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dissertation entitled

PRIMARY PREVENTIONOF INFANT GROWTH AND
DEVELOPMENT DYSFUNCTION: THE PROMOTION OF
POSITIVE PARENTING PRACTICES

presented by
DEBRA KAY TAYLOR '

has been accepted towards fulfillment
of the requirements for‘

PH.D. degfieh, PSYCHOLOGY :-

WWW

Robert A. CaIdweII
MSU is an Affirmative Action/Equal Opportunity Insrilution 0-12771

 

 

 

, LIBRARY
Michigan State
LUnIversity

 

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MSU Is An Affinnative Action/Equal Opportunity Institution
c:\cIrc\dateduaprn3—p.1

 

 

 

PRIMARY PREVENTION OF
INFANT GROWTH AND DEVELOPMENT DYSFUNCTION:

THE PROMOTION OF POSITIVE PARENTING PRACTICES

BY
D. Kay Taylor

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
DOCTOR OF PHILOSOPHY
Department of Psychology

1991

 

s59 - 3x977

ABSTRACT

PRIMARY PREVENTION OF INFANT GROWTH AND DEVELOPMENT
DYSFUNCTION: THE PROMOTION OF POSITIVE PARENTING PRACTICES

BY
D. Kay Taylor
There exists a national need for more primary
prevention in child welfare. One in every four children in
the United States lives in poverty. Low socioeconomic
status characterizes the infant vulnerable for problematic
developmental outcomes. The purpose of this study was to
evaluate a primary prevention effort directed at the
enhancement of parent caretaking and relational skills in an
at-risk population. It was hypothesized that such an
enhancement would influence infant growth and developmental
outcomes. A posttest—only control group design was employed
for this study. Eighty mother-infant pairs were randomly
assigned to either the control or experimental groups.
Control families obtained routine hospital services and the
receipt of education material packets; experimental families
obtained the aforementioned services plus a series of home
visits which provided direct instruction, modeling
techniques, and social support. Post and follow—up
assessment procedures were employed at three—months and six~
months postpartum. Infants of the experimental families
fared better on deveIOpmental scores at three—months, but
there was no difference at six months and no effect on
growth at either measurement period. Future directions for

parenting programs are discussed.

To the memory of my grandparents

ii

 

ACKNOWLEDGEMENT S

I wish to acknowledge the support and guidance provided
by my committee: Robert Caldwell, Anne Bogat, Hiram
Fitzgerald, and Frank Floyd. As the committee chairperson,
Bob's counsel and direction was especially significant.

I wish to thank the nursing instructors and students of
both Hurley Medical Center and Mott Community College. And
of course the families who participated in this study.

Special thanks to the many student interns who assisted
me in numerous ways: Anne Stratton, Cathy Sharich, Sean
Azelton, Sharon Gould, Virginia Scott, Cheryl Carpenter,
Corien van Dis, Aimee Miltech, and Brenda Scales.

Heartfelt thanks to my family for their love and
encouragement: Mom, Dad, Linda, Ed, John, James, Vick, and
Jenny; Mom, Dad, Jim, Nancy, Carmen, Jordan, Aaron, Jill,
Mike, Jason, and Debbie. And to my husband, Jay, my son,
Josh, and my daughter, Tara——I love you for your endless

support and patience.

iii

TABLE OF CONTENTS

Page
LIST OF TABLES viii
CHAPTER
I INTRODUCTION 1
Statement of the Problem . 2
At—Risk Populations 2
Parent Education . 3
Rationale 3
Delivery Mode 4
Content . . 5
Caretaking skills . 6
Relational skills 6
Mechanism . . . . . . . . . . . . . . . . . 7
Effectiveness . . . . . . . . 10
Justification for Study Implementation . . 10
Theoretical Arguments/Concerns. . . . . . . 10
Entry point. . . . . . . . . . . . . . . 10
Program content. . . . . . . . 16
Methodological Arguments/Concerns . . . . . 23
Subjects . . . . . . . . . . . . . . . . 23
Sample size . . . . . . . . . . . . . 23
Risk status . . . . . . . . . . . . . 23
Design . . . . . . . . . . . . . 24
Random assignment . . . . . . . . . . 24
Procedures . . . . . . . . . . . . . 26
Data collection . . . . . . . . . . 26
Measurement. . . . . . . . . . . . . . . 27
Analysis . . . . . . . . . . . 28
Utility Arguments/Concerns. . . . . . . . . 29
Summary . . . . . . . . . . . . 31
Scientific Rationale . . . . . . . . . . 31
Service Rationale. . . . . . . . . . . . 33
II METHOD . . . . . . . . . . . . . . . . . . . . . 37
Hypotheses . . . . . . . . . . . . . . . . . . 37
Setting. . . . . . . . . . . . . . . . . . . . 40
Subjects . . . . . . . . . . . . . . . . . . 42
Restrictions. . . . . . . . . . . . . . . . 42
Number. . . . . . . . . . . . . . . . . . . 44
Demographics. . . . . . . . . . . . . . 45
Equivalency of Groups . . . . . . . . . . . 46
Design . . . . . . . . . . . . . . . . . . . . 46

iv

Procedures . . . .
Recruitment . . . . .
Intake and Informed Consent .
Assignment to Conditions.
Data Collection .

Conditions .

Control Condition . .
Experimental Condition.

Training of student nurses/parent aides.

In— hospital services
Aftercare services
Measures . . .
Caretaking Skills . .
Feeding. . . . .
Formula preparation . . . . .
Feeding questionnaire . . . .
Hygiene. .
Safety .
Organization of environment
Safety questionnaire. . .
Health . .
Clinic records. .
Health questionnaire.
Relational Indices.
Child— rearing Attitudes.
PARI. . . . . .
Avoidance of restriction/punishment
Developmental Knowledge. .
Expectancy scale.
Competency. . .
Mother- Infant Interaction.
Verbal stimulation.
Emotional/verbal responsivity
Infant Outcomes . . . . .
Growth Indices . . . . . .
Developmental Skills

Additional Evaluation Areas
Implementation/Process
Efficiency . .
Unintended Outcomes.
Successful/Unsuccessful Participants
Summary. .

III Results

Condition/Time Effects
Caretaking Measures
Feeding. . . .
Formula preparation

V

Page

48
48
48
49
50
50
50
52
53
54
54
57
58
58
58
61
64
66
66
66
68
68
7O
71
71
71
75
78
78
81
81
81
83
85
85
89
95
95
96
97
98
99

101

101
103
103
103

Feeding questionnaire
Safety . .
Health .

Relational Measures
PARI
Developmental Knowledge.

Expectancy questionnaire.
Competency interview.
Interaction.

Infant Measures . . . . .
DDST . . . . . . . . . . . .
Growth

Summary

Predictors of optimal Infant Outcomes.

Three— Months Postpartum .
Infant Development
Infant Growth.

Six—Months Postpartum
Infant Development
Infant Growth.

Implementation/Process Considerations.

Implementation.

Process .
Efficiency Considerations.
Unintended Outcomes. .
Successful Program Participants

III DISCUSSION

Condition/Time Effects
Caretaking Skills
Relational Indices
Infant Outcomes

Predictors of Optimal Infant Outcomes

Implementation/Process Considerations
Implementation
Process .
Efficiency Considerations
Unintended Outcomes .
Successful Program Participants
Implications and Conclusions
Study Strengths .
Study Weaknesses . . . . . .
Future Directions for Research

vi

Page

103
106
106
106
106
105
105
108
108
108
108
108
111
111
113
113
113
115
115
116
116
116
118
119
121
121

125
125
127
128
129
130
130
131
132
134
135
137
137
138
141

Page

IV REFERENCES 144

V APPENDICES

A. Informed Consent . . . . . . . . . . . . 147
B. Student Nurse Contract . . . . . . . . . 149
C. Training Schedule . . . . . . . . . . . . 150
D. Program Materials . . . . . . . . . . . . 152
E. Measures . . . . . . . . . . . . . . . . 183
F. Coding Guide . . . . . . . . . . . . . . 215

vii

Table

10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.

24.

LIST OF TABLES

Examination of Published Studies

Comparison of Services

Home Visit Topic Areas

0

Caretaking Skills Measurements

0

Measurement Refinement Outcomes: Caretaking

Internal
Internal
Internal
Internal
Internal

Internal

Consistency
Consistency
Consistency
Consistency
Consistency

Consistency

(Formula Preparation)

(Feeding - 3 Months).

(Feeding — 6 Months).

(Safety - 3 Months)

(Safety — 6

(Health — 6

Relational Indices Measurements

Measurement Refinement Outcomes:

Internal
Internal
Internal
Internal
Internal
Internal

Internal

Consistency
Consistency
Consistency
Consistency
Consistency
Consistency

Consistency

(Attitude —
(Attitude —
(Expectancy
(Expectancy

(Competency)

Months)

Months)

Relational

3

6

I

Months)

Months)

3 Months)

6 Months)

(Verbal Stimulation)

(Emotional/Verbal)

Infant Outcome Measures

Measurement Refinement Outcomes:

Internal Consistency (Growth — 3 Months)

Infant

0 O

Internal Consistency (Growth — 6 Months)

viii

O

0

Page

34
51
56

59

62
63
65
67

69

73
74
76

77

82
84
86
87
88
90

90

25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.

41.

Internal Consistency (DDST — 3 Months)

Internal Consistency (DDST — 6 Months)

Scope of Evaluation

Summary of Means and Standard Deviations
Analysis of Variance (Formula Preparation)
Repeated Measures (Feeding Questionnaire).

Repeated Measures (Safety Questionnaire)

Repeated Measures (PARI)

Repeated Measures (Expectancy Questionnaire)

Analysis of Variance (Competency)

Repeated Measures (DDST)

Summary of Results

Stepwise Regression (DDST - 3 Months)

Stepwise Regression (DDST — 6 Months)

Projected Program Budget

Unintended Outcomes

Summary of Comparison Variables

ix

0

Page
92
93

100
102
104
106
106
107
109
109
110
112
114
117
120
122

123

CHAPTER I

INTRODUCTION

In their review of the history of the developmental
study of infants, Kopp and Krakow (1983) identified four
research phases. First, from 1920 to World War II, research
about risk conditions showed diverse themes. The articles
were scattered in a variety of journals, and were often
produced by professionals other than developmentalists.
Second, during the postwar years, research focused on the
cognitive and emotional consequences of various handicaps,
particularly cerebral palsy and poliomyelitis. Third, the
1960s produced research about the characteristics of infants
and children at risk. This period of research mirrored the
social and political consciousness of the times. Study
findings emphasized the link between poor developmental
outcomes and disadvantaged environments-—involving infants
largely of the poor, the black, and the very young.

Finally, the 1970s onward is viewed as the "growth" decade
for developmental research. The entry of new ideas,
theoretical perspectives, and models marks this era.
Directed by the knowledge gained in the previous decade of
those factors which threaten optimal development,

researchers turned toward the task of implementing primary

preventic
and testi
preventir

of the g:

A}
generallj
develOpml
parent 5'
(Olds, H
environm
Signific
Children
a Variet
(Lempers
Effects
enVironr
(Michiga
1989; w
Status (
1985), e
Midelfox
environn

accident

prevention strategies. However, the emergence of the design
and testing of interventions with the objective of

preventing the consequences of risk has been slow in spite

of the great need.

Statement of the Problem
At-Risk Populations
Any one of the following characteristics are
generally believed to predispose an infant to health and
develOpmental problems: (a) young age of mother, (b) single~
parent status, and (c) low socioeconomic status of family
(Olds, Henderson, Chamberlin, & Tatelbaum, 1986). Family
environments and social conditions appear to exert a
significant influence on the health and development of
children. Economic hardship is known to be associated with
a variety of physical and psychological problems in children
(Lempers, Clark—Lempers, & Simons, 1989). Developmental
effects or outcomes associated with high~risk families and
environments include increased health/medical problems
(Michigan Department of Social Services and Public Health,
1989; Wise & Meyers, 1988), lower intellectual/cognitive
status (Sameroff & Seifer, 1987; Schweinhart & Koshel,
1986), and lags in language development (Leventhal &
Midelfort, 1986; Walker, 1989). Children of these high—risk
environments are subject to greater inflicted trauma,

accidental trauma, nonorganic failure to thrive,

 

 

 

 

failure t
I White,
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failure to thrive, and poisoning (Newberger, Hampton, Marx,
& White, 1986; Parker, Greer, & Zuckerman, 1988).
Consequently, these families are targeted for inclusion in

primary prevention studies.

Parent Education

The major objectives of primary prevention are the
promotion of healthy development and reduction of
vulnerability. Research or program efforts have generally
focused on parent education. It has been thought that the
promotion or enhancement of competencies in this arena would
serve to buffer the children of high-risk families from
potential developmental dysfunctions.

Rationale

It is generally assumed that parenting skills are
instinctive, or develop naturally as a part of having been a
member of a family. However, changes in family structure
have prompted many professionals to challenge such an
assumption (Boger, 1983; Hicks & Williams, 1981; Hughes &
Durio, 1983;) The large extended family of two or three
generations ago provided ample opportunity for experiences
with young children that today's small, mobile, nuclear
family cannot offer. Urbanization has isolated individual
families from their supportive extended families. Also,
families are smaller with fewer adults and fewer children.

Other structural changes include the dramatic increase of

 

 

 

both pare
reconstii
provided
respond 1

(Roberts

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these a

unSuite

both parents in the labor market, single parents, and
reconstituted families. It is assumed that if parents are
provided with knowledge, skills, and support, they can
respond more positively and effectively to their children
(Roberts, Wasik, Casto, & Ramey, 1991).
Delivery Mode

In recent years there has been a rapid growth in
parent education activities. The most popular strategies
for dissemination of child care information include the
print (magazines, books) and television mediums. In
addition to these avenues, parenting workshops or programs
have been made available to parents. Program methods in
general use include teaching parents in groups, singly, by
means of directed observation of children, and/or the use of
special devices such as reading assignments. Educational
methods include lecture, discussion, role play, and
simulation. The lecture method is perhaps the most overused
and highly ineffective means of acquiring information (Hicks
& Williams, 1981). Hughes and Durio (1983) have questioned
the effectiveness of these modes of parent information
dissemination. Other researchers have echoed such
sentiments (Clarke—Stewart, 1978; Kazdan, 1979; Stevens,
1978;). Abram and Dowling (1979) have also pointed out that
these avenues of parent education/training are especially

unsuited for the less well—educated or low

 

 

socioecor
instructi
research
informat:
deliverii
Advocate:
effectivI
educatIO‘
have see

is expec

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regardin
Parent e
general
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"normal"
There is
Skills,
family c
in Parer
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relatim

 

socioeconomic parent—~who may be in greatest need of such
instruction. Hughes and Durio (1983) concluded that
research has provided us with guidance as to what types of
information are important, however, the techniques for
delivering this information are fraught with many problems.
Advocates for low socioeconomic families stress the
effectiveness of the home as a setting for intervention/
education activities (Roberts et al., 1991). Recent years
have seen an increase in home visiting services. This trend
is expected to continue.
Content

Although conclusive research data are limited
regarding the effectiveness of the various approaches to
parent education, there exists within the profession a
general consensus that certain types of parenting patterns
are detrimental whereas others are conducive to a happy,
"normal" growth and development (Hicks & Williams, 1981).
There is a sizeable body of knowledge concerning parental
skills, knowledge, and attitudes that is related to optimal
family outcomes. Information that is selected for inclusion
in parenting programs can be divided into two broad
categories: (a) caretaking skills information, and (b)

relational skills information.

 

 

 

Insist!
P]
the feed:
feeding ‘
problems
care, di.
(institu
caring f
visits,
R
caretaki
Farber (
a high-r
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Caretakj
Outcomes
Taylor's
feeding
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between

Pr<

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Child mi

and Par.

 

CaretakingVSkills

Program participants generally receive instruction in
the feeding of infants (breast feeding, formula preparation,
feeding techniques, amounts, schedules, common feeding
problems and recommended solutions), hygiene regimens (cord
care, diapering practices, bathing), and health guidelines
(institution of safety precautions in the home environment,
caring for the ill infant, immunization schedules, well—baby
visits, nutrition).

Recent studies have demonstrated the importance of
caretaking proficiency to infant development. Egeland and
Farber (1984) in their study of infant—mother attachment in
a high—risk population (=economically disadvantaged
families) found that qualitative differences in mother
caretaking skills were more highly related to optimal infant
outcomes than were mother nurturant behaviors. Similarly,
Taylor's (1989) study of mother—infant interaction (in a
feeding session utilizing Egeland's
tool) found that caretaking skill level best discriminated
between organic and nonorganic failure—to—thrive infants.

Relational Skills

 

Program topics generally include child development
norms (e.g., stages of personal or social development),
child management techniques (e.g., methods of discipline),

and parent—child relationship development (e.g., emotions

 

and their
It
that a Si
“factual'
routine c
domain (I
that cha:
extended
interact
and Weis
quality
modeling
breakdow
0f prOgr
the impo
CaPabili
Process
m0deling
an under

Capabiij

the PIOI

Predict

 

and their expression).

It is important to note that many professionals feel
that a successful program must not only contain the
"factual“ information about parenting (the process of
routine caretaking skills), but must focus on the affective
domain (Marion, 1982). Ruger and Wooten (1982) reported
that changes in their family life education program has
extended the content far beyond information to emphasize the
interactional aspects of parenting. Dietrich, Starr,
and Weisfeld (1983) concluded that attempts to improve the
quality of caretaker-child interaction through teaching and
modeling can play an important role in preventing a
breakdown in adequate caretaking. Boger (1983) is critical
of programs which are highly “how to" oriented—~stressing
the importance of a parent/infant transaction and infant
capabilities focus. Parenting is defined as a "holistic“
process that may require extensive support, education, and
modeling of behavior. Caregiving skills are important, but
an understanding of the physical, psychological, and social
capabilities of the newborn is also necessary.

Mechanism

 

While the major objectives of primary prevention are
the promotion of healthy development and the reduction of
vulnerability——how is it that parent education programs are

predicted to accomplish these goals in a high-risk

 

 

populati<
interven‘
developm:
recent al
analysis
developm

In

dev

pre
stres
depre
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mater
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in an

In Jolly
the chi}
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the 1
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ideni
(P. I
JollY ne
(1988)<
provide:
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optimal

 

population? In general, educational strategies for
intervention have grown from a transactional model of child
development. Parker, Greer, and Zuckerman (1988) offered a
recent account of this model of development in their
analysis of the impact of poverty on early child
development:

In a low SES environment, more risk factors for adverse

developmental and behavioral outcomes are likely to be

present. The most pertinent of these include increased
stress, diminished social support, and maternal
depression. These risk factors, in turn, exert their
influence on the child through the quality of the home
environment and the parent—child interactions, to name
two of the most widely studied mechanisms. Changes in
maternal depression) can create positive transformations
any aspect of the ecology of the child's world (e.g.,
in another (e.g., environmental stimulation). (p. 1229)

In Jolly's (1988) assessment of the impact of deprivation in
the child's environment, he also offered the following point
of hope:

One does not need to look far to find some surprising
strengths in many situations which persist in a context
of poverty. The ability of many households to fulfil
the needs of the child, despite situations which put the

child at risk, points to avenues which should be
identified, encouraged, and studied for application.

(p. 24)

Jolly named the identical "avenues" which Parker et al.
(1988) detailed. He concluded that the quality of care
provided by the parent, and the affective quality of the
early parent-child relationship were the basic
characteristics which encouraged, fostered, and stimulated

Optimal infant and child growth.

 

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the need
adaptatii
services
caregivi
inadequa
mechanis

W
review 0
to stren

Based
famil
its

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a set
enhar
of ve
and r
estee
and j
The prin
grOWth (
prOVide
also out
inherem
concel‘m
nondefii

QuestioE

 

Advocates for children from high—risk families stress
the need to focus on those factors that promote successful
adaptation in children. Parent educational
services/programs are intended to enhance the quality of
caregiving thereby ameliorating risk factors (e.g.,
inadequate social support) and enhancing protective
mechanisms (e.g., improving the health status of children).

Weiss (1989) offered the following summary in her
review of preventive family support and education programs
to strengthen families:

Based on the ecological premise that factors outside the
family affect the family's capacity to nurture and rear
its children, these programs frequently fill an empty
niche in the continuum of community services. They
provide a variety of types of social support to achieve
a set of interrelated ends. These include the
enhancement of child health and development; prevention
of various child and family dysfunctions, such as abuse
and neglect; enhancement of parental knowledge, self—
esteem, and problem solving; and promotion of informal
and formal community support for families. (p. 32)
The primary intent of Weiss' paper was to emphasize the
growth of public interest in programs and policies that
provide support and education to high—risk families. She
also outlined critical areas identified as "challenges"
inherent in the proliferation of such programs including
concerns of family privacy and the implementation of a
nondeficit service delivery ideology. Although she did not

question the need to assess the effectiveness of these

programs, this certainly should be a primary concern.

 

 

T
the chan
unknown.
publishe
measurem
and/or f
followin
problems
effectiv
studies
an evalr
divided

methodo]

Mm

during 1
adjustm‘
researc‘;
L0wry,

Heinick
Jerauld

Britten

10

Effectiveness

The effectiveness of parent education in producing
the changes hoped for in parents and Children is simply an
unknown. Reported research is meager. Most programs in
published reports list vaguely stated goals, contain no
measurement of behavioral change, are limited in scope,
and/or fail to utilize an experimental design. The
following review should serve to highlight the major
problems which have hampered progress in demonstrating the
effectiveness of prevention programs. Each of the reviewed
studies represent educational interventions which include
an evaluation of impact on the infant. This review is
divided into the three major sections of theoretical,

methodological, and utility arguments/concerns.

Justification for Study Implementation
Theoretical Arggments/Concerns
Entry point
One—half of the reviewed studies failed to intervene

during the critical early postpartum period—~the time when
adjustment to parenthood is at its peek. Substantial
research has shown the vulnerability of this period (Ali &
Lowry, 1981; Boger, 1983; Danziger, 1979; Garbarino, 1980;
Heinicke, Diskin, Ramsey—Klee, & Given, 1983; Klaus,
Jerauld, Kreger, McAlpine, Steffa, & Kennell, 1972; Lozoff,

Brittenham, Trause, Kennell, & Klaus, 1977; Rising, 1974;

Rubin, 1'
“vulnera
stress/a
receptiv
early pa

interact

parent-t
competen
infant r
continge
infant;

readable
reSponse
Continge
EXPEIimt
includer
infant i
neEds, .
PIOgram
Weeks, .
tWelVe :
obSQIVa

resPOnd

m0re fr

11

Rubin, 1975; Stranik & Hogberg, 1979). This judgment of
"vulnerability" is based on evidence of increased
stress/anxiety experienced at this time, a greater
receptivity to ideas/assistance, and the predictive value of
early parenting behavior regarding later parent—child
interactions.

Dickie and Gerber (1980) studied the effects of a
parent—training program designed to increase parent—infant
competence (parent competence involving the anticipation of
infant needs, reading of infant cues, and responding
contingently, as well as initiating contacts with the
infant; infant competence involving the provision of
readable, predictable cues to parents, elicitation of
responses from the environment, and responding often and
contingently to parents and the environment).

Experimental parents attended a training program which
included discussions and lectures on child development,
infant temperament and individuality, parent feelings and
needs, contingent responding, and problem solving. The
program, which consisted of a total of 16 hours over 8
weeks, was initiated when infants were between four and
twelve months. It is interesting to note that although
observation measures indicated that the experimental parents
responded more appropriately to infant cues, and provided

more frequent verbal and non—verbal contingent

 

response
affected
initiate
percepti
I
potentia
health a
objectix
environn
infant j
pairs) v
conditic
the seve
Visit f:
15 mont]
during .
months .
receive.
Larson
enViIOn
interac
were be
Visits
to haVe

LarSOH

12

responses, self—report measures of competence was not
affected by training. Perhaps if the training had been
initiated earlier—~it may have served to impact on the
perception of competence.

