Hopp til innhold

Systematic review

Effect of adapted interventions for primary child health care services

This report is an overview of systematic reviews on the effects of adapted interventions for families with low socioeconomic status, ethnic minority families and teenage mothers, and interventions to promote interaction with the child for mothers with postpartum depression.

This report is an overview of systematic reviews on the effects of adapted interventions for families with low socioeconomic status, ethnic minority families and teenage mothers, and interventions to promote interaction with the child for mothers with postpartum depression.


Key message

Pre-school child health services shall provide equitable services that caters to different families' circumstances and needs. This report is an overview of systematic reviews on the effects of adapted interventions for families with low socioeconomic status, ethnic minority families and teenage mothers, and interventions to promote interaction with the child for mothers with postpartum depression.

We included ten systematic reviews of high methodological quality. The findings show that:

  • Counselling, education and information about breastfeeding by health care workers adapted for low-income women can probably increase the proportion who initiate breastfeeding and who breastfeed at 3-6 months. Such interventions can perhaps also increase the proportion who initiate exclusive breastfeeding.
  • Home visiting programs for families with low socioeconomic status can probably reduce the prevalence of childhood injuries. It is uncertain whether it has any effect on uptake of childhood vaccinations.
  • Parent training programs adapted for socially disadvantaged families can perhaps prevent some externalizing behaviour of the child.
  • Support or outreach by lay health care workers for families with low socioeconomic status do probably not alter the proportion who initiate breastfeeding, but can perhaps considerably increase the prevalence of exclusive breastfeeding the first 6 months and who breastfeed the first year. Such interventions can probably also increase the uptake of childhood vaccinations, but has probably little effect on child fruit intake

Several of the study populations included ethnic minorities, but none of the systematic reviews addressed effects of interventions adapted for the needs of ethnic minorities. There is very limited documentation on whether parent training programs for teenage mothers and interventions for mothers with postnatal depression can improve aspects of mother-child interaction. Many of the studies were conducted in countries where the health services are organised differently from our country.

Due to aspects of study design and implementation or small studies, we had generally moderate to low confidence in the documentation. When we have low confidence in the documentation this does not mean that the interventions are ineffective, but that the documentation is limited to infer on the magnitude of any effects.

Summary

Background

The role of the Norwegian primary child health services is to promote health and prevent disease for families with children aged 0-5 years, irrespectively of social standing or background. Studies show that groups with low socioeconomic status or immigrant groups have more health problems and struggle to interact efficiently with the health care services. Pre-school child health services also encounter families that may have various needs for support. Interventions that adapt health promotion and disease prevention efforts to the needs of these families can make the service more equitable. The Norwegian Directorate of Health requested summarized knowledge about the effect of such adapted services.

Objective

The aim of this report is to write an overview of systematic reviews on the effect of interventions in pre-school (0-6 years) child health care services adapted for families with low socioeconomic status, ethnic minority families or teenage mothers, and interventions for mothers with postpartum depression that promote mother-child interaction.

Method

We searched 13 international databases up until October 2013. Two independent persons reviewed the titles and abstracts and judged appropriateness for inclusion based on full text assessment. We included all systematic reviews of high methodological quality that evaluated the effect of interventions adapted for the four defined population groups. Risk of bias assessments in the results were based on the review authors’ judgements. The quality of evidence was considered for each outcome using the GRADE methodology. The documentation was judged to be of either of high quality (⨁⨁⨁⨁), moderate quality (⨁⨁⨁◯), low quality (⨁⨁◯◯), or very low quality (⨁◯◯◯).

Results

We included ten systematic reviews of high methodological quality. Four of these specifically address adapted interventions. The remaining answer aspects of our aim through sub-analyses or indirectly. The results are grouped into six categories of similar interventions, rather than by population group. None of the reviews report possible unwanted effects related to implementation of the intervention.

One systematic review (ten studies from the USA and UK) looks at the effect of counselling, education and information about breastfeeding by health care workers adapted for low-income women compared with standard health care. They found an increase in the proportion who initiate breastfeeding (RR 1.39, 95% CI: 1.21 to 1.59) (⨁⨁⨁◯), initiate exclusive breastfeeding (RR 1.72, 95% CI: 1.34 to 2.21)(⨁⨁◯◯) and breastfeed at 3-6 months (RR 1.15, 95% CI: 1.01 to 1.30)(⨁⨁⨁◯).

