A community engagement approach for an integrated early childhood development intervention: a case study of an urban informal settlement with Kenyans and embedded refugees.

BACKGROUND: Community engagement is crucial for the design and implementation of community-based early childhood development (ECD) programmes. This paper aims to share key components and learnings of a community engagement process for an integrated ECD intervention. The lessons shared are drawn from a case study of urban informal settlement with embedded refugees in Nairobi, Kenya. METHODS: We conducted three stakeholder meetings with representatives from the Ministry of Health at County and Sub-County, actors in the ECD sector, and United Nations agency in refugee management, a transect walk across five villages (Ngando, Muslim, Congo, Riruta and Kivumbini); and, six debrief meetings by staff from the implementing organization. The specific steps and key activities undertaken, the challenges faced and benefits accrued from the community engagement process are highlighted drawing from the implementation team's perspective. RESULTS: Context relevant, well-planned community engagement approaches can be integrated into the five broad components of stakeholder engagement, formative research, identification of local resources, integration into local lives, and shared control/leadership with the local community. These can yield meaningful stakeholder buy-in, community support and trust, which are crucial for enabling ECD programme sustainability. CONCLUSION: Our experiences underscore that intervention research on ECD programmes in urban informal settlements requires a well-planned and custom-tailored community engagement model that is sensitive to the needs of each sub-group within the community to avoid unintentionally leaving anyone out.

Health seeking behaviors and childcare patterns in an informal settlement of Nairobi, Kenya: A cross-sectional study.

Children in urban informal settlements experience high risks for poor health and development. Understanding health seeking behaviors and childcare patterns of caregivers in urban informal settlements is important for devising effective interventions. This study describes household characteristics and aspects of nurturing care among caregivers of children aged 0-2 years in Dagoretti informal settlement, Nairobi-Kenya. In this cross sectional study, data were collected on household socio-demographic characteristics, antenatal care and child delivery practices, infant and young child feeding practices, activities that promote play, learning and school readiness, and on childcare and protection practices. Descriptive statistics of proportions and means were used to summarize the data. The study covers a total of 458 Kenyan and 118 immigrant households. Caregivers from immigrant households, with low education and from the younger age-group (less than 20 years) were vulnerable to sub-optimal caregiving and health seeking practices, including relatively lower rates of age-appropriate breastfeeding and poor dietary diversity. Seventy-five percent of expectant mothers attended less than four antenatal care visits. Households surveyed had limited possession of children's books (2% with three or more books), limited access to play materials (43% had two or more play materials), and low paternal involvement in child stimulation and early learning activities (14%). One-third and half of the children were left with inadequate care and disciplined using both violent and non-violent methods, respectively. Our findings highlight the urgent need for contextually appropriate and integrated interventions anchored in the WHO's nurturing care framework. These interventions can benefit from extensive involvement of caregivers, facility and community-based healthcare workers, policy makers, and other relevant stakeholders.

Methodology for the Development of the Australian National Nursing and Midwifery Digital Health Capability Framework.

Internationally healthcare organisations and governments are grappling with the issue of upskilling healthcare workforces in relation to digital health. Significant research has been undertaken in relation to documenting essential digital health capability requirements for the workforce. In 2019 the Australian Digital Health Agency funded work by the Australasian Institute of Digital Health to develop a National Nursing and Midwifery Digital Health Capability Framework. This paper describes the methodological approach used in the development of the Framework.

Supporting Child Development Through Parenting Interventions in Low- to Middle-Income Countries: An Updated Systematic Review.

