Early intervention and child physical health: Evidence from a Dublin-based randomized controlled trial

Impact of the Korea Early Childhood Home-visiting Intervention (KECHI) on child health and development and maternal health: a randomised controlled trial protocol

INTRODUCTION

Randomised controlled trials (RCTs) of early childhood home-visiting interventions led by nurses have been conducted mainly in Western countries, whereas such trials have been limited in non-Western cultures, including Asia. In South Korea, a national nurse home visit programme (Korea Early Childhood Home-visiting Intervention (KECHI)) was developed in 2020 and launched throughout the country. We designed a pragmatic RCT to evaluate the effectiveness of KECHI on child health and development and maternal health.

METHODS AND ANALYSIS

Eligible participants will be pregnant women at <37 weeks of gestation with risk factor scores of 2 or over, who are sufficiently fluent in Korean to read and answer the questionnaire written in Korean and live in districts where the KECHI services are available. Eight hundred participants will be recruited from the general community and through the District Public Health Centres. The participants will be randomised 1:1 to KECHI plus usual care or usual care. KECHI encompasses 25-29 home visits, group activities and community service linkage. Participants will complete assessments at baseline (<37 weeks gestation), 6 weeks, 6 months, 12 months, 18 months and 24 months post partum. The six primary outcomes will be (1) home environment (assessed by Infant/Toddler Home Observation for Measurement of the Environment), (2) emergency department visits due to injuries, (3) child development (assessed using Korean Bayley Scales of Infant and Toddler Development-III), (4) breastfeeding duration, (5) maternal self-rated health and (6) community service linkage.

ETHICS AND DISSEMINATION

This trial has received full ethical approval from the Institutional Review Board of the Seoul National University Hospital. Written consent will be obtained from the participants. The results will be reported at conferences, disseminated through peer-reviewed publications and used by the Korean government to expand the KECHI services.

TRIAL REGISTRATION NUMBER

NCT04749888.

Maternal mental health and social support from online communities during pregnancy

Social determinants of public health have gained increasing attention. This paper studied whether social support from online communities related to maternal mental health. We focused on online maternity communities that group users with a similar prenatal status to facilitate their exchange of personal experiences and knowledge about maternal caring during pregnancy. Such online maternity communities are getting increasingly popular and can be found across countries and societies. We invited users-currently pregnant and gave birth within 1 year at the time of the study-from one such community in China to participate in a survey. The survey measured their perceived social support (PSS) exclusively from the peer group in the online community, their mental health and newborns' birth outcomes (N = 500). Users reported high score in PSS from the online peer group which was comparable to the ones from family, significant other and friends in other studies. We used linear regression models to examine the effects of PSS on mental health and birth outcomes. We found that a one-point increase in the PSS score was associated with a 0.19-point (p < 0.1) decrease in the prenatal depression and a 0.26-point (p < 0.01) decrease in the postnatal depression, which was equivalent to 3% and 4.5% of the average respectively. Moreover, a one-point increase in the PSS score was associated with a 14.49-gram increase in a newborn's weight (p < 0.01).

Parental educational level and childhood wheezing and asthma: A prospective cohort study from the Japan Environment and Children's Study

BACKGROUND

The influence of mothers' and fathers' educational levels in separate evaluations of asthma has not been fully investigated. This study aims to examine the associations of the mother's and fathers' educational levels with childhood wheeze and asthma adjusting for crude and pre-and post-natal modifiable risk factors.

METHODS

We conducted a prospective cohort study using data from the Japan Environment and Children's Study, which recruited pregnant women from 2011 to 2014. The mother's and father's educational levels were surveyed by a questionnaire during the pregnancy, and childhood wheezing and doctor-diagnosed asthma were estimated using a 3-year questionnaire. Multilevel logistic regression analysis was performed to evaluate the association between the mother's and father's educational levels and childhood wheezing and asthma, adjusted for pre-and post-natal factors.

RESULTS

A total of 69,607 pairs of parents and their single infants were analyzed. We found 17.3% of children had wheezing and 7.7% had asthma. In crude analyses, lower educational level of parents was associated with an increased risk of childhood wheezing and asthma. After full adjustment, a lower educational level of mothers was associated with an increased risk of childhood asthma (junior high school (reference: high school); odds ratio (OR): 1.17, 95% CI, 1.01-1.36), and higher educational level, especially the mother's, was associated with an increased risk of childhood wheezing (technical junior college, technical/vocational college, or associate degree (ECD3); OR: 1.12, 95% CI, 1.06-1.18, bachelor's degree, or postgraduate degree; OR: 1.10, 95% CI, 1.03-1.18), and asthma (ECD3; OR: 1.13, 95% CI, 1.04-1.21).

