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Because of this, healthcare institutions are placing increased importance on supporting their employees emotional needs so they can better care for patients. Another name and concept directly tied to compassion fatigue is moral injury. Moral injury in the context of healthcare was directly named in the Stat News article by Drs.

However, the systemic issues facing physicians often cause deep distress because the patients are suffering, despite a physician's best efforts. This concept of Moral Injury in healthcare [26] is the expansion of the discussion around compassion fatigue and 'burnout. Caregivers for dependent people can also experience compassion fatigue, which can become a cause of abusive behavior in caring professions.

It results from the taxing nature of showing compassion for someone whose suffering is continuous and unresolvable. One may still care for the person as required by policy, however, the natural human desire to help them is significantly diminished desensitization and lack of enthusiasm for patient care. These people may develop symptoms of depression , stress , and trauma.

Those who are primary care providers for patients with terminal illnesses are at a higher risk of developing these symptoms. In the medical profession, this is often described as " burnout ": the more specific terms secondary traumatic stress and vicarious trauma are also used. Some professionals may be predisposed to compassion fatigue due to personal trauma. Mental health professionals are another group that often suffer from compassion fatigue, particularly when they treat those who have suffered extensive trauma.

A study on mental health professionals that were providing clinical services to Katrina victims found that rates of negative psychological symptoms increased in the group. Many social workers are at a constant battle not only within their casework but within themselves. A social worker's career comes at a personal price with putting personal beliefs aside, managing compassion fatigue, and getting the mental help needed to cope with the traumas that are dealt with daily.

The way a social worker feels must be put aside when in the field due to the possibility of those feeling swaying the appropriate action that must be taken. If a social worker is consciously aware of compassion fatigue and burnout happening within themselves early on, then they hold capability to seek the help needed to combat them before any negative impression is felt externally.

Being able to objectively evaluate situations at work aides in keeping social workers professionally safe. Self-awareness of compassion fatigue and burnout flow into the mental and physical management that keep those feelings under control. When a social worker puts in the time to take care of themselves their personal life and work life are both positively influenced. Critical care personnel have the highest reported rates of burnout, a syndrome associated with progression to compassion fatigue. These providers witness high rates of patient disease and death, leaving them to question whether their work is truly meaningful.

This has created a workload-reward imbalance--or decreased compassion satisfaction. It can negatively affect the worker's sense of self, safety, and control. Those with a better ability to empathize and be compassionate are at a higher risk of developing compassion fatigue. Those who stay in the healthcare field after developing compassion fatigue or burnout are likely to experience a lack of energy, difficulty concentrating, unwanted images or thoughts, insomnia, stress, desensitization and irritability.

Unfortunately, despite recent, targeted efforts being made to reduce burnout, it appears that the problem is increasing. Recent research shows that a growing number of attorneys who work with victims of trauma are exhibiting a high rate of compassion fatigue symptoms. In fact, lawyers are four times more likely to suffer from depression than the general public.

They also have a higher rate of suicide and substance abuse. Most attorneys, when asked, stated that their formal education lacked adequate training in dealing with trauma. Besides working directly with trauma victims, one of the main reasons attorneys can develop compassion fatigue is because of the demanding case loads, and long hours that are typical to this profession. There is an effort to prepare those in the healthcare professions to combat compassion fatigue through resiliency training.

Teaching workers how to relax in stressful situations, be intentional in their duties and work with integrity, find people and resources who are supportive and understand the risks of compassion fatigue, and focus on self-care are all components of this training. Stress reduction and anxiety management practices have been shown to be effective in preventing and treating STS. Taking a break from work, participating in breathing exercises, exercising, and other recreational activities all help reduce the stress associated with STS. Conceptualizing one's own ability with self-integration from a theoretical and practice perspective helps to combat criticized or devalued phase of STS.

In addition, establishing clear professional boundaries and accepting the fact that successful outcomes are not always achievable can limit the effects of STS. Social support and emotional support can help practitioners maintain a balance in their worldview. In order to be the best benefit for clients, practitioners must maintain a state of psychological well-being. Some counselors who use self-compassion as part of their self-care regime have had higher instances of psychological functioning. Self-awareness as a method of self-care might help to alleviate the impact of vicarious trauma compassion fatigue.

From Wikipedia, the free encyclopedia. Nursing Research and Practice. Petersburg Bar Association Magazine. Archived from the original PDF on November 20, Retrieved February Melissa; Strand, Elizabeth B. Journal of Human Behavior in the Social Environment. Dart Center for Journalism and Trauma. Archived from the original on Retrieved June Traumatization and comfort: Close relationships may be hazardous to your health. Catastrophes: A overview of family reactions. Figley and H. McCubbin Eds. Journal of Traumatic Stress. Characteristics of secondary victims of sexual assault.

International Journal of Family Psychiatry, 9 4 , Rape and the family. Treating stress in families , Issues in Mental Health Nursing. The intervention was modeled on the Baby-Friendly Hospital Initiative of the World Health Organization and UNICEF, which emphasized health care worker assistance with initiating and maintaining breastfeeding and postnatal breastfeeding support or a standard-of-care control. This study provided strong evidence that this intervention could increase the duration and exclusivity of breastfeeding and decrease the risk of gastrointestinal tract infection, respiratory infection, and atopic eczema in the infants' first year of life.

