National Framework for Universal Child and Family Health Services

Appendix 4: Interventions appropriate in the child and family health service context

Page last updated: 20 May 2013

Examples of brief universal interventions in response to population needs

The following interventions are universal interventions and as such, they address a population or community need rather than respond to an individual’s identified need. These interventions are by definition provided to all children and families at core contacts and seek to improve population outcomes

Reach Out and Read (ROR)

Read focuses on health professional-based literacy in a three-step model designed to take advantage of health professional access, knowledge and the forms and functions of the clinical setting. The three steps of the model are:
  • volunteer readers in the clinical waiting room;
  • anticipatory guidance from the health professional; and
  • a new book for each child [49].
Steps 2 and 3 were adapted in a program tested in Victoria – Let’s Read, a joint initiative by the Centre of Community Child Health and The Smith Family. Let’s Read incorporates its two core components from ROR: children are given a quality book and parents are given guidance on how to effectively interact with their child when reading.

Several studies have found positive effects from the Reach out and Read program including: higher levels of parents reading to their children; higher levels of book ownership and higher levels of parents’ literary orientation and higher speaking and language understanding in children [103].

Dental health Teeth cleaning

A teeth cleaning and mouth demonstration is administered by child and family health services as part of schedule core contact visits;6-8 months, 12 months, 18 months, two, three and four years of age.

Mouth checks comprise three steps – lift the lip (to view the mouth) look (at tooth services) and locate (locate a dental professional if referral is required). Anticipatory guidance appropriate to the age of the infant is provided to parents at health checks.

Examples of guidelines are available at Dental health Services Victoria. For more information please visit Dental health Services Victoria and NSW Health website.

Examples of universal interventions delivered outside the core contacts

The following interventions are primary prevention interventions and as such, they address a population or community need rather than respond to an individual’s identified need. These interventions are by definition provided to all children and families and seek to improve population outcomes. All of the following interventions could be appropriately delivered in a primary care setting.

Smoking cessation among parents of young children

Some individual trials have demonstrated efficacy in assisting parents to cease smoking [105]. The evidence, however, does not determine which interventions are most effective for decreasing parental smoking and preventing exposure to tobacco smoke in childhood. Although several interventions, including parental education and counselling programs, have been used to try to reduce children’s tobacco smoke exposure, their effectiveness has not been clearly demonstrated. The review was unable to determine that one intervention reduced parental smoking and child exposure more effectively than others, although four studies were identified that reported intensive counselling provided in clinical settings was effective.

The Smoke Free Families intervention has had meta-analyses performed on its effectiveness. The results of these show that brief (five to 15 minute) interventions delivered by a trained provider and paired with pregnancy-specific self-help materials can increase cessation rate among pregnant smokers by 30 to 70 per cent [129].

Infant sleep interventions

A recent Cochrane review suggests [130] education on sleep enhancement appears to increase infant sleep. In Australia a study by Hiscock [104, 131] found behavioural strategies to be effective in addressing sleeping problems in young children. The treatment group for the research received three consultations from a maternal and child health nurse to develop an individualised sleep management plan. Infants were 10 months of age or over. The plan included positive bedtime routines such as controlled comforting, camping out and phasing out nighttime feeds and dependence on dummies.

The program was effective in helping parents resolve infant sleep problems. Sleep problems were resolved for more participants in the treatment group than in the control group and those sleep problems that remained in the treatment group were less severe. The intervention was effective in reducing depression symptoms overall. The results were best for mothers who entered the study with higher levels of depression [104, 131].

Peer support for breastfeeding

Two systematic reviews of support for breastfeeding indicate all forms of extra support demonstrate an increase in initiation and duration of any (partial and exclusive) breastfeeding. Peer support can be delivered through telephone
counselling, through one-to-one contact and in groups [102].