Background: Over 250 million children in low- and middle-income countries are at risk of not achieving their fullest developmental potential due to co-occurring risks such as poor nutrition and inadequate learning opportunities. Early intervention programs integrating the aspects of nurturing care, that is, good health, adequate nutrition, safety and security, responsive caregiving, and learning opportunities, may ameliorate against the negative impact of these adverse conditions. Methods: This meta-analytic review updates the evidence base of parenting interventions comprising stimulation and responsive caregiving components on developmental outcomes for children under age 2 years in low- and middle-income countries. It also describes and assesses the moderation effects of population characteristics and implementation features on the intervention effectiveness. Studies were identified based on previous systematic reviews and an updated literature search in eight databases and the gray literature up to December 2020. A random-effect model was used to explore the pooled effect sizes accounted for by the intervention for developmental outcome of cognition, language, motor, and social-emotional capacities. Exploratory moderation analyses were also conducted. Results: Twenty-one randomized controlled trials representing over 10,400 children from 12 low- and middle-income countries and regions across three continents (Africa, Latin America, and Asia) were identified. The interventions showed overall small-to-moderate effects on children's cognitive development (ES = 0.44; 95% CI = [0.30, 0.57]); language development (ES = 0.33; 95% CI = [0.18, 0.49]); and motor skills (ES = 0.21; 95% CI = [0.10, 0.32]). The overall effect on social-emotional development was non-significant (ES = 0.17; 95% CI = [-0.01, 0.34]). Effect sizes (ES) varied significantly across the studies. Parenting programs that targeted vulnerable groups, including rural communities and caregivers with lower education levels, had more significant effects on children's development. Group sessions (vs. individual visits) and high program dose (≥12 sessions) were also associated with stronger effects on child development. Further research is needed to determine the effectiveness of the workforce and training on programmatic outcomes. Conclusion: The findings indicate that parenting interventions that encourage nurturing care are effective in improving the early development of children, especially among vulnerable populations. We discuss opportunities to strengthen the implementation of research-based parenting interventions in such contexts.

Psychosocial impact on mothers receiving expanded newborn screening results.

Expanded newborn screening (NBS) for genetic disorders has improved diagnosis of numerous treatable diseases, positively impacting children's health outcomes. However, research about the psychological impact of expanded NBS on families, especially mothers, has been mixed. Our study examined associations between maternal experiences of expanded NBS and subsequent psychosocial functioning and parenting stress in mothers whose infants received either true negative (TN), true positive (TP) or false positive (FP) results after a 4- to 6-month period. The Parenting Stress Index and the Depression, Anxiety and Stress Scale were used to assess symptoms of anxiety, stress and depression in 3 sets of mothers, whose infants received TN (n = 31), TP (n = 8) or FP (n = 18) results. Multivariate analyses of variance (MANOVA) results revealed no significant differences among these three groups of mothers regarding overall anxiety, stress and depression. However, FP mothers experienced lower levels of stress related to their own health compared to TN group. Two potential trends were also identified; results suggested TN mothers might experience higher levels of isolation than mothers in the TP group and that FP mothers might report higher stress levels in relation to spousal relationships compared to the TN group. FP mothers seemed to report similar or better levels of psychosocial functioning than TN mothers. Our findings are encouraging with respect to impacts of NBS on maternal well-being. We also identify key areas for improvement (parental education) and research (isolation and spousal relationships).

New insight on intergenerational attachment from a relationship-based analysis.

Research on attachment transmission has focused on variable-centered analyses, where hypotheses are tested by examining linear associations between variables. The purpose of this study was to apply a relationship-centered approach to data analysis, where adult states of mind, maternal sensitivity, and infant attachment were conceived as being three components of a single, intergenerational relationship. These variables were assessed in 90 adolescent and 99 adult mother-infant dyads when infants were 12 months old. Initial variable-centered analyses replicated the frequently observed associations between these three core attachment variables. Relationship-based, latent class analyses then revealed that the most common pattern among young mother dyads featured maternal unresolved trauma, insensitive interactive behavior, and disorganized infant attachment (61%), whereas the most prevalent adult mother dyad relationship pattern involved maternal autonomy, sensitive maternal behavior, and secure infant attachment (59%). Three less prevalent relationship patterns were also observed. Moderation analyses revealed that the adolescent-adult mother distinction differentiated between secure and disorganized intergenerational relationship patterns, whereas experience of traumatic events distinguished between disorganized and avoidant patterns. Finally, socioeconomic status distinguished between avoidant and secure patterns. Results emphasize the value of a relationship-based approach, adding an angle of understanding to the study of attachment transmission.

Serotonin transporter gene (SLC6A4) polymorphism and susceptibility to a home-visiting maternal-infant attachment intervention delivered by community health workers in South Africa: Reanalysis of a randomized controlled trial.