There are a variety of other interventions that have been studied with the majority focusing on breastfeeding counseling by health care workers to mothers in groups or in one-on-one sessions during antenatal newborn care. In Bangladesh, Akhter and colleagues demonstrated that nutrition counseling during the third trimester of pregnancy resulted in statistically significant increases in breastfeeding within 1 hour of birth.

These counseling sessions were often augmented with brochures and pamphlets and media to provide additional information. The counseling was delivered by health care workers, nurses or those providing antenatal newborn care. There were also studies that included postnatal home visits by community-based midwives or health workers to promote breastfeeding. In a study conducted by Omer, Mhatre, Ansari, Laucirica, and Andersson in Pakistan, home visits by lady health workers during pregnancy and the postnatal period using locally embroidered communication tools resulted in increased rates of colostrum feeding as well as maintenance of exclusive breastfeeding up to 4 months of life.

To engender community support, a study in Thailand provided education to women as well as community leaders and youth on breastfeeding, which was associated with significant improvements in colostrum feeding Saowakontha, Community-based interventions that include prenatal counseling, training, and health services for pregnant mothers, combined with postnatal home visits demonstrated a positive impact on long-term exclusive breastfeeding Akhter et al.

Inclusion of fathers and other community members in breastfeeding promotion may significantly increase colostrum feeding and exclusive breastfeeding Saowakontha et al. Green reviewed 51 studies intervention versus control and baseline comparison designs focused on interventions to promote early initiation of breastfeeding, feeding colostrum, exclusive breastfeeding, and continued breastfeeding. Many of these studies showed improvements in the quantity and quality of breastfeeding behaviors through a combination of counseling, home visits, group sessions, and changes in policy e.

2. While They’re Still Here: A Memoir

A promising strategy to ensure that developmental delays do not occur is the early role of touch in stimulating babies and feeding enhancement which are both associated with better physical, emotional, and cognitive development. Infants who received stimulation in early childhood were reported to be less involved in fights and serious violent behaviors and had higher IQ scores and school achievement later in life. These studies indicate that early stimulation can even have a lasting and positive impact on next the generation of parents and their behaviors for nonviolent, responsive, and sensitive feeding of their children.

Poor mothers of young children in rural Bangladesh attended a year of educational sessions on responsive stimulation and feeding Aboud, The mothers who were trained received higher scores on child-rearing knowledge and on the Home Observation for Measurement of the Environment HOME Scale, a systematic assessment of a caring environment in which the child is raised.

However, the trained mothers did not communicate differently with their children while doing a picture-talking task, and children did not show benefits in nutritional status or language comprehension. Although the parenting sessions conducted by peer educators were informative and participatory, the mothers did not have time to practice or problem-solve, which is essential to bring about behavior change in parenting style. These results informed Aboud and Akhter's subsequent study of a village-level family nutrition intervention for parent education and support with peer coaching and modeling in Bangladesh.

The study tested whether a responsive stimulation and feeding intervention delivered to mothers of children 8—20 months old in Bangladesh would improve developmental and nutritional outcomes. One treatment group received 18 sessions, which included modeling and coaching practices in feeding and verbal responsiveness with the child during play.

The other group received the sessions plus 6 months of a food powder fortified with minerals and vitamins, while the control group only received 12 information sessions. At follow-up, responsive stimulation-feeding groups had better scores on the HOME scale. The children were engaged in more responsive talking, expressive language, mouthfuls of food eaten, and handwashing. Micronutrient fortification resulted in more weight gain but not greater height.

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The second study tested the relative effects of each element nutrition and coaching , separately and together, in comparison with information sessions alone over 7 months. Families in the villages receiving the combined intervention had higher scores on the HOME scale, and these mothers exhibited more responsive talking and the children ate more food.

Mothers in both intervention groups recalled more information at follow-up than did the comparison group. These results corroborated Engle and colleagues' assertion that being coached helps caregivers remember information provided to them. Safe, appropriate, high quality complementary food and micronutrients, along with responsive and sensitive child care and feeding practices are also important for preventing malnutrition, especially among the most disadvantaged children in LMICs. These practices improve child health, nutrition, and developmental outcomes.

Mothers' education correlated significantly with nutritional and developmental gains of their children. Children in the experimental group were given a home stimulation program delivered by their caregivers that was updated every 3 months. The home program included activities to promote motor, cognitive, speech, and language development. Children in the comparison group received no developmental intervention.

The children in this study came from poor socioeconomic backgrounds and their nutritional status was suboptimal. Children in the experimental group showed significantly greater improvement in cognitive and motor development over time than children in the comparison group. Inadequate feeding and care may contribute to high rates of stunting and underweight and cognitive development among children in families. A cluster-randomized trial conducted in rural India tested the hypothesis that teaching caregivers appropriate complementary feeding and strategies for how to feed and play responsively during home visits would increase children's dietary intake, growth, and development when compared with home visit complementary feeding education alone or routine care Vazir et al.

Biweekly visits by trained village women provided the complementary feeding and play messages to the caregivers. This study demonstrated that mental development scores can be improved with a low-cost education intervention strategy, even when there were no improvements in growth.

These findings have important implications for helping undernourished children from rural communities begin school at appropriate developmental levels for their age. These studies together demonstrate that good evidence-based interventions exist to change feeding practices and that home stimulation programs taught to caregivers can significantly improve cognitive and motor development in young children infected.