Two systematic reviews (33 studies from the USA, Canada, Australia, UK, New Zealand, Ireland and Turkey) look at the effect of home visiting programs for families with low socioeconomic status compared with standard health care. They found reduced incidence of childhood accidents (RR 0.83, 95% CI: 0.73 to 0.94) (⨁⨁⨁◯), but the effect on uptake of child vaccinations is uncertain (⨁◯◯◯).

Two systematic reviews (16 studies from the USA, Canada, Australia and Germany) look at the effect of adapted parent training programs compared with standard health care. Programs adapted for socially disadvantaged families give some reduction in externalizing behaviour in the child after 12-16 months: The Incredible Years Program (SMD symptom assessment -0.22, 95% CI: -0.42 to -0.02) (⨁⨁◯◯) or Triple-P (SMD symptom assessment -0.27, 95% CI: -0.47 to -0.07) (⨁◯◯◯). It is uncertain whether programs adapted for teenage mothers have an effect on mother-child interaction (⨁◯◯◯).

One systematic review (seven studies from the US, Canada, Bermuda, Jamaica and Ireland) looks at the effect of home-based child development interventions for families with low socioeconomic status compared with no intervention. It is uncertain whether the intervention has any effect on the child's cognitive development (⨁◯◯◯).

Three systematic reviews (16 studies from the USA, UK, Brazil, Mexico and Ireland) look at the effect of support and outreach by lay health care workers for families with low socioeconomic status compared with standard health care. One finds no change in the proportion who initiate breastfeeding (RR 1.11, 95% CI: 0.93 to 1.31) (⨁⨁◯◯), but a substantial increase in exclusive breastfeeding (RR 4.31, 95% CI : 1.27 to 14.6) (⨁⨁◯◯) and increase in breastfeeding the first year (RR 1.29, 95% CI: 1.31 to 1.48) (⨁⨁⨁◯). The second finds higher uptake of childhood vaccination (RR 1.19, 95% CI: 1.09 to 1.30) (⨁⨁⨁◯). The third finds no effect on the children's fruit intake (SMD fruit intake 0.01, 95% CI: -0.09 to 0.11) (⨁⨁⨁◯).

 

One systematic review (eight studies from the USA, UK or Australia) looks at the effect of interventions for mothers with postpartum depression to promote interaction with the child. It is uncertain whether such interventions have an effect on mother-child interaction and child cognitive development (⨁ ◯◯◯).

Discussion

Our findings show that relatively few systematic reviews focus on interventions adapted for vulnerable groups of parents with children aged 0-6 years. Due to aspects of study design and implementation or small studies, we have generally moderate to low confidence in the documentation. When we have low confidence in the documentation this does not mean that the interventions are ineffective, but that the documentation is limited to infer on the magnitude of any effects. Many of the studies were conducted in countries where the health services are organised differently from our country, which is of relevance to the transferability of results.

Specific issues for each of the six categories of interventions were:

  • In the studies of counselling, education and information about breastfeeding by health care workers, breastfeeding initiation rates in the study populations were much lower than in Norway. A majority of the studies offered frequent contact with health care workers around the time of giving birth.
  • Most of the home visiting programs were complex. The majority offered frequent contact with counselling about a broad range of topics, including child health and development, social issues and the parental role, all offered in the home.
  • The study populations for the three comparisons of parent training programs were very different. The reviews give sparse descriptions of the theoretical content of the programmes and how these were adapted to the target groups.
  • Home-based child development interventions promoting child cognitive development intersect the responsibilities of the health care and educational systems, containing a curriculum and age-appropriate learning resources.
  • In the studies of support or outreach by lay health care workers, these persons either took the role of a guide or an advocate in relation to capitalize on the opportunities of the health care system or they gave advice and support. They often came from the same social and cultural groups as the families they contacted. Most were women.
  • The interventions for mothers with postnatal depression can be categorised into two groups: different forms of individual therapies or support groups offering companionship, training in assessing infant behaviour and/or baby massage.

Conclusion

The summarized evidence on the effect of adapted interventions in child health services for families with children aged 0-6 years is limited. Four main categories of interventions show possible effect on at least one outcome: Breastfeeding counselling, education and information by health care workers; home visiting programs; adapted parent training programs; and support or outreach by lay health care workers. All the interventions were adapted for families with low socioeconomic status. Several of the study populations included ethnic minorities, but none of the reviews addressed effect of interventions adapted for ethnic minorities. There is very limited evidence whether parental training program for teenage mothers and interventions of depressed mothers may affect the mother-child interaction.

About this publication

  • Year: 2014
  • Authors Mosdøl A, Blaasvær N, Vist GE.
  • ISSN (digital): 1890-1298
  • ISBN (digital): 978-82-8121-891-8