BACKGROUND: Clear recognition of the damaging effects of poverty on early childhood development has fueled an interest in interventions aimed at mitigating these harmful consequences. Psychosocial interventions aimed at alleviating the negative impacts of poverty on children are frequently shown to be of benefit, but effect sizes are typically small to moderate. However, averaging outcomes over an entire sample, as is typically done, could underestimate efficacy because weaker effects on less susceptible individuals would dilute estimation of effects on those more disposed to respond. This study investigates whether a genetic polymorphism of the serotonin transporter gene moderates susceptibility to a psychosocial intervention. METHODS AND FINDINGS: We reanalyzed data from a randomized controlled trial of a home-visiting program delivered by community health workers in a black, isiXhosa-speaking population in Khayelitsha, South Africa. The intervention, designed to enhance maternal-infant attachment, began in the third trimester and continued until 6 mo postpartum. Implemented between April 1999 and February 2003, the intervention comprised 16 home visits delivered to 220 mother-infant dyads by specially trained community health workers. A control group of 229 mother-infant dyads did not receive the intervention. Security of maternal-infant attachment was the main outcome measured at infant age 18 mo. Compared to controls, infants in the intervention group were significantly more likely to be securely attached to their primary caregiver (odds ratio [OR] = 1.7, p = 0.029, 95% CI [1.06, 2.76], d = 0.29). After the trial, 162 intervention and 172 control group children were reenrolled in a follow-up study at 13 y of age (December 2012-June 2014). At this time, DNA collected from 279 children (134 intervention and 145 control) was genotyped for a common serotonin transporter polymorphism. There were both genetic data and attachment security data for 220 children (110 intervention and 110 control), of whom 40% (44 intervention and 45 control) carried at least one short allele of the serotonin transporter gene. For these 220 individuals, carrying at least one short allele of the serotonin transporter gene was associated with a 26% higher rate of attachment security relative to controls (OR = 3.86, p = 0.008, 95% CI [1.42, 10.51], d = 0.75), whereas there was a negligible (1%) difference in security between intervention and control group individuals carrying only the long allele (OR = 0.95, p = 0.89, 95% CI [0.45, 2.01], d = 0.03). Expressed in terms of absolute risk, for those with the short allele, the probability of secure attachment being observed in the intervention group was 84% (95% CI [73%, 95%]), compared to 58% (95% CI [43%, 72%]) in the control group. For those with two copies of the long allele, 70% (95% CI [59%, 81%]) were secure in the intervention group, compared to 71% (95% CI [60%, 82%]) of infants in the control group. Controlling for sex, maternal genotype, and indices of socioeconomic adversity (housing, employment, education, electricity, water) did not change these results. A limitation of this study is that we were only able to reenroll 49% of the original sample randomized to the intervention and control conditions. Attribution of the primary outcome to causal effects of intervention in the present subsample should therefore be treated with caution. CONCLUSIONS: When infant genotype for serotonin transporter polymorphism was taken into account, the effect size of a maternal-infant attachment intervention targeting impoverished pregnant women increased more than 2.5-fold when only short allele carriers were considered (from d = 0.29 for all individuals irrespective of genotype to d = 0.75) and decreased 10-fold when only those carrying two copies of the long allele were considered (from d = 0.29 for all individuals to d = 0.03). Genetic differential susceptibility means that averaging across all participants is a misleading index of efficacy. The study raises questions about how policy-makers deal with the challenge of balancing equity (equal treatment for all) and efficacy (treating only those whose genes render them likely to benefit) when implementing psychosocial interventions. TRIAL REGISTRATION: Current Controlled Trials ISRCTN25664149.

Do infant behaviors following immunization predict attachment? An exploratory study.