Larson (1980) sought to evaluate the preventive
potential of prenatal and postpartum home visits on infant
health and development with working class families. Program
objectives included well—child care, enhancement of home
environment, and the promotion of more positive mother—
linfant interaction patterns. Subjects (115 mother—infant
pairs) were assigned to one of three experimental
conditions: group A received a prenatal home visit during
the seventh month of pregnancy and a postpartum hospital
visit followed by nine home visits during the child's first
15 months of life; group B received 10 home visits beginning
during the infant's sixth week of life through 15
months of life; and group C served as the control and
received no visits or other forms of intervention.

Larson reported higher scores for assessments of home
environment and maternal behavior and lower prevalence of
interaction or feeding problems in group A (in which visits
were begun prenatally), however, Group B (in which home
visits began when infants were six weeks of age), appeared
to have gained little when compared to control pairs.

Larson subsequently claimed that these results demonstrated

the effi
pregnanc
dimensio
the sing
recogniz
postpart
after 6
critical
h
(ILP) in
parents
this prc
infant v
exPerier
emPhasi:
the PIOY

these 5}

13

the efficacy of a home visitor program if begun during
pregnancy. But because groups A and B differed on multiple
dimensions, it is not possible to claim group A's success on
the single issue of prenatal contact. Larson failed to
recognize——or attach significance——to the issue of the early
postpartum period. Group B's visits did not begin until
after 6 weeks postpartum——thus excluding a recognized
critical time of adjustment for the new family.

Metzl (1980) utilized her Infant Language Program
(ILP) in an intervention designed to teach middle—class
parents a strategy for enhancing infant development. In
this program, the parent was encouraged to provide the
infant with varied and increasingly complex stimuli and
experiences. It was hypothesized that instruction which
emphasized the infant's early potential for interaction, and
the provision of techniques for generating and responding to
these subtle early interactions could create a higher
quality relationship between parent and child. Subjects
(60) were randomly assigned to one of three groups: control,
mothers receiving the ILP, and mothers and fathers receiving
the ILP simultaneously. A trainer made home visits for
instruction when the infants were 6, 12, and 18 weeks old.
Testing at 6 weeks and 6 months revealed that infants in
groups two and three scored higher on the Bayley Mental

Standard Scores, and the environments of both

groups w
effects
training
that the
example,
the Bayl
Group 3
may have
By choos
6 weeks
the ear:
daifs/wee
1
Program:
governm.
nOnaranu
Occurri
Partici
QYOUp 0
program
Mothers
weekly
buildin
SuPPOrt

lmPIOVe

 

14

 

groups were rated higher on the HOME index. (Beneficial
effects were greater when both parents had received the
training.) An examination of mean scores, however, revealed
that the actual impact of training was minimal. For
example, Group 1 and Group 2 differed by only four points on
the Bayley scores, and only two points separated Group 1 and
Group 3 on the Caldwell scores. Stronger treatment effects
may have been obtained if the point of entry had differed.
By choosing to initiate home visits when the infant reached
6 weeks of age, the recognized critical adjustment period of
the early postpartum

days/weeks was ignored.

Resnick (1985) examined the effects of two prevention
programs for sole—support mothers (single mothers living on
government assistance) with pre-school—aged children. A
non—randomized design was employed with select measures
occurring before, after, and one year following
participation in the two intervention groups and for the
group of matched comparison subjects. Both experimental
programs (Opportunity for Advancement and New Directions for
Mothers) were similar in nature. Each consisted of 14
weekly groups sessions. Program objectives were esteem
building and goal setting with an emphasis on strengthening
support networks. Program philosophy stated that

improvement in the individual's life skills would result in

 

improved
There we
parent-c
of long-
function
However,
women wi
parentir

]
training
competer
twelve r
(designe
include<
infants
her Inf.
Parents
Choose -
Resnick
Program
rationa
these 8
there w

eXplore

 

15

 

improved parenting. Project results were disappointing.
There were no significant differences in parent attitudes or
parent-child interactions. Resnick concluded that the lack
of long—term competency enhancement effects appeared to be a
function of the short—term, low—intensity program approach.
However, an equally "valid" interpretation would be that
women with pre-school—aged children have established
parenting practices which most likely resist change.

In summary, Dickie and Gerber's (1980) parent—
training program designed to increase parent~infant
competence was initiated when infants were between four and
twelve months; Larson’s (1980) home visitor program
(designed to improve infant health and development outcomes)
included one study group in which home visits began when the
infants were six weeks of age; Metzl (1980), who utilized
her Infant Language Program in an intervention to teach
parents a strategy for enhancing infant development, also
choose to begin intervention at six weeks postpartum; and
Resnick (1985) targeted pre—school—aged children with a
program designed to improve parent—child interactions. The
rationale for point of entry was not detailed in any of
these studies. Furthermore, it is interesting to note that
there was no consideration of "delayed" entry when authors

explored reasons for the failure of the intervention.

 

success.
certainl
postpart
vulnerah
opportur
attentic
force tc
detailec
interveI

the infe

Mm

reCOgni:
Interve:
nature.
informa
in gene
Profici
was not
StUdies
Caretak
Farber

a high-

familie

16

Early intervention does not in itself guarantee

 

success. This timing may not be essential——but the evidence
certainly reveals that it is beneficial. The early
postpartum period—-because it is regarded as a time of high
vulnerability-—should be approached as a time of ideal
opportunity. When designing primary prevention efforts,

attention to entry or timing may serve to lend power or

 

force to the planned intervention. The study/intervention
detailed here "seized" this opportunity by initiating
intervention in the hospital setting following the birth of
the infant.
Program Content

Three—fourths of the reviewed studies failed to
recognize the significance of caretaking proficiency.
Intervention components were of a relational competency
nature. A very small percentage of programs included
information about basic child care skills. It appeared that
in general researchers have assumed either that caretaking
proficiency was unimportant, or that the target population
was not in need of instruction in this area. Recent
studies, however, have demonstrated the importance of
caretaking proficiency to infant development. Egeland and
Farber (1984) in their study of infant—mother attachment in
a high-risk population (=economically disadvantaged

families) found that qualitative differences

 

in mothe
optimal
behavior
infant 5
tool) fc
between

(
educati<
African-
routine
series .
of life
second,
Visits -
tactile
Study c
Point 0
focus 0
parenti
address
data re
Signifj
Intellj
mean Sc

mother

17

in mother caretaking skills were more highly related to
optimal infant outcomes than were mother nurturant
behaviors. Similarly, Taylor's (1989) study of mother—
infant interaction (in a feeding session utilizing Egeland's
tool) found that caretaking skill level best discriminated
between organic and nonorganic failure-to-thrive infants.
Gutelius and Kirsch (1975) described a parent-infant
education program in which the mothers of 92 firstborn
African—American infants were randomly assigned to high and
routine contact groups. High contact groups received a
series of home visits by a nurse during the first 3 years
of life. Visits numbered eight, six, and four in the first,
second, and third years of life. The purpose of these
visits was to provide instruction in the visual, auditory,

tactile, and motor stimulation of infants. Although this

 

study contained some ideal design features——such as early
point of entry—-its scope was much too limited. The narrow
focus on infant stimulation ignored other important areas of
parenting skills. Instructional sessions did not
address/explore caregiving basics. An analysis of project
data revealed that although experimental infants scored
significantly higher at 3 years of age on the Stanford—Binet
Intelligence Test, Form L—M (a mean score of 102 versus a
mean score of 96), there were no significant differences on

mother or child interactive behaviors.

 

 

F
parent-t
to twelx
lectures
individr
respond;
compete]
importa:
althougi
period)

caretak

Provide
lower-c
infants
team (i
African
were as
mileStc
apprOpI
facilit
infants

hOpeS C

18

As described previously, Dickie and Gerber's (1980)
parent—training program involved parents of infants age four
to twelve months attending a series of discussions and
lectures on child development, infant temperament and
individuality, parent feelings and needs, contingent
responding, and problem solving. Self—report measures of
competence was not affected by training. Again, it may be
important to consider the scope of the intervention. For
although the majority of a parent's time (during the infancy
period) may be devoted to caretaking behaviors--
caretaking skills were not addressed.

Field, Widmayer, Stringer, and Ignatoff (1980)
provided a home-based, parent—training program for teenage,
lower-class, African—American mothers and their preterm

infants. Home visits were made biweekly by a two-person

 

team (including a trained interventionist and a teenage,
African—American female work/study student). Program goals
were as follows: (a) to offer instruction in developmental
milestones and child rearing practices, (b) to teach age-
appropriate stimulation techniques/exercises for
facilitating sensorimotor and cognitive development in
infants, (c) to enhance mother-infant interactions with

hopes of developing communication skills and creating more

 

 

positive
reportec
receivec
Developr
months.

more op1
milestor
ratings
group r.
Invento:
are imp
Will be
neglect
cannot

hOlisti

Infant
Promote
and inc
regults
(i.e.,

the int

emPhasj

potentj

19

   

positive mother—infant relationships. Field at al. (1980)
reported that the preterm infants of teenage mothers who
received intervention showed more optimal growth, Denver
Developmental scores, and face—to—face interactions at 4
months. Also, mothers rated their infants' temperaments
more optimally, expressed more realistic developmental
milestones and child rearing attitudes, and received higher
ratings on face—to-face interactions. At 8 months, this
group received superior Bayley mental, Caldwell (HOME
Inventory), and infant temperament scores. These results
are impressive (although certain methodological concerns
will be addressed later)——but again, program goals
neglected the enhancement of basic caregiving skills. One
cannot help but ponder the potential for impact if a more
holistic approach had been adopted.

As described previously, Metzl (1980) utilized her
Infant Language Program (ILP) in an intervention designed to
promote infant development through the provision of varied
and increasingly complex stimuli to infants. Project
results, although statistically significant, were minimal
(i.e., increases in mean scores were small). The focus of
the intervention was quite limited. The restricted
emphasis on relational skills ignored the importance of the

potential contribution of enhancement of caretaking skills.

V
the fol]
interver
incidenc
Do their
developr
parentii
support.
number
history
graduat
an adol
eXperim
Service
Workers
women w
less in
to four
months)
9r0wth
materne
mother
incideI
PlaCemf

serViCe

20

 

Velasquez, Christensen, and Schommer (1984) examined
the following three questions: (a) Can intensive, early
intervention with high—risk mothers result in reduced
incidence of abuse, neglect, and out—of—home placement? (b)
Do their infants attain normal/optimal growth and
development? (c) Does intervention lead to improvement in
parenting skills and a parent's ability to deve10p a
supportive network? High—risk status was determined by a
number of family—background indicators such as childhood
history of abuse, foster home placement, high school non-
graduate, alcohol or drug abuse, involvement with police as
an adolescent. Twenty-three women were assigned to the
experimental group which received intensive health care
services (= 2 to 4 hours of contact with nurses and social
workers every week for a minimum of 18 months). Thirty—two
women were assigned to the comparison group which received
less intensive health—related services (=visits at two—week
to four—week intervals with termination at approximately 13
months). Services included teaching mothers about infant
growth and development, feeding patterns and practices,
maternal concerns, health, and attachment issues between
mother and infant. Reported outcomes included a reduced
incidence of child abuse and neglect as well as out—of—home
placement (based on reported incidents with the area social

services department), the promotion of normal growth

 

 

of the i
and the
from the
Statistf
the out<
of these
the pro,
of thej
design .
flaws--
on pare
limited
that so
importa

were ig

improve
indivic
setting
in the
attituc
a Wide}
baSiCs.

enhanC<

21

of the infant (based on measurements of weight and height),
and the promotion of normal development (based on scores
from the Denver Developmental Screening Test).

Statistically significant differences were not obtained on
the outcomes of parenting skills and support networks (both
of these outcomes were measured by two scales developed by
the project investigators). Although the credibility of any
of the project outcomes is highly suspect—-as the study
design and implementation contained gross methodological
flaws--it is interesting to note the lack of program effects
on parenting skills. Perhaps this failure was the result of
limited attention to basic child care skills. It appeared
that some feeding issues were addressed, but other

important child care practices such as hygiene and safety
were ignored.

As described previously, Resnick (1985) attempted to
improve parenting outcomes through the improvement of the
individual’s "life skills" (e.g., esteem building and goal
setting). Project results were disappointing. Involvement
in the model programs did not appear to impact on parent
attitudes or parent—child interactions. Again, attention to
a wider range of parenting skills——including caretaking
basics——may have served to produce the long—term competency
enhancement effects hOped for.

In summary, the parent—training programs evaluated by

 

 

 

 

Gutelius
Ignatoff
stimulai
sensoriI
and Ger]
needs--i
skills.
Christe
0f pare

basic c

Signifi
ignored
Interve
Compete
Care sk
time de
Period.
holistj
Careta}

represe

22

Gutelius and Kirsch (1975), Field, Widmayer, Stringer, and
Ignatoff (1980), and Metzl (1980) primarily focused on
stimulation techniques aimed at facilitating the
sensorimotor and cognitive development in infants. Dickie
and Gerber (1980) stressed infant and parent feelings and
needs-—while Resnick (1985) concentrated on parent life
skills. Finally, the intervention designed by Velasquez,
Christensen, and Schommer (1984) addressed a greater number
of parenting issues, however, there was limited attention to
basic child care skills.

An examination of program content revealed that the
significance of caretaking proficiency was generally
ignored. The scope of the model programs was non—holistic.
Intervention components were most often of a relational
competency nature. This lack of attention to basic child
care skills is unfortunate when one considers the amount of
time devoted to caretaking activities in the early parenting
period. This study/ intervention viewed parenting as a
holistic process. The importance of both relational and
caretaking skills was recognized. Intervention components

represented an attempt to strengthen or enhance each area.

 

 

 

 

Subject:

sample

consist
(1980)

(1980)

Velasqu
subject
10, and
aforeme
the fig
complet
treatme
C0mplet

0f the

low~ris
estimal
approal
childr.
(1985)

target

23

Methodological Arguments/Concerns

 

Subjects

Sample size.
One-half of the reviewed studies based conclusions on
sample sizes of which at least one treatment or condition

consisted of only 10 to 23 group members. Dickie and Gerber

 

(1980) compared two groups with 19 subjects each; Metzl

 

(1980) compared three groups with 20 subjects each;
Velasquez et al. (1984) compared two groups with 23 and 32
subjects; and Resnick (1985) compared three groups with 10,
10, and 13 subjects. (Although for some of the
aforementioned studies the original sample size was greater,
the figures presented here represent the number on which
completed data was obtained.) This study generated two
treatment groups with forty members in each condition.
Completed data was obtained on 72 subjects——or 90 percent
of the original sample.

Risk status.

More than one-third of the reviewed studies targeted
low-risk individuals-—although common procedures for target
estimation (including the key informant and the indicators
approach) highlight the vulnerability of infants and
children living in poverty. Rossi, Freeman, and Wright
(1985) argue that evaluation will be most efficient when the

targets reached are restricted to units that need the

 

 

interver
providir
reduce 1
(St. Pi!
with Si:
more sil
subgrou‘
specula
poverty
focus.)
pairs.

menu

not rar
Larson'
had shc
Shared
theref(
random;

have or

POSsib
the ab

24

 

intervention. Random sampling may be appropriate for
providing descriptive information, but practical constraints
reduce the utility of random sampling for impact evaluations
(St. Pierre & Cook, 1983). Intervention

with single, poor, or unmarried women appears to result in

 

more significant program effects than that offered to other

subgroups (Roberts et al., 1991). (It is interesting to

 

speculate if the difficulties inherent in working with
poverty families serves to deter researchers from such a
focus.) This study recruited only low-income mother-infant
pairs.

Design

Random assignment.

Approximately 40 percent of the reviewed studies did
not randomly assign subjects to treatment conditions. In
Larson's (1980) project, it was claimed that a pilot study
had shown that mothers who received a hospital visit had
shared their experience with other women in the same room-—
therefore, group A mothers were not included in the
randomization in order to avoid the effect these women might
have on the hospital experience of mothers in groups B and
C. (Such a trade—off seems questionable, for although a
possible reduction in potential "contamination" was gained,
the ability to infer causation was lost.) Assignment to

groups B and C was random——followed by the

 

enrollme
The gror
(Group I
interver
interver
intense
mothers
volunte
interes
perform

rather

 

25

 

enrollment of group A mothers until a predetermined date.
The group A intervention represented the experimental model.
(Group B was thought of as a control for the timing of
intervention, and Group C as a control for the
intervention.) Because the group A program was the most
intense (demanding the greatest time commitment from the
mothers), it seems plausible that those women who
volunteered for that group may have been more serious, or
interested, or enthusiastic. Consequently, their superior
performance may be the result of these motivational factors
rather than the experimental condition.

Velasquez et al. (1984) claimed that "although random
assignment of subjects to concurrent treatment and control
groups would have produced more credible results, this
alternative was neither possible or desirable“. The stated
reason for this decision was a concern that the project's
staff would be prevented from discussing their services with
other health care professionals~—thus the treatment (=
intensive health services) and control (= less intensive
health services) groups received intervention at different
times. It was felt that if discussion between health care
professionals took place——the differences between the
services would have gradually become less distinct. In
summary, the rationale for not incorporating random

assignment into the study design was that it would

 

 

interfer
approacl
seems qr
potentia

to infe:

stated

experim
recruit
for Adv
targete
0f volu

local r

assign“
inferer

Mu

 

26

 

interfere with "legitimate testing of the treatment
approaches". As with the Larson study, such a trade~off
seems questionable——for although a possible reduction in
potential contamination may have been gained, the ability
to infer causation was lost.

Finally, Resnick's (1985) study--although it was
stated that certain hypotheses were "tested"——was pre—
experimental or correlational in nature. Women were
recruited from two existing prevention programs (Opportunity
for Advancement and New Directions for Mothers) which
targeted impoverished families. A control group consisted
of volunteers solicited from posters and advertisements in
local newspapers and radio.

The presented study design incorporated random
assignment of subjects to conditions thus permitting causal
inferences.

Procedures

Data collection.

In one—fourth of the reviewed studies there was
evidence that blind raters were not employed in the
administration of tests. The status of those who
administered measures was not clearly stated in Resnick's
study (1985), and testers were aware of group
assignment/membership in the Velasquez et al. project.

This situation existed because the same individuals who

 

acted a
appear
inciden
be redu
interve
to the
or not
(=those
health-
who rec
group n
timing
example
were me
intake
COmpari
study,

aSSiSt;

publis
negleC
Proble
In thi

eviden

27

acted as interventionists also collected data. This would
appear to be especially dangerous when examining reported
incidence of abuse and neglect (which the authors claimed to
be reduced in the experimental group) since the
interventionists were also the ones to report such concerns
to the authorities. A legitimate questions would be whether
or not they would be more likely to report a control family
(=those who received less intensive
health-related services) than an experimental family (=those
who received intensive health care services). Awareness of
group membership could of course introduce bias. Also, the
timing of administration differed between the groups. For
example, growth rates for infants in the experimental group
were measured quarterly, while such rates were measured at
intake and closing for the "majority" of infants in the
comparison group. In this
study, assessments were conducted by trained research
assistants who were blind to group membership.
Measurement

A representative sample of studies drawn from
published program evaluation literature has shown that the
neglect of validity and reliability issues are common
problems (Lipsey, Crosse, Dunkle, Pollard, & Stobart, 1985).
In this current review, such measurement concerns were also

evident. Although most researchers employed

 

multiple
behavior
measures
studies
1980; Re
multiple
Velasque
research
actions
need to
In this
bOth thr
assessme
0f relie
Section.

1
an asses
et a1, (
particu]
implemer
detail t
implemer
neaSureE

emphaSiz

 

28

multiple dependent measures (which generally included a
behavioral or observational assessment technique), repeated
measures were not undertaken in one-half of the reviewed
studies (Dickie & Gerber, 1980; Field et al., 1980; Metzl,
1980; Resnick, 1985)-—and one—half failed to utilize
multiple methods (Gutelius & Kirsch, 1975; Metzl, 1980;
Velasquez et al., 1984; Resnick, 1985). Recent reviews of
research on links between parents' ideas and parents'
actions (revealing only modest correlations) highlight the
need to employ multiple methods of testing (Goodnow, 1988).
In this study, the majority of measures were conducted at
both three— and six-months postpartum, and included multiple
assessment techniques. (A detailed plan of the addressment
of reliability and validity issues is included in the Method
section.)
Analysis

The evaluation of model programs generally focuses on
an assessment of impact-—or treatment effectiveness. Lipsey
et al. (1985) have criticized this narrow focus—~in
particular with respect to the neglect of treatment
implementation issues. Rossi, Freeman, and Wright (1982)
detail three major program evaluation areas: 1)
implementation, 2) process, and 3) utility (including
measures of both program effectiveness and efficiency)——

emphasizing the importance of developing a comprehensive

 

 

evaluat:
examinal
primary
analysis
outcome:

process

met all
"criter;
(1986) ;
were eil
Status)
COnditi<
Child a1
Provisi,
well-ch;
SCreeni]
Provisi<
SCreeni]
d HUISS
through<
screenil
familie:

treatmel

 

29

evaluation plan. Finally, Davidson (1989) also suggests an
examination of unintended outcomes. In this study, a
primary objective was to include multiple levels of
analysis. Implementation, process, utility, and unintended
outcomes were addressed. (The scope of the evaluation
process is detailed in the Method section.)
Utility Arguments/Concerns

Of the studies reviewed, there was one study which
met all of the aforementioned theoretical and methodological
"criterion". Olds, Henderson, Chamberlin, and Tatelbaum
(1986) randomly assigned high-risk families (=primiparas who
were either teenagers, unmarried, or of low socioeconomic
status) and low-risk families (=primiparas) to one of four
conditions: (a) provision of developmental screening of
child at one and two years of age (=control group); (b)
provision of free transportation for regular pre—natal and
well-child care at a local clinic plus developmental
screening of child at one and two years of age; (c)
provision of a nurse home visitor during pregnancy plus
screening and transportation services; and (d) provision of
a nurse home visitor during pregnancy and
throughout the child's first two years of life plus
screening and transportation services. (A total of 400
families participated in the study.) With respect to

treatment conditions three and four, the nurses served both

 

 

 

an educe
program
health a
neglect.
were col
treatmer
to as tl
fewer ir
their hc
frequent
their be
during t
life, tl
emergenc
frequent
grOup it
functior
Childrer
fairly i
rational
randqu E
Size, en
Early en
relation

 

30

an educational and support function. The home visitation
program was designed to prevent a wide range of childhood
health and developmental problems, including abuse and
neglect. For the analysis, treatment groups one and two
were collapsed and referred to as the comparison group;
treatment groups three and four were collapsed and referred
to as the nurse—visited group. The nurse—visited group had
fewer instances of verified maltreatment, were observed in
their homes to restrict and punish their children less
frequently, provided more appropriate play materials, and
their babies were seen in the emergency room less frequently
during the first year of life. During the second year of
life, the nurse-visited group infants were seen in the
emergency room fewer times, and were seen by physicians less
frequently for accidents and poisonings than comparison
group infants. Finally, there was improved intellectual
functioning of 9 to 11 points on the developmental tests for
children from the highest risk families. These results are
fairly impressive (although it was unclear as to the
rationale for collapsing groups for analysis). There was
random assignment, a large sample

size, employment of multiple methods and repeated measures,
early entry, and the inclusion of both caretaking and
relational skills information. However-—in light of the

intense length of contact/intervention (= 2 years)——the

 

questioz

implemeI
extremei
scientis
designir
utilizat
efficier
it is ur
course_.
involven
WOUid p1
such a ]
target t
in" at t

of effic

Mm

l
are defi
reductic
Preventi
referred

31

question of feasibility must be addressed.

