Effectiveness of a large-scale home visiting programme (PIM) on early child development in Brazil: quasi-experimental study nested in a birth cohort

The Happy Child Program's Intersectionality: Prenatal Home Visit Frequency, Food Insecurity Risk, Symptoms of Depression, and Parental Practices in Brazilian Women Assisted during Pregnancy

Food insecurity (FI) is a critical issue in developing countries, particularly in low-resource settings, where it can worsen women's mental health. Psychosocial factors such as low household income, limited education, multiparity, and vulnerability are linked to depressive symptoms during pregnancy. Additionally, the family environment influences parental practices, which may impact mental health. This study evaluates the association of socioeconomic factors, parental practices, FI risk, and home visit frequency with depressive symptoms in pregnant women enrolled in the Happy Child Program (Programa Criança Feliz-PCF) in the Federal District, Brazil. In this cross-sectional study, 132 pregnant women monitored by PCF from May to July 2023 were assessed using a self-administered questionnaire for socioeconomic data, the two-item Triage for Food Insecurity (TRIA) instrument for FI risk, the Scale of Parental Beliefs and Early Childhood Care Practices, and the Beck Depression Inventory-II for depressive symptoms. Most participants were multiparous (87.9%), had low income (under 200 USD/month; 80.8%), presented depressive symptoms (67.4%) and were at risk of FI (81.8%). About half demonstrated adequate parental practices (50.8%) and received four home visits per month during pregnancy (54.5%). Women who received four PCF home visits had a lower prevalence of depressive symptoms compared to those with fewer visits (PR 0.76, 95% CI 0.59-0.98). No significant association was found between FI or parental practices and depressive symptoms. These findings suggest that the PCF home-visiting program may strengthen vulnerable families, support social networks, and improve mental health during pregnancy. Additionally, the results of this study highlight the need for targeted interventions aimed at reducing food insecurity and promoting mental health during pregnancy, particularly among socially vulnerable populations. Furthermore, they reinforce the importance of expanding access to home-visiting programs as an effective strategy to improve maternal mental health and well-being, while fostering healthier prenatal environments for both mothers and their children.

Predictors of early child development for screening pregnant women most in need of support in Brazil

Background

Home visiting programmes can support child development and reduce inequalities, but failure to identify the most vulnerable families can undermine such efforts. We examined whether there are strong predictors of poor child development that could be used to screen pregnant women in primary health care settings to target early interventions in a Brazilian population. Considering selected predictors, we assessed coverage and focus of a large-scale home visiting programme named Primeira Infância Melhor (PIM).

Methods

We undertook a prospective cohort study on 3603 children whom we followed from gestation to age four years. We then used 27 potential socioeconomic, psychosocial, and clinical risk factors measurable during pregnancy to predict child development, which was assessed by the Battelle Developmental Inventory (BDI) at the age of four years. We compared the results from a Bonferroni-adjusted conditional inference tree with exploratory linear regression and principal component analysis (PCA), and we conducted external validation using data from a second cohort from the same population. Lastly, we assessed PIM coverage and focus by linking 2015 cohort data with PIM databases.

Results

The decision tree analyses identified maternal schooling as the most important variable for predicting BDI, followed by paternal schooling. Based on these variables, a group of 214 children who had the lowest mean BDI (BDI = -0.48; 95% confidence interval (CI) = -0.63, -0.33) was defined by mothers with ≤5 years and fathers with ≤4 years of schooling. Maternal and paternal schooling were also the strongest predictors in the exploratory analysis using regression and PCA, showing linear associations with the outcome. However, their capacity to explain outcome variance was low, with an adjusted R2 of 5.3% and an area under the receiver operating characteristic curve of 0.62 (95% CI = 0.60, 0.64). External validation showed consistent results. We also provided an online screening tool using parental schooling data to support programme's targeting. PIM coverage during pregnancy was low, but the focus was adequate, especially among families with longer enrolment, indicating families most in need received higher dosage.

Conclusions

Information on maternal and paternal schooling can improve the focus of home visiting programmes if used for initial population-level screening of pregnant women in Brazil. However, enrolment decisions require complementary information on parental resources and direct interactions with families to jointly decide on inclusion.