CONCLUSIONS

Parents' lower educational level was a crude risk factor for childhood wheezing and asthma. However, an increased risk of wheezing due to mothers' higher educational level was found after adjusting for pre-and post-natal factors.

Impact of an early childhood intervention on the home environment, and subsequent effects on child cognitive and emotional development: A secondary analysis

The objective of this study was to use secondary data from the Preparing for Life (PFL) trial to test (1) the impact of a prenatal-to-age-five intervention targeting women from a disadvantaged Irish community on the quality of the home environment; (2) whether any identified changes in the home environment explain the positive effects of the PFL program on children’s cognitive and emotional development at school entry which have been identified in previous reports of the PFL trial (ES = .72 and .50, respectively). Pregnant women were randomized into a treatment (home visits, baby massage, and parenting program, n = 115) or control (n = 118) group (trial registration: ISRCTN04631728). The home environment was assessed at 6 months, 1½, and 3 years using the Home Observation for Measurement of the Environment (responsiveness, acceptance, organization, learning material, involvement, variety). Cognitive skills were assessed at 5 years using the British Ability Scales. Emotional problems were teacher-reported at 5 years using the Short Early Development Inventory. Latent growth modeling was used to model changes in the home environment, and mediation analyses to test whether those changes explained children outcomes. Compared to controls, treatment children were exposed to more stimulating environments in terms of learning material (B = -1.62, p = 0.036) and environmental variety (B = -1.58, p = 0.009) at 6 months, but these differences faded at 3 years. Treatment families were also more likely to accept suboptimal child behaviors without using punishment (acceptance score, B = 1.49, p = 0.048) and were more organized at 3 years (B = 1.08, p = 0.033). None of the changes mediated children’s outcomes. In conclusion, we found that the program positively impacted different home environment dimensions, but these changes did not account for improvements in children’s outcomes. Exploratory analyses suggest that the impact of improvements in the home environment on child outcomes may be limited to specific groups of children. Limitations of the study include the potential lack of generalizability to other populations, the inability to assess the individual treatment components, and sample size restrictions which precluded a moderated mediation analysis.

Does maternal attachment to her infant mediate the link between perceptions of infant crying at 6 months and parenting stress at 24 months? A structural equation modelling approach

BACKGROUND

Parenting stress is influenced by many factors including maternal attachment and excessive infant crying, yet the nature of these relationships is not well understood. For example, excessive infant crying despite maternal soothing may impact maternal attachment to the child, leading to higher stress. This paper explored whether maternal perception of excessive infant crying at 6 months was associated with higher maternal parenting stress at 24 months, and whether maternal attachment mediated this relationship.

METHODS

All families, present at 24 months in a randomized controlled trial of a 5-year early intervention programme targeting school readiness skills in disadvantaged area of Ireland, were included. At 6 months, infant crying was assessed using a maternal reported measure of duration of infant crying, and maternal attachment to the infant was assessed using the Condon Maternal Attachment Scale. Parenting stress was assessed at 24 months using the childrearing stress subscale from the Parenting Stress Index. Structural equation modelling was used to explore the direct and indirect effects of maternal perceptions of excessive infant crying on parenting stress, controlling for infant, maternal, and environmental characteristics, and focusing on the mediating role of maternal attachment.

RESULTS

Reporting excessive infant crying at 6 months was associated with lower maternal attachment at 6 months, which led to higher parenting stress at 24 months. In addition, vulnerable adult attachment style, previous maternal mental health difficulties, low paternal education, paternal involvement with the child, and not being married were associated with higher parenting stress.

CONCLUSION

Findings suggest that the association between maternal perceptions of excessive crying at 6 months and later parenting stress may be mediated through maternal attachment to the infant. Interventions based on improving maternal attachment could be investigated to determine the effectiveness of supporting mothers with low attachment.

A Multicomponent Early Intervention Program and Trajectories of Behavior, Cognition, and Health

OBJECTIVES

To investigate the developmental impact of a prenatal-to-age-5 multicomponent early intervention program targeting families living in low socioeconomic conditions.

