Stress Index), parenting skills and behaviour (the HOME Inventory), parent- child interaction (the Nursing Child Assessment Satellite Training Scale), risk for child abuse (the Child Abuse Potential Inventory and Conflict Tactics Scale), child cognitive and motor development (the Bayley scales of mental and motor development), language development (the Pre-school Language Scale-3), child behaviour problems (the Child Behaviour Checklist) and reports of child abuse and injuries from medical records. Outcomes No evidence was found of home visits improving maternal psychosocial health, parenting skills and behaviour, child abuse risk and child health and development from a meta-analysis.

Study Gagnon & Sandall (2007) Title Individual or group antenatal education for childbirth or parenthood or both. Participants Nine studies with randomly controlled trials (RCTs) were included in the review, containing a total of 2,284 expectant parents from the U.S., Canada and Iran. Interventions Antenatal education programmes varied greatly but were all structured educational programs offered to individuals or a group by an educator and focused on preparations for childbirth, childcare and psychosocial adjustment of parents associated with the transition to parenthood. All studies contained a control group where no intervention was received. Measures Measures in the studies included questionnaires with measures of knowledge acquisition, labour pain, infant care abilities, psychological and social adjustment to parenthood (EPDS), obstetrical interventions, maternal sense of control, attachment behaviours and use of medication to reduce pain in labour. Outcomes No meta-analysis was able to be conducted and there was no consistent results found for any of the measures. However, one study found that an antenatal program tended to reduce labour length in participants (Mehdizadeh et al., 2005), another found that an antenatal program had effects of increasing satisfaction with maternal role preparation (Hamilton- Dodd et al., 1989) and two studies found that an antenatal program lowered the prevalence of unhealthy attachment behaviours (Carter-Jessop, 1981; Davis & Akridge, 1987).

Study Macdonald, Bennett, Dennis, Coren, Patterson, Astin & Abbott (2007) Title Home-based support for disadvantaged teenage mothers. Participants Five studies with RCTs were reviewed and contained 1838 disadvantaged teenage mothers (younger than 20 years of age) and their children from the U.S. and Australia. Interventions All participants were screened for social deprivation using established indices or data relating to their socioeconomic status. All studies contained a group who received home visits by professional or specially trained lay nurses that began antenatally and continued into the postpartum period and a group who received normal healthcare services. Measures The studies contained measures of maternal depression and anxiety (the RAND mental health scale), parenting skills and behaviour (the HOME Inventory), risk for child abuse (the Bavolek total child abuse potential score), child cognitive and motor development (the Bayley scales of

56 mental and motor development), child intelligence (Stanford-Binet IQ scale and the Cattell Infant Intelligence Scale), long-term academic achievement (the Kaufman Assessment Battery for Children), child behaviour problems (the Child Behaviour Checklist) and reports of child abuse and injuries from medical records. Outcomes None of the studies could be combined into a meta-analysis. There were no significant effects of the nurse home-visits on maternal depression and anxiety, child’s mental or motor development in any of the studies except for improvements at 12 and 24 months noted in one study. The Elmira Study (Olds et al., 1986) found significantly fewer arrests, convictions, violations of probation and fewer lifetime sex-partners in children of nurse-visited women at 15 years follow-up. There was also evidence in one other study of reduced child abuse potential with home visits.

Study McNaughton (2004) Title Nurse Home Visits to Maternal-Child Clients: A Review of Intervention Research. Participants Thirteen studies with RCTs were included containing 4708 mothers and their children from the U.S., Australia and Taiwan. Interventions All studies contained a group who received home visits began antenatally or during early motherhood and a group who received normal healthcare services. Measures The outcomes measured in the different studies included measures of postnatal depression (the EPDS and BDI), child cognitive and motor development (the Bayley scales of mental and motor development and Denver Developmental Screening Test), parenting skills and behaviour (the HOME Inventory), risk for child abuse (the Child Abuse Potential Inventory), breastfeeding (breastfeeding experience and attitude scales) and reports of child abuse and injuries from medical records. Outcomes None of the studies could be combined into a meta-analysis. About half of the studies found nurse home visits to be effective in significantly improving physical health in the children and encouraging a positive rearing environment in the home by decreasing harsh punishment and reducing reports of abuse or injury in the child significantly. No significant effects were found with home visits for improving maternal mental health, child motor/cognitive/language development, breast-feeding behaviours or parenting knowledge.