It would seem doubtful that such a program could be
implemented on a wide scale basis. The cost would be
extremely high. Fairweather (1980) has advised social
scientists to always consider the issue of feasibility when
designing an intervention program. To maximize
utilization, it is imperative to consider program
efficiency. If costs appear to heavily outweigh benefits,
it is unlikely that such a program would be adopted. Of
course—~perhaps some families may require long—term
involvement with a supportive program. In those cases--it
would probably be better if agencies worked together to plan
such a long—term commitment. (For example, one program may
target the newborn phase-—while a second program would “step
in" at the time of mobility.) In this study, an examination
of efficiency (=program cost per family) was performed.

gummy-'1

Scientific Rationale

 

Typically, the major objectives of primary prevention
are defined as the promotion of healthy development and
reduction of vulnerability. But the concept of primary
prevention remains abstract and ambiguous. Cowen (1977)
referred to it as a religio—spiritistic ideal in search of

concrete operational practices. Although the idea of

 

primary
problem.
all incl
influenc
subject
unfortur
design,
indeed--
primary
publishe
nethodol
1
Program
Methodol
SUbjects
With res
0“ relat
represen
difficul
design,
treatmen
prOCQQUr
neaSHres
meaSHreS

administ

 

32

primary prevention has widespread appeal-—doing it is the
problem. The damnation of primary prevention is that it is
all inclusive (DeWild, 1980). If a multitude of factors
influence an outcome—-then those same factors can be
subject to preventive programming. And yet it would be
unfortunate if this complexity was to block efforts to
design, implement, and test prevention strategies. But
indeed——a review of the literature reveals a scarcity of
primary prevention efforts. Furthermore, an examination of
published studies reveals a number of theoretical,
methodological, and utility concerns.

Theoretical issues include the selected time of
program entry, and the scope of program content.
Methodological issues include flaws with respect to
subjects, design, procedures, measurement, and analysis.
With respect to subjects, conclusions were generally based
on relatively small samples, and study groups frequently
represented low—risk populations--thus making it more
difficult to detect program effects. With respect to
design, random assignment of program participants to
treatment conditions was not always present. Regarding
procedures, there were problems in the administration of
measures——in which the status of those who administered
measures was not always clear, or the timing of

administration differed for the experimental and control

 

 

groups.
frequent
utilize
scope of
examinir
include
feasibil
0f prime
accurate
research
Particul
intent c
address
Consider
lfora

§§£ll§e_

l
Praventi
the Unit
is this
fOr Prob
MidelfOr
& seifEr
Fagan, D
1988).

 

 

33

groups. Regarding measurement, repeated measures were
frequently not undertaken-—and investigators failed to
utilize multiple methods. And with respect to analysis, the
scope of evaluation was generally quite narrow
examining only treatment effects. Finally, utility issues
include the question of program efficiency—-and thus the
feasibility of program adoption. Cowen's (1983) evaluation
of primary prevention programs appears to be starkly
accurate-—they have been underresearched and inadequately
researched. For although a study may “excel" in one or two
particular areas——it contains flaws in other key areas. The
intent of the study presented here was to successfully
address each of the theoretical, methodological, and utility
considerations as outlined in this review. (Refer to Table
l for a summary of these considerations.)
Service Rationale

There exists a national need for more primary
prevention in child welfare. One in every four children in
the United States live in poverty (Bumpers, 1984). And it
is this variable which characterizes the infant vulnerable
for problematic developmental outcomes (Leventhal &
Midelfort, 1986; Parker, Greer, & Zuckerman, 1988; Sameroff
& Seifer, 1987; Schweinhart & Koshel, 1986; Singer, Drotar,
Fagan, Devost, & Lake, 1983; Walker, 1989; Wise & Meyers,

1988). Parker et al. (1988) appraised this vulnerability

 

 

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H mHDmC...

 

 

34

 

 

 

 

 

 

 

 

 

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x. x . x «$23 .Hm no nonmmflm>
x x 8%: Human
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cases. .55. sham Bahama wands v3.2 29am 88am

 

8038858 #3328232 9a Hoflflomfi
“masons Bfinnpa no cozquaxm

H mHan

 

young c
disturb
nuclear
Pr0tect
Farguha
1991).

essenti
Thus it
Process

PerSist

informa
Krakow

C0nditi
eduCati
have 61

1988; w

 

35

as a "double jeOpardy":
Children living in poverty experience double jeopardy.
First, they are exposed more frequently to such risks
as medical illnesses, family stress, inadequate social
support, and parental depression. Secondly, they
experience more serious consequences from these risks
than do children from higher socioeconomic status. It
is the synergistic double jeopardy of increased
exposure to and greater sequelae from environmental
risks that predispose children living in poverty to
adverse developmental outcomes. (p. 1227)

The physical and emotional growth and development of
young children proceeds on a time-table which is rarely
disturbed for long without permanent implications. The
nuclear family is the critical unit for the nurture,
protection, and socialization of young children (Steward,
Farquhar, Dicharry, Glick, & Martin, 1986; Roberts et al,
1991). Appropriate caretaking has been identified as one
essential requirement of normal growth and development.
Thus it is recommended that disturbances in the caretaking
process should be sought, predicted, and corrected, with
persistence (Kempe, 1970).

In formulating a strategy to obtain needed
information about mediators of risk influences, Kopp and
Krakow (1983) suggested an examination of the external child
conditions of caregiving and social support through
educational programs. Other family/parenting professionals

have also issued this challenge (Jolly, 1988; Parker et al.,

1988; Weiss, 1988). The intervention detailed here

 

represel
compone1
parent a
and sup}
compleme
skills a

disadvar

are most
satisfac
addresse
rePreser
Preventj
availab]
“0t nece
SOmehow

With the
damaging
enVir0nm
to exert
present,
envirOHm
PrOgram

treetmen

p0pulati

 

36

represented such a program. Each of the planned program
components—-delivered in the home setting by highly trained
parent aide volunteers who functioned in both an educational
and supportive role, were designed to work in an integrated,
complementary fashion to promote or enhance parenting

skills and developmental outcomes for infants in socially
disadvantaged families.

It is recognized that parenting and infant outcomes
are most likely multiply determined and therefore cannot be
satisfactorily explained by single-factor theories——or
addressed by single-level interventions. This project
represented a population welfare model of primary
prevention. In this approach, supportive services were made
available to a population presumed at risk. This model did
not necessarily View the targeted individual as being
somehow defective, but rather as one who would fare better
with the provision of particular resources. It is the
damaging climate of poverty—-or the child-rearing
environments represented by these families--that is believed
to exert a destructive influence on infant development. At
present, however, the feasibility of altering that
environment is questionable. This model
program offered an economical-~and theoretically valid--

treatment/intervention modality to serve this at-risk

population.

 

the enh

mothers

formula

nOthers
concern;

schedul:

mOthers
Concernj

diaPEIir

mOtherS
Safety P

mOtherS
health p

visits

 

CHAPTER II

METHOD

Hypotheses

It was hypothesized that:
1. Participation in the model program would promote
the enhancement of infant caretaking skills.

a. Compared to control mothers, participant
mothers would be more likely to prepare and store infant
formula according to suggested guidelines

b. Compared to control mothers, participant
mothers would be more likely to gain greater knowledge
concerning appropriate feeding techniques including
scheduling and amounts

c. Compared to control mothers, participant
mothers would be more likely to gain greater knowledge
concerning appropriate infant hygiene including bathing and
diapering practices

d. Compared to control mothers, participant
mothers would be more likely to implement recommended
safety practices in the home environment and to exhibit
greater knowledge about such practices

e. Compared to control mothers, participant
mothers would be more likely to adhere to recommended
health practices by completing the infant's well—baby
visits

37

 

 

the enhe

mothers
or knowl

realist

mothers

0f belie

mothers
Potentie

t0 the n

mothers

in the p
3

the Opti

exhibit

infants

eXhibit

 

38

2. Participation in the model program would promote
the enhancement of relational skills.

a. Compared to control mothers, participant
mothers would be more likely to gain greater understanding
or knowledge of infant behavior and thus express more

realistic developmental milestones

b. Compared to control mothers, participant
mothers would be more likely to adopt a more positive set
of beliefs or attitudes concerning child-rearing

c. Compared to control mothers, participant
mothers would be more likely to recognize the infant's
potential for interaction and thus become more responsive
to the mutual transmission of messages

d. Compared to control mothers, participant
mothers would be more likely to display greater competency
in the parenting role

3. Participation in the model program would promote
the optimal growth and development of infants.

a. Compared to infants of control mothers,
infants of participant mothers would be more likely to
exhibit greater physical or motor capabilities

b. Compared to infants of control mothers,
infants of participant mothers would be more likely to
exhibit greater mental or cognitive capabilities

c. Compared to infants of control mothers, infants

 

of parti
ideal ph
I
and cont
hypothes
1
related
capabili
2
interven
relation
F
great in“
Prodicti.
(1.6-, t:
the foll:
l
(feeding.
0f posit;
2.
(developr
quality c

lnfant or

 

39

of participant mothers would be more likely to achieve
ideal physical growth percentiles

In addition to these comparisons of the experimental
and control groups, the following additional research
hypotheses were examined:

1. Caretaking proficiency would be more highly
related to optimal infant outcomes than will relational
capabilities.

2. The quality of support provided by the
interventionist would influence both parent caretaking and
relational skill acquisition.

Finally, there were additional research questions of
great interest, however, it was not possible to generate
predictions because of the lack of prior foundation work
(i.e., there is no theoretical groundwork). These included
the following:

1. Which aspects of caretaking competence or mastery
(feeding, hygiene, safety, or health) are most predictive
0f positive infant outcomes?

2. Which aspects of relational competence or mastery
(developmental knowledge, child rearing attitudes, or
quality of interaction) are most predictive of positive

infant outcomes?

identif;
intervex
populati
practice
represer
transact
bEhavior
& Lowry,
1983).
Parent-c
positiVe
fuflctiOn
to intro
distingu
Parentin
may be 0
murthran.
Ti
eXperime:
generall:
repreSem
that an :

COuld pm

 

40

Setting

The time of hospitalization for delivery has been
identified as an ideal target for initiation of a planned
intervention due to the ready accessibility of the
population (Gordon & Gordon, 1979). In addition to this
practical consideration, the early postpartum period
represents a beginning from which future parent—child
transactions spring (Boger, 1983). Patterns of
behavior emerge which can influence or shape relations (Ali
& Lowry, 1981; Heinicke, Diskin, Ramsey—Klee, & Given,
1983). It can be thought of as the foundation of the
parent—child relationship. The potential for reinforcing
positive transactions at the beginning of parenting
function exists. This period also represents an ideal time
to introduce or develop positive caretaking skills. In
distinguishing between dysfunctional and non—dysfunctional
parenting, there is evidence that adeptness in caretaking
may be of greater significance than the display of
nurturant behaviors (Egeland & Farber, 1984; Taylor, 1989).

The entry point of intervention in this field
experiment was the hospital——where the event of birth
generally takes place. The early postpartal period
represents an ideal target for intervention. It is felt
that an interruption or alteration in hospital routine

Could prove to be of enormous benefit because of the

vulnera
respons
beyond
infant :
opportu:
BOO-bed
located
Populate
disturbe
and unen
the pOPL
aPProxin
hospital
involve
being at
result 0
Midelfor
Oldsl He
Drotar,
I
it allOW
fOrCe to
availabi

 

41

vulnerability of this period. The hospital's role or
responsibility in promoting positive parenting must go
beyond ”permitting" practices that enhance the parent—
infant relationship, it should entail seizing the
opportunity to promote such enhancement (Garbarino, 1980).

This study was conducted at Hurley Medical Center, a
BOO—bed teaching hospital of Michigan State University,
located in Flint, Michigan. Flint is a moderately
populated (250,000) city in the mid—Michigan area. It is
disturbed by various social problems including high crime
and unemployment. The hospital serves a cross section of
the population. The number of births annually is
approximately 3,000——the greatest number of the city's five
hospitals. Approximately one—third of these births
involve Medicaid patients——who are typically categorized as
being at risk for various parenting dysfunctions as a
result of their low socioeconomic status (Leventhan &
Midelfort, 1986; Newberger, Hampton, Marx, & White, 1986;
Olds, Henderson, Chamberlin, & Tatelbaum, 1986; Singer,
Drotar, Fagan, Devost, & Lake, 1983).

In summary, the hospital setting was ideal in that
it allowed entry at a critical point——thus lending power or
force to the intervention. Other advantages included the
availability of the target population, their readiness or

interest being maximum to participation, and the status of

the med

partici

Partici
were 18
good he

Payment

Th:
concern
the fir:
Stress <
Eichler
Weinberg
such a 1
likelihc
Parents
They hac
Child.re
Boger (1
SurrOmnc'
the firs
need, bu

impact.

 

42

the medical profession serving to sanction that
participation.

Subjects

Study participants were maternity—ward patients.
Participation in the study was restricted to women who: (a)
were 18 years of age or older; (b) were judged to be of
good health; (c) were primiparous; (d) whose method of
payment was Medicaid.

Restrictions

The final two restrictions reflected the study's
concern with primary prevention. With respect to parity,
the first-time parent experiences the greatest degree of
stress or anxiety (Boukydis & Burgess, 1982; Grossman,
Eichler & Winichoff, 1980; Rollins & Galligan, 1978;
Weinberg & Richardson, 1981). Also, Olds (1984) found that
such a focus (i.e., first-time parents) increased the
likelihood of subjects embracing program goals. Such
parents were more likely to be open to offers of help.
They had not established deeply ingrained attitudes about
child—rearing that would interfere with program goals.
Boger (1983) also emphasizes the high readiness to learn
surrounding the arrival of the first child. In summary,
the first-time parent represents not only the greatest
need, but there also exists the potential for the greatest

impact. With respect to method of payment, Medicaid (or

 

low soc
for num
maltrea
Hampton
Vazquez
1983), 4
delays
1986).
et al. 3
related
1
hOSpital
attendir
infants)
routine
Procedur
upon dis
mother a
hospital
Particip
T
exiSting

 

 

43

low socio—economic) mothers appear to be at greater risk
for numerous parenting dysfunctions including child
maltreatment (Egeland & Brunquell, 1979; Newberger,
Hampton, Marx, & White, 1986), failure to thrive (Gordon &
Vazquez, 1985; Singer, Drotar, Fagan, Devost, & Lake,
1983), and children who exhibit significant developmental
delays (Ruger & Wooten, 1982; Leventhan & Midelfort,
1986). In developing a high-risk family profile, Newberger
et al. found that welfare dependency was most highly
related to negative outcomes for children.

Health status was determined by projected length of
hospital stay. This information was obtained from
attending physicians and ward nurses. Mothers (or their
infants) who were not expected to be discharged at the
routine target data were excluded from recruitment
procedures. Since home intervention commenced immediately
upon discharge—-and entailed the presence of both the
mother and her infant-—health problems which delayed
hospital discharge, consequently prevented their
participating in the study.

The age restriction was imposed as a result of
existing programs operating in the community which targeted

adolescent mothers and their newborns.

 

for par
to part
partici
decisic
use of

race, n
0f infa
differs
basis 0
no evid

the Stu

Meflsure
eXperim
refusal
state (i
C0mtrol
asseSSm'
(fouF e:
Out of :
COuld n:

and One

 

44

Number

A total of 97 women were approached with requests
for participation in the study. Eighty women volunteered
to participate. (The majority of those who declined to
participate would not provide a rationale for their
decision.) Non—volunteers (=17) were examined (through the
use of hospital records) on six variables (including age,
race, marital status, prenatal care, delivery mode, and sex
of infant). Six comparisons were made and no significant
differences were observed. Therefore, at least on the
basis of these six demographic variables tested, there was
no evidence that this non—participant group differed from
the study participants.

Seventy—two women completed the post assessment.
Measures could not be completed on eight women (three
experimentals and five controls). These included five
refusals (three experimental and two controls), two out—of—
state (both controls), and one lost to follow-up (a
control). Sixty—one women completed the follow—up
assessment. Measures could not be completed on 11 women
(four experimentals and seven controls). Six women moved
out of state (one experimental and five controls), four
could not be located (two experimentals and two controls),

and one refused the evaluation (an experimental).

 

partici
educati
additio
employm
or trea
pregnan
to the

weight,
COllect

assesse

Charact
21 and

African
were Si:
graduat.
graduat.
percent
“0 reli.
area Ia]
Standar(
had beel
siblingE

 

45

Demggraphics

Various demographic variables were collected on the
participant group including age, race, marital status,
education level, religion, and length of residence. In
addition, the family history variables of parental
employment and number of siblings were collected. Medical
or treatment variables collected included prenatal care,
pregnancy complications, and delivery mode. With respect
to the infant, the variables of sex, gestational age,
weight, APGAR scores, and birth complications were
collected. Finally, the quality of the residence was
assessed.

The 72 women who participated had the following
characteristics: age ranged from 18 to 32 with a mean of
21 and standard deviation of three; 43 percent were
African—American and 57 percent were Caucasian; 83 percent
were single and 17 percent were married; 16 percent had not
graduated from high school, 43 percent were high school
graduates, and 41 percent had some college experience; 56
percent were affiliated with a church and 44 percent stated
no religious affiliation; length of residence in the Flint
area ranged from one to 28 years with a mean of 15 and
standard deviation of eight; 59 percent of their mothers
had been employed and 73 percent of fathers; number of

siblings ranged from none to 12 with a mean of three and

 

standar
prenata
percent
had no

while 3

were ma
ranged

deviati
grams w
and 64

were C0
WhEn ra
environ
P6rcent

Poor.

Squdre
Were f0‘

for thi:

 

46

standard deviation of two; 54 percent had received routine

prenatal care and 46 percent had not received such care; 27
percent experienced pregnancy complications and 72 percent

had no complications; and 68 percent had vaginal deliveries
while 32 percent had caesarean deliveries.

Infant characteristics were as follows: 44 percent
were male and 56 percent were female; gestational age
ranged from 35 to 42 weeks with a mean of 38 and a standard
deviation of two; weight ranged from 2420 grams to 5488
grams with a mean of 3449 and a standard deviation of 563;
and 64 percent of the births were problem-free while there
were complications in 36 percent of the cases. Finally——
when rating the home (or subsequent caretaking)
environments——14 percent were rated as excellent, 30
percent as good, 28 percent as fair, and eight percent as
poor.

Equivalency of Groups

In order to evaluate the success of random
assignment in creating equivalent groups, a number of chi-
square tests were performed. No significant differences
were found out of six comparisons (examining the

aforementioned demographic variables).

Design
A Posttest—Only Control Group design was employed

for this study. Eighty mother-infant pairs were randomly

 

assigne
(Random
validit
period
months

of 199C

employe
effecti
traditi
With th
COmpete
Outcome
formula
includi
suggest
0f nece
Second,
healthi
of brea
OutCOme
knoWled.
positiv.

the Part

 

47

assigned to either the control or experimental groups.
(Random assignment was intended to maximize the internal
validity of the study.) Recruitment procedures involved a
period of three months in both the Fall of 1989 (in the
months of October, November, and December) and the Winter
of 1990 (in the months of January, February and March).
Post and follow-up assessment procedures were
employed at three—months and six-months postpartum. The
effectiveness of the experimental group was compared with
traditional hospital services on multiple outcome criteria.
With the first objective of this project to increase
competency in the parenting role, the following caretaking
outcome criteria were selected for examination: appropriate
formula preparation and feeding techniques, proper hygiene
including bathing and diapering practices, adherence to
suggested well-baby clinic visits, and the implementation
of necessary safety precautions in the home environment.
Second, with the objective of promoting happier and
healthier parent-infant relations (thus reducing the risk
of breakdown between parent and child) the following
outcome criteria were selected for examination: greater
knowledge of infant/child development, the adoption of more
positive child—rearing attitudes, increased competency in
the parenting role, and increased quality of interaction

between parent and infant. Finally, it was predicted that

 

 

 

 

 

the enh
relatio
develop
selecte
(includ
or cogn
languag
weight,
outcome

variabl.

researcl
pOStpart
Caesaree
Recruith
Director
Variable
partiCiE

mEdiCal

Via 6 ha

particul

 

48

the enhancement of infant caretaking skills and parent
relational skills would promote optimal infant growth and
development. The following infant outcome criteria were
selected for examination: physical or motor capabilities
(including fine motor and gross motor performance), mental
or cognitive capabilities (including personal/social and
language performance), and growth (including length,
weight, and head circumference measures). These infant
outcome criteria represented the critical dependent

variables of interest.

Procedures
Recruitment
Introduction and request for participation in the
research project occurred approximately one to two days
postpartum (dependent on the condition of vaginal or
caesarean delivery). All mothers were approached by the
Recruitment Coordinator accompanied by the Project
Director. Prior to the contact, the six demographic
variables specified earlier for comparison purposes between
participants and non—participants were extracted from the
medical chart of the patient.
Intake and Informed Consent
Information was provided to prospective participants
via a handout and a prepared script detailing the project's

particulars including a brief description of the two

 

 

service
assignn
complin
appreci
informe
Univere
and the

(see A;

Of the

~drawin
2), pla
envelop
blocks

any Var
0f Subj
the pro]
very sf]
level, i
had Com;
the ages
With res
diviSioI

alSO trl

 

 

49

service components they might receive, the random
assignment procedure, the measure—taking process, and the
complimentary infant products they would receive in
appreciation of their participation. Volunteers signed an
informed consent form approved by the Michigan State
University Committee on Research Involving Human Subjects
and the Hurley Medical Center Institutional Review Board
(see Appendix A).
Assignment to Conditions

The Recruitment Coordinator (under the supervision
of the Project Director) assumed the task of randomization—
-drawing cards (labeled Service Group 1 or Service Group
2), placing these in envelopes, sealing and numbering
envelopes. The randomized assignments were completed in
blocks of four. There was no plan to stratify or block on
any variable on the random assignment procedure. A review
of subject demographics (from the one-year pilot phase of
the proposed study/program) revealed that participants were
very similar with respect to marital status, education
level, and age. The vast majority of mothers were single,
had completed either 11th or 12th grade, and were between
the ages of 20 and 25 (again—-no minors were involved).
With respect to race, it was an approximately equal
division between African-American and Caucasian. This was

also true with respect to sex of infant.

 

 

who weI
impleme
Project

supervi

study.

2<0rE
hOSpita
PaCkage
Service
include
Visits -
techniq-
of Serv.

refer t.

SGI‘ViCeE
IQCQipt
baSed St

bottleij

 

 

 

Data Collection

 

All data was collected by two research assistants
who were blind to group membership. (A "team" approach was
implemented due to the nature and number of measures.) The
Project Director was responsible for the training and

supervision of project staff in data collection techniques.
Conditions

Two services or conditions were compared in this
study. The control condition was labeled as Service Group
2 (or Educational Materials) which included routine
hospital services and the receipt of education material
packages; the experimental condition was referred to as
Service Group 1 (or Parent Aide Intervention) which
included the aforementioned services plus a series of home
visits which provided direct instruction, modeling
techniques, and social support. (For a detailed comparison
of services provided to experimental and control subjects,
refer to Table 2.)

Control Condition

Subjects in the control condition received those
services routinely offered to postpartum patients plus the
receipt of parent educational materials. Current hospital~
based services included a brief introduction to infant

bottle-feeding techniques and an infant bath demonstration

 

 

 

 

 

In-hosy

l-week
POStpar

2—weeks
pOStpaI

3‘Weeks
POStpar

4‘Wmoks
p08tpar

3~weeks
postpar

lZ-week
pOStpar

*Both
abOVe

**89rvi

In—hospital

1—week
postpartum

2-weeks
postpartum

3—weeks
postpartum

4—weeks
postpartum

8-weeks
postpartum

12—weeks
postpartum

 

 

Table 2

 

Comparison of Services

Experimental

Introductory meeting

with Parent Aide
**General feeding
instructions
**Bath demonstration
Home Visit 1
Home Visit 2
Home visit 3
Home visit 4
Home visit 5
Home visit 6
Home visit 7

gaming;

**General feeding
instructions

**Bath demonstration
Education Packet 1
Education Packet 2
Education Packet 3
Education Packet 4
Education Packet 5

Education Packet 6

Education Packet 7

*Both groups received incentive packages at each of the

above eight visits.