Early stimulation should be an important component of nutrition interventions with infants. The evidence from these trials strongly support the use of skin-to-skin care Kangaroo Mother Care and feeding as effective, low-cost interventions in both healthy and low birth weight infants. Many of these evidence-based interventions have the potential to be scaled up in LMICs, especially for families with preterm or low-birth weight babies. Improving parenting skills can contribute to better clinical outcomes in children's attachment and engender a strong child—parent relationship.

Many programs begin engendering parental skills development to ensure attachment while mothers are still pregnant while others are designed to improve parent and caretaking skills when the children are older. Most of the interventions to improve parent and caretaking skills have been delivered during home visits.

Parent support programs to increase parent and caretaking skills to enhance child development from birth to 3 years of age have used a variety of approaches to enhance the ability of the mother or primary caregiver to engage in positive interactions with their children. A 4-day training program for maternity ward staff was conducted and the staff worked with the mothers to improve their knowledge and skills to care for their newborns.

Three months after delivery, mother—newborn pairs were interviewed at home. Mothers achieved significant improvement in umbilical cord care practices at home. Findings document that mothers can improve the clinical outcomes of newborns. Children who also received food supplementation performed better than those who did not, especially on motoric subtests. The effect of food supplementation on behavior appeared to be contemporaneous. The effects were stronger for girls than for boys. Although these interventions reduced the gap in cognitive performance between lower and upper socioeconomic classes, disparities in performance still existed.

A program for pregnant adolescent mothers 14—19 years of age in Chile Aracena et al. Health educators delivered an intervention to mothers to improve their parenting skills and health care practices, such as handwashing. Results included better mental health and nutrition for the mothers, and better communication development for their infants in comparison to mothers who received only standard-of-care at health centers. Another study was conducted with high-risk pregnant American Indian adolescents who share many of the risk factors of pregnant adolescents in the developing world Barlow et al.

The goal was to assess the impact of an intervention delivered by paraprofessionals to promote child care knowledge, skills, and involvement during home visits. Pregnant American Indian adolescents were randomly assigned to intervention or control groups. The paraprofessionals delivered 41 prenatal and infant care lessons in participants' homes when the fetus was approximately 28 weeks old until 6 months after childbirth.

Mothers in the intervention when compared with the control had significantly higher parent knowledge scores at 2 and 5 months after childbirth. Intervention group mothers scored significantly higher on maternal involvement scales 2 months after the child's birth and scores approached significance at 6 months after childbirth; however, there were no differences between groups on child care skills. Another study conducted in South Africa with pregnant and poor women in a periurban settlement assessed the efficacy of an intervention designed to improve the mother-infant relationship and strengthen the infant attachment Cooper et al.

The intervention was delivered during late pregnancy and for 6 months after childbirth. Women were visited in their homes by trained lay community workers who provided the intervention that was designed to promote sensitive and responsive parenting. The intervention was associated with significant benefit to the mother—infant relationship. At both 6 and 12 months, compared with control mothers, mothers in the intervention group were significantly more sensitive and less intrusive in their interactions with their infants. The intervention was also associated with a higher rate of secure infant attachments at 18 months.

A Jamaican study evaluated the program called Roving Caregivers, an intervention model first piloted by a nongovernmental organization Powell, Visits were conducted by community health workers who demonstrated play activities and involved the mother, or primary caregiver, in play sessions with the child. The interventions combined language activities, games, songs, simple jigsaw puzzles, and crayon and paper activities. Homemade toys and simple picture books were used and left in the homes that were exchanged at the next visit.

Emphasis was placed on enriching verbal interaction between the mother and child. Mothers were also encouraged to use positive feedback and praise and to avoid physical punishment. The overall evaluation of Roving Caregivers in St. The program was culturally adapted for Bangladesh which included traditional games and songs. Visits were conducted by village women in one study and female health workers in another.

In addition to the home visits, in both studies mothers attended centers where there were individual play sessions Nahar et al. Mothers and their to month-old children received weekly home visits by locally trained and supervised workers over the course of 18 months. Adopting the holistic approach used successfully in Jamaica Walker et al.

The investigators reported an increase over the course of the intervention in both play materials and activities incorporated by the family that enriched the child's learning environment. All evaluations of parental support provided through home visits demonstrated significant benefits for child development. A few had small effect sizes, but typically effects were medium to large.

The evaluations of home-visit interventions provide strong evidence that they can be successfully implemented by women who have completed only primary education or partially completed secondary education. Walker and Chang asserted that visits should be at least twice monthly to ensure sustainable changes in their parenting practices was corroborated by Powell and Grantham-McGregor Despite the consistent evidence that providing parenting education through home visits benefits child development, this is a high-intensity intervention that is difficult to scale up in resource poor communities.

To address this problem, some home-visit interventions have been combined with group sessions. An intervention evaluated in Brazil combined group sessions to demonstrate and practice play activities and interaction with home visits to reinforce the workshops through play sessions with the mother and child Eickmann et al. Individual play sessions with mother and child can also be conducted at visits to a community clinic Nahar et al. Alternative strategies to reach greater numbers of children are needed, but evidence of their impact on child development is limited.

One approach is to provide parents with individual counseling and training when they access health services. The package provides guidelines for health professionals to counsel parents on how to promote development and includes cards for mothers with age-specific messages and illustrations of activities. Counseling sessions lasted for only 5 to 10 minutes and were conducted with individual mothers when they brought their well or sick child to visit the health service.

