Evaluation of an intervention aimed at supporting new parents: the Baby Newsletter project

Parenting consists of a core set of interrelated components, including behaviors, attitudes, and knowledge regarding caregiving, stimulation, responsiveness, and safety [1]. Parenting is often defined as a primary mechanism of socialization [2]. Education and support for parents to learn and practice important parenting skills have the potential to promote supportive behaviors, parenting confidence, and the child’s well-being [3].

Many kinds of interventions supporting parents have been proposed based on ecological [4], transactional [5], attachment [6], or ecobiodevelopmental theory [7]. In pediatric primary care, the self-efficacy theoretical model is often applied [8]; it is based on parents’ belief that they are capable of being competent parents. Self-effective parents have confidence in their ability to successfully raise their child and are thus more convinced about what they do; this contributes to the quality of their relationship with their child [9, 10]. Parenting self-efficacy is usually assessed via self-report measures. The general measures focus on self-efficacy but also on other related constructs (competence, self-esteem, self-confidence, satisfaction, self-regulation) [11]. Among the 34 outcome measures identified by Wittkowski’s systematic review related to self-reported parenting skills, the “Tool to Measure Parenting Self-Efficacy” [12], developed by the UK National Health Service, focusses on 8 domains [13].

Anticipatory guidance consists of information that the clinician gives to the family on the stages of child development and growth and on the benefits of healthy practices, behaviors, and lifestyles. Further, it provides indications on how best to promote the child’s growth potential according to evidence-based medicine [14]. there are many anticipatory guidance topics, it is virtually impossible for a pediatrician to touch on them all during the short time of a well-child visit [15]. The Bright Futures Guidelines of the American Academy of Pediatrics have identified over 1200 anticipatory guidance that can be offered to parents during the 32 well-child visits (from ages 0 to 21 years), divided into 38 topics on 8 main themes: family support, child development, mental health, nutrition, physical activity, oral health, sexual development and sexuality, and accident prevention and safety [16]. Mass media, including printed matter such as newsletters, play a potentially important role in a comprehensive, population-based strategy to improve parents’ confidence, skills and knowledge concerning raising their child. Further, newsletters are an efficient and affordable format, in association with interviews with the pediatrician during well-child visits [17]. Effective anticipatory guidance must be timely, appropriate, and relevant so that key recommendations can be adopted by the family, thus making it formative in improving the parent’s and child’s well-being [16, 18‐20]. There is evidence that some anticipatory guidance on injury prevention, feeding, vaccination, addiction, physical activity, abuse, infectious disease prevention and care, and reading aloud are effective [21‐24].

Many surveys have highlighted how few parents receive anticipatory guidance [15, 25‐31]. Parents with high education level have easier access to primary care, receive more advice, and ask the doctor for more information [25, 28], while families with less social support and who are more deprived (for example, newly arrived immigrants in Italy) often receive less advice and almost certainly have less access to understandable anticipatory guidance for developmental milestones [32]. Written advice is a useful tool for families [27] but may have some disadvantages related to parents’ literacy and health literacy [33, 34]. The use of pictograms and images and of short simple sentences can reduce this disadvantage [35, 36]. Patient information should be written at the reading level of a 9- or 10-year-old (4th–5th grade in the USA) [33], although even highly educated parents prefer succinct, easy-to-read materials [31].

In 2014, an intervention to improve parenting skills was implemented in one municipality in the province of Reggio Emilia, Northern Italy.

The intervention included mailing anticipatory guides, the Baby Newsletter, to all new parents. The Baby Newsletter was designed to prepare parents for the stages of their child’s development. It describes the child’s skills and abilities in relation to the correct moment of development and offers advice on what to do with the child at that specific age. As parents’ beliefs about child development serve as the foundation of their teaching and behavior management practices, this information helps parents not to have unrealistic expectations of their child’s skills, to improve the quality of their relationship, and to prevent possible behavior problems and stress on the family. Knowing about the domains of sensory, neuromotor, and socio-emotional development can help improve parents’ relationship with their child and the dyadic regulatory process [16, 37, 38]. In particular, the Newsletter offers simple activities such as word or singing games, reading, and music activities. Several studies have observed that these activities improve parental function, support intersubjectivity, reduce the duration of the baby’s crying, and improve regulation [39‐43]. The aim of this study was to evaluate the effectiveness of the intervention in terms of parental self-efficacy as measured through the eight domains investigated by the TOPSE: emotion and affection; play and enjoyment; empathy and understanding; pressures of parenting; self-acceptance; learning and knowledge; control; discipline and setting boundaries.