Parent groups

Quasi-experimental and qualitative research reports have demonstrated increased levels of social support and parenting confidence and high levels of satisfaction among parents who attend new parents groups facilitated by child and family health nurses [97-99]. These groups appear to be successful in de-emphasising the power and expertise of the professional [99]. These groups often become self-sustaining social networks providing important support for parents [98]. Parent groups are gatherings of parents to receive group wellchild care and usually facilitated by a health care professional. When compared to having individualised well-child care, parent groups were found to have equal or favourable benefits to parents [80].

Parents as Teachers

Parents as Teachers has run from 1984 and currently remains in multiple sites in the United States and internationally. Parents are offered regular home visits, group meetings and printed information on child development. The program also helps to develop children’s cognitive, language, social and motor development skills (Parents as Teachers National Centre Inc., 2005). Evaluations indicate that Parents as Teachers participating children have higher academic achievements in maths and reading and participating parents are more knowledgeable about child development issues [107, 132].
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Examples of targeted interventions in response to identified needs or risk delivered outside core contacts

The following interventions are interventions designed to target children and families with an identified need or from a high risk group. These interventions can appropriately be delivered in a primary healthy care setting but will require additional resources and time that would make them impractical for delivery within the schedule of core contacts. In addition most of these interventions require collaboration with other universal service providers such as child care, education, specialist health providers and/or NGO’s.

Circle of Security

The Circle of Security is a US-based early intervention program that utilises attachment theory to strengthen a parent’s ability to observe and improve their care-giving capacity. Useful diagrammatic representations (including the one below) show how the infant uses the attached parent as a secure base in which to explore the world, all the time knowing they can return to a ‘safe haven’ whenever they become stressed. The Circle of Security is used in many parenting programs in Australia. To find out more go to the following website - www.circleofsecurity.org (This website link was valid at the time of submission) [109, 110]

Group-based parenting programs

The findings of a Cochrane review [133] provide some support for the use of structured group-based parenting programs to improve the emotional and behavioural adjustment of children with a maximum mean age of three years
11 months. The evidence concerning the long-term effects of improvements is inconclusive. It may be that during this period of rapid development, input at a later date is required. Specific programs such as Incredible Years and Tripe P have a strong evidence base (see below).

Incredible Years

The Incredible Years program originated in the United States in 1982 and now also operates in the United Kingdom. Anticipated benefits of the Incredible Years are:
  • decreases in problem behaviours including aggression, non-compliance and disruptive classroom behaviour;
  • improvement of children’s social skills, conflict management skills and decrease negative attributions;
  • increases in children’s academic engagements, school readiness and cooperation with teachers;
  • increases in parenting competencies in behaviour management and parenting skills;
  • foster involvement with children and improve parent/child interaction;
  • prevent delinquency, drug abuse and violence.
The program comprises three main series of interventions – parent training, teacher training and child training.

The Incredible Years program has a strong evidence base [111, 134]. An evaluation of the early childhood component has shown that in summary, compared with the control group:
  • participating mothers had less frequent problem behaviours;
  • participating children displayed more positive behaviour (Webster-Stratton);
  • teachers observed that participating children had larger decreases in behavioural problems; and
  • participating children had higher scores on the Strengths and Difficulties
Questionnaire for conduct problems in two periods.

Positive Parenting Program (Triple P)

The Triple P program is currently being run in Australia as well as other locations internationally. The program is divided into five developmental periods – infants, toddlers, preschoolers, primary school-aged and teenagers and each period has five targeted levels. There have been several evaluations in Australia [108, 135, 136].

In general, the trials have found Triple P to help improve parenting skills and conclude that the more intensive levels of the program have larger effects. Some specific outcomes include:
  • a reduction in the number of behaviour problems as well as a reduction in the intensity of behaviour problems at 12 and 24 month follow-ups;
  • increased sense of competence and satisfaction in parenting and increase in the use of positive parenting strategies with a reduction in self-reported dysfunctional parenting strategies;
  • significant reductions in aversive maternal behaviour and increased maternal satisfaction with partner support training;
  • decreases in parental depression, anxiety and stress as well as small but significant improvements in mental health; and
  • significant improvement on observed and home mealtime behaviour.