The efficacy of the Care for Development materials was tested by Jin and colleagues in families with a child younger than 2 years of age from seven randomly selected villages in an impoverished rural county in Anhui Province, China. Two counseling sessions were delivered to 50 families randomly selected from among the study participants. All children were assessed with Gesell Developmental Schedules and families' knowledge, attitudes, and child development practices was collected on a questionnaire that was administered at the beginning and conclusion of the study.

Children in families who received counseling had significantly higher development quotient scores in cognitive, social, and linguistic domains. Questionnaire data on childrearing suggested that responsive and consistent caregiving correlated with higher scores. Engle and colleagues in collaboration with investigators from Kyrgyzstan Kyrgyz Republic and Tajikistan conducted a process evaluation of the Integrated Management of Childhood Illness. Even though there was not strict fidelity in the implementation of the intervention, there was evidence that families who received the intervention were more likely to initiate new activities with their children and the children had improved levels of development.

Children's scores were significantly higher in intervention groups than control ones for communication, gross motor skills, and social development, but not for fine motor skills or problem solving. This intervention can be delivered to caregivers in about 5 minutes, so it is very cost-effective and feasible in clinics.

The participants consisted of 91 parents whose children attended maternal and child health centers and child assessment centers for service and were between 3 and 7 years old. Participants were randomly assigned to the intervention and a waitlist control group. There were no significant differences in preintervention measures between the two groups.

However, at postintervention, participants in the treatment group reported significantly lower dysfunctional parenting styles, and higher parent sense of competence, which contributed to lower levels of child behavior problems, compared with the control group. This is critical for school age children who will benefit more from instruction if they are not acting out in class. The results of the analysis of 55 studies confirm that the Triple P program is associated with positive changes in parenting skills, parental well-being, and child problem behavior in the small to moderate range, varying as a function of the intensity of the intervention.


The larger effects were found on parent report in comparison with observational measures and more improvement was associated with intensive formats and initially more distressed families. The resulting intervention was called the Mediational Intervention for Sensitizing Caregivers, which was designed to improve the quality of adult—child interactions and consequently, to promote children's learning potential. The indigenous childrearing practices and philosophies of parents, their expectations for their children, and children's language, motor, and socioemotional development were examined.

Parent-child interactions were videotaped and analyzed and used to tailor the intervention for the family. One year after the intervention, mothers in the intervention group were more sensitive, responsive, and optimistic about their potential to affect their child's development than were the mothers in the comparison group. Six years after the intervention, significant changes were still noted in the quality of adult—child interactions and in developmental measures of the children.

The findings confirmed that an individual intervention that can increase age-appropriate, sensitive and effective caregiving interactions can have lasting positive effects on children's cognitive and socioemotional development. In another study, mothers or caregivers of HIV-infected children were coached in individual stimulation plans when they attended the clinic for the child's regular 3-month visit Potterton et al. Activities centered on developmentally appropriate play that could be part of the family's usual daily routine.

After 1 year, significant benefits to mental and motor development were seen from the intervention, although both intervention and control groups remained severely delayed, which may have been more likely the result of HIV disease than of poor parenting.

More evidence is needed on the use of individual counseling of parents during health visits to promote child development. Counseling sessions need to be long enough so that caretakers can observe the health professionals' demonstration of activities and practice so that they can engage in those behaviors at home. In the available studies, interventions were conducted by health professionals, which would have implications for scaling up. The number of parents and children reached by interventions to improve parenting behaviors could also be increased by delivering them through group sessions.

For a parenting program in Bangladesh, groups of about 20 mothers attended minute educational sessions on health, nutrition, and promotion of child development Aboud, Sessions were conducted by women with some secondary education who were given training and supervision. Mothers attended an average of 16 sessions. No benefits were seen for children's receptive vocabulary, which was the only measure of child development, or for mother—child verbal interaction.

Small to moderate effects on mothers' knowledge and stimulation in the home were seen. Within the sessions, adaptive behaviors were encouraged and attempts were made to engage the mothers in discussion and problem solving. This may have had limited results as fewer materials were used; the group format should have been expected to provide more opportunity for interactions and role modeling.

Parents attended monthly meetings at which they were encouraged to promote development by playing and chatting with their children in order to improve cognitive development and the caregiving environment. Volunteers also conducted home visits. The infants and toddlers who participated in the Pastoral del Nino intervention scored significantly higher at 0—4 months and 20—24 months on cognition.

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Overall, best predictors for cognitive development scores included health, nutrition, and education variables, while best predictors for IT-HOME scores also included caregiver education. The World Health Organization developed the Care for Development Intervention and subsequently developed an additional module which was designed to increase caregivers' play and communication with their children during visits for acute care.

The purpose of this study conducted in Turkey was to determine the efficacy of the module when implemented with caregivers during a young child's younger than 24 months visit for acute minor illness Ertem et al. The results support the assertion that the intervention is an effective method of supporting caregivers' efforts to provide a more stimulating environment for their children and can be delivered by health care professionals during visits for acute minor illness, which increase the potential coverage of the approach.

Similar results were obtained in a study in Uzbekistan Zaveri, The effectiveness of interventions to increase parenting skills justifies the integration of training in early infant stimulation programs into existing health services. Its focus was on verbal and play interaction between mother and children between 1 and 12 months of age. The evaluation of activities of the program indicated that the amount of stimulation was greater during the first 6 months of life than later.