57 Appendix 2 - Exemplars of Key Studies [Alphabetical Order]

Study Aiello & Lancaster (2007) Aim To investigate the influence of perceptions of being parented, separation- individuation, maternal-infant attachment and maternal separation anxiety on the development of infants of adolescent mothers. Participants 71 mother-infant pairs who were recruited antenatally from a public hospital in Melbourne, Australia were administered with questionnaire instruments over four different time periods (from pregnancy to late in the first year of the child’s life). During the second year of the child’s life, a psychologist assessed the infant’s development and behaviour. Measures During pregnancy, mothers were assessed on perceptions of being parented with the Parental Bonding Instrument and level of separation- individuation with the Separation-Individuation Process Inventory. Maternal-infant attachment was assessed over early, mid- and late postpartum periods using the Maternal Postnatal Attachment Scale and maternal separation anxiety was assessed at mid- and late postpartum using the Maternal Separation Anxiety Scale. At two years postpartum, a psychologist assessed infant development using the mental development and psychomotor development subscales of the Bayley Scales of Infant Development. Outcomes No significant correlations existed between any of the variables except that better-resolved adolescent separation-individuation scores tended to predict higher scores on infant mental development.

Study Austin, Hadzi-Pavlovic, Leader, Saint & Parker (2005). Aim To investigate if links exist between maternal trait anxiety, perceived stress, depression and infant temperament Participants 970 Australian women from Sydney were assessed on psychological self- report questionnaires during the third trimester of pregnancy and these women and their partners were assessed again at 4-6 months postpartum. Measures The antenatal questionnaire contained the State Trait Anxiety Inventory to measure anxiety, the Edinburgh Postnatal Depression Scale to measure antenatal depression and an antenatal social risk questionnaire to assess perceived stress relating to life events. At 4-6 months, mother and father reports were taken on the Short Infant Temperament Questionnaire and maternal depression was assessed again on the Edinburgh Postnatal Depression Scale. Outcomes Maternal trait anxiety in the postpartum period tended to have a significant effect of increasing the prevalence of “difficult” infant temperament and postnatal depression. Antenatal depression and perceived life event stress had no effects on infant temperament.

Study Barnes, Belsky, Broomfield, Dave, Frost, Melhuish & the National Evaluation of Sure Start Research Team (2005) Aim To investigate if there are substantial differences in localised areas of disadvantage identified by the SSLPs and they constitute different “typologies” of disadvantage

58 Measures Administrative data was obtained for different SSLP areas from national databases (e.g. census information) in the U.K. with regard to demographic information, socio-economic information and aspects of child and family functioning. Outcomes 5 distinct SSLP “types” emerged from cluster analysis based on socio- demographic and economic characteristics, each area containing a different average level of economic deprivation and proportion of ethnic minorities. These areas tended to differ with respect to measures like child educational attainment and use of child health services.

Study Belsky, Melhuish, Barnes, Leyland, Romanuik & the National Evaluation of Sure Start Research Team (2006) Aim To evaluate the positive effects of SSLPs on children and their families. Participants 3,927 mothers and their 36 month-old children from 150 SSLP areas in the U.K. and 1,101 mothers and their 36 month-old children from comparison communities in the U.K. Measures A 90-minute home-visit to the mother and child involved 1) a structured interview with the mother on topics such as community services in the area, family functioning and parenting skills and 2) the administration of the British Ability Scales to three year-old children. Outcomes SSLP programmes were found to have beneficial effects on non-teenage mothers with respect to parenting practices and social functioning in children but had adverse effects on children of teenage mothers with regard to social functioning and adverse effects for children of single parents who did not work with regard to verbal ability.

Study Berlin, Brady-Smith & Brooks-Gunn (2002). Aim To investigate if teenage mothers were more at risk than older women for the use of negative and hostile parenting practices towards their children and if race/ethnicity, education level or marital status has any effect on these types of behaviours? Participants 1,702 low-income American mothers taken from an Early Head Start Research and evaluation Project. The sample contained 704 White mothers, 595 Black mothers and 403 Latina mothers. One-third of the sample was classified as teenage mothers (younger than 19 years at birth of child). Measures Demographic Information was collected from an intake questionnaire. Parenting behaviours were assessed at 14 months postpartum by coding a videotaped 10-minute “Three Bag” free play assessment with the NICHD Study of Early Child Care’s Three Box Coding Scale. Outcomes Teenage mothers were found to be significantly less supportive, more detached, more intrusive and more hostile towards their infant, irrespective of race/ethnicity, marital status or education level.

