A Tale of Two Parenting Interventions: Programme Effects on Sensitive and Responsive Caregiving in Brazil and the United Kingdom
Background The mechanisms underpinning global parenting interventions to support optimal early development are not well understood. Questions pertaining to how these programmes drive child outcomes, *for whom* they are most effective, and *whether longitudinal* effects can be sustained *real-world contexts*, continue to persist. This thesis contributes empirical evidence on the topic by evaluating the effectiveness of two large-scale, standard-care parenting interventions in Brazil (Primeira Infância Melhor; PIM) and the United Kingdom (Video Feedback for Positive Parenting and Sensitive Discipline; VIPP-SD). Treatment impacts on key parent behavioural outcomes (i.e. sensitivity and responsiveness) and potential moderation by program dosage and family demographics are explored. Settings, Participants, Primary Measures Findings are based on two separate impact evaluation studies. The first is a propensity score matched, longitudinal, quasi-experimental study which uses data from the *2015 Pelotas Birth Cohort* in Brazil. Out of 4,275 children in the cohort, 797 were enrolled in the state-wide home-visiting program, PIM. Children who received PIM were matched with other cohort children on 25 key covariates. Families were assessed prenatally, at baseline, 3-months, 24-months and four-years. Effects of PIM were estimated at four-year follow-up on five parenting behavioural outcomes, including three observational measures of parent sensitivity, coerciveness and responsiveness. Separate moderation analyses were conducted for each moderator: family income, child age and duration of participation. The second study uses data from *Healthy Start Happy Start*, a pragmatic, two-arm, multi-site randomized controlled trial in the United Kingdom. Participants included 300 families, with children between 12 to 36 months of age at high risk for behaviour problems. Data were collected at baseline, 5-months and 24-month-follow-up. Effects of VIPP-SD on caregiver sensitivity at 5-months and child executive function (EF) skills at 24-months follow-up were estimated. Potential mediation of intervention effects on child EFs through parent sensitivity and moderation of treatment through family demographics and program dosage were also explored. Results Results from PIM’s effects on parenting (Chapter 2) and VIPP-SD's effects on sensitivity (Chapter 3) and executive function, including potential mediation through changes in sensitivity (Chapter 4), are presented. We found a positive effect of PIM on parent responsiveness (β=0.08, 95% CIs 0.002 to 0.16) and sensitivity at four years (β=0.10, 95% CIs 0.02 to 0.19). No effect was found for any secondary parenting outcomes. Subgroup analyses provided some evidence of a stronger positive effect of PIM on sensitivity for low-income parents (β=0.18, 95% CIs 0.03 to 0.34) compared to high[1]income caregivers (β=0.02, 95%−0.11 to 0.15), with a p value of 0.11 after Cochrane’s Q 2 heterogeneity testing. Next, impact findings of VIPP-SD in the UK on parent sensitivity at 5-months revealed a positive effect of the intervention on sensitivity (β =0.40, 95%CIs 0.10 to 0.72). There was no strong evidence for effect modification as result of parent depression or caregivers’ levels of education. Children whose caregivers received VIPP-SD outperformed control children on two measures of child executive function at 24-months, including inhibitory control (β=0.09, 95%CIs 0.04 to 0.15) and effortful control (OR=1.69, 95%CIs 1.01 to 2.83). No evidence of an effect was found for cognitive flexibility (OR=0.90, 95%CIs 0.53 to 1.53). Further, there was no evidence of effect modification by other moderators including child age, child behavioural symptomology, or program dosage. Finally, mediation analyses revealed a small partial mediation of VIPP-SD's effects on child inhibition through improvements in maternal sensitivity at 5-months (β=0.015, 95%CIs 0.002 to 0.03). For the child effortful control outcome, no evidence of treatment mediation by sensitivity was found. Conclusion Two pragmatic parenting interventions which were delivered in the heterogeneous settings in Brazil and UK were found to improve caregivers’ sensitive and responsive care and children’s executive function skills at longitudinal follow-up. Findings suggest that caregiving interventions can achieve sizable improvements in key parent behaviours, even when delivered in standard-care real-world contexts. Effects of the PIM programme were more pronounced for families facing greater socioeconomic adversity, indicating the importance of purposeful targeting.
Early childhood development, Early intervention, Executive function, home visiting, Parenting intervention, Parenting programme, Policy evaluation, Propensity score matching, Quasiexperimental study, Randomized controlled trial, Responsiveness, Self-regulation, Sensitivity
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