The effectiveness was assessed by the Developmental Quotient at 2 years of age. The difference in the mean Developmental Quotient between the treatment and control group was statistically significant. In the control group, statistically significant differences in mean Developmental Quotient by educational standard of mother, country of origin, and birth order were noted.

This additional example of the feasibility of the program in a routine preventive service suggests that this program could be scaled up and incorporated into health services. In conclusion, the studies reviewed provide evidence that interventions delivered to individual caregivers at clinic visits can improve parent—child interactions and learning opportunities for children from birth to age 3 years using a variety of approaches that benefit the cognitive development of children from poor families in LMICs.


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Children who receive interventions earlier are more likely to benefit more from preschool and subsequently from later schooling. Because early cognitive ability at school entry predicts school outcomes such as achievement levels and grade level attained Grantham-McGregor et al. Increased educational gains will result in higher earning power, higher functioning in society and better parenting of the next generation.

Although some of these interventions are resource intensive, others can be delivered in the context of normal health services so can be very cost-effective. The role of caretakers continues to be integral to the biological, psychological, and emotional development as the child moves beyond the home and into a more formal educational environment. Healthy development is a continuous process that has some predictable developmental outcomes but each child will express these in unique ways based on caretaking experiences and environmental influences.

Healthy child development describes the successful achievement of more complex tasks as children grow older. The parent and caretaking developmental programs discussed in the previous section are still important during this period. However, the children are now being groomed to enter preschool. We review several behavior change interventions designed to enhance the process of preparing to leave the home and attend school. Conditional cash transfer programs provide money to poor families to target poverty and increase family capital contingent on caretakers engaging in certain target behaviors, such as sending children to school, taking them for health clinic visits, and ensuring vitamin supplements and nutritious food.

There is promising evidence for the benefits of conditional cash transfer programs for families with young children. Mexico has had a dynamic conditional cash transfer program originally called Progresa when it was established in , and later renamed to Opportunidades in From April to October , low-income communities were randomly assigned to be enrolled in Oportunidades immediately early treatment or 18 months later late treatment. In , children were assessed for outcomes including physical growth, cognitive and language development, and socioemotional development.

The primary objective was to investigate outcomes associated with an additional 18 months in the program. Early enrollment reduced behavioral problems for all children in the early versus late treatment group, but no difference between groups for mean height-for-age, assessment scores for language, or cognition.

An additional 18 months of the program before age 3 years for children whose mothers had no education resulted in improved child growth of about 1. The money itself also had significant effects on most outcomes, adding to existing evidence for interventions in early childhood. When these programs are evaluated, it should provide guidance to other LMICs about how this kind of program could help increase child survival and healthy development. This is potentially a cost-effective program that could be scaled up and benefit the entire family. As children move along the developmental continuum, intervention programs need to be more complex and focused on higher level skills in order to achieve the major Millennium Development Goal that all children attain at least by primary schooling United Nations, Multidimensional educational programs to be delivered by caretakers or in preschools have been developed in some countries that have been effective with children from limited backgrounds.

A new follow-up assessment of the long-term outcomes of the Turkish Early Enrichment Project, an intervention carried out in from to with 4—6-year-old children from deprived backgrounds, confirms long-term benefits of early interventions. Evaluations were carried out at the completion of the intervention and also 7 years later. The evaluation was conducted with data from of the original participants Kagitcibasi, The results support more favorable outcomes for children who received either mother training or educational preschool, or both, compared with those who had neither, in terms of educational attainment, occupational status, age of beginning gainful employment, and some indicators of integration into modern urban life, such as owning a computer.

A majority of the children who received early enrichment had more favorable trajectories of development into young adulthood in cognitive achievement and social developmental domains than comparable children who did not receive enrichment. Participants were caretakers who were randomly assigned to an experimental group which delivered the Better Parenting Programme or a control group.

Before and after the Better Parenting Programme, all participants completed questionnaires to assess their knowledge regarding key areas of child development, activities with their children, discipline practices, and perceptions regarding behaviors that constitute child abuse and neglect. Over time, participants in the experimental group but not the control group improved on parenting knowledge, spending time playing and reading books with their children, using more explanations during the course of disciplining their child, and accurately perceiving behaviors that constitute child neglect.

Results suggest modest beneficial effects of participation in the Better Parenting Programme. This case study by Tinajero reported the results of the impact of the Educate Your Child program in Cuba between and The study found that the program had a positive impact on caregivers' ability to foster healthy development in their children and contributed to the children's readiness for early childhood school, and later performance in primary and secondary education.

It provided evidence that the integration of health and education programs can have a more significant effect on the development of young children. The program was delivered in 69 communities in three regions to caregivers and community leaders to educate them about child development, such as physical wellbeing, emotional maturity, social competences, cognitive development, and language and communication. For the purpose of the evaluation, 43 interventions and 27 control communities were randomly selected after 4 years.

Both qualitative and quantitative approaches were developed to evaluate its impact. Data were collected through interviews, focus group discussions and direct observation of parents and other key family members. Questionnaires on the various aspects of holistic development of children including nutrition, health, psychosocial development and protection were developed to guide interviews and focus group discussions. Findings revealed that many parents and caregivers in both the experimental and control communities have been able to build on their traditional child rearing knowledge and practices and demonstrated improvement in skills in early child care and development.