Study Buckelew, Pierrie & Chabra (2006) Aim To investigate the personal and service-related needs of fathers from San Mateo County in California. Participants 204 local fathers of children aged 0-5 years completed questionnaires and an additional 80 fathers and community representatives participated in nine focus groups.

59 Measures Questionnaires contained 35 items on demographic information, general fathers’ needs, service-related needs and health-care needs. Focus groups covered topics such as parenting needs, social support and community resources. Outcomes Fathers indicated that financial and housing needs were most important to be met. Fathers and community members indicated that they would like the county to provide more father-child activities and services.

Study Coyl, Roggman & Newland (2002) Aim To examine the effects of stressful events, maternal depression, negative parent-infant interactions and spanking on infant attachment behaviours. Participants 169 mostly European-American mothers and infants from an Early Head Start program in Utah completed interview and self-report assessments at 14 months postpartum. Measures Attachment security was measured using the Q-set attachment security measure; stressful events were measured by a stressful events checklist of 20 items; depression was measured using the Center for Epidemiological Studies Depression Scale; Parent-child negative interactions were measured using the Parenting/Child Stress Index/Short Form and spanking was measured on the HOME Inventory. Outcomes Maternal depression, negative interactions and spanking were found to have significant negative effects on infant attachment security. In addition, relationship stress and economic stress increased spanking and maternal depression (i.e. indirectly affecting infant attachment security).

Study Doherty, Erickson & LaRossa (2006) Aim To assess the ability of a group educational intervention involving couples to enhance the quality of father-child involvement and interaction. Participants 165 first-time couples from the U.S. who volunteered to take part. Intervention The experimental group (95 couples) received an 8-session group educational program (in additional to normal health care) that involved discussion of pregnancy and parenting topics, interaction with infant participants and specifically addressed father involvement. The control group (70 couples)received normal health care from health professionals Measures All measures were taken at 6 and 12 months post-partum. Quality of father-child interaction was measured using the Parent Behaviour Rating Scale during a videotaped 5-min free play situation. Father Involvement was assessed using time diaries and mother and father self-reports. Outcomes The intervention had positive effects on father-child interactions and fathers’ skills at handling the child. It also increased father involvement on work days but not during home days.

Study Fabian, Radestad, & Waldenstrom (2005) Aim To investigate mothers’ views on antenatal education and compare participants vs. non-participants in education classes with regard to the experience of childbirth and parenting knowledge and skills. Participants 1197 Swedish women who volunteered to take part (1,096 attended

60 Swedish government-offered antenatal classes; 101 did not). Measures Questionnaires administered during early pregnancy contained demographic information questions. At 2 months post-partum, an additional questionnaire contained questions about whether antenatal classes had prepared mothers for childbirth, their labour experiences and what pain relief techniques they used during childbirth. A final questionnaire at 1 year post-partum asked about duration of breastfeeding, opinions about parental skills and if they still met with other antenatal class members. Outcomes No effects of antenatal classes on parenting skills or experience of childbirth were found but classes tended to expand a mothers’ social network.

Study Florsheim & Smith (2005) Aim To examine if the quality of relationship between expectant adolescent couples would predict parenting behaviour. Participants 36 expectant adolescent American couples who were first-time parents were recruited through an antenatal care clinic. Questionnaire data and observed interpersonal relationship data was recorded during the second trimester. At two years follow-up, observational parenting data was collected from 27 mothers and 20 fathers, with 35 couples contributing relationship status information. Measures During the first trimester, relationship quality was assessed on the Quality of Relationship Inventory and couples interpersonal behaviour was measured on a 10-minute videotaped conflict task that was coded using the Structural Analysis of Social Behaviour model. At follow-up, each parent participated in a videotaped 10-minute structured-play activity that was also coded using the Structural Analysis of Social Behaviour model. Outcomes Hostile controlling behaviour between partners was associated with hostile controlling parenting behaviour for both fathers and mothers. Additionally, fathers who were treated in a hostile manner by their partners tended to be significantly more hostile towards their children (this was not the case for mothers). Couples who had positive interactions before pregnancy were also more likely to have remained together at two years follow-up.

