PROJECT OF MENTAL HEALTH PROMOTION DURING PREGNANCY AND EARLY CHILDHOOD

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• PROJECT OF MENTAL HEALTH PROMOTION DURING
  PREGNANCY AND EARLY CHILDHOOD
• 7th Masters on Public Health
• Lisbon-Galway, 8th July 2004

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THEORETICAL STATEMENT

• Mental Health is
• a state of well-being in which the individual
  realizes his or her own skills, can cope with the
  normal stresses of life, can work productively
  and fruitfully, and is able to make a
  contribution to his or her community
• (WHO, 2004)

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Mental Health Determinants
Coping
Early Experiences
Social Suport
Genetics
Employment
Housing
Health Care
Socio-Economics
Life Events
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Mental Health Influences
Social
Relationships
Coping
Mental Health
Communication
Education
Physical
Psychological
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Burden of Disease

• Mental problems
• One in four people around the world (WHO, 2001)
• 20 of the adult and adolescents population in EU
  (Lavikainen, Lahtinen, Lehtinen, 2000)
• 2020 2nd cause of global burden of disease (WHO,
  2001)

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Mental Health and Health Promotion

• () some mental disorders can be prevented most
  mental and behavioural disorders can be
  successfully treated and () much of this
  prevention, cure and treatment is affordable.
  (WHO, 2001)
• Every country, no matter what its resource
  constraints, can do something to improve the
  mental health of its people. What it requires is
  the courage and the commitment to take the
  necessary steps. (WHO, 2001)

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Mental Health and Health Promotion

• In todays society no one can avoid confronting
  stressful situations and setbacks, and the way in
  which people react to such stress is a decisive
  factor for their mental health. A more positive
  approach to mental health should therefore be
  developed, with special programmes () that teach
  people life skills, i.e. interpersonal skills
  and mature decision-making and stress-coping
  techniques.
• (Health for all for the twenty-first century
  the heath policy for Europe WHO, 1997)

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Salutogenesis

• The salutogenic orientation primarily explores
  the conditions of health and the factors that
  protect health and contributes to
  invulnerability. (Bengel Strittmatter
  Willmann, 1999)
• Sense of Coherence
• Comprehensibility Manageability
• Meaningfulness

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Why did we choose to intervene in these life
stages?
Social Factors
Psychological Factors
Attatchment
Parental Skills
Child benefits
FAMILY FOCUSED INTERVENTION social support
network, childhood cetres, school and health
services (Lahtinen, Lehtinen Riikonen)
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Why did we choose to intervene in these life
stages?

• State of the art
• Pregnancy as a stage of adaptation (Born, Zinga,
  Steiner, 2004)
• Pregnancy experience and early attachment (Born,
  Zinga, Steiner, 2004)
• Intervention during pregnancy and child benefits
  (WHO, 2004)
• Early childhood as a basis of a healthy
  development (WHO, 2004)
• Interventions focused at early stages are more
  efective on preventing children mental health
  problems (Lahtinen, Lehtinen Riikonen)
• Relevance of psychosocial factors during
  pregnancy to promote the early attachment and
  parental skills (Lahtinen, Lehtinen Riikonen)
• Family focused intervention social support
  network, childhood centres, school and health
  services (Lahtinen, Lehtinen Riikonen)

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Description

• PLACE
• Almada and Seixal Municipalities
• PROMOTERS
• 3 Health cetres
• 1 Central Hospital
• 2 Drug Addiction Prevention and Treatment Units
• Child and Youth Protection Comission
• National School of Public Health
• TARGET POPULATION
• Pregnant women that initiate Maternal Health
  Appointments between November 2005 and January
  2006.
• Children born between July and September 2006
  witch mothers were intervened.
• PROJECT LENGTH
• 5 years (possible extent for one more year)

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Planning Steps
Common needs in mental heath promotion
Diagnoses Work with local stakeholders
Prior intervention groups Action areas selection
Settings
Action Research