These cross-cutting interventions are handwashing, symptom identification and care seeking, insecticide-treated nets to prevent malaria, and oral rehydration therapy. Multiple strategies have been developed and tested in interventions to teach handwashing skills for parents and caretakers.

These interventions can be delivered to individuals, families, and communities. In both one-on-one and group programs and in mass media, the selection of the message is critical Curtis et al. There are framing issues in developing the messages that can ensure the intervention is more effective in changing behavior.

In a study in several rural Indian villages, Biran and colleagues used a neutral message in a randomized controlled trial of a program to build awareness of germ theory and its association with the spread of disease. In another study involving eight rural villages in Zimbabwe, Waterkeyn and Caincross also used a negative-framed message in community-based education meetings.

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Soap was provided to all households, and handwashing facilities were established. Luby and colleagues conducted a study in Karachi, Pakistan using a positive-framed message. Beneficial results were also achieved by Haggerty and colleagues conducting a study in rural Zaire using a positive-framed message in an educational randomized controlled trial at informal community meetings.

One excellent example of an intervention strategy similar to others is the Karachi Soap Health Study Luby et al. Fieldworkers visited caregivers weekly for one year to help them develop handwashing skills to teach their children including inculcating the habit of using soap multiple times a day and to ensure recording any health-related symptoms experienced by members in the households. The use of soap by caretakers tripled in the intervention neighborhoods, but it is interesting that the incidence of disease did not differ significantly between households given plain soap versus antibacterial soap.

Results did not begin immediately because of time required to change handwashing practices. For example, Scott and colleagues conducted an observational study of the Ghanaian National Truly Clean Hands campaign that was conducted in 5 of Ghana's 12 regions from December to May , and evaluated beginning in July A mass media campaign created by a professional advertising agency was conducted on TV and radio, and at community events.

Seventy percent of women reported that they heard the campaign. Exposure to the TV advertisement resulted in more handwashing with soap after using the toilet and before preparing food. Many respondents reported that they were impressed by the campaign content because they had mistakenly believed that water was sufficient to clean their hands.

Fewtrell and colleagues demonstrated that there was no statistically significant difference between programs of handwashing with soap and poor quality water and handwashing with soap with clean water on disease outcomes; therefore, water quality has not yet been established as an important issue. There are multiple demonstrations of caretakers and children acquiring the skill of correct and consistent handwashing and other hygienic practices after brief one-on-one and group instruction from a health care provider Blanton et al.

Reinforcement of proper handwashing habits by health personnel and trained lay persons was important in ensuring that these programs were sustained. There also needs to be access to free or inexpensive soap, clean water, and latrines. These results are based on both intervention studies that have a disease outcome and those that have handwashing as the outcome Kariuki et al. Handwashing behavior change interventions have adopted multiple simple techniques which are described below.

A study in Kenya conducted in a maternal and child health clinic used nurses to train their caretakers in chlorination of household water and in the six steps of proper handwashing Parker et al. After receiving a 4-hour training course, nurses delivered positively framed diarrhea prevention messages and taught their clients how to wash their hands in 5-minute one-to-one encounters and minute group sessions lectures, demonstrations, discussions, and question-and-answer sessions as part of their regular clinic visit.

Evaluations were conducted on a random basis including interviews about knowledge and practice and the observed availability of household items for purifying water and washing hands. In conclusion, correct and consistent handwashing skills can be taught to caretakers and their children. This is a basic skill that is critical to their hygiene and health interventions across the lifespan.

Appropriate symptom identification and care seeking for illness are crucial for survival of children across the age span, but there was limited evidence on behavior change interventions to improve caregiver knowledge of signs of complications or engage appropriate care seeking. In one study in Benin, job aids were used during antenatal newborn care to provide caregivers information on danger signs of complications, birth planning, clean delivery and newborn care.

Although the behavioral impact of this program is unclear, the use of these job aids at least increased knowledge and awareness of symptoms among caretakers Jennings et al. As shown in a high-quality study in India, community-based public meetings to disseminate information on entitlement to health services and village resources resulted in caregivers identifying symptoms and seeking antenatal care examinations, tetanus toxoid vaccinations, and infant vaccinations Pandey et al.

In a review of antenatal educational interventions, the investigators concluded that the benefits of various antenatal care education interventions remain unclear. Based on strong evidence that insecticide-treated nets reduce malaria transmission and related morbidity and child mortality Lengeler, , local and international organizations in Africa have been promoting and distributing insecticide-treated nets for more than 10 years.

Although this has resulted in greater availability of insecticide-treated nets in Sub-Saharan African countries and elsewhere, promoting the requisite behaviors of correct and consistent use of insecticide-treated nets by caretakers has proven challenging Macintyre et al. In a recent effort to develop correct and consistent use strategies, Eisele and Root conducted an extensive review of the literature to document the factors associated with insecticide-treated net use among these vulnerable groups.

They concluded that there is insufficient empirical evidence to determine the effective strategies to increase insecticide-treated nets use in households that own such nets. Nevertheless, there is growing evidence that family members who are most vulnerable to malaria get preference in the households with insufficient insecticide-treated nets. Baume and Marin , in a study that reviewed data from nine large-scale household surveys with 12, respondents conducted in six African countries Ethiopia, Ghana, Mali, Nigeria, Senegal, and Zambia in and , concluded that children younger than 5 years old and pregnant women—the two most vulnerable groups—were most likely to be under the bed net.