Study Haslam, Pakenham & Smith (2006) Aim To explore the effects of social support and self-esteem on postpartum depressive symptomatology. Participants 247 first-time Australian mothers from Queensland completed questionnaires during their last trimester and 192 of these women completed further questionnaires at 4 weeks postpartum. Measures Depression was measured using the Edinburgh Postpartum Depression Scale and the Beck Depression Inventory, Maternal Self-efficacy was measured using the Parental Sense of Competence Scale and Social Support was measured using a standard questionnaire. Outcomes Higher parental support and higher maternal self-efficacy were associated with lower levels of depressive symptoms post-partum and partner support was found to be unrelated to depressive symptomatology and maternal self-efficacy. Parental support, on the other hand, was found to lower

61 depression through self-efficacy enhancement.

Study Izzo, Eckenrode, Smith, Henderson, Cole, Kitzman & Olds (2005) Aim To examine the impact of the Nurse Family Partnership’s (NFP) program of nurse home visits in reducing mothers’ vulnerability to the effects of stressful life events in the years following the program’s completion. Participants 300 first-time adolescent American mothers from New York took part in the study. Intervention The control group received sensory and development screening at age 12 and 24 months and clinical referrals if they were required; some of the controls also received free transportation for prenatal and well-child care for the first 24 months (n=184). The intervention group were given the same program as controls with the addition of nurse home visits antenatally and for the first 24 months postpartum (n=116). These home visits were focused on improving pregnancy outcomes, health and development of the child and the mothers’ economic situation through information and practical guidance. Measures Demographic information was taken at intake before the 25 th week of gestation. At 15 years following the intervention, a structured interview was conducted with the mothers assessing number of stressful life events in the past four years with the National Comorbidity Survey stressful life-events items, mental health using the Rand Mental Health Inventory and reported the number of binge drinking episodes in the last year and cigarettes smoked per day. Adolescents reported on maternal behaviours at this point using the Child Report of Parental Behaviour Inventory and on a measure of parental supervision. Outcomes Stressful life events significantly predicted less emotional stability for the controls but not for the intervention group. The program had a greater effect in reducing vulnerability to negative effects of life events (e.g. poor mental health outcomes) if participants were younger or had a lower sense of personal control.

Study Koniak-Griffin, Mathenge, Anderson & Verzemnieks (1999) Aim To investigate the efficacy of a program of prenatal education classes and nurse home visits in order to improve health outcomes for adolescent mothers and their infants. Participants 121 Californian mothers and their infants from predominantly low-income backgrounds. Intervention Intervention group participants (n=63) received 4 prenatal education classes that focused on topics such as the transition to motherhood and staying healthy and 17 home visits from public health nurses both prenatally (focusing on nutrition, use of health services and pregnancy and childbirth concerns) and postnatally (focusing on self-care, infant-care, well-baby health services, family planning and using problem situation worksheets and video-modelling feedback). The tradition public health nursing group participants (n=58) received three nurse home visits for intake, prenatal care and postpartum/well-baby care information. Measures Medical records were obtained for the participants to provide information

62 on childbirth outcomes and infant health; nurse-administered Neonatal Behavioural Assessment scale was used to obtain information on infant behaviours; maternal responses to written questionnaires and nurse interviews were used to assess maternal depression levels. Outcomes Lower incidence of premature birth and significantly fewer hospitalization days for infants in the intervention group. No other significant effects were reported but mothers with a history of substance abuse were at a high risk of recidivism postpartum regardless of group.

Study Luyben & Fleming (2005) Aim To investigate the important aspects of antenatal care for pregnant mothers Participants 23 women using routine antenatal care from midwifes or nurses in Scotland (n=7), Switzerland (n=7) and the Netherlands (n=9) Measures Semi-structured interviews explored the needs and expectations of pregnant mothers and were conducted from 0-6 months post-partum. Outcomes Central to women seeking antenatal care is a feeling of responsibility. This feeling of responsibility is obtained through confidence and a sense of autonomy gained from antenatal care.