**Services routinely offered to postpartum patients.

 

 

 

 

 

by a w
materi
adheri
Group

only t1
writtel

projec1

hospitg
Period
adjustn
innovat

fUHCtic

"Studen
Nursing
(Both 8
program
CurriCu
neQOtia
to allo
hourS d
researc

Proiect

 

 

52

by a ward nurse. The dispensing of parent educational
materials was performed by key research staff persons
adhering to the same home visitation schedule regimen for
Group 1. These visits were extremely brief as they served
only two functions: (a) to provide the mother with the
written materials; (b) to provide the mother with the
project incentive package of baby care products.
Experimental Condition

The experimental model consisted of special in—
hospital and aftercare services spanning a three-month
period (what is generally considered a time period when
adjustment to parenthood is at its peak). Central to the
innovative model was the parent aide volunteer. She/he
functioned as the family's advocate, friend, and educator.

The volunteer parent aides were recruited from two
"student" sources: 1) Hurley Medical Center School of
Nursing; and 2) Mott Community College School of Nursing.
(Both schools are located in the city of Flint. The
programs are similar with respect to program goals,
curriculum, and student profile.) The Project Director
negotiated with key administrative persons at each school
to allow students to receive compensatory time for the
hours devoted to the study. Student involvement in the
research project was credited as clinical experience. The

Project Director was not responsible for any evaluation of

 

 

studen

contra

nursin
commit
great

that m
commun
nursin
studen
infant

Traini'

PErforI
Studen1
SChOOlg
C0mmunj
(This I
School'
ClaSSrc
one“(inc
throngk
exerCie
trainin
deveiOP

Appendi

 

 

53
student nurse performance. (See Appendix B for nurse
contract.)

Students who expressed an interest in community
nursing or home care were especially appropriate for such a
commitment. Participation in the study was of particularly
great value/benefit to these students. (It should be noted
that many professionals in the health care field view
community nursing or home care as the future direction for
nursing in light of shortened hospital stays.) Each
student was assigned a total of two families or mother-
infant pairs.

Training of Student Nurses/Parent Aides

Screening and training of student nurses was
performed by key members of the research team. Ten
students were selected from each of the
schools/institutions (Hurley Medical Center and Mott
Community College—Flint) for a total of 20 parent aides.
(This number broke down to five students per semester per
school.) Training of students involved 12 hours additional
classroom time over a two—week period (consisting of eight
one—and-one-half hour sessions) with students working
through program manuals, outside readings, and class
exercises/role plays. These students had received formal
training in such vital areas as postpartum care, child
development, family dynamics, and empathy skills. (See

Appendix C for training schedule.)

 

 

 

routir
feedir
introc
meetin
First,
family
Opport
birth

aide r
Purpos
Of her
Close

the ff
Aftegg
the pa
at One
Postpa
week p.
(Utili
Satisf,

uniVer;

 

54

In-Hospital Services

In—hospital services—~in addition to those services
routinely offered to postpartum patients (the general
feeding instructions and bath demonstration) included an
introductory meeting with the parent aide volunteer. This
meeting was intended to serve two important functions.
First, it provided an opportunity for the parent aide and
family to become acquainted. Second, it provided a formal
opportunity for an "active" resolution of the labor and
birth experience through intense discussion with the parent
aide regarding all details of the mother's ordeal. The
purpose of this focus was to enhance the mother's feeling
of her own worth and of the value of her infant. At the
close of this initial meeting, the parent aide scheduled
the first home visit.
Aftercare Services

In addition to contact within the hospital setting,
the parent aide volunteer made a total of seven home visits
at one, two, three, four, eight, and twelve weeks
postpartum. (Two visits were scheduled during the first
week postpartum.) Volunteers traveled in pairs.
(Utilization of a team approach for home visitation
satisfied any safety concerns of the hospital, school, and

university.) This extended contact into the home

 

 

 

envirc
to fig
Each v
of 155
was re
follow
audio
fideli
resear
interv
intern

medica

 

 

 

environment was seen as essential—~permitting the volunteer
to figure prominently in the family's support network.

Each visit was approximately one hour in length. A variety

 

of issues or topics were explored—-which the parent aide
was responsible for managing or coordinating. She/he
followed the manual provided in training. Home visits were
audio taped for purposes of supervision (thus insuring the
fidelity of the experimental model), and to aid the
researchers in understanding more fully the process of the
intervention. These tapes were reviewed by undergraduate
interns employed in the Department of Research at the
medical center.

Topics explored during the home visits included such
areas as baby care basics, infant development issues and
utilization of community resources. (Refer to Table 3 for
a detailed account of home visit topic areas.) It is

important to note here that the mothers were not viewed (or

 

treated) as passive recipients of knowledge——but rather

were encouraged to adopt an active learning role in each of

 

the scheduled home visits. The material was structured in
such a fashion—-containing numerous thought questions and
learning exercises. Although direct instruction was a part
of the teaching process, the observation and modeling of
appropriate behavior was central to this intervention. For

example, the parent aide volunteer and the mother worked

 

 

 

Visit

One

Two

Three

Four

Five

Six

Seven

 

Table 3

Home Visit Topic Areas

Topic

Formula preparation
Feeding schedules/amounts

Nutrition
Common feeding problems

Baby care basics
Soothing techniques

Infant development
Modified Brazelton

Baby's health
Immunization record

Baby's safety
Home environment check

Parenting concerns
Community resources

 

 

 

 

 

57

together in preparing formula so that the mother could
learn proper preparation and storage techniques. Also, the
parent aide demonstrated such things as burping techniques.

(See Appendix D for educational materials.)

Measures

The experimental model represented an attempt to
intervene during the critical adjustment period (early
postpartum) for high—risk, first—time parents and their
infants. The provision of support and education was seen
as being vital to the success of this adjustment phase.
The major objectives of the planned intervention were to
enhance parent caretaking skills and interactive behaviors
thereby promoting optimal infant growth and development.
There were three primary measurement areas: caretaking
skills, relational indices, and infant outcomes. In order
to simplify the analysis and interpretation of the large
number of variables in this study, various scale
construction and item analysis strategies were employed.
Initially, the response frequency of all scale items were
reviewed. Low variance items were discarded from further
analysis. Specifically, if 90 percent or more of the
respondents provided a single response, the item was
deleted. (Since such items do not affect the variability
of test scores, they contribute nothing to the reliability

or validity of the test.) Next, reliability coefficients

 

 

 

 

 

58

were reviewed. Specifically, the item total correlations
and internal consistency of the scales were examined.
Problem items (those of low correlative value) were
eliminated. This strategy was based on a desire to help
characterize the behavior domain or trait sampled by the
test (thus contributing to its construct validity).
However, throughout these refinement steps the logical—
conceptual intent of the scales and items were also weighed
when a decision was made to modify a standard or rationally
constructed scale.
Caretaking Skills

The caretaking skills of infant feeding (formula
preparation and feeding techniques), hygiene (bathing and
diapering practices) safety (organization of home
environment) and health (adherence to clinic well—baby
visits and provision of immunizations) were examined. (See
Table 4 for an overview of the administration of these
measures, and Table 5 for a summary of the measurement

refinement outcomes.)

 

Feeding

Formula preparation.

A criterion checklist was developed to evaluate
formula preparation performance. The checklist consisted
of the 11 steps specified by Meade Johnson for prOper
formula preparation. At three months, research staff

questioned the mother about procedures of formula

 

 

 

Hygiene

Safety

Health

59

Table 4

Caretaking Skills

Measurements

Instrument

Formula Preparation
Performance Criterion
Checklist

Feeding Questionnaire

Infant Care
Questionnaire

Safety Questionnaire
HOME (Organization of

Environment)

Health Questionnaire

Clinic Records
Checklist

Time

3 months

3, 6 months

3, 6 months

3, 6 months

6 months

3, 6 months

3, 6 months

 

Reliability

Inter—
rater

Test—
retest

Test—
retest

Test-
retest

Inter—
rater

Test—
retest

Inter—
rater

 

 

60

Table 5

Measurement Refinement Outcomes:
Caretaking Skills

Instrument Decision Number of Alpha
Items

 

Formula Preparation

Criterion Checklist Retain 7 .49
Feeding Questionnaire
Three—Month Retain 17 .69
Six—Month Retain 18 .65
Infant Care
Questionnaire
Three-Month Eliminate 7 .37
Six—Month Eliminate 7 .42
Safety Questionnaire
Three—Month Retain 14 .61
Six-Month Retain 15 .70
HOME (Organization of
Environment) Eliminate 2 .32
Health Questionnaire
Three-Month Eliminate 5 .15
Six-Month Retain 6 .75

Clinic Records
Checklist Retain 2 .81

 

 

 

 

 

61

preparation. Her responses were audiotaped. Two student
interns (trained to 90 percent reliability) assessed the
audiotapes checking either passed or failed for each step.
(When final calculations were performed on their scores, a
95 percent agreement rate was established. A coin was
tossed to determine one rater's scores for analysis
purposes.)

Endorsement frequencies dictated the deletion of
four items. Although the internal consistency of the
remaining seven—item scale was only .49, the decision was
made to keep these seven items. (See Table 6 for a
complete listing of the scale items and the internal
consistency analyses.)

Feeding guestionnaire.

A feeding technique questionnaire was developed to
assess knowledge concerning formula preparation,
scheduling, and amounts, and the handling of common feeding
problems. The questionnaire consisted of 25 multiple
choice items. It was administered at three and six months.
Completed forms were scored twice by independent raters
(who were in perfect agreement).

At three months, endorsement frequencies dictated
the deletion of five items. An examination of item total
correlations resulted in the deletion of three additional

items. The internal consistency of the new 17~item scale

 

 

 

 

Item .

Q2

Q3

Q4
Q5
Q6

Q10

Q11

Alpha

 

No

 

.49

62

Table 6

Internal Consistency Analysis:

Formula Preparation

Item

Boiled bottles and nipples
for five minutes

Boiled water for five
minutes

Let water cool to touch
Wiped can

Shook can, poured formula
into pitcher

Made sure that formula
was not too hot

Threw out formula left in
bottle

 

Corrected Item/
Total Correlation

.16

.27

.39

.32

.29

.20

.03

 

 

 

63

Table 7

Internal Consistency Analysis:
Feeding Questionnaire
Three—Months

Corrected Item/

 

Item No. lggm Total Correlation
Q3 Starting solid foods early .30
Q4 Water is important for baby .44
Q5 Most infants need approximately .34
Q6 Baby will need --- feedings .32
Q7 ——— babies will probably need .14
Q10 To help with colic, I might .21
Q11 A healthy infant may spit up .28
Q13 It may take -—— to complete .22
Q14 If baby is vomiting, I should .17
Q15 If baby is constipated .25
Q16 It is best to burp baby .33
Q17 To burp baby it is best to .13
Q18 If baby does not finish .44
Q19 Bottles and equipment should .32
Q20 Prepared formula should be .42
Q24 You should prop a bottle .39

Q25 Baby may have a three—meals .14

 

 

 

 

64

was .69. (See Table 7 for a complete listing of the scale
items and the internal consistency analyses.)

At six months, endorsement frequencies dictated the
deletion of six items. An examination of item total
correlations resulted in the deletion of only one
additional item. The internal consistency of the new 18—
item scale was .65. (See Table 8 for a complete listing of
the scale items and the internal consistency analyses.)

The correlation between the three—month and six—months
scores was .80 yielding a .001 significance level.
Hygiene

An infant care questionnaire was constructed to
appraise knowledge of bathing and diapering practices. The
questionnaire consisted of 10 multiple choice items. It
was administered at three and six months. Completed forms
were scored twice by independent raters (who were in
perfect agreement).

At three and six months, endorsement frequencies
dictated the deletion of the same three items. And at both
three and six months, an examination of item total
correlations resulted in the decision to eliminate the
entire scale. (The internal consistency of the seven—item

scales was .37 and .42 respectively.)

 

 

 

 

65

Table 8

Internal Consistency Analysis:
Feeding Questionnaire

 

Six-Months
Corrected Item/
Item No. lpgm Total Correlation
Q1 Baby may be fed .29
Q3 Starting solid foods early .29
Q4 Water is important for baby .32
Q5 Most infants need approximately .17
Q7 ——- babies will probably need .12
Q8 Can tell babies are hungry .16
Q9 To help with hiccups, I might .19
Q10 To help with colic, I might .31
Q11 A healthy infant may spit up .18
Q13 It may take -—— to complete .56
Q14 If baby is vomiting, I should .24
Q16 It is best to burp baby .20
Q17 To burp baby it is best to .11
Q18 If baby does not finish .44
Q19 Bottles and equipment should .33
Q20 Prepared formula should be .37
Q21 When preparing formula .10
Q25 Baby may have a three—meals .15

Alpha = .65

 

 

66

Safety

Organization of environment.

Section III, Organization of Environment, of the
HOME (Home Observation for Measurement of the Environment)
instrument was utilized to evaluate safety. This subscale
of the HOME measure consisted of six dichotomously scored
items. At six months, the research team (trained to 90%
reliability) observed conditions in the study participant's
home——checking either yes or no for each item (e.g.,
Child's play environment appears safe and free of
hazards). (When final calculations were performed on their
scores, a 93 percent agreement rate was established.)

Endorsement frequencies dictated the deletion of
four items, and the examination of item total correlations
resulted in the decision to eliminate the entire scale.
(The correlation of the remaining two items was only .32.)

Safety guestionnaire.

A safety questionnaire was also developed to assess
knowledge of "babyproofing" practices in the home

environment. The questionnaire consisted of 20 multiple

choice items. It was administered at three and six months.

Completed forms were scored twice by independent raters
(who were in perfect agreement).
At three months, endorsement frequencies dictated

the deletion of three items. An examination of item total

 

25¢, ‘ . 'w-_ '53, -- .- ‘7-

wim " “' -

 

 

67

Table 9

Internal Consistency Analysis:
Safety Questionnaire
Three-Months

Corrected Item/

 

 

Item No. lpgm Total Correlation
Q1 If baby is choking .18
Q2 If baby has swallowed .35
Q3 To prevent baby from getting .19
Q4 When bathing baby .23
Q5 Parents need to babyproof .10
Q8 When the stove is not in use .17
Q9 If furniture has sharp edges .32
Q10 When driving in a car .32
Q11 The car safety seat should .34
Q13 Best to keep crib equipped .23
Q14 A good location for the crib .29
Q15 Plastic bags should be .27
Q17 To protect baby from basement .19
Q20 Because baby may try to chew .26

Alpha = .61

 

 

 

68

correlations resulted in the deletion of three additional
items. The internal consistency of the new l4—item scale
was .61. (See Table 9 for a complete listing of the scale
items and the internal consistency analyses.)

At six months, endorsement frequencies dictated the
deletion of five items. It was not necessary to delete any
items based on the examination of item total correlations.
The internal consistency of the new 15-item scale was .70.
(See Table 10 for a complete listing of the scale items and
the internal consistency analyses.) The correlation
between the three-month and six-months scores was .63
yielding a .01 significance level.

Health

Clinic records.

A clinic records checklist was developed to evaluate
the number and "content" of both routine and sick/emergency
visits. The routine visit checklist examined adherence to
the suggested immunization schedule, and any documented
general care comments made by the health care provider
(including hygiene, attitude of mother, and overall well
being of infant). The sick/emergency checklist examined
the presenting problem, and any documented general care
comments made by the health care provider (including
hygiene, attitude of mother, and overall wellbeing of

infant).

 

69

Table 10

Internal Consistency Analysis:
Safety Questionnaire

 

 

Six—Months
Corrected Item/
Item No. ngm Total Correlation
Q2 If baby has swallowed .11
Q3 To prevent baby from getting .29
Q4 When bathing baby .27
Q5 Parents need to babyproof .44
Q8 When the stove is not in use .28
Q9 If furniture has sharp edges .18
Q10 When driving in a car .48
Q11 The car safety seat should .27
Q12 Crib slats can't be more .27
Q13 Best to keep crib equipped A .36
Q14 A good location for the crib .29
Q15 Plastic bags should be .45
Q17 To protect baby from basement .15
Q18 Glass or ceramic knickknacks .12
Q20 Because baby may try to chew .49

Alpha = .70

 

- chL.:1E__—_—“ \-—-4‘.A.»

 

 

70

At three and six months, two research staff (trained
to 90% reliability) extracted and recorded this data.
(When final calculations were performed on their scores, a
92 percent agreement rate was established. A coin was
tossed to determine one rater's scores for analysis
purposes.) Low variance resulted in the deletion of
general care comments. Also, it was unnecessary to
separately examine adherence to suggested immunization
schedule and adherence to recommended well—baby visits-—
since physicians always immunized infants brought in for
routine visits. Remaining variables included total number
of routine and sick visits.

Health guestionnaire.

A health questionnaire was also developed to assess
knowledge of recommended health practices including well~
baby visits, immunizations, and nutrition. This
questionnaire consisted of 10 multiple choice items. It
was administered at three and six months. Completed forms
were scored twice by independent raters (who were in
perfect agreement).

At three months, endorsement frequencies dictated
the deletion of five items. An examination of item total
correlations resulted in the decision to eliminate the

entire scale. (The internal consistency of the five—item

scale was .15.)

 

 

 

71

At six months, however, it was not necessary to
delete any items based on endorsement frequencies. The
examination of item total correlations resulted in the loss
of four items. The internal consistency of the new
six—item scale was .75. (See Table 11 for a complete
listing of the scale items and the internal consistency
analyses.)

Relational Indices

The relational indices of child-rearing attitudes,
knowledge of infant/child development, and play
interactions were examined. (See Table 12 for an overview
of the administration of these measures, and Table 13 for a
summary of the measurement refinement outcomes.)
Child—Rearing Attitudes

PAR;-

Ten scales of the Parental Attitude Research
Instrument were utilized to assess attitudes concerning
child rearing. The 10 scales tested were Strictness,
Breaking the Will, Irritability, Fostering Dependency,
Martyrdom, Comradeship and Sharing, Approval of Activity,
Acceleration of Development, Intrusiveness, and Seclusion
of the Mother. Items consisted of statements on a
four—point Likert scale ranging from "Strongly Agree" to
"Strongly Disagree". Thirty items were administered at

each data collection period. Completed forms were scored

 

 

 

72

Table 11

Internal Consistency Analysis:
Health Questionnaire

 

 

Six-Months
Corrected Item/
Item No. Item Total Correlation
Q3 You can telephone the doctor .66
Q4 Immunizations usually begin .38
Q5 During a regular check—up .74
Q8 Records of baby's immunizations .74
Q9 Good nutrition is .20
Q10 A good diet will help baby .23

Alpha = .75

 

 

 

Index

Child—rearing
attitudes

Developmental
knowledge

Mother-infant
interaction

73

Table 12

Relational Indices

Measurements

Instrument

 

PARI

HOME (Avoidance
of Restriction
and Punishment)

Expectancy scale

Competency scale

Stimulation scale

HOME (Emotional
and Verbal
Responsivity

of Mother)

 

Time

3, 6 months

6 months

3, 6 months

6 months

3 months

6 months

Reliability
Split
half

Inter-
rater

Test
retest

Inter—
rater
Inter-

rater

Inter—
rater

 

 

74

Table 13

Measurement Refinement Outcomes:

Relational Indices

Instrument

Parental Attitude

Research Instrument
Three—Month
Six—Month

HOME (Avoidance of
Restriction/Punishment)

Expectancy Scale

Three-Month
Six-Month

Competency Scale

Stimulation Scale

HOME (Emotional and
Verbal Responsivity)

Decision

 

Retain
Retain

Eliminate

Retain
Retain

Retain

Retain

Retain

 

Number of
Items

15
14

15
14

11

Am

.71
.67

.11

.64
.68

.57

.58

.84

75

twice by independent raters (who were in perfect
agreement).

Endorsement frequencies revealed variance on all
items. However, an examination of item total correlations
and the internal consistency of the scales resulted in the
collapsing of scales. At three months, the examination of
item total correlations resulted in the loss of 15 items.
The internal consistency of the new lS—item scale was .71.
(See Table 14 for a complete listing of the scale items and
the internal consistency analyses.) At six months, the
examination of item total correlations resulted in the loss
of 16 items. The internal consistency of the new 14-item
scale was .67. (See Table 15 for a complete listing of the
scale items and the internal consistency analyses.) The
correlation between the three—month and six-months scores
was .32 yielding a .01 significance level.

Avoidance of restriction and punishment.

Section II, Avoidance of Restriction and Punishment,
of the HOME (Home Observation for Measurement of the
Environment) instrument was also utilized to assess child—
rearing attitudes. This subscale of the HOME measure
consisted of eight dichotomously scored items. At six
months, the research team (trained to 90% reliability)
observed behavior in the study participant's home——checking

either yes or no for each item (e.g., Mother does not

 

 

76

Table 14

Internal Consistency Analysis:
Attitude Questionnaire
Three—Months

Corrected Item/

 

 

Item No. lpem Total Correlation
Q2 ..child thinks parent is wrong .21
Q3 ..business to know everything .30
Q4 ..right to rebel and be stubborn .31
Q7 ..encouraged to undertake .26
Q8 ..make up a lot of stories .37
Q9 ..keep control of their temper .33
Q10 ..feeling she is tied down .25
Q12 ..rather than punishment .22
Q16 ..take all the time he wants .30
Q17 ..give up their own happiness .33
Q19 ..should never keep a secret .35
Q20 ..parent should be concerned .24
Q23 ..training should be put off .57
Q27 ..should admit it to his child .45

Q28 ..should protect their child .27

 

 

 

77

Table 15

Internal Consistency Analysis:
Attitude Questionnaire

 

 

 

 

 

Six—Months
Corrected Item/
Item No. lpgm Total Correlation
Q2 ..children are just so bad .32
Q8 ..children bother you .33
Q9 ..children is an easy job .37
Q10 ..parent feels held down .38
Q16 ..parents have to give up .34
Q17 ..situations on their own .15
Q20 ..parents are pretty content .40
Q21 ..child resent his parents .27
Q22 ..always be loyal to them .18
Q23 ..make a child behave .17
Q24 ..trained to use the potty .33
Q25 ..child's deepest thoughts .24
Q26 ..don't owe their mothers .35

Q30 ..feels that she can't get out .28

 

 

 

78

express overt annoyance with or hostility toward child).
(When final calculations were performed on their scores, a
93 percent agreement rate was established.)

Endorsement frequencies dictated the deletion of six
items. An examination of item total correlations resulted
in the decision to eliminate the entire scale. (The
correlation of the remaining two items was only .11.)
Developmental Knowledge

Expectancy scale.

An expectancy scale was utilized to evaluate
knowledge about the motor and social development of
infants/children. Two tests consisting of 30 parallel
multiple choice items were administered at three and six
months. Completed forms were scored twice by independent
raters (who were in perfect agreement).

At three months, endorsement frequencies dictated
the deletion of 12 items. An examination of item total
correlations resulted in the deletion of three additional
items. The internal consistency of the new lS-item scale
was .64. (See Table 16 for a complete listing of the scale
items and the internal consistency analyses.)

