PROJECT OF MENTAL

HEALTH PROMOTION

DURING PREGNANCY

AND EARLY CHILDHOOD

7th Masters on Public Health

Lisbon-Galway, 8th July 2004

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)

Mental Health Determinants

Mental Health

Genetics

Early Experiences

Life Events

Coping

Social Suport

HousingEmployment

Socio-Economics

Health Care

Mental Health Influences

Mental Health

Physical Psychological

Social

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)

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)

Mental Health and Health Promotion

”In today’s 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)

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

Social Factors Psychological Factors

Pregnancy

Attatchment Parental Skills

Why did we choose to intervene in these life stages?

FAMILY FOCUSED INTERVENTIONsocial support network, childhood cetres,

school and health services(Lahtinen, Lehtinen & Riikonen)

Child benefits

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)

Description

PLACEAlmada 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 LENGTH5 years (possible extent for one more year)

Planning Steps

Intervention planning Evaluation planning

Work with local stakeholders

Diagnoses Work with local stakeholders

Prior intervention groups Action areas selection

Settings

Intervention on field with local partners

Evaluation

Common needs in mental heath

promotion

Partners

Partners

Partners

Partners

Action Research

Mental Health Promotion Approach

Mental Health and Selected Areas

Prenatal Care Social Support ParentalSkills

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)

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 children’s social and pshycological skills• Improvement of professional skills

Main Long-Term Benefit

Improvement of children’s well-being (social, psychological, physical, spiritual)

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 women’s social and psychological adjustment.

Prenatal Care

General Goals …

1. To increase to 90% the number of pregnant women who are

systematically evaluated on mental health, at the Maternal Health

Appointment.

2. To increase to 60% the number of pregnant women identified with

mental risk factors, at the Maternal Health Appointment.

3. To increase the number of pregnant women whom are diagnosed

with mental health problems at the Maternal Health Appointment.

4. To increase the number of pregnant women who receive an

intervention to face their mental health needs (skills promotion).

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

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.

Social Support

General Goals …1. 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 .

2. 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 patient’s participation in the activities of the Health Centres involved.

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 partner’s 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

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.

Parental Skills

General Goals …

1. 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

2. To reinforce parental skills of “pregnant couples”.

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 project’s development and involving experts from the different areas – Develop personal skills

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.

Childhood Development

General Goals…

1. To establish, or optimise, a network between childhood centres and child health team, in order to support the child and his family during childhood

2. To promote health nutrition in children, at childhood centres with the support of Social Security

3. To promote autonomy and psychosocial development of children

4. To optimize appropriate answer to family with economical needs in partnership with social network

5. To improve parents and educators participation near Social Security to apply legislation considering the correct number of educator/child needs

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

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.

Evaluation of the Project’s Effectiveness

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

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)

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

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

Results EvaluationCalendar

Years 2004 2005 2006 2007 2008 2009 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 +

ProjectCalendar

Years 2004 2005 2006 2007 2008 2009 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

+

“Actions speak louder than words”