Life-course influences of poverty on violence and homicide: 30-year Brazilian birth cohort study

BACKGROUND

Homicide is the leading cause of death among young people in Latin America, one of the world's most violent regions. Poverty is widely considered a key cause of violence, but theories suggest different effects of poverty, depending on when it is experienced in the life-course. Longitudinal studies of violence are scarce in Latin America, and very few prospective data are available worldwide to test different life-course influences on homicide.

METHODS

In a prospective birth cohort study following 5914 children born in southern Brazil, we examined the role of poverty at birth, in early childhood, and in early adulthood on violence and homicide perpetration, in criminal records up to age 30 years. A novel Structured Life Course Modelling Approach was used to test competing life-course hypotheses about 'sensitive periods', 'accumulation of risk', and 'downward mobility' regarding the influence of poverty on violence and homicide.

RESULTS

Cumulative poverty and poverty in early adulthood were the most important influences on violence and homicide perpetration. This supports the hypothesis that early adulthood is a sensitive period for the influence of poverty on lethal and non-lethal violence. Results were replicable using different definitions of poverty and an alternative outcome of self-reported fights.

CONCLUSION

Cumulative poverty from childhood to adulthood was an important driver of violence and homicide in this population. However, poverty experienced in early adulthood was especially influential, suggesting the importance of proximal mechanisms for violence in this context, such as unemployment, organized crime, drug trafficking, and ineffective policing and justice systems.

The effects of a large-scale home visiting programme for child development on use of health services in Brazil

Partnership between early childhood development interventions and primary health care services can help catalyse health care uptake by socially vulnerable families. This study aimed to assess the real-life effects of a large-scale home visiting programme [Primeira Infância Melhor (PIM)] in Brazil on the use of preventive (prenatal visits, well child visits, dentist visits and vaccination) and recovery (emergency room visits and hospitalization) health services. A quasi-experiment nested in a population-based birth cohort study was conducted. The intervention group was firstly defined as all children enrolled in PIM up to age 6 months, and afterwards stratified between those enrolled during pregnancy or after birth up to 6 months. Children receiving PIM were matched with controls on propensity scores based on 27 confounders to estimate effects on health service use from prenatal to age 2 years. Double adjustment was applied in outcome Quasi-Poisson regressions. No evidence was found for effects of PIM starting anytime up to 6 months (262 pairs), or for the children enrolled only after birth (133 pairs), on outcomes occurring after age 6 months. When the programme started during pregnancy (129 pairs), there was a 13% higher prevalence of adequate prenatal visits (prevalence ratio = 1.13; 95% confidence interval 1.01-1.27), but no effect on use of any other health service. Sensitivity analyses suggested longer participation in the programme with reduced visitor turnover might improve its impact on prenatal visits. Integration between PIM and primary health care was not adequate to affect overall patterns of contacts with health services. Nevertheless, prenatal home visits showed potential to increase health service contact during a sensitive period of development, indicating the need to start such programmes before birth, when there is more time for maternal care, and family engagement in a network of services is facilitated.

Towards a better understanding of real-world home-visiting programs: a large-scale effectiveness study of parenting mechanisms in Brazil

BACKGROUND

The scale-up of parenting programmes to support early childhood development (ECD) is poorly understood. Little is known about how and when early interventions are most effective. Sustainability of ECD programming requires a better understanding of the mechanisms of real-world interventions. We examined the effects on caregiving practices of Primeira Infância Melhor (PIM), a state-wide home-visiting programme in Brazil.

METHODS

This propensity score matched, longitudinal, quasiexperimental study uses data from the 2015 Pelotas Birth Cohort. We matched children who received PIM at any age with other cohort children on 25 key covariates. Sensitivity, guidance and responsiveness were assessed using video-recorded play tasks. Coerciveness and the parent-child relationship were assessed using the Parenting and Family Adjustment Scales. All parenting outcomes were examined at age 4 years. Separate moderation analyses were conducted for each effect modifier: family income, child age and duration of participation.

RESULTS

Out of 4275 children in the cohort, 797 were enrolled in PIM up to age 4 years. 3018 children (70.6%) were included in the analytic sample, of whom 587 received PIM and 2431 were potential controls. We found a positive effect of PIM on responsiveness (β=0.08, 95% CIs 0.002 to 0.16) and sensitivity (β=0.10, 95% CIs 0.02 to 0.19). No effect was found for any secondary outcomes. Moderation analyses revealed a stronger positive effect on sensitivity for low-income parents (β=0.18, 95% CIs 0.03 to 0.34).