At six months, endorsement frequencies dictated the
deletion of 13 items. An examination of item total
correlations resulted in the deletion of three additional

items. The internal consistency of the new 14—item scale

 

 

 

 

 

 

 

79

Table 16

Internal Consistency Analysis:
Expectancy Questionnaire
Three-Months

Corrected Item/

 

 

 

 

 

Item No. lpem Total Correlation
Q4 Follows simple instructions .36
Q5 Can become spoiled .28
Q8 Rooting reflex observed .27
Q9 First words appear .10
Q10 Some self—feeding .11
Q11 Colic seems to disappear .22
Q13 Soft spot in head will close .22
Q15 Associate actions with words .26
Q16 Begins to imitate sounds .15
Q17 Can now pick up small objects .28
Q20 Stack blocks .38
Q22 May sleep through the night .29
Q23 May use a Spoon and fork .45
Q24 Babinski reflex observed .39

Q30 Can turn toward sound .18

 

 

 

80

Table 17

Internal Consistency Analysis:
Expectancy Questionnaire

 

 

 

 

 

Six—Months
Corrected Item/
Item No. item Total Correlation
Q2 May remain dry through night .20
Q3 Can see, hear, smell, taste .21
Q4 Understands some adult commands .37
Q5 Insists on having own way .22
Q8 Sucking reflex observed .18
Q9 May say first words .40
Q10 Mastered partial self—feeding .32
Q17 Grasping very small objects .14
Q19 May be able to stand unaided .24
Q20 Piling objects on top .25
Q23 Feeds self with little mess .48
Q24 Plantar grasp reflex .38
Q29 Begins negative stage .37

Q30 Startle reaction is observed .40

 

 

 

81

was .68. (See Table 17 for a complete listing of the scale
items and the internal consistency analyses.) The
correlation between the three-month and six—months

scores was .30 yielding a .02 significance level.

Competency.

An open—ended questionnaire consisting of eight
items was also utilized to assess developmental knowledge.
The intent of the questions was to elicit
suggestions/options to posed child rearing problems.
Questions were posed verbally (with responses audio taped)
at six months. Two student interns (trained to 90%
reliability) independently assessed each audio tape (adding
up the number of options provided by the parent). (When
final calculations were performed on their scores, an 89
percent agreement rate was established. A coin was tossed
to determine one rater's scores for analysis purposes.)

The internal consistency of the eight-item scale was .57.
(See Table 18 for a complete listing of the scale items and
the internal consistency analyses.)

Mother-Infant Interaction

Verbal stimulation.

A verbal stimulation scale was employed to evaluate
the quality of mother-infant interaction. A ten—minute
videotape of a play interaction between mothers and infants

was filmed at three months. Films were viewed by two

 

 

 

 

82

Table 18

Internal Consistency Analysis:
Competency Scale

Corrected Item/

 

 

Item No. lpem Total Correlation
Q1 ..check when baby awakes.. .37
Q2 ..suggestions offer new mother.. .26
Q3 ..persons might contact.. .15
Q4 ..changes make in home.. .34
Q5 ..conditions contact doctor.. .34
Q6 ..introducing solid foods.. .54
Q7 ..methods of discipline.. .42
Q8 ..how to reduce stresses.. .08

Alpha = .57

 

 

 

83

independent raters trained to 90% reliability. (When final
calculations were performed on their scores, a 96 percent
agreement rate was established. A coin was tossed to
determine one rater's scores for analysis purposes.)

Raters (blind to group membership) scored a total of 15
items (e.g., Mother attempts to imitate infant's
vocalizations). Scoring was based on an interval scale
(i.e., an actual counting of the number of times a behavior
was observed).

Endorsement frequencies dictated the deletion of two
items. An examination of item total correlations resulted
in the deletion of two additional items. The internal
consistency of the new ll—item scale was .58. (See Table
19 for a complete listing of the scale items and the
internal consistency analyses.)

Emotional and verbal responsivity.

Section I, Emotional and Verbal Responsivity of
Mother, of the HOME (Home Observation for Measurement of
the Environment) instrument was also utilized to assess the
quality of mother infant interaction. This subscale of the
HOME measure consisted of 11 dichotomously scored items.

At six months, the research team (trained to 90%
reliability) observed routine activity in the study
participant's home—-checking either yes or no for each item

(e.g., Mother caresses or kisses child at least once during

 

 

 

Item No.

Q1
Q2
Q4
Q5
Q8
Q9
Q11
Q12
Q13
Q14

Q15

Alpha =

.58

84

Table 19

Internal Consistency Analysis:

Verbal Stimulation

I_t_6m

Parallel talk
Mood expression
Back talk
Musical
Informative
Personhood
Admiration
Investigate
Responsive
Global

Need

 

Corrected Item/
Total Correlation

.48

.39

.30

.19

.36

.17

.19

.50

.32

.52

.46

 

85

visit). (When final calculations were performed on their
scores, a 93 percent agreement rate was established. A
coin was tossed to determine one rater's scores for
analysis purposes.)

Endorsement frequencies dictated the deletion of
four items. It was not necessary to delete any additional
items
based on the examination of item total correlations. The
internal consistency of the new seven-item scale was .84.
(See Table 20 for a complete listing of the scale items and
the internal consistency analyses.)

Infant Outcomes

Infant outcomes that were assessed included growth
indices (length, weight, and head circumference) and
developmental skills (fine motor, gross motor,
personal/social, and language capabilities). (See Table 21
for an overview of the administration of these measures,
and Table 22 for a summary of the measurement refinement
outcomes.)

Growth Indices

The research team (trained to 90% reliability)
measured and weighed the babies at three and six months.
Measurement included length and head circumference. Weight
was measured with a portable scale. Length and head
circumference was measured with a tape. (When final

calculations were performed on their scores, a 95 percent

 

 

86

Table 20

Internal Consistency Analysis:
Section I, Emotional and Verbal Responsivity of Mother,
of the HOME (Home Observation for Measurement of the
Environment)

Corrected Item/

 

 

Item No. lpgm Total Correlation
Q1 Spontaneously vocalizes .73
Q2 Responds to child's vocal .72
Q3 Tells child the name of object .40
Q5 Initiates verbal interchange .71
Q6 Expresses ideas freely .74
Q8 Praises child's qualities .62
Q10 Caresses or kisses child .35

Alpha = .84

“WW . .u.

 

Skill

 

Fine Motor

Gross Motor

Personal/

Social

Language

Growth

87

Table 21

Infant Outcome

Measures

Instrument

Denver Developmental
Screening Test

Denver Developmental
Screening Test

Denver Developmental
Screening Test

Denver Developmental
Screening Test

Length

Weight

Head Circumference

 

Time

3,

6

O'\

O\

O\

on

ON

0)

months

months

months

months

months

months

months

Reliabilit

Test—
retest

Test—
retest

Test—
retest

Test—
retest

Inter—
rater

Inter—
rater

Inter—
rater

88

Table 22

Measurement Refinement Outcomes:
Infant Measures

Instrument Decision Number of

Items

Denver Developmental
Screening Test

Three—Month Retain l3
Six—Month Retain 13

Growth Score
Three—Month Retain
Six—Month Retain

U000

 

Adm

.75
.74

.32
.12

89

agreement rate was established. A coin was tossed to
determine one rater's scores for analysis purposes.)
Results were graphed onto assessment charts developed by
the National Center for Health Statistics (NCHS). Two
growth scores were generated (one at three-months and one
at six—months postpartum) which indicated the number of
physical growth indices (0—3) which fell above the 90th
percentile or below the 10th percentile of the physical
growth NCHS guidelines. Although the internal
consistencies of the three—item scales were quite low (.32
at three—months and .12 at six-months) the decision was
made to retain the growth scores. (See Tables 23 and 24
for a complete listing of the scale items and the internal
consistency analyses.)
Developmental Skills

The Denver Developmental Screening Test (DDST) was
employed to evaluate fine motor, gross motor,
personal/social, and language skills. The DDST consists of
a series of developmental tasks which are used to determine
if a child's development is within the normal range. This
instrument has been used to screen the development of young
children (one month to six years of age) in more than 20
countries around the world. Validity studies show that the
test correctly identifies children likely to have

developmental problems 92 percent of the time. The test

 

90

Table 23

Internal Consistency Analysis:
Growth Indices
Three—Months

Corrected Item/
Total Correlation

 

Item No. Item
1 Length .07
2 Weight .22
3 Head Circumference .26
Alpha = 32
Table 24

Internal Consistency Analysis:
Growth Indices

 

Six-Months
Corrected Item/
Item No. Item Total Correlation
1 Length -.11
2 Weight .08
3 Head Circumference .23

 

91

was administered at three and six months by the research
team member who had previous training in this area.

At three months, five personal—social, 12 fine
motor—adaptive, seven language, and six gross motor items
were deleted due to low variance. The remaining 13 items
(=four personal—social, three fine motor—adaptive, one
language, and five gross motor) were retained. (An
examination of item total correlations based on subscale
groupings resulted in the decision to generate one
developmental score.) The internal consistency of the new
13—item scale was .75. (See Table 25 for a complete
listing of the scale items and the internal consistency
analyses.)

At six months, eight personal—social, 11 fine motor-
adaptive, five language, and 11 gross motor items were
deleted due to low variance. One language item was deleted
due to low item total correlations. The remaining 13 items
(= three personal—social, four fine motor—adaptive, two
language, and four gross motor) were retained. (Again——
fine motor, gross motor, personal/social and language
subscales were combined.) The internal consistency of the
new 13—item scale was .74. (See Table 26 for a complete
listing of the scale items and the internal consistency
analyses.) The correlation between the three—month and
six—month scores was —.1 yielding a .56 significance level.

In summary, there were three primary measurement

 

Item .

PS
PS
PS
PS
FM
FM

FM

GM
GM
GM
GM

GM

Alpha

No

.75

92

Table 25

Internal Consistency Analysis:

Three—Months

Item

Feeds self crackers

Works for toy out of reach
Plays peek—a—boo

Resists toy pull

Follows 1800

Regards raisin

Reaches for object

Turns to voice

Sto—head up 900

Sto chest up arms support
Rolls over

Pull to sit no head lag

Bear some weight on legs

 

Denver Developmental Screening Test

Corrected Item/

Total Correlation

.35
.60
.38
.26
.35
.39
.52
.38
.28
.52
.35
.34

.11

 

93

Table 26

Internal Consistency Analysis:
Denver Developmental Screening Test
Six—Months

Corrected Item/

Item No. lpgm Total Correlation
PS Feeds self crackers .42
PS Plays peek—a-boo .35
PS Initially shy with strangers .10
FM Passes cube hand to hand .45
FM Sit looks for yarn .28
FM Sit takes two cubes .45
FM Rakes raisin attains .42
L Dada or mama nonspecific .28
L Imitates speech sounds .53
GM Sits without support .45
GM Stands holding on .44
GM Pulls self to stand .28
GM Gets to sitting .27

Alpha = .74

 

94

areas: caretaking skills, relational indices, and infant
outcomes. Approximate time required for administration of
all measures was one hour and thirty minutes for each
testing period. (See Appendix E for copies of all
measures/instruments.) Infant outcomes represented the
critical dependent variables of interest. Multivariate
analysis of variance (for the formula preparation, health
questionnaire, clinic visit, competency, verbal
stimulation, and HOME measures), and repeated measures
analysis of variance (for the feeding, safety, PARI, and
expectancy questionnaires, and the DDST and growth score
measures) was performed to assess group differences. In
addition to testing the effectiveness of the model program,
stepwise multiple regression analysis was employed to
examine predictors of optimal infant outcomes. Caretaking
skills, relational indices, demographic, medical history,
and treatment variables were entered into the analysis.
The primary intent of the regression was to examine the
influence and relative importance of each independent
variable on the dependent variables (=infant development
and growth scores) thus the entry of a large number of
variables. Whereas the goal of the multivariate and
repeated measures analysis of variance was to test
hypotheses——the goal of the multiple regression analysis

was to generate hypotheses.

 

95

Additional Evaluation Areas

In this study, an objective was to include multiple
levels of analyses. Thus in addition to the assessment of
infant outcomes——program implementation, process,
efficiency, and unintended outcomes were explored.
ImplementationgProcess

Home visits were audio taped for purposes of
supervision (thus insuring the fidelity of the experimental
model), and to aide the principal investigator in
understanding more fully the process of the intervention.
These tapes were evaluated by undergraduate interns
(trained to 90% reliability) employed in the Department of
Research at the medical center. (When final calculations
were performed on their scores, a 92 percent agreement rate
was established. A coin was tossed to determine one
rater's scores for analysis purposes.)

With respect to implementation issues, tapes were
carefully reviewed to determine that the student nurses had
indeed taught (or "covered") assigned material with the
program participants. Regarding process issues, tapes were
carefully reviewed to determine the level or quality of
support provided by the student nurses to the program
Participants. The areas of emotional aide,
advice/information, and socialization were assessed. (See

Appendix F for the implementation/process coding guide.)

 

96

Emotional aide included incidents of student nurse
empathy/sensitivity, facilitation of information gathering,
and positive regard. Advice/information represented the
number of additions in educational instruction to the
program material. Socialization equalled the number of
minutes devoted to the home visit. A total of 185 tapes
were evaluated. (Forty—eight tapes were inaudible;
nineteen visits were not recorded.) A mean score for each
support area (and a global support score) was calculated.
The reason for this averaging process was twofold. First,
some visits could not be scored because a tape was
inaudible——or a student nurse failed to record a visit.
(Thus the calculation of a mean score allowed for fair
comparisons between subjects with seven individual scores
and subjects with six individual scores.) Second, the
averaging helped to simplify the analysis of the support
data. It is also important to note here that an
examination of support scores across visits revealed no
particular pattern (i.e., scores were approximately equal
thus the collapsing of scores posed no threat to the
interpretation of the data).
Efficiency

Cost considerations were important to this study.
First—~there were limited funds available to implement the

services (both experimental and control “programs“.)

 

97

Second——the likelihood of program adoption by the
institution (medical center) would be highly influenced by
the balance of costs and benefits. Fairweather (1980) has
advised social scientists to always consider the issue of
feasibility when designing an intervention program. To
maximize utilization, it is imperative to consider program
efficiency. In this study, an examination of efficiency
(=program cost per family) was performed. Budget items
necessary for operations included the salary for a Program
Coordinator, secretarial support, participant incentive
items, and office space, supplies, and equipment. This
figure would represent the dividend in the cost equation.
An estimate of the number of families which could be served
by such a program was based upon an annual total volunteer
staff (= Parent Aides) of 50 individuals. This figure
would represent the divisor in the cost equation. The
"quotient” would represent the cost per family. Costs were
estimated for programs with and without an evaluation
component attached.

Unintended Outcomes

 

At six—months postpartum, the following two open—
ended questions were posed to all program participants:
1) "As you think back on the past six months,

what are your feelings or thoughts about
becoming a parent?"

2) ”What do you think about your involvement
in this study?"

 

 

98

Subject responses were audiotaped. Because the intent of
this evaluation component was strictly qualitative in
nature——and its purpose was to explore unintended outcomes,
it was not possible to detail the manner of assessment in
advance. The principal investigator carefully reviewed the
tapes. Key words or phrases from the responses were
recorded. These words/phrases were studied to determine if
some common theme or themes existed. Regarding the first
question, it was decided to simply collapse the responses
into "negative" and "positive" appraisals. With respect to
the second question, it was decided to collapse responses
into "helpful" and "enjoyment" appraisals. Percentages
were calculated (based on group assignment) to provide
descriptive information about experimental and control
mothers.
Comparison of Successful and Unsuccessful Participants
Finally, a determination of a "successful" program
participant was generated in order to examine what factors
or variables characterized such individuals. Descriptive
statistics were executed on all dependent measures (= eight
caretaking, seven relational, and four infant outcome
measures). Subjects received one "success" point for each
measure in which they scored more than one standard
deviation above the mean. Frequencies were executed on the

number of success points. (Subjects' totals ranged from

 

99

one to ten.) Based on the examination of these
frequencies, it was decided to assign those subjects with
five or more success points (N=25) to the successful
program participant group. (If the cutoff had been placed
at four——the number of successful participants would have
exceeded half of the total number of subjects; if the
cutoff had been placed at six——the number of successful
participants would have only equalled one—fifth of the
total number of subjects.) Chi—square analyses were
executed on the following variables: education, marital
status, age, race, prenatal care, religion, employment
history (mother and father), parenthood appraisal, and
group assignment (experimental vs. control).
Summary

A study goal was to include multiple levels of
analyses. Program utility (including effectiveness and
efficiency), implementation, process, and unintended
outcomes were evaluated. Finally, a comparison of
successful and unsuccessful program participants was
conducted. (See Table 27 for an overview of the evaluation

process.)

 

 

100

Table 27

Scope of Evaluation

Implementation

Process

Effectiveness

Efficiency

Unintended Outcomes

Exploratory

Review of audiotaped visits
to determine coverage of
program material

Review of audiotaped visits

to assess level/quality of

nurse support

Assess parent caretaking,
relational skills
Assess infant growth,
developmental outcomes

Calculate cost per family

to provide program/service

Examine responses to open—
ended questions

Comparison of successful
and unsuccessful program
participants

CHAPTER III

RESULTS

Condition/Time Effects

As a result of the various refinement steps, eight
caretaking outcome variables remained: two scale scores for
the feeding questionnaire (for each data collection
period), the formula preparation score, two scale scores
for the safety questionnaire, one scale score for the
health questionnaire (at six—months postpartum), and two
clinic measures (number of routine and sick visits). Seven
relational outcome variables remained: two scale scores for
the attitude questionnaire, two scale scores for the
expectancy measure, one scale score for the competency
measure, one scale score for the stimulation scale, and one
scale score for the HOME. Finally, four infant outcome
variables remained: two DDST scores (fine motor, gross
motor, personal/social and language subscales were combined
at each collection period), and two growth scores
(indicating the number of physical growth indices which
fell above the 90th percentile or below the 10th percentile
of the National Center for Health Statistics percentile
guidelines). The means and standard deviations for all
measures are presented in Table 28. Only those measures
with significant results are detailed in the text.

101

 

Means and Standard Deviations

Formula Preparation
Feeding Questionnaire
Three—Month
Six—Month
Safety Questionnaire
Three—Month
Six—Month
Health Questionnaire
Six—Month
Clinic Visits
Routine
Sick
PARI
Three-Month
Six—Month
Expectancy Questionnaire
Three—Month
Six—Month

Competency Interview
Verbal Stimulation

Emotional Responsivity

Denver Developmental
Three—Month
Six—Month

Growth Score
Three—Month
Six—Month

Table 28

102

Summary of

Experimental
Mean SD
5.25 1.34
12.81 2.53
13.81 2.16
10.47 1.66
12.09 1.86
4.94 1.46
1.54 1.72
.80 1.30
44.28 5.83
38.06 6.51
10.06 2.28
10.07 2.47
13.31 4.94
47.53 29.37
5.41 1.90
9.56 2.39
8.72 2.90
.86 .88
.78 .71

 

Control
Mean SD
3.72 .11

9.78 2.49
9.69 2.32
7.03 2.02
8.14 2.40
4.76 1.70
1.18 2.14
.68 1.53
43.92 11.26
37.76 4.63
7.42 2.81
7.61 2.71
10.17 4.12
51.39 31.17
4.89 2.17
6.35 2.40
8.07 2.58
.61 .90

.77 .82

103

MANOVA (multivariate analysis of variance) was
employed. The variables of formula preparation, health
questionnaire, competency measure, stimulation scale, HOME,
and the clinic measures of routine and sick visits were
examined. Strong treatment effects were detected.
Repeated measures were employed for those variables
administered at both time periods. These included the
feeding, safety, PARI, expectancy, DDST, and growth
measures. Again, strong treatment effects were detected
as well as both time and interaction effects. The
univariate tests for the individual variables are examined
in the text.

W
Feeding
Formula preparation.

Significant condition effects were detected.
Experimental subjects were more likely to prepare and store
formula according to suggested guidelines (see Table 29).

Feeding guestionnaire.

At both three and six—months postpartum,
experimental subjects were more likely to display greater
knowledge concerning appropriate feeding techniques
including scheduling and amounts. In addition to treatment
effects, there was an interaction (condition by time)

effect which revealed that experimental subjects' scores

 

 

104

Table 29

Analysis of Variance:
Formula Preparation
by Experimental Condition

 

Source Df Ms F Sign.
Between conditions 1 42.01 27.75 .001

Within conditions 70 1.51

 

 

 

 

105

were significantly improved at six—months postpartum (see
Table 30).
Safety
At both three and six—months postpartum,

experimental subjects were more likely to exhibit greater
knowledge concerning recommended safety practices. In
addition to these treatment effects, there was an effect
for time which revealed that both experimental and control
subjects' scores were significantly higher at six—months
postpartum (see Table 31).
Health

There were no significant differences between groups

on the health measures.

MW

Hi

There were no significant differences between groups
on the attitude measure at either three or six—months
postpartum. There were, however, time effects which
revealed that both experimental and control subjects'
scores were significantly lower at six—months postpartum
(see Table 32).
Developmental Knowledge

Expectancy guestionnaire.
At both three and six—months postpartum,

experimental subjects were more likely to express realistic

 

 

 

106

Table 30

Repeated Measures
Analysis of Variance:
Feeding Questionnaire

 

 

 

Source Df Ms F Sign.
Condition 1 418.58 43.32 .001
Time 1 5.21 2.98 .089
Condition by Time 1 10.46 5.99 .017
Table 31
Repeated Measures
Analysis of Variance:
Safety Questionnaire
Source Df Ms F Sign.
Condition 1 438.26 85.27 .001
Time 1 59.80 21.05 .001
1 .78 .28 .601

Condition by Time

 

 

 

 

107

Table 32

Repeated Measures
Analysis of Variance:

 

PARI
Source Df Ms F Sign.
Condition 1 24.77 .54 .467
Time 1 798.19 39.51 .001
.582

Condition by Time 1 6.19 .31

 

 

 

108

developmental milestones. There were no time or
interaction effects detected (see Table 33).

Competency interview.

Significant condition effects were detected.
Experimental subjects were more likely to offer a greater
number of options to posed child rearing problems (see
Table 34).

Interaction
There were no significant differences between groups

on the mother—infant interaction measures.

Infant Measures

At three—months postpartum, infants of experimental
subjects were more likely to show evidence of developmental
progress, however, there were no significant differences
between groups on the DDST at six—months postpartum. There
were, however, time effects detected which revealed that
control subjects' scores were significantly improved at
six—months postpartum (see Table 35).

Growth

There were no significant differences between groups
On the growth assessment at either testing period. In
addition, there were no time or interaction effects

detected.

 

109

Table 33

Repeated Measures
Analysis of Variance:

 

 

Expectancy
Source Df Ms F Sign.
Condition 1 184.34 25.93 .001
Time 1 .13 .02 .882
Condition by Time 1 .03 .00 .947
Table 34

Analysis of Variance:
Competency Interview
by Experimental Condition

 

Source Df Ms F Sign.
Between conditions 1 124.81 6.37 .01

Within conditions 59 19.59

 

 

110

Table 35

Repeated Measures
Analysis of Variance:
Denver Developmental Screening Test

 

Source Df Ms F Sign.
Condition 1 95.26 17.23 .001
Time 1 5.68 .74 .393

Condition by Time 1 38.14 4.97 .030

 

111

Summary

An examination of condition effects included
eight caretaking, seven relational, and four infant outcome
variables. Significant condition effects were found for
the formula preparation and competency measures, the
feeding, safety, and expectancy questionnaires (at both
three and six—months postpartum), and the Denver
Developmental Screening Test (at three—months postpartum).
Table 36 presents a summary of these results.

Significant time effects were detected on the safety
questionnaire (with both experimental and control subjects‘
scores increasing over time), and the attitude measure
(with both experimental and control subjects' scores
decreasing over time).

Significant interaction effects were detected on the
feeding questionnaire (with experimental subjects' scores
increasing over time), and the Denver Developmental
Screening Test (with control subjects' scores increasing
over time).