Study Matthey, Kavanagh, Howie, Barnett & Charles (2004) Aim To assess the effects of a psychosocial intervention within a program of antenatal classes on the postpartum adjustment of men and women. Participants 268 expectant Australian couples from Sydney who attended antenatal classes. Intervention Control group couples (n=101) were given a 6 weekly antenatal education course, covering topics like breastfeeding, delivery processes etc. Experimental group couples (n=89) received the same antenatal education course but with an additional session that focused on postpartum psychosocial issues. The non-specific control group couples (n=78) received the same antenatal education course as the normal control group but with an additional session on various baby play issues. Measures Structured interview data and self report information (containing standardised measures of self-esteem, mood, social support, parenting competence and partner awareness) were collected from 202 couples at 6 weeks postpartum and 180 couples at 6 months postpartum Outcomes At 6 weeks, the intervention had significant effects on maternal anxiety, mood and sense of competence. However, there were no significant intervention effects at 6 months postpartum. There were no significant effects of the intervention on men at either time period.

Study Melhuish, Belsky, Anning, Ball, Barnes, Romaniuk, Leyland & the National Evaluation of Sure Start Research Team (2007) Aim To examine the links between variations in programme implementation of Sure Start Local Programmes (SSLPs) and their effectiveness. Participants Home-visit data were gathered on 12,575 9 month-olds and 3,927 36 month- olds who were randomly sampled from the first 150 SSLPs in the U.K. Measures Implementation proficiency information about the SSLPs assembled from an

63 extensive survey of SSLP policies and practices, programme publications, publicity materials and organisational diagrams. At 9 months, maternal acceptance (characterised as avoidance of negative parenting behaviours) and household chaos were measured by two separate inventories. At 36 months, a 90-minute home-visit to the mother included a measure of maternal acceptance for the mother and the administration of the British Ability Scales to three year-old children. Outcomes There was a moderate relationship between programmes that were judged to be more efficient and those that had the most positive impacts. In particular, more empowerment of mothers and staff through the programme design was related to greater maternal acceptance in mothers of 9 month-olds and the fostering of a stimulating home environment for 36 month-olds. In addition, stronger ethos and better overall programme efficiency was positively related to greater maternal acceptance in mothers of36 month-olds.

Study Olds (2002) Aim To assess the impact of the NFP program of nurse home-visits in improving the early health and development of low-income mothers and children and their later health and behavioural outcomes. Participants Two studies of NFP home visits were conducted on two different populations; 400 mainly Caucasian American mothers and infants from New York and 1,139 mainly African-American women and their children from Memphis. Intervention In the New York study, a control group received sensory and development screening at age 12 and 24 months, clinical referrals if they were required and some received free transport to prenatal and well-child clinics (n=184). The intervention group received antenatal home visits solely (n=100) or antenatal and postpartum home visits (n=116). The home visits were the same as detailed in Izzo et al. (2005), above. In the Memphis study, the control group received free transportation to prenatal care or free transport to prenatal care with developmental screenings at 6, 12 and 24 months (n=681). The intervention group received the same services as the control group with the addition of one home visit before and after birth or continued home visits up to the child’s second year (n=258). Measures Mothers from both studies were assessed for prenatal health behaviours upon intake (before the 25 th week of gestation) and at the end of pregnancy with questionnaires. Prevalence of birth complications were recorded at childbirth. Sensitive competent care of the child was measured using the HOME Inventory at 34 and 46 months for the New York Study and at years for the Memphis Study. Child-abuse was measured by state-verified reports of child abuse during the first two years. Injuries and neglect were measured by medical records and the numbers of hospitalisations in the first two years postpartum in both studies. Post-Intervention early parental life course was measured after 4 years in the New York study and after 2 years in the Memphis study in a questionnaire that focused on the number of subsequent pregnancies and

64 workforce participation levels. Post-Intervention later parental life course was measured on a questionnaire after 15 years in the New York study and after 5 years in the Memphis study that focused on delinquent behaviours, substance abuse and consumption, number of pregnancies and health behaviours. Adolescents were assessed for delinquent behaviour, substance abuse and consumption and number of sex partners at 15 years of age on a questionnaire in the New York Study. Outcomes Both studies found fewer injuries and ingestions associated with child abuse, fewer subsequent maternal pregnancies and greater maternal workforce participation in the intervention group vs. controls. The intervention group in the New York Study also produced long-term positive effects on delinquent behaviours, substance abuse and pregnancy in 15 year-old adolescent children of participants.