In all countries, children younger than 2 years of age were more likely than were any other family member to be under a bed net that commonly covered two to three people. If a baby net was used, fewer people used the family net. They also found that pregnant women were more likely to use a net in than in This study enumerated all household members and bed nets owned and analyzing only net-owning households.

The challenge is to close the gap between insecticide-treated net ownership and correct and consistent use, yet few rigorous studies exist. Deribew and colleagues , in a cluster randomized trial that was tailored to heads of households about the proper use of nets, showed a positive effect in the utilization of nets in 11 villages in Ethiopia. The utilization of nets in all age groups in the intervention villages was increased by Similarly, Bowen and colleagues used national survey data collected at baseline before and after a communication campaign which consisted of radio, TV, and SMS messages on insecticide-treated net use by adults and their children who were younger than 5 years of age.

They found that exposure to the communication campaign was associated with a 6. There is also increasing support for using community health advisors to conduct community events, going house-to-house to provide caregivers with accurate information on malaria transmission, explaining how insecticide-treated nets protect against malaria, and teaching how to hang nets properly. These prevention efforts must be complemented by effective services to help caregivers identify symptoms of malaria infection so that they can seek early treatment, which can prevent serious illness and death of children.

A recent study of net utilization promotion was conducted in Ghana. The intervention consisted of three main components: community dramas, mobile information vans, and community health volunteers. These three modes were used to communicate bed net use messages to the communities in the intervention district. Evaluation teams randomly sampled individuals from both intervention and control communities for the pre-post evaluation. Both qualitative and quantitative results showed that the promotion of net utilization exceeded the program planners' predictions. The social norms about bed net use changed and community members became convinced that bed nets were necessary.

Instead of just promoting usage, the program increased demand for new bed nets. Overall, the increase in the use of insecticide-treated nets the night before increased at a statistically significant rate in the intervention communities compared to control communities in a neighboring district. In conclusion, there is limited but growing evidence that the promotion of insecticide-treated nets, through community events, health care workers visiting homes combined with policy changes that make bed nets widely available, can be accomplished and thus are recommended. Behavior change interventions that included modeling of appropriate net use appeared to be effective, and have moderate research support.

In addition, there is increasing support for utilizing community health advisors to conduct community events and to go house to house to provide caregivers with accurate information on malaria transmission, explain how insecticide-treated nets protect against malaria, and help them hang their nets properly. These prevention efforts must be complemented by effective services to help caregivers identify symptoms of malaria infection so that they can seek early treatment which can prevent serious illness and death of children.

Diarrhea is not a disease but rather a symptom associated with bacterial and other microbial infection, food poisoning, and other illnesses associated with childhood Ruxin, Because it causes dehydration, diarrhea can quickly compromise bodily functions. Oral rehydration therapy was widely introduced in ; giving the mixture of sugar, salts, and water called oral rehydration salts quickly demonstrated its effectiveness as a method to control diarrhea by reducing the number of deaths from 4.

To prevent diarrhea, caretakers need to wash their hands with soap and water after using latrines and changing diapers, must change hygiene practices, and prepare food with clean hands. This analysis indicated that children who were 6—23 months, from poor households, and boys were more likely to receive oral rehydration salts but mothers' education had no impact.

Government clinics were more likely to prescribe oral rehydration salts than private health centers. The investigators were concerned that the antibiotics should be taken off the market and oral rehydration therapy should be stressed in the curricula in medical universities in order to change the behavior of health care providers. There are several problems with scaling up oral rehydration therapy. Program staff disseminated information and social marketing of packets of oral rehydration salts. Other promotional programs included public education, mass media, commercial advertising and sales, community outreach, and programs to educate caretakers.

The investigators determined that the characteristics of the caretakers themselves and not the episodes were most important in these decisions. They also found that urban caretakers were more informed than rural ones and were more likely to use the method. This is partly due to the fact that the preferred method of delivery was the packets which were more available in urban areas in clinics, grocery stores, and pharmacies. To be scaled up, caregiver demand for evidence-based oral rehydration therapy interventions will need to be coupled with better availability of the products.

Because a mother's skepticism about a treatment can delay her implementation, interventions with caretakers must stress the effectiveness of oral rehydration therapy. However, health professionals have often been focused on the techniques of using the product and not the mothers' belief in the procedure. This led them to seek antibiotics from local markets. Zinc was therefore added to the oral rehydration therapy regimen to reassure caretakers that the treatment was working.

The investigators indicated that, to gain acceptance for combining zinc with oral rehydration salts, the fathers and grandmothers and traditional healers should also be convinced because this treatment is more expensive than the traditional medicines or antibiotics. Thus, there is evidence that behavior change interventions that target caregiver knowledge about oral rehydration therapy can enhance its utilization.

Although oral rehydration therapy can prevent diarrheal deaths, it is not a final solution to the global threat of diarrhea. However, this therapy provides time to develop clean water, sanitation systems, and other infrastructure projects that require more time and resources. Reducing early childhood deaths from preventable causes has been a priority for international and national organizations, and substantial gains have been made over the past three decades Liu et al. However, 3 million newborns continue to die every year from causes we know how to prevent.

In addition, Walker and colleagues estimated that more than million children worldwide still do not achieve their developmental milestones. We have reviewed a large body of research showing that there are effective behavior change interventions targeting caregivers that can enhance child survival and early development.