Predictors of Optimal Infant Outcomes

In addition to testing the effectiveness of the
model program, stepwise multiple regression analysis was
employed to examine which aspects of parenting were most

related to better infant outcomes (i.e., caretaking

 

 

 

112

Table 36

Summary of Results:
Caretaking, Relational, and Infant Outcomes

Measurement Area 3—Month 6—Month

Caretaking Skills

Formula Preparation * ——
Feeding Questionnaire * *
Safety Questionnaire * *
Health Questionnaire —- NS
Well—Baby Clinic Visits —— NS
Sick Clinic Visits —— NS

Relational Indices

PARI NS NS
Expectancy Questionnaire * *
Competency —— *
Verbal Stimulation NS -—
HOME -- NS
Infant Outcomes
DDST * NS
Growth Score NS NS

 

* = p < .01, hypothesis confirmed.

 

113

proficiency or relational capabilities). Demographic,
medical history, and treatment variables were also entered
into the analysis.
Three—Months Postpartum

Infant Development

In an effort to examine infant developmental status
(dependent variable = DDST score at three—months
postpartum), the following independent variables were
included in the analysis: the three—month feeding, formula
preparation, and safety scale scores (= caretaking outcome
variables); the three—month attitude, expectations, and
interaction scale scores ( = relational outcome variables);
mother's age, race, level of education, and marital status,
and sex of infant (= demographic variables); mother's
prenatal care status, and pregnancy and birth
complications, and the infant's gestational age, weight,
and APGAR scores (= medical history variables); and group
assignment (= treatment variable). Only the
treatment variable met the significance level for entry
(p < .001) accounting for 36 percent of the variance (see
Table 37).
Infant Growth

In an effort to examine infant growth status
(dependent variable = growth indices score at three—months

postpartum), the following independent variables were

 

 

114

Table 37

Stepwise Regression
to Predict DDST

Three—Months Postpartum

 

Variable
Entered

Group

R RSQ Increase Adjusted Sign.
in RSQ RSQ
.60 .36 .36 .59 .001

 

115

included in the analysis: the three—month feeding, formula
preparation, and safety scale scores (= caretaking outcome
variables); the three—month attitude, expectations,
and interaction scale scores ( = relational outcome
variables); mother's age, race, level of education, and
marital status, and sex of infant (= demographic
variables); mother's prenatal care status, and pregnancy
and birth complications, and the infant's gestational age,
weight, and APGAR scores (= medical history variables); and
group assignment (= treatment variable). No variables met
the significance level for entry to predict growth at
three—months postpartum.

W

Infant Development

In an effort to examine infant developmental status
(dependent variable = DDST score at six—months postpartum),
the following independent variables were included in the
analysis: the six—month feeding, safety, and health scale
scores, and the two clinic measures (= caretaking outcome
variables); the three—month attitude, expectations,
competency, and HOME scale scores ( = relational outcome
variables); mother's age, race, level of education, and
marital status, and sex of infant (= demographic
variables); mother's prenatal care status, and pregnancy

and birth complications, and the infant's gestational age,

 

116

weight, and APGAR scores (= medical history variables); and
group assignment (= treatment variable). Only one
caretaking outcome variable (= the health questionnaire
score) met the significance level for entry (p < .01)
accounting for 13 percent of the variance (see Table 38).
Infant Growth

In an effort to examine infant growth status
(dependent variable = growth indices score at six—months
postpartum), the following independent variables were
included in the analysis: the six—month feeding, safety,
and health scale scores, and the two clinic measures
(= caretaking outcome variables); the six—month attitude,
expectations, competency, and HOME scale scores
( = relational outcome variables); mother‘s age, race,
level of education, and marital status, and sex of infant
(= demographic variables); mother's prenatal care status,
and pregnancy and birth complications, and the infant's
gestational age, weight, and APGAR scores (= medical
history variables); and group assignment (= treatment
variables). No variables met the significance level for

entry to predict growth at six—months postpartum.

Implementation/Process Considerations
Implementation
No omissions of program material were detected. The

only type of error noted was that of "order". For example,

 

117

Table 38

Stepwise Regression
to Predict DDST

Six—Months Postpartum

 

Variable
Entered

Health

R RSQ Increase Adjusted Sign.
in RSQ RSQ

.36 .13 .13 .12 .01

 

 

 

118

in reviewing "Infant Soothing Techniques“ in home visit
three, a nurse mentioned singing prior to talking. Or in
home visit five, a nurse first discussed page two of the
"Birth to Birthday Safety” booklet——and then returned to
page one. These order errors were not regarded as serious.

There are four likely reasons for the lack of
omissions: 1) home visits were audio taped (and student
nurses were aware that their "performance" would be
evaluated), 2) program material was relatively brief, 3)
program participants were also given a copy of the
materials—-and reviewed the pages with the student nurse,
and 4) student nurses were highly motivated, skilled
individuals.

E£9£§§§

The mean score for emotional aide was 5.0 with a
standard deviation of 2.2. The mean score for
advice/information was 1.75 with a standard deviation of
2.0. Finally, the mean score for socialization was 66.7
with a standard deviation of 12.5. Global support scores
ranged from a total of 46 to 94 with a mean score of 73.4
and a standard deviation of 15.8.

Correlational analyses revealed no significant
relationship between global support scores and the infant
outcome measures of growth and development. Chi—square

analyses revealed no significant relationship between low

 

119

vs. high support scores and key demographic variables.

Efficiency Considerations

It was projected that a total of 200 families could
receive program services in a one—year period. (This
figure represents the divisor in the cost estimate
equation.) This estimate was generated from an expected
annual volunteer staff (= Parent Aides) of 50 individuals.
Each volunteer would be required to service four families
through the year. The total projected budget required to
operate the program (= amount requested) would be
$15,000.00 (see Table 39). (This figure represents the
dividend in the cost estimate equation.) Thus—-the program
cost per family would be approximately $75.00. (This
figure represents the quotient in the cost estimate
equation.)

This estimate does not represent the actual expenses
incurred during the implementation of the research project.
(If a comprehensive evaluation component is "attached" to
the service program—-the cost per family is significantly
higher.) The total budget for a one—and—one—half year
period was $31,300. (The Community Foundation of Greater
Flint funded the Program Director, Recruitment Coordinator,
and Research Assistant positions, and miscellaneous

expenses. The Junior League of Flint, Inc. funded the

 

 

120

Table 39

Projected Program Budget

Amount
Cost Requested
Program Coordinator 15,000. 15,000,
Salary
Secretarial
Support 500. --_-
Incentive
Items 4,000. ———_
Office
Space 4,200. ____
Office
Supplies 1,000, ____
Office
Equipment 1,000, ____
($25,700.) $15,000.

121

Volunteer Coordinator position.) Eighty families received

services. Thus—~the program cost per family was $391.25.

Unintended Outcomes

In response to the question, "As you think back on
the past six months, what are your feelings or thoughts
about becoming a parent?“, 82 percent of the responses were
positive in nature (84 percent of experimental subjects, 79
percent of control subjects) while the tone was more
negative for 18 percent of subjects (16 percent of
experimental subjects, 21 percent of control subjects). In
response to the question, "What do you think about your
involvement in this study?“, the responses were evenly
divided between a focus on the learning value of the
program (48 percent) and the fun or enjoyment of
participation (52 percent). Sixty—three percent of
experimental subjects stressed the learning opportunity
while only 31 percent of control subjects focused on this

value (see Table 40).

Examination of Successful Program Participants

A comparison of successful and unsuccessful program

participants is presented in Table 41. Chi-square analyses

revealed two statistically significant relationships:

122

Table 40

Unintended Outcomes

Positive feelings about
parenthood

Negative feelings about
parenthood

Learning value of
program

Pleasure value of
program

Control

79%

21%

31%

69%

 

Experimental

84%

16%

63%

37%

 

123

Table 41

Summary of Comparison Variables

Group
Experimental
Control

Education
Non—graduate
High school
Some college

Marital Status
Single
Married

Age
< 21
=> 21

Race
African—American
Caucasian

Prenatal Care
Routine
Non—routine

Religion
Affiliated
Non-affiliated

Mother Employed
Yes
No

Father Employed
Yes
No

Appraisal
Positive
Negative

Unsuccessful
Participants

33%
67%

20%
47%
33%

89%
11%

41%
59%

56%
44%

50%
50%

50%
50%

56%
44%

72%
28%

76%
24%

 

Successful
Participants

80%
20%

12%
36%
52%

76%
24%

28%
72%

24%
76%

58%
42%

64%
36%

60%
40%

76%
24%

86%
14%

 

124

1) condition (i = 11.08, p = .001), and 2) race (i = 4.79,

p = .02).

 

 

CHAPTER IV

DISCUSSION

The purpose of this study was to evaluate a primary
prevention effort directed at the enhancement of parent
caretaking and relational skills in an at—risk population.
It was hypothesized that such an enhancement would
influence infant growth and developmental outcomes. There
were three primary measurement areas: caretaking skills,
relational indices, and infant outcomes. Infant outcomes
represented the critical dependent variables of interest.
In addition to testing the effectiveness of the model
program, predictors of optimal infant outcomes were
examined. Caretaking skills, relational indices,
demographic, medical history, and treatment variables were
considered. Finally, additional areas of analyses included
program implementation, process, efficiency, unintended
outcomes, and an examination of successful program
participants.

Condition/Time Effects

W12
Three feeding, two safety, and three health measures
were retained for analysis. Experimental subjects
performed better on the feeding questionnaires (at both

three and six—months postpartum) and the formula

125

 

 

 

126

preparation measures. Involvement in the model program
impacted on knowledge about appropriate feeding techniques
including scheduling and amounts, common feeding problems
and possible solutions, and the proper preparation and
storage of infant formula. Also, significant time effects
were detected on the feeding measures with experimental
subjects‘ scores increasing over time. This may have been
a result of the strong emphasis placed on feeding in the
home visits. Experimental subjects also performed better
on the safety questionnaires (at both three and six months
postpartum) than the control mothers. Involvement in the
model program impacted on knowledge about safety practices
in the home environment including preventive measures

(= the "babyproofing" of rooms) and emergency actions (for
chocking, electrical shock, and poisoning). Significant
time effects were also detected on the safety measures with
both experimental and control subjects' scores increasing
over time. This was most likely the result of a heightened
sensitivity to safety issues as the infant gained in
mobility. No differences were observed between groups on
the health measures. The lack of program effects on
adherence to well—baby visits was quite discouraging. An
examination of the number of routine and sick visits
revealed that the infants of both groups were underserved.

Whereas pediatricians recommend that a healthy infant

 

 

 

 

 

 

127

should see a doctor approximately four times in the first
six months of life, the study infants had a mean number of
routine visits of 1.6. The most immediate concern with the
lack of adherence to well—baby visits is that these infants
were not adequately immunized. In hypothesizing probable
reasons for this non—compliance, it is possible that these
women did not appreciate or understand the importance of
routine health care for their infants. However, an
examination of the study area might also suggest that
problems in transportation may account for poor health care
follow—up. It may be necessary for home visitation
programs to incorporate on—site medical care in the
services offered to impoverished families.
Relational Indices

Two child—rearing attitude, three developmental
knowledge, and two mother—infant interaction measures were
retained for analysis. Experimental subjects fared better
than control on all knowledge measures including the
expectancy questionnaires (at both three and six months
postpartum) and the competency interview. Involvement in
the model program impacted on knowledge about the motor and
social development of infants/children, and on problem—
solving abilities related to common child—rearing dilemmas.
No differences were observed between groups on the attitude

or interaction measures. The absence of program effects on

 

 

 

 

the interaction measures was a major disappointment——since
these represented true behavioral indices. With respect to
the attitude measure, it was interesting to note that over
time-—both experimental and control subjects' scores
significantly decreased. This decline may be the result of
increased pressures/demands as the infant enters the
"mobility" phase of development.
Infant Outcomes

Two growth and two developmental scores were
analyzed. These infant outcomes represented the critical
dependent variables of interest. Involvement in the model
program did not impact on the growth measures. With
respect to developmental status, experimental infantsfldid l,
seriempetter. .02 fess PDST. at three-months Potsartumbut
no differences were detected at six—months postpartum. And
the repeated measures analysis of variance revealed that
control subjects' scores were significantly improved at
six—months postpartum (having an approximate mean value of
six points at three—months postpartum and an approximate
mean value of eight points at six—months postpartum). It
appeared that these infants “caught up" with their
accelerated experimental counterparts——but of course it is
not known whether or not the experimental infants would
have continued to make strides if the intervention had

continued (and thus possibly remained ahead of the control

 

T7—

129

infants). Since DDST scores were higher at the post
measure for experimental infants (and no program effects
were detected at the follow—up)——it may be necessary to
remain involved with target families for a greater length
of time in order to sustain early program effects. These
results suggest that early intervention may be important,

but may not be adequate for continued success. At-ripk,

 

familieswmsx require ongoisgsspsort: .

Predictors of Optimal Infant Outcomes

In addition to the comparisons of experimental and
control groups to detect treatment effects, an additional
research area centered on an examination of parenting
functions. Two research questions of great interest were
as follows: 1) Which aspects of caretaking competence or
mastery (feeding, hygiene, safety, or health) are most
predictive of positive infant outcomes (= growth and
developmental status)?; and 2) Which aspects of relational
competence or mastery (developmental knowledge, child
rearing attitudes, or quality of interaction) are most
predictive of positive infant outcomes?. It was theorized
that caretaking proficiency would be more highly related to
optimal infant outcomes than would relational capabilities.

Multiple regression analysis was employed to examine
these questions. (Demographic, medical history, and

treatment variables were also entered into the analysis.)

 

 

130

Group assignment was significantly related to infant
developmental status at three—months postpartum, and health
care knowledge was significantly related to developmental
status at six—months postpartum. No variables met the
significance level for entry to predict growth at either
three or six—months postpartum.

These results did not provide any clear direction in
assessing parenting factors. First, only one variable was
significant at each time period. Second, this single
variable differed at each time period. It might be claimed
that each variable represented a "caretaking proficiency"
factor. (With respect to group assignment--the
experimental model primarily focused on the enhancement of
caretaking skills. And the health measure was categorized
as a caretaking skill indicator.) However——it appears to
be of little value to argue such a claim—~since the
evidence to support the caretaking skills hypothesis in

this study was too weak.

Implementation/Process Considerations
Implementation
No omissions of program material were detected. The
only type of error noted was that of "order“. For example,
in reviewing "Infant Soothing Techniques" in home visit
three, a nurse mentioned singing prior to talking. Or in

home visit five, a nurse first discussed page two of the

 

 

131

"Birth to Birthday Safety" booklet——and then returned to
page one. These order errors were not regarded as serious.

There were four likely reasons for the lack of
omissions: 1) home visits were audio taped (and student
nurses were aware that their “performance" would be
evaluated), 2) program material was relatively brief, 3)
program participants were also given a copy of the
materials——and reviewed the pages with the student nurse,
and 4) student nurses were highly motivated, skilled
individuals.

B£9£§§§

Although there were differences among the student
nurses in the level of support provided to families-—the
relationship between quality of support and infant outcomes
was not significant. Also, an examination of key
demographic variables and level of support failed to reveal
any significant relationships. It is interesting to note
that the correlation between the nurse's support score for
her first family and the support score for her second
family was significant (r = .67, p < .01). Also, mean
support scores across visits were very similar. This
suggests that a helping or interaction style was quite
stable.

In summary, student nurses adhered well to the

training manual——providing participants with all program

 

 

132

material. Thus the implementation of the model program was
very successful. With respect to the process of the
intervention, an examination of level of support did not
serve to clarify its role in assisting at—risk families.

It appeared that the nurses were quite adequate as caring
professionals. For example, the mean score of 5.0 for
emotional aide breaks down to one "incident" every 12
minutes. Scores for information/advice were somewhat low,
but this is understandable. The primary intent of the
program was to provide families with critical caretaking
information——and there was not a strong need to make
additions to the program material. The final aspect of
support——that of socialization——most likely represents the
area in need of intensification. Although families
received five home visits in the first month——they received

only one visit in the second and third months.

Efficiency Considerations

The projected program cost estimate of $75.00 per
family is truly remarkable. This amount would include a
total of eight service "contacts” (one hospital and seven
home visits). Dividing these figures results in a cost of
$9.38 per visit/contact. Of course even when the cost is
this low——a calculation of program benefits is still
necessary. (Although for many human service programs there

is no evidence regarding their actual "worth", it seems

 

133

essential that the introduction of a new program should
result from a scientific demonstration of its value for the
targeted population.) The study results revealed a
short-term impact on developmental status (i.e., increased
DDST scores). If these results were replicated in
additional studies——than the value of such a program would
appear to be sufficient. This would be especially true if
the service could be viewed as an early or "first" segment
in a ”First—Year—of—Life Program". If various community
agencies/organizations could coordinate their efforts to
offer at—risk families a long—term assistance option—~such
an arrangement may solve two key problems. First, the
division of costs would address the feasibility issue which
was explored in the Introduction section (Justification for
Study: Utility Concerns). Second, the provision of ongoing
support may result in the sustainment of early program
effects.

The most difficult task in establishing such a
program would be the successful recruitment of a program
director. The job would require a very enterprising
individual. There are a number of problems inherent in a
service program staffed by volunteers. The ongoing
recruitment, screening, training, and monitoring of persons
is an enormous responsibility. Also~—volunteer programs

had traditionally relied on "non—working" women. With the

 

 

134

majority of women now active in the work force——it is often
difficult to acquire needed support (especially if the
commitment is fairly extensive in nature). Also, there are
problems inherent in the operations of a service program
which targets poor families. Safety concerns for
volunteers is a grim reality. And often it is difficult to
maintain contact with families due to frequent moves and
other disruptions. Finally, the half—time status of the
program director position may represent an obstacle in
attracting qualified applicants. The institution might
consider assembling a "package" deal (i.e., two half—time
positions). Such an offer may appear more attractive to

qualified applicants.

Unintended Outcomes

The responses to the question, "As you think back on
the past six months, what are your feelings or thoughts
about becoming a parent?“, were mostly predictable. The
majority of mothers (regardless of group assignment)
expressed their pleasure with parenthood. Typical replies
included the following:

"I love it."
"My baby is the most important thing in my life."
"I really enjoy it."

"I wouldn't trade it.“
"It's the greatest thing in the world."

135

 

The percentage of negative responses——though much smaller——
were rather disturbing. Examples of such replies included
the following:

"I would rather have waited."

"She‘ll probably be an only child."

”If I had known it was going to be this much

work, I wouldn't have done it."

"Everything is different now. I don't have

as much time to myself as I used to."

"I guess some kids are worse."
It is somewhat sad to ponder how this early perception of
one's infant might influence later parent-child
relationships.

The responses to the question, "What do you think
about your involvement in this study?", were easily
categorized into two viewpoints. Mothers either stressed
the learning value of the program, or the fun/enjoyment of
participation. And the apparent difference between
experimental and control mothers (with a greater number of

experimental mothers offering an educational appraisal)

was not surprising.

Examination of Successful Program Participants

The comparisons of successful and unsuccessful
Program participants (on the variables of condition,
education, marital status, age, race, prenatal care,
religion, family employment history, and parenting
appraisal status) revealed two statistically

Significant relationships: 1) condition and 2) race.

 

136

Regarding the latter, Caucasian study participants fared
better than the African—American women. In hypothesizing
probable reasons for this outcome, it is suggested that the
longer history of impoverishment experienced by the
African—American women most likely contributed to the
differences observed. An analysis of additional variables
(including such factors as types of support offered by
family members) could aid in understanding determinants of
program success. Also, an examination of helper
characteristics should be undertaken. In constructing a
profile of the successful program participant——the older,
better educated, Caucasian woman was represented. This
profile "matches" the description of the "typical“ Parent
Aide helper. The majority of student nurse volunteers were
over 25 years of age and Caucasian. Also——those students
who volunteered for the project tended to be the "better“
students (=higher grade point averages). It could be
argued that the mothers and infants in greatest need of the
model program (i.e., those women at greater risk for
parenting dysfunctions, and those infants at greater risk
for growth and developmental dysfunctions)-—were least
helped by the program. It may be necessary for programs to
more actively recruit helpers similar in characteristics to

the targeted population.

 

137

Implications and Conclusions
Study Strengths
In designing, implementing and evaluating this study--
key theoretical, methodological, and utility
arguments/concerns were addressed. With respect to
theoretical issues, the entry point of intervention was
early (recognizing the critical period of adjustment for
new parents) and program content was holistic (including
both caretaking and relational skill information).
Regarding methodological concerns--an adequate sample size
was obtained (with data collected on 90 percent of the
original sample), at-risk families were targeted (whose
infants are more vulnerable to problematic growth and
developmental outcomes), random assignment was employed
(thus permitting causal inferences), research assistants
were blind to group membership (reducing the likelihood of
rater bias), multiple and repeated measures were conducted
(strengthening the validity and reliability of assessments)
and multiple levels of analysis were employed (including
program effectiveness, implementation, process, and
unintended outcomes). Finally, utility concerns prompted
an assessment of program efficiency (including cost
estimates for programs with and without a comprehensive

evaluation component).

 

 

138

Study Weaknesses

The major objective of the principal investigator was
to assess the impact of the model educational—support
program on parent caretaking and relational skills, and
infant growth and developmental outcomes in an at—risk
population. In assessing condition/treatment effects, it
was noted that the greatest impact was on parent caretaking
skills (with significant group differences obtained on five
of eight measures). This outcome was quite understandable
given that the major focus of the model program was on the
enhancement of these skills. Although relational aspects
of parenting were targeted, the emphasis was ”secondary"
(and significant group differences were obtained on only
three of seven measures). The success ratio for infant
outcomes——which represented the critical dependent
variables of interest—~was quite disappointing (with
significant group differences obtained on only one of four
measures). Furthermore——the differences detected in parent
caretaking and relational skills were in knowledge
attainment and not behavioral outcomes.

With respect to caretaking mastery, involvement in the
model program did not serve to increase adherence to
recommended health practices. It was hoped that program
mothers would be more likely to follow important guidelines

for well—baby visits. With respect to relational skills,

139

involvement in the model program did not serve to enhance
the quality of mother-infant play interactions—-nor were
differences obtained on Section I, Emotional and Verbal
Responsivity of Mother, of the HOME. (But it was
interesting to note the high degree of variability on each
of these interactive measures.) It was hoped that program
mothers would be more aware of the interactive capabilities
of the infant and would therefore display a greater
sensitivity or responsivity toward their babies.

This program was not unique in its failure to link
parents' ideas and parents’ actions. In Goodnow's (1988)
extensive review of "belief—behavior consistency", she
concluded that the overall results from parenting programs
were not encouraging. The relationship between ideas and
actions were——at best——"quite modest".

Goodnow's introductory paragraph to her review was as
follows:

Two recent reviews of research on links between

parents' ideas and parents' actions end with the

suggestion that developmentalists turn to social
psychology in order to enrich a relatively
atheoretical field and supply new methods and
directions for research...The present article

follows through on that suggestion and extends

it to cover not only the issue highlighted by

these reviews (i.e., belief-behavior consistency)

but also some other issues basic to research on

parents's ideas: the likelihood of change...and

links to developmental outcomes.

(p. 286)

Goodnow‘s suggestions for the modification of models

 

 

140

included the consideration of two possibilities regarding
the link between knowledge and behavior: 1) agreement is
more likely to occur with some people rather than others;
and 2) agreement is more likely to occur under some
conditions than others.