METHODS

Pregnant women from a disadvantaged Irish community were randomly assigned into a treatment group (home visits, baby massage, and parenting program; n = 115) or control group (n = 118). Children's behavioral problems (externalizing, internalizing), cognitive skills (general, vocabulary), and health service use (number of health clinic visits), were regularly assessed (6 months to 4 years of age). Children's developmental trajectories were modeled by using latent class growth analyses to test whether certain subgroups benefited more than others.

RESULTS

High and low developmental trajectories were identified for each outcome. Treated children were more likely to follow the high-level trajectory for cognition (odds ratio = 2.89; 95% confidence interval = 1.55-5.50) and vocabulary skills (odds ratio = 2.02; 95% confidence interval = 1.08-3.82). There were no differences by treatment condition in the risk of belonging to a high externalizing or high health clinic visit trajectory. However, within the high externalizing trajectory, treated children had lower scores than controls (Hedges' g range (2-4 years) = 0.45-0.58; P < .05) and, within the high health clinic visit trajectory, only children in the control group experienced an increasing number of visits.

CONCLUSIONS

This program revealed moderate positive impacts on trajectories of cognitive development and number of health clinic visits for all children, whereas positive impacts on externalizing behavior problems were restricted to children with the most severe problems.

Evaluating the effects of a targeted home visiting program on maternal and child health outcomes

We evaluate the effects of home visiting targeted towards disadvantaged first-time mothers on maternal and child health outcomes. Our analysis exploits a randomized controlled trial and combines rich longitudinal survey data with unique administrative health data. In a context in which the target group has comprehensive health care access, we find no effects of home visiting on most types of health utilization, health behaviors, and physical health measures. However, the intervention has a positive effect on some maternal mental health outcomes, reducing depression reported in the survey data by eleven percentage points and prescription of psycholeptics recorded in the administrative data by seven percentage points.

Health and income inequalities in Europe: What is the role of circumstances?

Equality of opportunity theories distinguish between inequalities due to individual effort and those due to external circumstances. Recent research has shown that half of the variability in income of World population was determined by country of birth and income distribution. Since health and income are generally strictly related, the aim of this paper is to estimate how much variability in income and health is determined by external circumstances. We use data from the Survey of Health, Ageing and Retirement (SHARE) and the English Longitudinal Survey on Ageing (ELSA), two comparable multidisciplinary surveys that provide micro-level data on health and financial resources among the elderly for a large number of European countries. Our baseline estimation shows that about 20% of the variability in income is explained by current country-specific circumstances, while health outcomes range from 12% using BMI to 19% using self-rated health. By including early-life circumstances, the explained variability increases almost 20 percentage points for income and for self-rated health but less for other health outcomes. Finally, by controlling for endogeneity issues linked with effort, our estimates indicate that circumstances better explain variability in health outcomes. Results are robust to some tests, and the implications of these findings are discussed.

Maternal warmth and toddler development: support for transactional models in disadvantaged families

Studies support cognitive and social domains of development as entwined in childhood, however, there is a paucity of investigation into the nature of the mother-child relationship within an interdependence framework. Furthermore, the focus on these processes within families from impoverished communities using frequent assessments in early childhood has been limited. Our objectives were to identify (1) the directional associations between toddler's communication ability and social competence, (2) to establish whether the association between toddler's communication ability and social competence is mediated by maternal warmth, and (3) to establish support for transactional models between toddlers' outcomes and maternal warmth in disadvantaged communities in Ireland. Participants included 173 toddlers and their families enrolled in a prenatally commencing prevention programme. Toddler's communication and social competence were assessed at 12, 18, 24 and 36 months and maternal warmth at 6 and 24 months. Cross-lagged models were estimated examining multiple paths of associations simultaneously. Direct and indirect paths of maternal warmth were also examined. Bi-directional associations were found between communication ability and social competence from 12 to 24 months but not thereafter. Maternal warmth did not significantly mediate these associations, however, support of a transactional model was found with social competence. The results support early positive associations between better communication ability and social competence in the first 2 years, however, they suggest that these associations are no longer present by the third year. The role of maternal warmth in fostering social competencies is important for toddlers and equally important is toddler's level of social competence in eliciting increased maternal warmth.