Interventions for parent education and support can lead to improvements in children's cognitive and psychosocial development, where a greater benefit may be observed for more disadvantaged younger children. These programs should be based on systematic curricula and training for both health care workers and parents, and use active strategies such as practice or coaching. Effect sizes were larger for interventions that included programs for both parents and children rather than for parents alone. Preschool can be an important point of intervention for vulnerable children, particularly if it is of higher quality and intensity.

Promising but not definitive evidence for the benefits of cash transfer programs to the family were evident. Last, other early education experiences through media e. Parenting programs which combine home-visiting and community-based interventions and provide counseling to parents and caregivers on early stimulation play and communication behaviors along with child health and feeding practices are the most common programs that can be scaled up. Evidence from Bangladesh, Brazil, Chile, Colombia, Jamaica, and Peru parenting programs are among the most promising ones.

They provide methods that can be adapted to other countries and settings. Both mass media campaigns and one-on-one and group interventions can dramatically increase handwashing of caregivers. These are scalable and cost-effective and can create awareness of the importance of correct and consistent handwashing. They can also increase health-seeking behavior if the child is exhibiting symptoms of illness. To be successful, evidence-based interventions must be adapted to the culture, especially in framing a positive message. Although many of the behavioral and biomedical interventions discussed in this article have demonstrated evidence of efficacy, they need to be continually implemented.

If there is not a proactive program to ensure that child survival and healthy development programs are continuously offered, we will not continue to have advancement in health statistics in LMICs. There is a large research literature supporting the effectiveness of behavior change interventions that promote child survival and healthy development.

For many target behaviors, there are a variety of proven interventions for implementers to choose from or to integrate into comprehensive programs. Our assessment is that we do not lack effective behavior change tools, but that these tools have not been widely enough used and prioritized within global health. We have tried to identify some of the most salient components of effective interventions in our review. There is strong support for scaling up interventions to promote healthy timing and spacing of pregnancy. These include interventions to increase the use of family planning and preventing pregnancy before age 18 and waiting at least 24 months after a live birth before attempting a pregnancy.

In addition, there is evidence that education, counseling, and community involvement are all effective interventions to promote neonatal survival and health. We found evidence supporting the Partnership for Maternal, Newborn and Child Health list of essential interventions for reproductive, maternal, newborn and children targeting parental and caregiver behaviors. For neonatal care, home visits by community-based health workers can develop caregiver skills to identify complications with newborns, provide first line treatment, and make informed decisions on referral for facility-based care.

Many studies also show that there are effective interventions to promote the quantity and quality of breastfeeding behaviors through a combination of counseling, home visits, group sessions, and changes in policy, sometimes supported by print and mass media.

The findings from trials also support the importance of skin-to-skin care Kangaroo Mother Care for increasing neonate survival and there are effective, low-cost interventions to increase this behavior, which have the potential to be scaled up. There is growing evidence that the promotion of insecticide-treated nets, through community events, health care workers visiting homes combined with policy changes that make bed nets widely available, can be accomplished.

We also conclude that behavior change interventions that target caregiver knowledge about oral rehydration therapy can enhance its utilization. Priority should be given to early childhood programs for caregivers because this is the most effective and cost-effective period. The number of contacts between parents and health care workers should be frequent a minimum of twice a month and should provide sufficient time to allow the caregiver to practice the new skills.

Interventions with caregivers should target improvement in a range of functioning in young children from eating more food, improving cognitive development, language skills, and social emotional-development to readiness for school. Quality early child development programs for caregivers should be given priority because they can contribute to overcoming inequalities and the perpetuation of economic disparities.

In most cases, several interventions have been shown to be effective for changing caregiver behaviors to enhance child survival and development.

Caregiver Stress and Depression - Dr. Helen Lavretsky - UCLA Health

Although this gives implementers a choice of interventions, there are no comparative effectiveness trials that might allow the selection of the most effective approach in a given situation. Similarly, there is a paucity of cost-effectiveness studies and implementation science research in this area to assist in program selection and scale up. In addition, studies reviewed in this article tend to assess one intervention for caregivers at a time.

Research is needed on combination interventions that can be delivered by caregivers and target multiple outcomes in young children. More implementation studies that scale up evidence-based interventions need to be conducted to identify what factors are associated with successful countrywide programs that increase child survival and healthy development.

As a first step, evidence-based interventions that were scaled up but did not work should be assessed to identify the barriers and facilitators of scaling up. We found few studies of behavior change interventions designed to increase caregiver recognition of symptoms of illness or to increase early engagement of health professions early in disease progression. Another step in scaling up is to adapt and test evidence-based interventions for health care workers that can be delivered to caretakers to ensure child survival and healthy development.

Related to this is the development of user-friendly manuals based on research protocols that health care workers can implement with caregivers. Another promising direction is to study the role of frequency of contact, length, quality of relationship between caregiver and intervener on the effectiveness of the prevention program in child survival and healthy development which affects the cost-effectiveness of studies and their sustainability in developing countries.

Another area where progress could be made is to develop behavior change programs for caregivers for interventions that are known to be effective but where uptake has been low e. For example, some interventions have shown to be effective in delaying early marriage and early pregnancy in adolescents, but they have been applied in research studies and in small scale and time limited projects.

Implementation research is needed in different contexts to test best approaches to expand the coverage of these interventions while maintaining quality.