With respect to the first consideration, there are
reports of higher idea/action correlations for middle—
income than for lower—income parents. (Goodnow also cites
studies which show that middle—income parents are more
likely to seek new information——and are more open to
change.) However——since infant outcomes are more negative
in impoverished families it would not make sense to alter
the model in this manner (i.e., to target a low—risk
group). Regarding the second consideration, cognitive
dissonance and impression—management theories highlight the
significance of "consistency” in establishing desired
behaviors (based on a need to either make adjustments that
avoid damaging one's image of oneself as consistent, or
arranging one's actions so that we appear consistent to
others). With respect to this consideration, certain
changes could have been incorporated in the model program
that may have increased the likelihood of success. For
example——following a discussion of the importance of health
practices (in which the student nurse would directly ask

the mother if she understood the importance of maintaining

 

 

141

immunization schedules)——the student nurse could have been
instructed to remind the mother about upcoming well-baby
visit "deadlines". (And perhaps that they would discuss
the mother's feelings about these doctor appointments on
subsequent home visits.) This strategy may have prompted
mothers to follow recommended guidelines for well—baby
visits.
Future Directions for Research

In general, program effects were detected on knowledge
as opposed to behavioral measures. The exception to this
was the three—month DDST scores-—although these differences
were immediate or short—term. Two suggestions for the
planning of future parent education programs are given.
First, it may be necessary to remain involved with at—risk
families for a greater length of time. (Although early
intervention may be important-~it may not be adequate since
program effects were evident at the post but not the
follow—up assessment time). This could be accomplished
through a coordination of area services in which program
"parts" are pieced together in order to offer families a
long—term assistance option. Such an arrangement could
successfully address the issue of cost feasibility.
Second, it is necessary to continue to devote time and
effort toward developing and refining educational

components. Specifically, program components or strategies

 

 

are needed which succeed in producing true behavioral
changes in at—risk families. This may require
modifications in models based upon cognitive dissonance and
impression—management principles. Future research in
parenting programs should be directed at the application of
these theories. Drawing from such fields as social
psychology can be used to benefit research on parenting and
child outcomes. If a link cannot be forged between
parents' ideas or knowledge and actions or behavior——the
likelihood of impacting on outcomes for children will be
minimal.

In conclusion, this study represented a primary
prevention effort directed at the enhancement of parent
caretaking and relational skills in an at—risk population.
It was hypothesized that such an enhancement would
influence infant growth and developmental outcomes.
Research or program efforts have generally focused on
parent education activities. It has been thought that the
promotion or enhancement of competencies in this arena
would serve to buffer the children of at—risk families from
potential developmental dysfunctions. Parent educational
services/programs are intended to enhance the quality of
caregiving thereby ameliorating risk factors (e.g.,
inadequate social support) and enhancing protective

mechanisms (e.g., improving the health status of children).

 

 

 

143

Recent years have seen an increase in home visiting
services——and this trend is expected to increase
considerably over the next decade. Roberts et al., (1991)
have stressed the need for research to answer the rather
complex question, "What kinds of family support programs
employing what kinds of staff serving what kinds of
families with what kinds of needs achieve what kinds of
results?” The model program examined here was moderate in
intensity (consisting of a total of eight contacts over a
three—month period), utilized trained student nurses (in
the senior year of their training), targeted impoverished,
first—time mothers and their infants, and was successful in
impacting on parent caretaking and relational skills
knowledge (although behavioral outcomes were somewhat
disappointing). Future research should continue to address
the above complex question——in particular, expanding on
what kinds of changes result from specific program
components, and which individuals appear to benefit from

participation.

 

 

 

 

 

 

 

 

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APPENDIX A

 

 

 

Request for Participation

INFORMED CONSENT

Researchers at Hurley Medical Center are interested in
studying parenting practices and infant growth/development
in the first six months of life. The purpose of this
project is to evaluate parent education programs for first—
time parents. If I agree to participate in the study, I
will take part in one of two programs (by means of random
assignment) and thus agree to the following:

1. If enrolled in Group 1, I will receive 1 hospital
visit and 7 home visits (in the first 3 months postpartum)
by a trained Parent Aide Volunteer (who is a student nurse)
that will include education and demonstration of
various infant caretaking skills.

2. If enrolled in Group 2, I will receive a total of 7
specially designed educational packets (in the first 3
months postpartum) which contain printed materials about
infant caretaking. These packages will be delivered to
my home by a research staff member.

3. At 3 and 6 months postpartum, I will be asked to
complete questionnaires about infant caretaking (such as
feeding and bathing), and to allow researchers to videotape
play interactions between myself and my baby. Also, growth
information about my baby will be evaluated (such as fine
and gross motor development). This should take about 90
minutes.

4. Medical information will be abstracted from mine
and my baby's medical records including pregnancy and birth
information from my obstetrical/postpartum records
(number of prenatal visits, pregnancy complications,
mode of delivery, birth complications, weight, gestational
age, and APGAR scores of baby), and health information
from my baby's clinic records (dates of visits,
immunizations, general health comments of physicians, and
length, weight, and head circumference of baby).

5. I will receive infant formula and various child
care products for participating in this study at no charge.

6. My participation is voluntary. I may withdraw from
the study at any time. My decision to participate or not
to participate will in no way affect the care that I
receive at Hurley Medical Center.

 

 

 

 

 

7. Any information that I share with researchers will
be held in strictest confidence. My name will not appear
on any completed questionnaire. Any papers, audio or video
tapes will be identified by a random number. I am
guaranteed complete confidentiality regarding all aspects
of this study. This guarantee of confidentiality could
be broken only in the event of some unforeseen emergency—
for example, if the health/welfare of the child appeared
to be in jeopardy. Participants remain anonymous in any
report of research findings. Only group results are
reported. Upon request, results of the project wil be
made available to you.

All interview sessions will be audiotaped so that content
can be verified.

Video and audiotapes will be erased following scoring.

I also understand that if I have any further questions
regarding this project, I can contact the Institutional
Review Board at Hurley Medical Center by calling 257—9134,
or I may contact the Project Director, Kay Taylor, by
calling 257—9963. The Project Director is a graduate
student in Psychology from Michigan State University.

 

 

Participant Signature Date

 

Project Director (or Designee) Signature

 

 

 

 

 

 

 

STUDENT NURSE CONTRACT

Responsibilities:

- To honor your commitment to the project by
attending the training sessions, and providing
intervention services to two families.

— To preserve the fidelity of the model by carrying
out the intervention as presented in training and
detailed in the parent aide manual.

— To abide by the confidentiality code of research in
regards to the rights of human subjects.

 

 

Date Student Nurse

Rights:

— To receive the necessary preparation for
successfully adopting the interventionist role.

— To have access to research staff for needed or
additional support/guidance.

— To receive all necessary materials for training and
service provision (notebooks, app01ntment cards,
parent aide manual).

 

 

Date Project Director

 

APPENDIX C

 

Session

Session

Session

Session

Session

Session

H

N

W

0'1

 

Training Schedule

Project Background
Role Clarification
Mechanics/Scheduling
Life Styles/Empathy Review
The Labor and Delivery Experience
Role Play: Hospital Visit

Safety Concerns
Teaching/Learning
Promoting Recovery
Infant Feeding Basics: Schedules/Amounts
Formula Preparation Demonstration
Role Play: Home Visit #1

Nutrition: Baby's First Year
Common Feeding Problems and Solutions
Burping Demonstration
Role Play: Home Visit #2

Beyond Feeding: Baby Care Basics
Diapering, Bath Demonstrations
Infant Soothing Techniques
Role Play: Home Visit #3

Infant States/Temperament
Modified Brazelton Demonstration

Film: The Amazing Newborn

Infant Development

Role Play: Home Visit #4

Preventive Medical Care
Maintaining Immunization Records
Role Play: Home Visit #5

151

Session 7 Safety in the First Year of Life
Film: A Guide to Making Baby's World a Safer
Place

Home Check Demonstration
Role Play: Home Visit #6

Session 8 Closure Issues
Support Systems: Identifying & Building
Utilizing Community Resources
Role Play: Home Visit #7

APPENDIX D

 

152

HOSPITAL VISIT
CHECKLIST

1) Introduction
— Self
"My name is . . . I'm your Parent Aide!"
— Project Goal
"I will be making home visits to you over the

next couple of months to share information about
feeding and caring for your baby."

2) Labor/Birth Experience
— Mother
"How did things go for you?“
— Baby

"Tell me about the baby!"

3) Obtain Contact Information

- Address, telephone
number of mother

— Address, telephone
number of 2 ”emergency"

persons (friends;
relatives)

4) Schedule Home Visit #1

— Establish date, time
(within 24 to 48 hours)

— Leave appointment card

153

CONTACT INFORMATION

Mother's Address:

 

 

Telephone:

 

Relative's Address:

 

 

Telephone:

 

Friend's Address:

 

 

 

Telephone:

154

HOME VISIT #1
CHECKLIST

1) Promoting Recovery

— Inquire about mother's health
> "How are you feeling?"

— Share recovery suggestions

2) Feeding Schedules/Amounts

— Review when/how much material

— Review material on pages 14, 15
in "Feeding Baby"

> "Do you have any questions about feeding
schedules/amounts?"

3) Formula Preparation

— Review 12 steps
— Demonstrate 12 steps

> ”Do you have any questions about formula preparation?"

4) Schedule Home Visit #2

— Establish date, time
(= 1 week postpartum)

— Leave appointment card

155

PROMOTING RECOVERY

* Diet/nutrition

It is important for you to
eat well. Don't forget to
include fruit and vegetables
in your daily meals!

* Exercise

A little exercise can help
to build your strength.
Walking is very good for
you.

* Time—out

You need time for yourself
and the companionship of
other adults. See if you
can arrange for someone you
trust to take over for a
while with the baby.

 

156
WHEN DO I FEED MY BABY?

Your baby's stomach will be empty about every 1 to 4 hours.
Each baby is different. Most newborn infants will need

6 to 8 feedings a day at about every 2 to 4 hours. This
can depend on their size.

Larger babies can usually take enough formula at one
feeding to last 4 to 5 hours. Smaller babies will probably
drink less formula at a feeding, and therefore will need
more feedings throughout the day.

Sometimes mothers learn to tell the difference between
their baby's cries——and can tell when they are hungry or
wet or just want to play.

But sometimes babies don't cry to tell mothers they are
hungry. Then it is important for mother to know that her
newborn will need about 6 to 8 feedings each day.

HOW MUCH SHOULD I FEED MY BABY?

Most infants need approximately 17 to 18 ounces of formula
each day.

If the infant can take he/she will need
about
2 ounces of formula 8 to 9 feedings
3 ounces of formula 5 to 6 feedings

4 ounces of formula 4 to 5 feedings

157

HOME VISIT #2
CHECKLIST

1) Nutrition

— Review nutrition materials

- Review material on page 2 in
"Your Special Baby"

"Do you have any questions about nutrition?"

2) Feeding Problems
- Review common feeding problems
materials
— Demonstrate burping techniques

"Do you have any questions about feeding problems?"

3) Schedule Home Visit #3

— Establish date, time
(= 2 weeks postpartum)

— Leave appointment card

 

158

WHAT IS NUTRITION?

Nutrition is the science that is the study of food and how
it is used by the body.

What we eat becomes part of our bodies. The old saying,
"You are what you eat", is true!

WHY GOOD NUTRITION?

Food helps a person to grow, play, work, think, and do many
other activities that make up life itself.

Good nutrition is especially important during infancy
because this is a time of very rapid growth.

After the first year of life, your child will never again
grow so rapidly!

Because of this rapid growth, a good diet is very
important!

HOW WILL A GOOD DIET HELP KEEP MY BABY HEALTHY?

A good diet:

— Helps your baby grow

- Helps your baby fight infections, and get better
faster when he/she is sick.

For your baby, it is important that he/she gets both the
right amount and right type of food.

 

159
WHAT DO I FEED MY BABY?

Milk—~but never cow's milk. Cow's milk does not provide
the special nutrients that baby needs.

WHY NOT SOLID FOODS?

Solid foods from your table or commercially prepared baby

foods are usually started somewhere between 6 months and 1

year of age. Of course, ask your doctor or pediatrician

for his/her advice. 1

There is no nutritional reason to start your baby early on
solid foods. Babies get all the nutrients they need in the
formula.

Some parents feed solid foods early hoping that their
babies will sleep through the night. This is a common
belief that has been proven to be untrue.

There is also the matter of cost. It will be more.
expensive to feed your baby once solid foods are given.

Finally, some doctors or physicians feel that starting
babies early on solid foods can increase a baby's chance of
getting food allergies. Thus they suggest that mothers
wait.

 

160

WHAT ABOUT WATER?

Water is very important for baby. They lose water more
quickly than the adult does! It is a good idea to offer
the baby unsweetened water several times each day. Offer
the water when the baby is awake, but not within 1 hour of
feeding time.
Extra water is especially important:

- During hot weather

— When the baby is constipated

- If the baby is having diarrhea
If the water bottles are made up ahead of time, they must
be sterilized. The temperature of the water depends on the

baby's individual taste. Some babies like water warm,
others like it cold.

WHAT ABOUT VITAMINS?

Ask your doctor or pediatrician what he/she recommends.

HOW WILL I KNOW THAT MY BABY IS GROWING WELL?
Your doctor or pediatrician will keep track of:

— Your baby's length

- Your baby's weight

- Your baby's head circumference

These are important measures of your baby's growth!

 

161

COMMON FEEDING PROBLEMS

HICCUPS

What are hiccups?

Hiccups are normal for babies and rarely cause them any
discomfort. These are caused by the return of air
bubbles that were swallowed.

What can I do to help?

The remedy is to allow the baby to continue to suck on
water or formula.

COLIC

 

What is colic?

A cramping or pain in the abdominal/stomach area. The baby
will cry and draw their legs up to the abdomen/stomach.
This may happen in young infants—-usually under 3 months of

age.

Sometimes the baby is hungry or has swallowed too much air,
or may be afraid, angry, or exc1ted.

Usually, colic is thought of as caused by air or gas. The
baby's sucking and swallowing reflexes are at work
sometimes when the baby is not eating. He/she may use.
these when they are overclothed, or thirsty, or even tired.

What can I do to help?

You can try feeding or burping. And, of course, call your
doctor or pediatrician.

162

SPITTING UP AND VOMITING

What is spitting up?

The return of small amounts of swallowed food during or
shortly after eating is called spitting up.

Spitting up is common in the first 6 months for many
babies. (For some babies, it can last up to 8 or 9 months.)

Some possible reasons include:
— baby has not been properly burped after eating

- baby has been laid to nap after eating with the
head lower than the rest of the body

— baby is upset or tense

During the early months, a healthy infant may spit up a
small amount at each feeding.

What can I do to help?
— make sure to burp baby
— place baby in the "prone" position (lying with the
face downward rather than upward) or the "right

lateral" position (on their right side rather than
their left side). This helps the food to digest.

— try to comfort baby

This problem begins to improve at about 3 months of age,
and is usually gone by 6 months of age.

 

What is vomiting?

Vomiting is the complete emptying of the stomach.

What can I do to help?

It is best to phone your doctor or pediatrician about this.

163

DIARRHEA

What is diarrhea?

Diarrhea is frequent loose watery stools.

What can I do to help?

It is best to phone your doctor or pediatrician about this.

CONSTIPATION

What is constipation?

Most babies have 1 or more stools per day——although some
normal infants have stools only once every 36 to 48 hours.
(It is the quality rather than the quantity of stools that

determines constipation.)

Constipation is hard stools that are difficult for the
infant to pass.

What can I do to help?

Increase fluid intake. It is best to phone your doctor or
pediatrician about this.

 

BURPING

Why?

 

Infants will swallow some air while they take formula.
Therefore it is necessary to allow the infant to get rid of
the swallowed air at least once for each 2 ounces of milk
taken during the feeding——and again at the end of the
feeding.

How?

* Demonstrate

The baby can be held upright over the shoulder and gently
patted or laid across the lap with his/her head elevated
and the back patted and stroked until he/she burps or held
in a sitting position with his/her chin supported and the
back patted.

You decide what method that you and baby like best!
l
l

>

>

 

HOME VISIT #3
CHECKLIST

1) Baby Care Basics
— Review material on pages 14, 15,
18, 19, 20, 23 in “Baby Care Basics"

"Do you have any questions about bathing or diapering?"

2) Infant Soothing Techniques
— Review suggestions

"Is there anything you have found to be helpful?"

3) Schedule Home Visit #4

— Establish date, time
= 3 weeks postpartum)

— Leave appointment card

 

166

INFANT SOOTHING TECHNIQUES

— Talking to baby
— Singing/music

— Walking

- Swaddling

~ Rocking

- Car ride

- Bath/massage

- Pacifier

— Warmth

> Is there anything you have found to be helpful?

When all fails, place baby on stomach in crib and let
him/her cry. If possible, have someone you trust take over
for a while. You would probably appreciate a break!

 

167

HOME VISIT #4
CHECKLIST v

 

1) Infant States/Temperament
— Review material on the Amazing Newborn

> "Do you have any questions about infant states?"

2) Modified Brazelton

— Review material on Brazelton

— Demonstrate Brazelton tasks
> "Do you have any questions about these tasks?“ 1
l
l

3) Infant Development

— Review newborn through 12 months in
"How Your Baby Grows"

> "Do you have any questions about growth or development?"

4) Schedule Home Visit #5

— Establish date, time
(= 4 weeks postpartum)

— Leave appointment card

 

 

168

THE AMAZING NEWBORN

The newborn is vital and responsive! From birth,
they are ready to learn about their world. All

of the newborn's senses are operating-—they can see,
hear, smell, touch, and cry.

We're going to look at your baby's ability for
interaction-~but first it is important for us to
learn about the different kinds of behavior in a
newborn.

There are 6 patterns of behavior, broken into 2
categories:

Sleep Awake
Quiet sleep Quiet alert
Active sleep Active alert
Drowsiness Crying

SLEEP STATES

Quiet sleep: The infant is at full rest. No body
movements except for occasional
startles. No eye movements under

their lids.

Active sleep: Eyes are closed but body is active.
Some facial expression such as
smiling or frowning. May suck.

Rapid eye movement.

Drowsiness: Lids are droopy. Eyes appear dull.
The infant may be still or mOVing.

"" h m-#’ '

 

AWAKE STATES

 

169

Quiet alert: The infant is fully awake and very

responsive. Eyes are wide and
bright. This is the time for critical
interaction between a baby and
his/her parents.

Active alert: This is the time when a newborn

Crying:

discovers their arms and legs. They
may also experiment with sounds such
as coos and gurgles. The active
alert state can be thought of as a
perfect playtime for baby.

The infant's eyes are tightly

closed. There may be a lot of body
movement. Gentle touching, rocking, and
holding may help to quiet baby.

 

170

MODIFIED BRAZELTON
The Brazelton was designed to test an infant's:

- reactions to objects
- reactions to sounds

— use of their reflexes

When we use the Brazelton, we are able to observe
the infant's ability to respond to his/her outside
environment.

It is important to understand that the Brazelton
usually takes between 20 and 30 minutes, and
involves about 30 different tasks!

Today, I would like to show you just a few of these
tasks.

It is also important to understand that certain
tasks can only be done when the baby is in a
certain state.

Vision

Babies can see at birth, but only a distance of
about 10 to 12 inches. This is about the distance
from the crook of your arm to your face. You need
to be close to your baby for him/her to see your

face.

TASK #1

By moving a ball 10 to 12 inches above the
infant, you can see your baby's ability to focus
on and follow an object!

 

171

* It is best not to talk during this
task since that might distract him/her

* It is best for your baby to be in an

alert state

Once you get his/her attention, move the ball slowly
from side to side. You might try jiggling the ball
above your baby to get his/her attention at first.

Hearing

Not only can your baby hear very well at birth,
he/she can also turn to the direction of sounds!

TASK #2

If we shake a rattle at the side of his/her
head, he/she will move toward the sound!

* It is best not to talk during this
task since that might distract him/her

* It is best for your baby to be in an
alert state

These first two tasks show us that babies are curious.

They are interested in the environment that surrounds
them!

Reflexes and Strengths

We will look at just a few of your baby's reactions
to certain kinds of touch.

..._ _. _ - .

 

 

 

172

TASKS #3, 4, 5, 6

Babinski: Stroke the sole of the foot

Watch for spread of toes!

Plantar Grasp: Push below toes; place index finger

in
infant's hand
Watch for curling or tightening of
fingers and toes!
Standing: Support infant under his/her arms and place
in an upright position
Watch for support given by the legs!
Rooting: Stroke cheek or corner of mouth
Watch for head to turn and search for
something to suck!
Of course, babies prefer certain kinds of touch such
as

stroking, patting, and holding. Babies even enjoy a
massage such as gently rubbing their back!

Other Senses

So far we have looked at vision, hearing, and
touch.

Babies can also smell. They even have the
the ability to recognize or remember smells!

(Such as your perfume or shampoo.)

173

Finally, babies can also "talk". Of course, the
language of a baby is different from an adult!

The newborn communicates by crying. At about

3 months of age, babies can coo. Then they begin
to babble. At about a year of age, they will

say their first words!

It is important to talk to babies as they grow
and develop. They enjoy the sound of the human
voice! Here are some suggestions:

* Demonstrate

Quiet Talk: Rocking, holding and talking to
baby at a special time each day.

 

Back Talk: Imitating and responding to your
baby's vocalizations.

 

Parallel Talk: Saying what the baby is doing
while he/she is doing it.

 

Saying what you are doing
while you are doing it.

 

174

HOME VISIT #5
CHECKLIST

1) Well Baby Check—Ups
— Review health material

> "Do you have any questions about your baby's check-ups?"

2) Immunizations
— Review schedule on page 15 in "A First Year
Guide to Feeding Your Baby"
— Demonstrate chart in back cover of "Baby's

Health Record and Formula Feeding Guide"

> "You can take this with you each time to the doctor's
office and ask him/her to complete it."

3) Schedule Home Visit #6

— Establish date, time
(= 8 weeks postpartum)

— Leave appointment card

 

175

HEALTH

WHY WELL BABY CHECK—UPS?

Your baby should have regular health visits. These visits
are important for keeping a check on his/her general health
and growth.

WHEN?

During your baby's first year, he/she should visit the
doctor at least 5 times. These visits are sometimes called
"well baby check—ups".

Of course, it is important to telephone the doctor anytime
you are worried about your baby's health.

WHAT WILL HAPPEN?

- a complete physical examination
— immunizations
- a chance for you to ask any questions you might

have about your baby (physical problems, care,
diet, behavior, etc.)

WHEN ELSE SHOULD MY BABY SEE THE DOCTOR?

— when your baby is ill (vomiting, temperature, etc.)

- when your baby just seems to be acting different——
even if you can't really explain what it is

1)

 

176

HOME VISIT #6
CHECKLIST

Safety

- Review safety material (in bold print) in
"Birth to Birthday Safety"
— Demonstrate emergency choking aid

— Review suggestions for babyproofing home

— Demonstrate home environment check

> ”Do you have any questions about safety?"

2)

Schedule Home Visit #7

— Establish date, time
(= 12 weeks postpartum)

— Leave appointment card

 

177

SUGGESTIONS FOR "BABYPROOFING" HOME

— Insert safety plugs into unused electrical sockets

— Install gates or childproof latches (at basement
door or any stairways)

- Move small glass or ceramic knickknacks

— Remove poisons from kitchen, bath

- Beware of unstable furniture that could tip

— Pet food and pet dishes should be out of reach

— Dangerous items (such as scissors, sewing kits,
silverware, matches) should not be left out

— Remove or cover control knobs on stove when not
in use; keep pot handles turned inward; beware
of appliance cords (could pull hot coffee on self)

- Do not leave small objects out (may place in
mouth and choke)

- Tape padding on sharp edges of furniture

— Do not leave plastic clothing bags out (may
suffocate)

— Keep all doors and drawers closed

178

HOME ENVIRONMENT CHECK

Whatever room that you and the mother are
meeting in (most likely the living room,
dining room, or kitchen)-—simply point out
a few changes that she might make in that
room as the baby becomes more mobile.

> "You might . . . . . . . "

Also, share with her the suggestion of
getting on her hands and knees to survey
the room.

> "This is what your baby sees."

179

HOME VISIT #7
CHECKLIST

1) Closure

— Reminder of final visit

- Review home visit topic areas

"Do you have any questions about any of these things?"

