What are the effects of different interventions for children and care-givers at pre- and postnatal periods? How do they support health equity? For good physical, social, and emotional development, children need nurturing care. Delivering nurturing care depends on creating the right environments for families to thrive at a macro and micro level, explains a team from DoRS. Their centre has assessed interventions in education and parenting support.
By Paola Capra, Mariella Di Pilato, Luisella Gilardi, Marta Grosini, Sonia Scarponi, on behalf of the DoRS working group on health inequalities and early childhood interventions
Children should be able to grow in an optimal environment which provides them with the physical, emotional, social, and cognitive nourishment necessary to ensure a good psychological, neurological, relational, and emotional development. To support and promotion of this an optimal environment must already begin in intrauterine life. It requires taking care of the mother, the father, the family unit and the context in which the family lives, both at the micro level (family, community) and the macro level (society, culture, policies, etc.).
A child’s physical, mental, and cognitive development can be compromised if a supportive environment is not protected and they are exposed to adversities or deprivation, such as care givers’ physical or mental health problems, maltreatment or family violence, environmental and cultural degradation, and economic and social poverty.
Investing in Early Child Development (ECD) from the earliest years of life encourages the baby’s physical and mental development, with benefits that have an impact throughout the entire life course. For this reason, early childhood must be a priority in policies and programs, since it is above all in those early years of life that future wellbeing is shaped.
Starting from the scientific evidence that have created attention around the ECD, in 2018 the World Health Organization, UNICEF and the World Bank, in collaboration with the Partnership for Maternal, Newborn & Child Health, the Early Childhood Development Action Network and many other partners, developed the ‘Nurturing Care Framework’. The aim of the document is to provide strategic directions and operational recommendations on how to invest in the development of children from pregnancy up to age 3. The “physical, social, emotional and cognitive nourishment” defined in the document as nurturing care is the set of conditions that provide for children’s health, nutrition, security and safety, responsive caregiving and opportunities for early learning.
‘Nurturing children’ means keeping them safe, healthy, and well nourished. It also means paying attention and responding to their needs and interests, encouraging them to explore their environment and interact with caregivers and others.
Parents and caregivers are most able to provide their children with nurturing care when they are secure – emotionally, financially, and socially. For this reason, to reach their full potential, children need the five components of nurturing care: good health, adequate nutrition, safety and security, responsive caregiving and opportunities for learning.
Early Childhood Development – ECD is an important, if not the most important, social determinant of health.
As Marmot reports in his review of 2010  – “…Giving every child the best start in life is crucial to reducing health inequalities across the life course. The foundations for virtually every aspect of human development – physical, intellectual and emotional – are laid in early childhood. What happens during these early years (starting in the womb) has lifelong effects on many aspects of health and well-being– from obesity, heart disease and mental health, to educational achievement and economic status. To have an impact on health inequalities we need to address the social gradient in children’s access to positive early experiences. Later interventions, although important, are considerably less effective where good early foundations are lacking…”.
Our Regional Health Promotion Documentation Center DoRS has published two reports describing and evaluating the efficacy of interventions of prenatal and postnatal education and parenting support on physical health and on cognitive, social and emotional development of children (from 0 to 3 years), as well as on parents’ psycho-physical wellbeing, to tackle health inequalities. The reports can be downloaded from DoRS.
The organizational framework PROGRESS Plus has been chosen because it evaluates those dimensions in which there may be health inequalities, as was argued by Campbell and Cochrane Equity Methods Group; it also includes the factors suggested by the Commission on social determinants of health.
The reports used the MEDLINE database to identify studies published from November 2007 to December 2018. Only studies providing for an assessment before and after the intervention and an evaluation at the follow up were included. All interventions also had to have effects on health inequalities, analysed according to the PROGRESS Plus factors. The organizational framework PROGRESS Plus  has been chosen because it evaluates those dimensions in which there may be health inequalities, as was argued by Campbell and Cochrane Equity Methods Group; it also includes the factors suggested by the Commission on social determinants of health (Tugwell 2010).
Report on interventions of prenatal and postnatal education
27 studies were included in the report; 23 of which take place in health care setting, 2 in the community, while 2 involve both settings.
Most of the studies target populations sharing more PROGRESS Plus factors (20). Low socio-economic status is the most represented factor, either alone (6 articles) or in combination with other factors (16 articles), mainly ethnicity, education, and place of residence.
With regard to the effects on inequalities, almost all studies (26 vs 27) adopt a target approach: this implies that if health outcomes of vulnerable populations will improve -according to one or more of the PROGRESS Plus factors- it is not possible to say that in general there is a reduction in health inequalities. It is evident that most studies privilege the psychophysical wellbeing of the future mother and the psychological development of the infant rather than the traditional information related to childbirth and pregnancy. Moreover, mainly group intervention models are used, also with the help of social media and the setting up of formal and not territorial networks.
Report on interventions of parenting support
19 studies included in the report are addressed to disadvantaged populations; 5 studies concern interventions taking place in health care setting, 9 in the community, 1 in the domestic field, while 4 involve both settings and therefore work in synergy.
As for PROGRESS Plus factors, the socio-economic disadvantage is the most represented factor, alone or in combination with other factors, mainly ethnicity, education and place of residence. The indicators ‘Religion’, ‘Social capital’, ‘Occupation’ were not considered (or only marginally), while sometimes the participant population is part of one or more of the Plus categories (e.g. single parent, adolescent age, consumer of alcohol and drugs). With regard to the effects on inequalities, 18 studies adopt a targeted approach: this implies that if health outcomes of vulnerable populations will improve -according to one or more of the PROGRESS Plus factors- it is not possible to say that in general there is a reduction in health inequalities.
In most studies the Nurturing Care Framework approach prevails, based on the reduction of risk factors through an increase of transversal parenting skills (listening capacity, responsiveness, understanding of the child’s needs etc.). Special attention is paid to providing parents with tools to increase the cognitive, sensory and affective stimuli offered to the child.
 The Marmot Review (2010). Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England post-2010, February 2010. UCL Institute of Health Equity.http://www.parliament.uk/documents/fair-society-healthy-lives-full-report.pdf
 PROGRESS – Place of Residence, Race/ethnicity, Occupation, Gender, Religion/culture, Education, Socio-economic status, Social capital/networks and Plus incorporate other important factors which impact on health equity, e.g. disability, sexual orientation, age.