Lay counselors: Thoughts on the crossing of ecological frameworks and the use of lay counselors in the scale up of early infant mental health interventions.

The recent call for the scale-up of evidence-based early childhood development interventions, in lower and middle-income countries and for minority groups in high-income countries, has seen numerous suggestions to train greater numbers of lay mental health workers to fulfill these functions. While studies have found that concepts from developed country settings, such as attachment, parental sensitivity, and containment, find purchase and relevance within developing settings, the management of contextual and cultural factors and the tensions of cultural interfacing in the rollout of these programs in developing country settings require consideration. Drawing on the experiences of two successful South African mother-infant home-visiting programs as examples, this article discusses some of the challenges in provision of attachment-based infant mental health programs and highlights the need for careful consideration of a number of factors pertaining to the recruitment, supervision, and management of lay mental health workers before large-scale rollout is conducted.

La reciente llamada para aumentar proporcionalmente las intervenciones sobre el desarrollo en la niñez con base en la evidencia, en países de ingresos más bajos e ingresos medios, y en el caso de grupos minoritarios en países de ingresos altos, ha visto numerosas sugerencias para entrenar un mayor número de trabajadores laicos de la salud mental que puedan realizar estas funciones. Mientras que los estudios han concluido con que conceptos provenientes de ambientes de países desarrollados, tales como afectividad, sensibilidad de los padres y contención, venden y encuentran relevancia dentro de escenarios de países en desarrollo, el tratamiento de factores contextuales y culturales y las tensiones de interconexiones culturales en la introducción de estos programas en escenarios de países en desarrollo requiere consideración. Utilizando las experiencias de dos exitosos programas madre-infante de visitas a casa en Sudáfrica como ejemplos, este artículo discute algunos de los retos en cuanto a la provisión de programas de salud mental infantil basados en la afectividad y subraya la necesidad de la cuidadosa consideración de un número de factores referentes al reclutamiento, supervisión y dirección de trabajadores laicos de la salud mental antes de que se lleve a cabo la introducción a gran escala.

L'injonction récente à intensifier les programmes d'intervention de développement de la petite enfance fondés sur des données probantes, dans des pays en voie de développement, et pour des groupes minoritaires dans les pays riches, a déclenché de nombreuses suggestions de formation d'un plus grand nombre de travailleurs laïcs de la santé mentale afin de remplir ces fonctions. Alors que des études ont établi que des concepts issus de contextes de pays développés, tels que l'attachement, la sensibilité parentale et la discipline trouvent acquisition et raison d'être au sein de contextes développés, la gestion de facteurs contextuels et culturels et les tensions d'interfaçage culturel dans le lancement de ces programmes dans des contextes de pays en voie de développement exigent d'être considérées et tenues en compte. A partir des expériences de deux programmes de Visite à Domicile Mère-Nourrisson Sud- Africains comme exemples, cet article discute certains des défis dans la prestation de programmes de Santé Mentale du Nourrisson basés sur l'attachement et met en lumière le besoin de considération attentionnée à un nombre de facteurs ayant trait au recrutement, à la supervision et à la gestion de travailleurs laïcs de santé avant que soit lancée une version à grande échelle du programme.

Improving quality of mother-infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial.