Study Pauli-Pott, Haverkock, Pott & Beckmann (2007) Aim To investigate if infant attachment quality and negative emotionality interact together to influence behaviour problems. Participants 64 healthy firstborn German children and their primary caregivers. Measures Negative emotionality was assessed at 4, 8 and 12 months using the Bayley Mental Scale and the “Infant Emotion Scale”. Attachment security was assessed at 18 months with Ainsworth’s Strange Situation Procedure. Child Behaviour Problems were assessed at 30 months using the clinical structured Mannheim Parent Interview. Outcomes No significant direct relation between negative emotionality and behaviour problems were found but disorganised attachment tended to predict later behaviour problems. In addition, there was a strong correlation between disorganised attachment behaviours and behaviour problems in infants high in negative emotionality.

Study Quinlivan, Box & Evans (2003) Aim To assess the impact of a postnatal home-visiting service for adolescent mothers on childbirth outcomes, knowledge of contraception, breastfeeding and infant vaccination. Participants 139 Australian adolescent mothers from Melbourne who were attending a pregnancy clinic were split into an intervention group who received five structured postnatal home visits by nurse-midwives (n=65) or a control group who received no home visits (n=71). Intervention The intervention group received five home visits at 1 week, 2 weeks, 1 month, 2 months and 4 months with topics ranging from breastfeeding and infant care skills, advice on contraception and infant vaccinations, maternal mood disorder information and alcohol/drug consumption and services information. The control group received no home visits but all of the study participants were given the option of receiving routine postnatal support, counselling and information services provided by the hospital. Measures An antenatal questionnaire was completed to assess mothers’ knowledge on breastfeeding, contraception and infant vaccination and the Edinburgh postnatal depression screen was also included to assess depressive

65 symptoms. At 6 months postpartum, the same questionnaire was distributed to mothers (n=124) with additional questions relating to use of contraception, compliance with infant vaccination schedules and breastfeeding behaviour. Outcomes Postnatal home visits had the effects of significantly reducing the presence of adverse neonatal outcomes, significantly increasing contraception knowledge but there were no significant increases in infant vaccination uptake or breastfeeding behaviours with these visits.

Study Rowe (2006) Aim To investigate the experiences of parent researchers in a Sure Start Research Programme and to evaluate the outcomes of their involvement. Participants 16 parent researchers who volunteered to carry out research for a Sure Start programme in the U.K. Intervention Parent researchers received a 10-week Open College Network (OCN) accredited course, developed a research questionnaire in group meetings, conducted 4-6 telephone interviews each, analysed the interview data and wrote a report. Measures Blank diaries were given to the researchers to record their experiences. Two postal questionnaires were sent to participants to investigate their feelings of how successful the project was, one prior to training and one after the completion of the project. A focus group was conducted after the completion of the project to allow the exploration of issues that arose during the project. Outcomes Participation in the project developed many skills for the parent researchers, including interview skills and questionnaire development and they showed sensitivity to the research process. Researchers felt that they impacted on local mothers’ lives because they were from the same area and felt that the experience of the project met or exceeded their expectations. There was full attendance by all researchers throughout all stages of the project and they were able to design a research tool that asked questions in an acceptable way for the local community.

Study Sword & Watt (2005) Aim To investigate the concerns and unmet learning needs of women in the hospital during childbirth and to compare these concerns and unmet learning needs among low-income and higher-income women. Participants 1,250 Canadian women from five hospitals in Ontario completed a self- report questionnaire in the hospital; 890 of these women took part in a structured telephone interview 4 weeks after discharge from the hospital. Measures The questionnaire contained demographic information and questions that related to concerns that they might have about several health-related topics like breastfeeding, infant care, sexual changes and intercourse and signs of illness in the child. The structured interview focused on health indicators and use of health services since the mother had discharged from the hospital. Outcomes Breastfeeding and signs of infant illness were of greatest concern to mothers, irrespective of their socioeconomic background. Women of low socioeconomic background were more likely to report higher levels of

66 unmet learning needs than those from higher socioeconomic backgrounds.

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