Can Early Intervention Improve Maternal Well-Being? Evidence from a Randomized Controlled Trial

Objective

This study estimates the effect of a targeted early childhood intervention program on global and experienced measures of maternal well-being utilizing a randomized controlled trial design. The primary aim of the intervention is to improve children’s school readiness skills by working directly with parents to improve their knowledge of child development and parenting behavior. One potential externality of the program is well-being benefits for parents given its direct focus on improving parental coping, self-efficacy, and problem solving skills, as well as generating an indirect effect on parental well-being by targeting child developmental problems.

Methods

Participants from a socio-economically disadvantaged community are randomly assigned during pregnancy to an intensive 5-year home visiting parenting program or a control group. We estimate and compare treatment effects on multiple measures of global and experienced well-being using permutation testing to account for small sample size and a stepdown procedure to account for multiple testing.

Results

The intervention has no impact on global well-being as measured by life satisfaction and parenting stress or experienced negative affect using episodic reports derived from the Day Reconstruction Method (DRM). Treatment effects are observed on measures of experienced positive affect derived from the DRM and a measure of mood yesterday.

Conclusion

The limited treatment effects suggest that early intervention programs may produce some improvements in experienced positive well-being, but no effects on negative aspects of well-being. Different findings across measures may result as experienced measures of well-being avoid the cognitive biases that impinge upon global assessments.

Effects of early intervention on dietary intake and its mediating role on cognitive functioning: a randomised controlled trial

OBJECTIVE

To investigate the impact of an early intervention programme, Preparing for Life, on dietary intake between 12 and 36 months of age, and the mediating role played by diet on cognitive functioning.

DESIGN

A randomised controlled trial evaluation of a community-based home visiting programme. The intervention involved biweekly visits from mentors from pregnancy until age 5 years and parent training at age 2 years. Dietary intake was assessed at 12, 18, 24 and 36 months using an FFQ to calculate the proportion meeting dietary recommendations. Cognitive functioning was measured at 24 and 36 months. Treatment effects were estimated using conventional χ 2 tests, permutation testing, inverse probability weighting and the stepdown procedure. Mediation analysis examined the indirect effect of the intervention on cognitive functioning via its effect on dietary intake.

SETTING

Socio-economically disadvantaged communities in Dublin, Republic of Ireland.

SUBJECTS

Pregnant women (n 233) were assigned to the intervention (n 115) or control (n 118) group using an unconditional probability randomisation strategy.

RESULTS

Positive treatment effects were observed for meeting dietary recommendations for protein foods at 24 (OR=2·52) and 36 (OR=2·42) months, and all food groups at 24 (OR=3·92) months. There were no effects on grain, dairy, fruit and vegetable, or fatty/sugary food recommendations in most models. The conventional and more novel methods yielded similar results. Mediation analysis indicated that 13 % of the intervention's effect on cognitive functioning was mediated by 36-month protein food consumption.

CONCLUSIONS

The study demonstrates some potential to alter early childhood dietary patterns through community-based intervention programmes.

Can Targeted Intervention Mitigate Early Emotional and Behavioral Problems?: Generating Robust Evidence within Randomized Controlled Trials

This study examined the impact of a targeted Irish early intervention program on children's emotional and behavioral development using multiple methods to test the robustness of the results. Data on 164 Preparing for Life participants who were randomly assigned into an intervention group, involving home visits from pregnancy onwards, or a control group, was used to test the impact of the intervention on Child Behavior Checklist scores at 24-months. Using inverse probability weighting to account for differential attrition, permutation testing to address small sample size, and quantile regression to characterize the distributional impact of the intervention, we found that the few treatment effects were largely concentrated among boys most at risk of developing emotional and behavioral problems. The average treatment effect identified a 13% reduction in the likelihood of falling into the borderline clinical threshold for Total Problems. The interaction and subgroup analysis found that this main effect was driven by boys. The distributional analysis identified a 10-point reduction in the Externalizing Problems score for boys at the 90th percentile. No effects were observed for girls or for the continuous measures of Total, Internalizing, and Externalizing problems. These findings suggest that the impact of this prenatally commencing home visiting program may be limited to boys experiencing the most difficulties. Further adoption of the statistical methods applied here may help to improve the internal validity of randomized controlled trials and contribute to the field of evaluation science more generally.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN04631728.