OBJECTIVE: To assess the efficacy of an intervention designed to improve the mother-infant relationship and security of infant attachment in a South African peri-urban settlement with marked adverse socioeconomic circumstances. DESIGN: Randomised controlled trial. SETTING: Khayelitsha, a peri-urban settlement in South Africa. PARTICIPANTS: 449 pregnant women. INTERVENTIONS: The intervention was delivered from late pregnancy and for six months postpartum. Women were visited in their homes by previously untrained lay community workers who provided support and guidance in parenting. The purpose of the intervention was to promote sensitive and responsive parenting and secure infant attachment to the mother. Women in the control group received no therapeutic input from the research team. PRIMARY OUTCOMES: quality of mother-infant interactions at six and 12 months postpartum; infant attachment security at 18 months. Secondary outcome: maternal depression at six and 12 months. RESULTS: The intervention was associated with significant benefit to the mother-infant relationship. At both six and 12 months, compared with control mothers, mothers in the intervention group were significantly more sensitive (6 months: mean difference=0.77 (SD 0.37), t=2.10, P<0.05, d=0.24; 12 months: mean difference=0.42 (0.18), t=-2.04 , P<0.05, d=0.26) and less intrusive (6 months: mean difference=0.68 (0.36), t=2.28, P<0.05, d=0.26; 12 months: mean difference=-1.76 (0.86), t=2.28 , P<0.05, d=0.24) in their interactions with their infants. The intervention was also associated with a higher rate of secure infant attachments at 18 months (116/156 (74%) v 102/162 (63%); Wald=4.74, odds ratio=1.70, P<0.05). Although the prevalence of maternal depressive disorder was not significantly reduced, the intervention had a benefit in terms of maternal depressed mood at six months (z=2.05, P=0.04) on the Edinburgh postnatal depression scale). CONCLUSIONS: The intervention, delivered by local lay women, had a significant positive impact on the quality of the mother-infant relationship and on security of infant attachment, factors known to predict favourable child development. If these effects persist, and if they are replicated, this intervention holds considerable promise for use in the developing world. TRIAL REGISTRATION: Current Controlled Trials ISRCTN25664149.

'It's not just about food': mother-infant interaction and the wider context of nutrition.

In recent years, attention has increasingly focused on the wider context of nutrition, rather than simply on calorie and nutrient intake. Recent estimates put the figure of people in the world living in extreme poverty (an income of less than $1 a day) at 1.1 billion. This has significant implications for nutritional deficiencies in infants and young children. In this paper, we will show how the physical growth and psychological development of infants and children are intimately linked, and how many of the same aetiological factors (such as caregiver sensitivity, psychosocial support, communicative exchange between infant/child and their caregiver) are implicated in both domains. Preliminary evidence indicates that community-based interventions impact on the mother-infant relationship as well as infant physical growth, and contribute to the increasing sense of how aspects of the early relationship between infants and their caretakers are crucial to any complete understanding of infant growth and development. The paediatric food-based dietary guidelines (PFBDGs) include guidelines relating to the mother-infant relationship and may thus prove to be a significant tool in community interventions.

Insiders and outsiders: Levels of collaboration in research partnerships across resource divides.

With increasing recognition of the health and psychosocial challenges in developing countries, more research in these countries is essential. Research collaborations between wealthier and less wealthy countries are, however, complex. A partnership model has been proposed which emphasizes the importance of mutually respectful and beneficial relationships in international research. Using an example of a mother-infant intervention project in South Africa we describe the elements of an equitable partnership model of research. An issue which has been overlooked, however, is the reality of power differentials within the poorer countries themselves. We show that there are many intersecting levels of relationships within intercountry research, and suggest that power dynamics within countries deserves equal attention as international issues. Based on our experiences, we present some tentative guidelines for international research which builds long-term capacity and recognizes the importance of multiple levels of analysis and interaction.

Impact of a mother-infant intervention in an indigent peri-urban South African context: pilot study.

BACKGROUND: A high rate of maternal depression and associated disturbance in the mother-infant relationship has been found in an indigent peri-urban South African community, Khayelitsha. The question arises whether a community-based intervention could be beneficial. AIMS: To train community workers to deliver an intervention to mothers and infants in Khayelitsha, and to compare mothers and infants receiving this intervention with a sample receiving no such intervention. METHOD: Four Khayelitsha women were trained in a mother-infant intervention, which they delivered to 32 women recruited in late pregnancy. At 6 months post-partum, maternal mood, the mother-infant relationship and infant growth were assessed. The findings were compared with a matched group of 32 mothers and infants. RESULTS: There was no reliable impact of the intervention on maternal mood. However, compared with the comparison sample, the quality of mother-infant engagement was significantly more positive for those who had received the intervention. CONCLUSIONS: The pilot study produced preliminary evidence of a benefit of a community-based mother-infant intervention delivered by trained, but otherwise unqualified, community workers, sufficient to warrant a formal controlled evaluation of this treatment.