CONCLUSION

A state-wide, home-visiting programme in Brazil improved aspects of responsive caregiving. Effects were more pronounced for low-income families, suggesting benefits of purposeful targeting.

Intimate partner violence victimisation and its association with maternal parenting (the 2015 Pelotas [Brazil] Birth Cohort): a prospective cohort study

BACKGROUND

Intimate partner violence (IPV) is highly prevalent in low-income and middle-income countries and has been a major obstacle towards reaching global health targets for women and children. We aimed to investigate cross-sectional and longitudinal associations between IPV victimisation and maternal parenting practices of young children in a population-based birth cohort study in Brazil.

METHODS

The 2015 Pelotas Birth Cohort is an ongoing, prospective cohort, including all hospital births occurring between Jan 1 and Dec 31, 2015, in the city of Pelotas, Brazil. When children were aged 4 years, mothers reported on emotional, physical, and sexual IPV victimisation in the past 12 months. Parenting outcomes were assessed through filming the mother and child in interactive tasks at age 4 years and maternal interviews at ages 4 years and 6-7 years. Interactive tasks were filmed at the Centre for Epidemiological Research facilities. Directly observed outcomes included negative (eg, coercive) and positive (eg, sensitivity and reciprocity) parenting interactions independently coded by a team of psychologists. Self-reported parenting was measured using the subscales on quality of parent-child relationship, positive encouragement, parental consistency, and coercive behaviour of the Parenting and Family Adjustment Scales questionnaire. Unadjusted and adjusted linear regression analyses were performed to assess the associations.

FINDINGS

Of the 4275 livebirths enrolled in the cohort, 3730 mother-child dyads were included in our analytical sample at age 4 years and 3292 at age 6-7 years. After adjusting for all potential confounders, emotional IPV and physical or sexual IPV were associated with the following self-reported parenting outcomes: poor parent-child relationship quality (emotional IPV: p=0·011), lower parental consistency (emotional IPV: p<0·001, physical or sexual IPV: p=0·0053), and more coercive behaviour (emotional IPV: p<0·001, physical or sexual IPV: p=0·0071) at age 4 years. Associations were not observed for self-reported positive encouragement and filmed parenting outcomes in fully adjusted models. Longitudinally, IPV at age 4 years predicted similar outcomes when children were aged 6-7 years.

INTERPRETATION

In this large cohort study, maternal IPV victimisation was consistently associated with poorer parent-child relationship, decreased parental consistency, and increased harsh parenting reported by mothers of young children. As well as initiatives to prevent IPV, parenting interventions focused on supporting the capacity of caregivers to provide nurturing care delivered at key stages early in the life course are crucial.

FUNDING

Wellcome Trust.

TRANSLATION

For the Portuguese translation of the abstract see Supplementary Materials section.

A Tale of Two Programs for Parents of Young Children: Independently-Conducted Case Studies of Workforce Contributions to Scale in Bhutan and Rwanda

Two case studies of parenting programs, aiming to improve parenting practices and child development outcomes, and implemented by Save the Children/Ministry of Health/Khesar Gyalpo University in Bhutan and Boston College/University of Rwanda/FXB in Rwanda, respectively called Prescription to Play and Sugira Muryango, were conducted by an independent research and learning group. Implementation research focused on the workforce, a crucial but little-studied element determining the success of programs going to scale. Mixed methods were used to examine their training, workload, challenges, and quality of delivery. Health assistants in Bhutan and volunteers in Rwanda were trained for 10-11 days using demonstrations, role plays, and manuals outlining activities to deliver to groups of parents (Bhutan) or during home visits (Rwanda). Workers' own assessments of their delivery quality, their confidence, and their motivations revealed that duty, confidence, and community respect were strong motivators. According to independent observations, the quality of their delivery was generally good, with an overall mean rating on 10 items of 2.36 (Bhutan) and 2.44 (Rwanda) out of 3. The facilitators of scaling for Bhutan included institutionalizing training and a knowledgeable workforce; the barrier was an overworked workforce. The facilitators of scaling for Rwanda included strong follow-up supervision; the barriers included high attrition among a volunteer workforce.