2) Support Systems

— Review support material

3) Community Resources

— Review community resource material

— Review highlighted material in "A Guide
to Children's Services in Genesee County"

4) Thank You

”Again, thank you for being a part of this study. Your
participation is really appreciated!"

 

180

CLOSURE

Reminder

This will be my last visit to your home. I want to thank
you again for letting me come into your home and visit with
you and your baby.

Review

Over the past several weeks, we've talked about a lot of
different things.

Formula preparation

Feeding schedules & amounts

Nutrition

Common feeding problems

Your baby's physical and social development

— Your baby's ability to respond to you and
things in his/her environment

— Caring for your baby (bathing
and diapering)

- Well-baby visits & immunizations
— Safety for baby in the home

~ Support systems for new parents

All of these things that we've talked about are very
important for caring for your baby!

Clarification

Do you have any questions about any of these things?

181

IDENTIFYING AND BUILDING
SUPPORT SYSTEMS

Having others in our lives that we can turn to for help, or
information, or friendship-—is very important. This is
especially true for new parents!

There are two sources of help that may be available to us:

Informal Support Systems

This includes friends, spouses, family members,
neighbors, or co-workers.

Formal Support Systems

This includes professional people such as ministers,
nurses, doctors, or social workers.

Identifying and building these helping relationships (both
formal and informal) can be a source of great personal

strength!

 

182

COMMUNITY RESOURCES

I would like to leave you this pamphlet, "A Guide to
Children's Services in Genesee County". It is divided
into different service sections.

I will point out just a few of these service sections:

- Child Care Services
- Health Services
— Emergency Assistance

If you think that you might be interested in any of
these services, please telephone them!

Of course, I would like to remind you of Hurley's health
services available to infants and children:

— Pediatric Clinic

Monday - Friday 9 a.m. to 3 p.m. . . .
[Appointment only——unless emergency or Sick ViSit.]

- After Hours Clinic

Monday - Friday 5:30 p.m. to 10:30 p.m.
Weekends; Holidays 12 noon to 11 p.m.

Thank You

Again, thank you for being a part of this study. Your

participation is really appreciated!

APPENDIX E

183

FORMULA PREPARATION PERFORMANCE CRITERION CHECKLIST

Passed Failed

1. Washed bottles, nipples
and pitcher + -

2. Boiled bottles and nipples
for five minutes + —

3. Boiled water for five

minutes + —
4.1 Let water cool to touch + -
5. Wiped can + -

6. Shook can, poured formula
into pitcher + -

7. Added one part water to
one part formula + -

8. Poured formula into
bottles + -

9. Covered pitcher, placed
in refrigerator + -

10. Made sure that formula
was not too hot + -

ll. Threw out formula left
in bottle + -

Total Items Passed:

184

FEEDING QUESTIONNAIRE

Please read each of the following statements and select what
you consider to be the best answer.

1. During the first year of life, baby may be fed

breast milk or formula
breast milk, formula, or cow's milk

breast milk, formula, cow's milk, or powdered milk

foods are usually started
at around 3 months of age
somewhere between 6 and 12 months of age

when the front teeth appear

3. Starting solid foods early may

5. Most
each

help baby sleep through the night
give baby extra nutrients

cause food allergies

is important for baby because

it can help fill up a hungry baby

they lose water more quickly than the adult does

it contains some nutrients and minerals

infants need approximately ounces of formula
day.

11 to 12
17 to 18

23 to 24

10.

185

Baby will need about feedings each day.
2 to 3
5 to 8

10 to 12

babies will probably need more feedings throughout

the day.

smaller
larger

ill

Mothers can tell that their babies are hungry by
whether or not baby cries
keeping track of ounces of milk drank

feeding baby at regular meal times

To help with hiccups, I might
allow baby to suck on water or formula
rock baby at a rapid pace

burp baby

To help with colic, I might
give baby a warm bath
try feeding or burping

massage baby's tummy

11.

12.

13.

14.

15.

 

186

A healthy infant may spit up
a small amount at each feeding
a small amount occasionally

only when overfed

To help with spitting up, I might
give baby less milk or food
give baby more milk or food

burp baby more times

It may take to to complete a feeding.

5 to 10 minutes
10 to 20 minutes

20 to 60 minutes

If baby is vomiting, I should
stop giving milk for that day
give more water to replace lost fluids

.—

telephone the doctor

If baby is constipated, I might try
feeding solid foods
putting sugar in the milk

increasing fluids

 

16.

17.

18.

19.

20.

187

It is best to burp baby
at the end of the feeding
for each 2 ounces of milk taken

only if baby seems slow to eat

To burp baby it is best to
pat the back gently
pat the back firmly

stroke the stomach

If baby does not finish a bottle, you should
cover tightly and place in refrigerator
throw away any formula baby does not finish

encourage baby to finish bottle

Bottles and equipment should be boiled for minutes.
five
ten

fifteen

Prepared formula should be refrigerated and used within
3 hours
12 hours

48 hours

 

21.

22.

23.

24.

25.

188

When preparing formula, you should use
1 part mix to 1 part water

1 part mix to 2 parts water

1 part mix to 3 parts water

The purpose of sterilization is to
stop the growth of bacteria in the milk
prevent colic

prevent constipation

To make sure that the formula is not too hot you should
dip one finger in the bottle
taste the formula

shake some milk on your wrist

You should prop a bottle for feeding
at night time only
whenever you are busy

never if possible

Baby may have a three-meals—per—day adult schedule at
approximately

3 months of age
6 months of age

12 months of age

 

189

INFANT CARE QUESTIONNAIRE

Please read each of the following statements and select what

you consider to be the best answer.

1. If possible, it is best to give baby a bath

daily
every other day

once each week

2. A tub bath is usually recommended

as soon as navel and circumcision are healed

when baby can sit on his/her own

at about one year of age

3. For the first few days or weeks of life,
usually recommended.

a sponge bath

a tub bath

no bath

4. It is necessary to change a baby's diaper

each day.
2 to 4
4 to 6

6 to 8

is

times

10.

190

To protect baby from diaper rash you might use

vaseline

corn starch
cream
cleansing baby,
do not disturb
pay special attention to

lubricate

The genital area should

be cleaned daily
not be touched

be cleaned occasionally

It is important to keep baby's skin

moisturized
fresh and dry

protected from air

using disposable diapers, you should
also use plastic pants
avoid oversized diapers

tape very tightly

The most frequent cause of baby skin problems is

soiled or soggy diapers

the use of too many lotions or creams

exposure to hot or cold air

the skin folds and creases.

 

191

SAFETY QUESTIONNAIRE

Please read each of the following statements and select what
you consider to be the best answer.

1. If baby is choking on a foreign object, you should first
Lay baby face down and give 4 back blows rapidly
between the shoulder blades with the heel of your
hand

Open your mouth wide and cover the baby's mouth and
nose giving puffs of air about every 3 seconds

Hold baby upside down by the feet and shake until
object comes loose

2. If baby has swallowed a poisonous substance, you should
first

Induce vomiting with syrup of ipecac

Call the Poison Control Center
Take baby's temperature and telephone the doctor
3. To prevent baby from getting into medicine or cleaning
products, probably the best thing to do is
Keep these products out of baby's reach
Watch baby every minute

Place childproof locks on cabinets

4. When bathing baby, the number one safety precaution is
A water level of no more than 6 inches
Remaining in the room at all times

Water that is warm to the touch

192

 

Parents need to "babyproof" a home when their baby is

2—3 months of age or when baby can grasp objects
6-9 months of age or when baby begins crawling

12 months of age or when baby may being walking

A good practice to protect baby from electrical shock is

. When

. When

Place tape over all socket openings
Insert safety plugs into unused sockets

Put heavy furniture in front of sockets

is it okay to leave baby alone in the house?

If baby is sleeping, and you will be gone only
a short time

If baby is placed in the crib with the sides up,
and you will be gone only a short time

It is never okay to leave baby alone

the stove is not in use, it is best to
Unplug it
Remove control knobs

Keep baby out of room

If furniture has sharp edges, you might

Teach baby to avoid

Tape edges

Watch baby closely

 

193

:0. When driving in a car with baby, keep the windows near
aby

Closed
Opened a few inches

Whatever way baby prefers

11. For a young infant, the car safety seat should
Face toward the front
Face backwards
Be placed in the front seat
12. Federal regulations specify that crib slats can't be
more than _____ inches apart.

____ 2 and three-eights

3 and three-sights

4 and three—eights

13. It is best to keep the crib equipped with
A low—hanging mobile
Soft pillows

A favorite toy

14. A good location for the crib is in
Your bedroom near you
A corner away from windows

A busy room for easy watching

15.

16

17.

18.

19.

20.

table

 

194

Plastic bags should be
Kept far away from baby
Thrown away immediately

Placed in a high cabinet
When baby is using the high chair or on the changing

Place rugs on the floor beneath
Hold baby down with one hand
____ Use safety straps

To protect baby from basement or any stairway you could
Always keep these doors closed

Install gates or childproof latches

Carpet the stairs

Glass or ceramic knickknacks
Can remain in room if baby is watched closely
Should probably be put away for now
____ May help to entertain baby
Pet food and pet dishes
Pose no real threat to baby
____ May be messy if baby tips over
Should be out of baby's reach

Because baby may try to chew on electrical cords or pull
down on them, you might

Use cord shorteners
Make sure cords are not frayed

Wrap tape around cords

 

 

195

HEALTH QUESTIONNAIRE

Please read each of the following statements and select what
you consider to be the best answer.

1. During baby's first year, he/she will probably visit the
doctor about time/s for check-ups.
one

three

five

2. Regular health visits are important
when baby may be ill
for keeping a check on growth

if baby has a handicap

3. You can telephone the doctor
anytime you are worried about baby's health
only when baby is very ill

if he/she has given permission

4. Immunizations usually begin at of age.
2 months
6 months

1 year

196

5. During a regular check—up, you can ask questions about

physical problems

physical problems and diet

physical problems, diet, and care instructions

6. In the first year of life, baby should receive
immunizations for

polio
polio, DTP (Diphtheria, Tetanus, Pertussis)

polio, DTP (Diphtheria, Tetanus, Pertussis), and a
TB test (Tuberculin)

7. In the second year of life, baby should receive
immunizations for

polio, DTP (Diphtheria, Tetanus, Pertussis)

polio, DTP (Diphtheria, Tetanus, Pertussis),
measles, German measles

polio, DTP (Diphtheria, Tetanus, Pertussis),

measles, German measles, mumps, Hva (Haemophilus b
Polysaccharide Vaccine)

8. Records of baby's immunizations should be kept by
a doctor

a doctor and the hospital

a doctor and you

9. Good nutrition is especially important during infancy
because

baby can't use vitamin supplements
this is a time of very rapid growth

you can control his/her diet

197

10. A good diet will help your baby
grow
grow and fight infections

grow, fight infections, and get better faster when
sick

 

 

198

CLINIC RECORDS CHECKLIST

Subject:
Staff:
Date:

 

 

 

Routine Visit

Immunization 6—Month Schedule:

Age Immunization Date Received
2 months DTP / /
Polio / /
4 months DTP / /
Polio / /
6 months DTP / /
Polio / /

General Care Comments:

Hygiene

 

 

 

 

 

 

 

 

 

 

199

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attitude
+ _
/ /
+ _
/ /
+ -
/ /
+ ...
/ /

Overall Wellbeing
+ _
/ /
+ _
/ /
+ _
/ /
+ _
/ /

 

Number of Visits:

0 1 2 3 4

 

 

 

200

Sick/Emergency Visit

Reason:

 

 

 

 

 

 

 

 

General Care Comments:

Hygiene

 

 

 

 

 

 

 

 

 

201

Attitude

 

 

 

 

 

 

 

 

Overall Wellbeing

 

 

 

 

 

 

 

 

Number of Visits:

 

 

 

202

PARENTAL ATTITUDE RESEARCH INSTRUMENT

The following questionnaire includes a series of statements.
Please read each statement and decide how STRONGLY you AGREE
or DISAGREE with the statement on a scale from 1 to 4.
Circle the appropriate number. Please read each statement;
it is important not to skip any statement. Do not spend too
much time with any one statement. Trust your first thought.

STRONGLY STRONGLY

AGREE DISAGREE

1. Strict discipline develops a strong

person who knows right from wrong. 1 2 3 4
2. When a child thinks his parent is

wrong he should say so. 1 2 3 4
3. A mother should make it her business

to know everything her children are

thinking. 1 2 3 4

4. Children have a right to rebel and be
stubborn sometimes. 1 2 3 4

5. Most children are trained to use the
potty by 15 months of age. 1 2 3 4

6. Parents shouldn't feel they have to
give up important things for their
children. 1 2 3 4

7. Children should be encouraged to
undertake tough jobs if they want to. 1 2 3 4

8. The trouble with giving attention to
children's problems is they usually
just make up a lot of stories to l 2 3 4
keep you interested.

9. A parent should keep control of their
temper even when children are demanding. 1 2 3 4

10. Having to be with the children all the
time gives a woman the feeling she is
tied down. 1 2 3 4

11. Strict training makes children unhappy. l 2 3 4

 

 

 

203

STRONGLY STRONGLY
AGREE DISAGREE

 

12. If a child acts mean he needs
understanding rather than punishment. 1 2 3 4

13. A wise parent will teach a child early
just who is boss. 1 2 3 4

14. There is nothing worse than letting a
child hear criticisms of his parents. 1 2 3 4

15. A child's thoughts and ideas are his
own business. 1 g 2 3 4

16. A child should take all the time he
wants to before he learns to walk. 1 2 3 4

17. A parent must expect to give up their
own happiness for their child's
happiness. 1 2 3 4

18. A child should learn that he has to
be disappointed sometimes. 1 2 3 4

19. A child should never keep a secret
from his parents. 1 2 3 4

20. A parent should be concerned with any
problem of a child no matter how small. 1 2 3 4

21. Most parents never get to the point
where they can't stand their children. 1 2 3 4

22. Most young mothers are upset more by
the feeling of being shut up in the
home than by anything else. 1 2 3 4

23. Toilet training should be put off
until the child shows that he is ready. 1 2 3 4

24. Almost any problem can be settled by
quietly talking it over. 1 2 3 4

25. Children who are held to strict rules
grow up to be the best adults. 1 2 3 4

 

 

26.

27.

28.

29.

30.

204

STRONGLY STRONGLY

AGREE

Taking care of a home doesn't have to
coop a woman up. 1

If a parent is wrong he should admit
it to his child. 1

A good parent should protect their
child from life's little problems. 1

Few women get enough thanks for all
they have done for their children. 1

Most parents can spend all day with their
children and remain calm and pleasant. I

DISAGREE
3 4
3 4
3 4
3 4
3 4

The following questionnaire includes a series of statements.
Please read each statement and decide how STRONGLY you AGREE
or DISAGREE with the statement on a scale from 1 to 4.

Circle the appropriate number.

 

205

PARENTAL ATTITUDE RESEARCH INSTRUMENT

it is important not to skip any statement.

much time with any one statement.

10.

11.

12.

STRONGLY STRONGLY
AGREE

A child will be glad later on that he
had strict training. 1

Some children are just so bad they
must be taught to fear grown-ups for
their own good. 1

Children have every right to question
their parents' opinions. 1

Children are entitled to keep their
own secrets. 1

The sooner a child learns to walk the
better he's trained. 1

There is no reason why a parent can't be
happy and make their child happy too. 1

A good parent lets their child learn
the hard way about life. 1

Children bother you with all their
little problems if you aren't careful
from the first. 1

Raising children is an easy job. 1
A young parent feels "held down" because
there are lots of things they want to

do while still young. 1

If children are given too many rules
they will grow up to be unhappy adults.l

A child should never be taught to fear
grown-ups. 1

Please read each statement;
Do not spend too
Trust your first thought.

DISAGREE
3 4
3 4
3 4
3 4
3 4
3 4
3 4
3 4
3 4
3 4
3 4
3 4

ul-

.-.:-

_.-

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

 

206

STRONGLY STRONGLY

AGREE

A parent should never be made to look
wrong in a child's eyes. 1
A parent should always be concerned
about upset feelings in a child. 1
A child should be taken off the bottle

or breast as soon as possible. 1
Children should realize how much

parents have to give up for them. 1
Children have to face difficult
situations on their own. 1
A parent should always be concerned
about upset feelings in a child. 1
Parents very often feel that they can't
stand their children a minute longer. 1
Most young parents are pretty content
with home life. 1
Strict training will make a child

resent his parents later on. 1
More parents should teach their

children to always be loyal to them

no matter what. 1
You can't make a child behave by
cracking down on him. 1
Very few children are trained to use

the potty by 15 months of age. 1
It is a parent's duty to make sure they
know their child' s deepest thoughts. 1
Children don't "owe" their mothers
anything. 1
A child needs to be emotionally close

to its parents for a long time. 1

DISAGREE
3 4
3 4
3 4
3 4
3 4
3 4
3 4
3 4
3 4
3 4
3 4
3 4
3 4
3 4
3 4

28.

29.

30.

 

207

A mother should do her best to avoid
any disappointment for her child.

Not many parents can be pleasant and
calm with their children all day.

One of the worst things about taking
care of a home is that a woman feels
that she can't get out.

STRONGLY STRONGLY

AGREE

DISAGREE
3 4

3 4

3 4

 

 

 

 

208
COMPETENCY

This questionnaire was designed to help us understand the
feelings and experiences of the first—time parent. Please
answer the following questions.

1. What do you check for when your baby awakes crying?

< Clarification: What kinds of things do you look for?
What do you think might be the
problem?

Is there anything else you might check for?

2. If a baby seems difficult to comfort, what are some
suggestions you might offer a new mother returning from
the hospital?
< Clarification: If a baby is fussy or crying, what —?
Are there any other suggestions you might offer?

3. If you were uncertain about how to handle a problem with

your baby's care, which person or persons might you
contact?

< Clarification: For example, if you experienced
difficulty in feeding the baby, or there was a
problem with diaper rash.
Is there anyone else you might contact?

4. As your baby becomes more mobile (able to crawl, walk),
what are some changes you might make in your home in
order to provide him/her with a safer environment?

< Clarification: How might you childproof your home?

Are there any other changes you might make?

h.-« _. ..-—‘- . ~. .

 

209
Under what conditions or circumstances would you contact
your baby's doctor?
< Clarification: What kinds of changes in your baby's
behavior would prompt you to contact

the doctor?

Is there anything else?
Many parents experience difficulty when introducing
solid foods into their baby's diet (he/she may resist

eating). How might you handle such a problem?

< Clarification: What are some things you might do to
make the meal time run more smoothly?

Is there anything else you might try?

Managing the behavior of the young child (1-3 years) can
become quite a chore. What are some methods of
discipline you might experiment with?

< Clarification: What are some different ways you might
manage that trying behavior?

Is there anything else you might try?
Raising a child can be a very demanding job. What
suggestions might you share with a new parent about

how to reduce the pressures or stresses in parenting?

< Clarification: When you were feeling tense or tired,
what sort of things did you do that seemed to help?

Anything else?

THANK YOU !

 

10.

11.

12.

MOTHER-INFANT INTERACTION:
VERBAL STIMULATION

Parallel

Mood
Expression

Explanatory

Back Talk

Musical

Amusement

Instruction

Informative

Personhood

Endearment

Affection

Admiration

 

 

210

Mother varballizes infant's behavior
or performance as infant is engaged
in activity. Must refer to a
specific physical action.

 

Mother defines infant's mood states.
May include an estimation of
infant's likes/dislikes.

Mother offers a causal
interpretation
of infant's behavior or mood state.

Mother attempts to imitate infant's
vocalizations. (Immediately follows
infant's vocalizations.)

Mother sings or hums.

Mother engages in laughter.

Mother tells the infant the name of
some object in a teaching style.

Mother describes/details some aspect
of her actions.

Mother calls child by name.

Mother uses "pet" names for infant.)

Mother expresses fondness of infant.

Mother praises baby's qualities or
behaviors.

13.

14.

15.

16.

17.

Investigate

Responsive

Repetition

Need

Global

211

Mother asks question of infant.

Mother provides answer to question.

Mother repeats sentence/message
(must follow immediately).

Mother makes request of infant.

Mother makes reference to things
other than caretaking activities
that are occurring. Apart from
immediate time/setting.

212

HOME OBSERVATION FOR MEASUREMENT
OF THE ENVIRONMENT
(Birth to Three Years)
Section I: Emotional and Verbal Responsivity of Mother

1. Mother spontaneously vocalizes to child at least twice
during visit (excluding scolding).

2. Mother responds to child's vocalizations with verbal
response.

3. Mother tells child the name of some object during visit
or says name or person or object in a teaching style.

4. Mother's speech is distinct, clear and audible.

5. Mother initiates verbal interchanges with observer——
asks questions, makes spontaneous comments.

6. Mother expresses ideas freely and easily and uses
statements of appropriate length for conversations.

7. Mother permits child occasionally to engage in messy
types of play.

8. Mother spontaneously praises the child's qualities or
behavior twice during visit.

9. When speaking of or to child, mother's voice conveys
positive feeling.

10. Mother caresses or kisses child at least once during
visit.

11. Mother shows some positive emotional responses to
praise of child offered by visitor.

Subscale Total (No. of Yes Answers):

Section II: Avoidance of Restriction and Punishment
12. Mother does not shout at child during visit.

13. Mother does not express overt annoyance with or
hostility toward child.

14. Mother neither slaps nor spanks child during visit.

 

213

Section II: Avoidance of Restriction and Punishment cont.

15. Mother reports that no more than one instance of
physical punishment occurred during the past week.

16. Mother does not scold or derogate child during visit.

17. Mother does not interfere with child's actions or
restrict child's movements more than 3 times during visit.

18. At least ten books are present and visible.
19. Family has a pet.

Subscale Total (No. of Yes Answers):

Section III: Organization of Environment

20. When mother is away, care is provided by one of three
regular substitutes.

21. Someone takes child into grocery store at least once a
week.

22. Child gets out of house at least four times a week.
23. Child is taken regularly to doctor's office or clinic.

24. Child has a special place in which to keep his toys and
treasures.

25. Child's play environment appears safe and free of
hazards.

Subscale Total (No. of Yes Answers):

 

214

Infant Measures

Growth

Two chart forms were employed. These were as follows:
Girls: Birth to 36 Months
Physical Growth
NCHS Percentiles *
Boys: Birth to 36 Months

Physical Growth
NCHS Percentiles *

* National Center for Health Statistics percentiles.

Development

Denver Developmental Screening Test forms were employed.
The form was as follows:

Revised DDST—R

 

 

 

 

APPENDIX F

215

CODING GUIDE

ADVICE/INFORMATION:

I. Follow manual (student nurse copy) while listening
to tape to check for any omissions in the four
areas listed below:

a. Instructions

 

 

b. Questions

 

 

c. Demonstrations

 

 

d. Handouts

 

 

Total number of omissions:

II. If student nurse provided any additional information
please record below:

 

 

 

 

Total number of additions:

 

216

EMOTIONAL AIDE:

I. Empathy/Sensitivity

a. Student nurse verbalized mother's
concerns or feelings

b. Student nurse reassured mother

c. Student nurse shared a personal
story or incident

Total number:

II. Facilitation of Information Gathering

a. Student nurse encouraged additional
questions

b. Student nurse confirmed mother's
understanding of material

c. Student nurse displayed positive
response to mother's questions

Total number:

III. Positive Regard
a. Student nurse praised infant
b. Student nurse praised mother

Total number:

SOCIALIZATION:
Length of Visit

Total number of minutes:

 

ADVICE/INFORMATION: (=additions)
EMOTIONAL AIDE:

SOCIALIZATION: TOTAL: ___ ___ ___

 

 

 
 

 

 

 

 

 

 

 

R IES

~ ”11111114414411

gill