OBJECTIVES: The relationship between infant behaviors during routine immunization, pre- and post-needle, and infant attachment was explored. METHODS: A total of 130 parent-infant dyads were recruited from a larger longitudinal study and videotaped during routine immunization at 12 months and the Strange Situation Procedure (SSP) at 14 months. Six infant behaviors were coded for 1-minute pre-needle and 3-minutes post-needle. Attachment was operationalized according to the secure/avoidant/resistant/disorganized categories. RESULTS: As expected, none of the pre-needle behaviors predicted attachment. Proximity-seeking post-needle significantly discriminated attachment categorizations. Secure infants were more likely to seek proximity to caregivers post-needle in comparison with avoidant and disorganized infants. Proximity-seeking following immunization was positively correlated with proximity-seeking during the SSP and negatively correlated with avoidance and disorganization during the SSP. CONCLUSIONS: Infant proximity-seeking during immunization is associated with attachment security and parallels behaviors observed during the SSP. More research is needed to identify behavioral markers of disorganization.

MATERNAL REPRESENTATIONS AND INFANT ATTACHMENT: AN EXAMINATION OF THE PROTOTYPE HYPOTHESIS.

The prototype hypothesis suggests that attachment representations derived in infancy continue to influence subsequent relationships over the life span, including those formed with one's own children. In the current study, we test the prototype hypothesis by exploring (a) whether child-specific representations following actual experience in interaction with a specific child impacts caregiver-child attachment over and above the prenatal forecast of that representation and (b) whether maternal attachment representations exert their influence on infant attachment via the more child-specific representation of that relationship. In a longitudinal study of 84 mother-infant dyads, mothers' representations of their attachment history were obtained prenatally with the Adult Attachment Interview (AAI; M. Main, R. Goldwyn, & E. Hesse, 2002), representations of relationship with a specific child were assessed with the Working Model of the Child Interview (WMCI; C.H. Zeanah, D. Benoit, & L. Barton, 1986), collected both prenatally and again at infant age 11 months, and infant attachment was assessed in the Strange Situation Procedure (M.D.S. Ainsworth, M.C. Blehar, E. Walters, & S. Wall, 1978) when infants were 11 months of age. Consistent with the prototype hypothesis, considerable correspondence was found between mothers' AAI and WMCI classifications. A mediation analysis showed that WMCI fully accounted for the association between AAI and infant attachment. Postnatal WMCI measured at 11 months' postpartum did not add to the prediction of infant attachment, over and above that explained by the prenatal WMCI. Implications for these findings are discussed.

Preschool ambivalent attachment associated with a lack of vagal withdrawal in response to stress.

The goal of the present study was to examine how quality of the child-caregiver attachment relationship related to children's cardiac vagal reactivity in response to a novel social stressor. Children's (N = 48; M age = 3 years 9 months) cardiac data were collected as they participated in an ambiguous and potentially threatening social situation together with their mothers. Their degree of behavioral inhibition also was observed. Attachment classifications were assessed separately. Children classified as Secure showed vagal withdrawal from baseline to the stressor, whereas children classified as Ambivalent did not show vagal withdrawal in response to the stressor. There was a marginally significant moderation of attachment-related differences in vagal withdrawal by level of behavioral inhibition. Among highly behaviorally inhibited children, those classified as Ambivalent demonstrated little or no vagal withdrawal compared to their Secure counterparts. In contrast, no attachment-related differences were found among those who appeared less behaviorally inhibited. Findings are discussed in relation to children's emerging self-regulation skills in the context of their attachment relationship.

It takes two to talk: longitudinal associations among infant-mother attachment, maternal attachment representations, and mother-child emotion dialogues.

Research on the attachment-dialogue link has largely focused on infant-mother attachment. This study investigated longitudinal associations between infant-mother attachment and maternal attachment representations and subsequent mother-child emotion dialogues (N = 50). Maternal attachment representations were assessed using the Adult Attachment Interview when children were 3 months, infant-mother attachment was assessed using the Strange Situation Procedure at 13 months, and mother-child emotion dialogues were assessed using the Autobiographical Emotional Events Dialogue at 3.5 years. Consistent with past research, the three organized categories of infant-mother attachment relationships were associated with later mother-child emotion dialogues. Disorganized attachment relationships were associated with a lack of consistent and coherent strategy during emotion dialogues. Autonomous mothers co-constructed coherent narratives with their children; Dismissing and Preoccupied mothers created stories that were less narratively organized. Although the Unresolved category was unrelated to classifications of types of mother-child discourse, mothers' quality of contribution to the dialogues was marginally lower compared to the quality of their children's contributions to the emotion discussion. Secure children showed highest levels of child cooperation and exploration. Autonomous mothers displayed highest levels of maternal sensitive guidance during emotion dialogues. We provide preliminary evidence for role reversal in dialogues between Preoccupied and Unresolved mothers and their children.