• Intervention planning
• Evaluation planning
• Work with local stakeholders

Intervention on field with local
partners Evaluation
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Mental Health Promotion Approach
Mental Health and Selected Areas Mental Health and Selected Areas
Prenatal Care Social Support Parental Skills Parental Skills Child Development
Population Groups Health Promotion Actions
Children Parents Care providers Skills development Organizational development Community strengthening Health services reorientation
Sectors and Settings for Action
Health (Primary and Hospital Care) Community Education (Child cetres)
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Mental Health Promotion Approach
Intermediate Outcomes
Improvement of parents well-being and psychosocial adjustment Improvement of parental skills More accessible and more involved organizations Improvement of social support Improvement of childrens social and pshycological skills Improvement of professional skills
Main Long-Term Benefit
Improvement of childrens well-being (social, psychological, physical, spiritual)
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Prenatal Care

• Problem
• A Maternal Health Appointment without detection
  and intervention ability in face of mental
  problems risk factors, signals and symptoms.
• Purpose
• To improve pregnant womens social and
  psychological adjustment.

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Prenatal Care

• General Goals
• To increase to 90 the number of pregnant women
  who are systematically evaluated on mental
  health, at the Maternal Health Appointment.
• To increase to 60 the number of pregnant women
  identified with mental risk factors, at the
  Maternal Health Appointment.
• To increase the number of pregnant women whom are
  diagnosed with mental health problems at the
  Maternal Health Appointment.
• To increase the number of pregnant women who
  receive an intervention to face their mental
  health needs (skills promotion).

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Prenatal Care

• Strategies
• Reorganization of the Maternal Health Appointment
  through the involvement of health and social
  professionals in order to introduce on it the
  mental health concerns Reorient health services
• Strengthening knowledge's and skills of the
  maternal health care professionals, concerning
  the evaluation and intervention on mental risk
  factors for mental health Develop personal
  skills
• Improvement of the articulation between the
  Maternal Health Appointment and the health and
  community resources relevant for mental health -
  Strengthen community action

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Social Support

• Problem
• The need to improve existing social support
  network for promoting mental health during
  pregnancy and infancy in the areas served by the
  health cetres involved.
• Purpose
• To improve the existing social support network
  for promoting mental health during pregnancy and
  infancy in the areas served by the health cetres
  involved.

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Social Support

• General Goals
• To carry out a detailed and up-to-date inventory
  of the social support resources available to
  pregnant women and the parents/family of infants
  .
• To improve the articulation between the Health
  Centres involved and the local resources
  providing social support to pregnant women and
  the parents/family of infants.
• 3. To improve early detection of risk cases
  and appropriate answers
• 4. To develop the psychosocial skills in
  mental health promotion in several health
  professionals and socials partners.
• 5. To promote a culture of larger patients
  participation in the activities of the Health
  Centres involved.

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Social Support

• Strategies
• Development of a wide and functional social
  support network, to pregnant women and
  parents/family of children, with several
  community partners (already existing or new ones)
  choosing the leadership according to each
  situation- Strengthen community action
• Development of health professional and partners
  psychosocial skills through training actions -
  Develop personal skills
• Client, family and community involvement in
  Health Centres activities, through improvement of
  accessibility and promotion of self-help groups
  Empowerment

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Parental Skills

• Problem
• Few supporting programmes to pregnant couples.
• Purpose
• Improve parental skills of pregnant couples
  that will have a baby for the first time and also
  of those parents who had been identified at risk,
  during Maternal Health Appointments.

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Parental Skills

• General Goals
• To create a supportive structure to first time
  parents and to parents identified in Maternal
  Health Appointment as being at risk of developing
  mental health disturbances
• To reinforce parental skills of pregnant
  couples.

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Parental Skills

• Strategies
• Development of a Parent School by creating a
  team with skilled professionals from the Maternal
  Health Appointment and volunteer parents
  Develop personal skills
• Development of professionals and parents skills
  involved in the Parent School, identifying
  skills needed to the projects development and
  involving experts from the different areas
  Develop personal skills

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Childhood Development

• Problem
• Lack of relationship between family, childhood
  centres and child health centre team, to promote
  health nutrition as a determinant of good
  physical, psychological, social and spititual
  development in childhood.
• Purpose
• Optimize the capacity of childhood centres to
  promote health nutrition and supply deficits, and
  also promote relationship among family, childhood
  centres and child health centre team.