Nurse-Family Partnerships (NFP)

The NFP model has been developed over the last 30 years by Professor David Olds and his team at the University of Colorado. The NFP focuses on home visits to first-time mothers at the beginning of their pregnancy and continuing to the child’s second birthday. The three goals of the program are to:
  • improve pregnancy outcomes by promoting health-related behaviours;
  • improve child health, development and safety by promoting competent care-giving;
  • enhance parent life-course development by promoting pregnancy planning educational achievement and employment [112, 113, 137-139] (NFP 2008).
The program is implemented through home visits that begin during pregnancy and continue until the child is 2 years of age. Home visits occur every week or fortnight and provide mothers with skills to identify health problems and monitor their health. The nurses teach mothers about:
  • positive health related behaviours
  • competent care of children
  • maternal personal development (family planning, educational achievement, and participation in workforce.
When the child is born, home visits continue to provide information on how to detect child illness and develop parent/child communication skills. The Nurse- Family Partnership has strong evidence base. The summarised findings from three tests of the effects of the NFP include:
  • women participants were more aware of the community services available and attended childbirth education classes more frequently;
  • babies of young mothers were born with a healthier birth weight;
  • pregnant women smoker participants had greater reductions in the number of cigarettes smoked; and
  • nurse-visited children had fewer health problems and hospitalisation rates.
At the 15-year evaluation, findings included that the participants compared with the control group: had fewer arrests and of those children born to unmarried women, a low socioeconomic background, there were fewer incidents of running away, fewer sexual partners and less alcohol consumption.

The Australian Nurse Family Partnership Program (ANFPP), based on the NFP model is currently undergoing a small scale implementation in Australia. The ANFPP supports women pregnant with an Aboriginal and/or Torres Strait Islander child until the child is two years old through a sustained program of home visits. The ANFPP will be evaluated to assess the effectiveness of the Program over the life of the Program and it is expected that the first evaluation will be finalised in 2011.
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Miller Early Childhood Sustained Nurse Home Visiting (MECSH)

The Miller trial was the first randomised control trial of nurse home-visiting in an area of profound socioeconomic disadvantage. Outcomes from the Miller trial are summarised in terms of outcomes at four weeks and at 12 months.

Outcomes at four weeks after birth compared with control group:
  • better knowledge of SIDS prevention;
  • mothers had better self-rated health; and
  • mothers felt significantly more able to manage their baby’s needs (NSW Health n.d.).
Outcomes at 12 months compared with control group:
  • mothers more likely to breastfeed and breastfeed for longer;
  • mothers more likely to create a quality and stimulating environment for their child;
  • higher use of primary services (e.g. early childhood health services, playgroup) and lower use of secondary services (e.g. Karitane, family support services).

Baby Happiness,Under-standing, Giving and Sharing Program (Baby HUGS)

Baby HUGS is based on the original HUGS program from Melbourne that was a parent/toddler group aiming to facilitate positive parent/child interactions. This version of the program extended from HUGS to work with parent/infant relationships.

Evaluation reported that maternal depression has reduced and there were significant reductions in tension, confusion and fatigue among the treatment group as well as significant differences between groups’ post-treatment [29, 140].

Parents under Pressure

The Parents Under Pressure (PuP) program combines psychological principles relating to parenting, child behavior and parental emotion regulation within a case management model. The program is home-based and designed for families in which there are many difficult life circumstances that impact on family functioning. Such problems may include depression and anxiety, substance misuse, family conflict and severe financial stress. The program is highly individualized to suit each family.

The overarching aim of the PuP program is to help parents facing adversity develop positive and secure relationships with their children. Within this strength-based approach, the family environment becomes more nurturing and less conflictual and child behavior problems can be managed in a calm non punitive [115-117]