Distress regulation in infancy: attachment and temperament in the context of acute pain.

OBJECTIVE: The relationship between attachment, temperamental fear, and pain-related distress was examined in a sample of 130 caregiver-infant dyads to explore the differential susceptibility hypothesis. METHOD: Infant distress was measured during routine immunization at 12 months, and attachment and temperamental fear were measured at 12 to 18 months (meanage = 13.74, SD = 1.35) using the Strange Situation Procedure and parent-rated Infant Behavior Questionnaire-Revised, respectively. RESULTS: Immediately before immunization, avoidant infants exhibited significantly less distress than secure infants. Temperamental fear moderated the relationship between attachment and regulation; under conditions of high temperamental fear, avoidant infants regulated distress more slowly than secure infants, whereas under conditions of low temperamental fear, secure infants regulated distress more slowly than avoidant and disorganized infants. CONCLUSION: The findings suggest that attachment interacts with extremes in temperamental fear to produce differences in the regulation of distress. The results partially support the differential susceptibility hypothesis.

Understanding sensitivity: lessons learned from the legacy of Mary Ainsworth.

On the basis of extensive home observations, Ainsworth proposed that a mother's sensitivity to her infant's signals is the primary determinant of attachment security. Although subsequent research has found a relationship between sensitivity and attachment security, the effect sizes are much smaller than those reported by Ainsworth. In addition to the amount of observation time that might account for the effect size difference, we consider Ainsworth's focus on understanding the organizational structure of relationships. We coded 30 minute video records of interactions between 64 mother-infant dyads from semi-structured home observations conducted at 10 months of age. Coding consisted of writing a narrative summary of the interactions, annotating a completion of Ainsworth's rating scales of acceptance, accessibility, cooperation and sensitivity and then describing the mother's behavior using the Maternal Behaviour Q-set. Sensitivity scores derived from the Q-sort descriptions were robustly related (r = .65) to secure-insecure classifications in the Strange Situation conducted at 13 months. We reflect on the process of assessing Ainsworth's construct of sensitivity.

Development of a Childhood Attachment and Relational Trauma Screen (CARTS): a relational-socioecological framework for surveying attachment security and childhood trauma history.

BACKGROUND: Current psychometric measures of childhood trauma history generally fail to assess the relational-socioecological context within which childhood maltreatment occurs, including the relationship of abusers to abused persons, the emotional availability of caregivers, and the respondent's own thoughts, feelings, and actions in response to maltreatment. OBJECTIVE: To evaluate a computerized approach to measuring the relational-socioecological context within which childhood maltreatment occurs. METHOD: The psychometric properties of a Childhood Attachment and Relational Trauma Screen (CARTS) were evaluated as a retrospective survey of childhood maltreatment history designed to be appropriate for completion by adults. Participants were undergraduates (n=222), an internet sample (n=123), and psychiatric outpatients (n=30). RESULTS: The internal reliability, convergent, and concurrent validity of the CARTS were supported across samples. Paired differences in means and correlations between rated item-descriptiveness to self, mothers, and fathers also accorded with findings of prior attachment and maltreatment research, illustrating the utility of assessing the occurrence and effects of maltreatment within a relational-socioecological framework. CONCLUSIONS: Results preliminarily support a new survey methodology for assessing childhood maltreatment within a relational-socioecological framework. Further psychometric evaluation of the CARTS is warranted.

Maternal interactive behaviour as a predictor of preschoolers' attachment representations among full term and premature samples.