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Childhood Development

• General Goals
• To establish, or optimise, a network between
  childhood centres and child health team, in order
  to support the child and his family during
  childhood
• To promote health nutrition in children, at
  childhood centres with the support of Social
  Security
• To promote autonomy and psychosocial development
  of children
• To optimize appropriate answer to family with
  economical needs in partnership with social
  network
• To improve parents and educators participation
  near Social Security to apply legislation
  considering the correct number of educator/child
  needs

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Childhood Development

• Strategies
• To create conditions for breastfeeding and health
  nutrition in order to assure good childhood
  development - Supportive Environment
• Workshops to educators, parents, professional
  health team and social support to promote health
  nutrition, considering economic needs and social
  problems of population target Equity
• To stimulate autonomy and socialization of
  children during meals - Autonomy
• Parents and educators approach near Social
  Security to apply legislation considering the
  correct number of educator/child needs -
  Strengthen community action

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An Example...

• General Goal To increase the proportion of
  mental health problems diagnosis in pregnant
  women, in three years
• Specific Goal To guarantee that 90 of pregnant
  woman from the Health Centres Maternal Health
  Appointment are monitorized according to specific
  technical guidelines for evaluation and
  intervention in mental health, in three years.
• Operational Goal To develop and implement
  specific technical guidelines for monitoring and
  intervening in pregnant mental health of pregnant
  woman from the Health Centres maternal
  appointment, in 8 months.
• Activity Promoting meatings between
  professionals from Maternal Health Appoitment,
  mental health and social care, from the
  geographic area of this project, in order to
  discuss monitoring and intervention areas that
  should be integrated in the technical guidelines
  of the Maternal Health Appointment.

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Evaluation of the Projects Effectiveness
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Process Evaluation

• Purpose
• Evaluate the reach on the target group
• Evaluate the participants satisfaction
• Evaluate the adequacy of used resources
• Evaluate the activities implementation
• Procedure
• Identify indicators
• Determine ways to evaluate indicators
• An example
• Activities developed / Previewed activities
  (registers)
• Number of professionals that refer the existence
  of specific technical orientations/ number of
  inquired professionals of the maternal health
  appointment

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Impact Evaluation

• Purpose
• Evaluate the immediate effect of the program
• Evaluate if the general and specific goals were
  achieved
• Procedure
• Identify indicators
• Determine ways to evaluate indicators
• An example
• Number of evaluated pregnant/ total number of
  pregnant 100 (checking the filling up of the
  pregnant clinical record)

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Results Evaluation

• Questions
• Did the intervention raised parents SOC?
• Did the intervention raised children physical,
  psychological and social development?
• Are the results of parents SOC correlated with
  the children physical, psychological and social
  development?
• Design
• Pre and post intervention evaluation of mothers
  and fathers SOC comparing to control mothers and
  fathers SOC
• Results evaluation on the physical, psychological
  and social development of intervened children
  comparing to non intervened children

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Results Evaluation

• Subjects
• Pregnants that initiate maternal health
  appointments in health centres between November
  2005 and January 2006.
• Children of Health centres comprising areas born
  between July and September 2006 witch mothers
  were intervened.
• Instruments
• Orientation to life questionnaire (SOC)
• Children Health Bulletin/ Clinical Schedule
  different percentiles for child growth
  development
• Clinical Schedule - psychomotor development
• Evaluation instrument of attachment

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Results EvaluationCalendar
Years 2004 2004 2004 2004 2005 2005 2005 2005 2006 2006 2006 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010
Trimester 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
SOC Questionnaire
Developmental Evaluation Child 8 months and 3 years
Attatchment Evaluation - Child 8 months and 3 years
Analysis
Presentation
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ProjectCalendar
Years 2004 2004 2004 2004 2005 2005 2005 2005 2006 2006 2006 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010
Trimester 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
Diagnoses
Intervention design
Intervention development
? Setting previous conditions
? Subjects selection
? Control group selection
? Action research other interventions
Evaluation
? Process evaluation
? Impact evaluation
? Results evaluation
? Results communication
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• Actions speak louder than words