Teaching home-visitors to support responsive caregiving: A cluster randomized controlled trial of an online professional development program in Brazil.

BACKGROUND: Home-visiting programs are a common and effective public health approach to promoting parent and child well-being, including in low- and middle-income countries. The World Health Organization and UNICEF have identified responsive caregiving as one key component of the nurturing care children need to survive and thrive. Nonetheless, the importance of responsive caregiving and how to coach it is often overlooked in trainings for staff in home-visiting programs. METHODS: To determine whether it is possible to enhance home-visitors' understanding of responsive caregiving and how to coach it, we conducted a cluster randomized controlled trial with 181 staff working in Brazil's national home-visiting program. We used a computerized random number generator to randomly assign half of participants to take an online professional development course about responsive caregiving immediately and the other half to a waitlist. Individuals assessing outcome data were blind to group assignment. RESULTS: Compared to those in the control group (N = 90, both randomized and analyzed), participants assigned to take the course (N = 91, both randomized and analyzed) were more knowledgeable about responsivity (Cohen's d = 0.64, 95% Confidence Interval (CI) = 0.34, 0.94) and its importance for children's socioemotional (odds ratio (OR) = 1.88, 95% CI = 1.00, 3.50) and cognitive (OR = 2.57, 95% CI = 1.15, 5.71) development, better able to identify responsive parental behaviors in videotaped interactions (d = 1.86, 95% CI = 1.51, 2.21), and suggested more effective strategies for coaching parents on responsivity (d = 0.51, 95% CI = 0.21, 0.80) and tracking goal implementation (OR = 3.20, 95% CI = 1.28, 7.99). There were no significant changes in participants' tendency to encourage goal setting and reflection, or their perspective-taking skills. Participants were very satisfied with the course content and mode of delivery and there was no drop-out from the program. CONCLUSIONS: A short, online professional development program created moderate to large improvements in home-visitors' knowledge and intended coaching practices. This suggests that such programs are feasible, even in low-income and rural areas, and provide a low-cost, scalable option for possibly maximizing the impact of home-visiting programs - particularly with regard to parental responsivity, and in turn, child outcomes.

Cross-Cultural Adaptation and Validation of the Brazilian Portuguese Version of an Observational Measure for Parent-Child Responsive Caregiving.

Responsive caregiving is the dimension of parenting most consistently related to later child functioning in both developing and developed countries. There is a growing need for efficient, psychometrically sound and culturally appropriate measurement of this construct. This study describes the cross-cultural validation in Brazil of the Responsive Interactions for Learning (RIFL-P) measure, requiring only eight minutes for assessment and coding. The cross-cultural adaptation used a recognized seven-step procedure. The adapted version was applied to a stratified sample of 153 Brazilian mother-child (18 months) dyads. Videos of mother-child interaction were coded using the RIFL-P and a longer gold standard parenting assessment. Mothers completed a survey on child stimulation (18 months) and child outcomes were measured at 24 months. Internal consistency (α = 0.94), inter-rater reliability (r = 0.83), and intra-rater reliability (r = 0.94) were all satisfactory to high. RIFL-P scores were significantly correlated with another measurement of parenting (r's ranged from 0.32 to 0.47, p < 0.001), stimulation markers (r = 0.34, p < 0.01), and children's cognition (r = 0.29, p < 0.001), language (r = 0.28, p < 0.001), and positive behavior (r = 0.17, p < 0.05). The Brazilian Portuguese version is a valid and reliable instrument for a brief assessment of responsive caregiving.

Maternal Adverse Childhood Experience and Infant Health: Biomedical and Psychosocial Risks as Intermediary Mechanisms.

OBJECTIVE: To assess the mechanisms accounting for the transfer of risk from one generation to the next, especially as they relate to maternal adverse childhood experiences and infant physical and emotional health outcomes. STUDY DESIGN: Participants were 501 community mother-infant dyads recruited shortly after the birth and followed up at 18 months. Mothers retrospectively reported on their adverse childhood experiences. The main outcome measures were parent-reported infant physical health and emotional problems. Potential mechanisms of intergenerational transmission included cumulative biomedical risk (eg, prenatal and perinatal complications) and postnatal psychosocial risk (eg, maternal depression, single parenthood, marital conflict). RESULTS: Four or more adverse childhood experiences were related to a 2- and 5-fold increased risk of experiencing any biomedical or psychosocial risk, respectively. There was a linear association between number of adverse childhood experiences and extent of biomedical and psychosocial risk. Path analysis revealed that the association between maternal adverse childhood experiences and infant physical health operated specifically through cumulative biomedical risk, while the relationship between adverse childhood experiences and infant emotional health operated specifically through cumulative psychosocial risk. This pattern was not explained by maternal childhood disadvantage or current neighborhood poverty. CONCLUSIONS: Maternal adverse childhood experiences confer vulnerability to prenatal, perinatal, and postnatal psychosocial health. The association between adverse childhood experiences and offspring physical and emotional health operates through discrete intermediary mechanisms.