BACKGROUND: Associations between maternal sensitivity and child attachment have been established in many samples, but the strength of the association varies across populations. The sensitivity-attachment link has never been examined at the level of representations nor among premature samples. OBJECTIVE: The present study is aimed at exploring associations between maternal interactive behaviour and children's attachment representations in a population of preterm and full-term infants. METHOD: Maternal interactive behaviour was assessed at 6 and 18 months (Ainsworth Sensitivity Scale & Care Index) and children's attachment representations were measured at 42 months (Attachment Story Completion Task) in a sample of preterm (N=48) and full-term (N=23) infants. RESULTS: Maternal unresponsiveness at 6 months and sensitivity at 18 months explained 54% of the variance of disorganized attachment representations in the full-term group but was not significantly related to attachment patterns in the preterm group. CONCLUSION: These results corroborate previous work on the causes of disorganized attachment and also point to the need to consider the development of attachment differently for children evolving in specific developmental contexts. They especially stress the importance of distinguishing between risk factors associated with the mother as opposed to the child.

The origins of cognitive vulnerability in early childhood: mechanisms linking early attachment to later depression.

This paper examines the theory and research linking attachment relationships to cognitive vulnerability to depression and assesses evidence that early attachment experiences contribute to the development of these cognitive processes. Most research in this area has involved adult participants using self-report measures of both attachment and depressive vulnerabilities and thus cannot convincingly speak to the existence of such a developmental pathway. Several studies, however, have followed individuals from infancy and examined the emergence of self-esteem and responses to failure throughout childhood and adolescence. These studies suggest that early experiences in non-secure attachment relationships place an individual at-risk for developing a cognitive framework that increases their vulnerability to depression following stressful life events. The paper concludes with a discussion of how future research might best explore specific mechanisms through which distinct attachment relationships may lead to divergent developmental pathways sharing the common outcome of cognitive processes that place individuals at risk for depression.

Validation of a short version of the maternal behavior Q-set applied to a brief video record of mother-infant interaction.

A 25 item version of the maternal behavior Q-set (MBQS) was validated with 40 adolescent mother-infant dyads. Observations were made from 10 min play interactions when infants were 10 months old. Results show that the short MBQS is reliable (r(i)=.94), is related to assessments using the full MBQS at 6 months (r=.35), to cognitive development at 10 and 15 months (r=.48), and attachment security at 15 months (r=.34), indicating appropriate psychometric characteristics.

An alternative model for case management in Flintshire.

This article presents and reviews the evidence from a local service that has been developed in order to meet the predicted rise in the level of chronic disease in Wales. Three nurse case managers have been proactively working with surgeries in Flintshire (North East Wales) for the past two years to introduce a case management approach for the patients from those practices. Using data for the 12 months before and after the case managers intervention for each patient, the service appears to reduce emergency admissions, by a median of 1 emergency admission per patient and reduces length of hospital stay by a median of 2 days.

Both maternal sensitivity and atypical maternal behavior independently predict attachment security and disorganization in adolescent mother-infant relationships.

Extant theory holds that variation in attachment security is largely determined by caregiver sensitivity whereas disorganization has its roots in atypical interactions that frighten the infant. These hypotheses were confirmed in the current study of a high-risk sample but, contrary to current theory, both atypical maternal behavior and maternal sensitivity were also significant independent predictors of attachment disorganization and security.

Similarities and differences in mothers' and observers' ratings of infant security on the Attachment Q-Sort.

This study examined the similarities and differences in maternal and observer Attachment Behavior Q-Sort ratings (AQS; Waters, 1995) and their relations to dimensions of the developmental ecology - maternal sensitivity, infant irritability, parental stress and psychosocial risk. Data was gathered from low risk (adult mothers; N=44) and high risk mother-infant dyads (adolescent mothers; N=83) when infants were aged 6, 10 and 15 months old, attachment being assessed at 15 months by both mothers and independent observers. A common factor was extracted from both sorts and served to operationalize the similarities between mother and observer ratings. Regressions were conducted to extract maternal and observer AQS scores that were unrelated to each other to represent the difference between the two sorts. Correlation analyses indicated that the common AQS factor was moderately linked to maternal sensitivity and parental stress, and showed a weak association to psychosocial risk and infant irritability. Residual maternal scores showed greater correlations with infant irritability and parental stress than did observer residual scores. Observer scores showed a greater correlation with psychosocial risk than maternal scores. Results suggest that common AQS variance presents a pattern of associations with ecological variables that is coherent with attachment research. Variance related to irritability, stress and risk appear to drive the differences between maternal and observer observations.