Of the 529 new parents, 143 could not be reached within 15 days from birth, 190 were not eligible, and 60 refused to participate; 136 accepted to participate and completed the baseline questionnaire (25.7%) (Fig. 2).

Compared with resident parents in the area, the included parents were, as expected, less frequently foreigners, and the Italian parents were more educated. We compared the BNG and CG for distributions of sociodemographic variables collected in the baseline questionnaire, and differences were compatible with random fluctuations. (Table 1).

The mean child’s age at baseline parent’s questionnaire was 8 days in the BNG group and 3 days in the control group (p-value < 0.01). Three baseline TOPSE questionnaires were completed more than 30 days after birth and were included in the analyses. All parents were contacted at t2; 53 and 68% in the BNG and CG, respectively, completed the final questionnaire on everyday habits. There were no differences between parents with complete follow up and all enrolled parents in both BNG and CG (Table 1). At the end of the follow up, 26 out of 29 families in the BNG reported having regularly received the newsletter, while 3, irregularly; 28 families declared they read all the received letters, 1 family declared it read only parts of the letters; 69% of the families retrieved the thank-you gift from the public library.

Completeness of TOPSE follow up was higher among mothers (72%) than fathers (67%).

Parenting skills at baseline were similar in the two groups for emotion and affection (delta − 0.2, p-value = 0.8827), self-acceptance (delta 0.8, p-value = 0.3753), and play (delta 1.8, p-value =0.2074), while the BNG had better scores for pressures of parenting (delta 5.3, p-value = < 0.001), empathy and understanding (delta 2.3, p-value = 0.0253), and learning and knowledge (delta 1.6, p-value = 0.0651) than the CG’s scores (Table 2). To test whether baseline differences were due to different timing in completing the questionnaire, an analysis was also conducted including only questionnaires completed in the first week after birth. However, the differences in TOPSE scores did not decrease.

Overall, parenting skill scores improved from t0 to t2 in all the domains. The improvement was slightly stronger in the BNG for almost all the skills except for learning and knowledge (linear regression coefficient − 0.48 [95%CI -3.17; 2.21]); differences were all compatible with random fluctuations except for play and enjoyment (Fig. 3) (linear regression coefficient 2.28 [95% CI 0.12; 4.25]). In all the models R2 are very small, the variation of the response variable that is explained by explanatory variables is very low. Results were similar for mothers and fathers (data not shown), while the differences in favor of the BNG were stronger in parents of firstborns, where all the coefficients were positive, particularly for emotion and affection and self-acceptance (linear regression coefficient 3.36 [95% CI 0.35; 6.37] and 4.55 [95% CI 1.01; 8.08], respectively). Differences were also stronger for parents with high education level. Indeed, for the emotion and affection and pressures of parenting domains we observed an opposite direction of the coefficient in parents with low education level, i.e. a greater improvement in the CG than in the BNG (Table 3): linear regression coefficients for parents with less than 13 years of school: -5.78 [95%CI -9.76; − 1.81] and − 12.55 [95%CI -22.57; − 2.52], respectively.

Most of the changes from baseline occurred from t0 to t1, although the differences between the two groups became appreciable between t1 and t2 in emotion and affection, play and enjoyment, and self-acceptance, i.e., the three domains where the improvement was stronger in the BNG (Fig. 4).

For the two domains not available at t0, control and setting boundaries, we compared groups by t2 value. The results show higher scores for the BNG: linear regression coefficient for discipline and setting boundaries was 2.08 [95%CI -0.16; 4.32] R² = 0.2102, and for control, 2.09 [95% CI -0.17; 4.35] R² = 0.2526.

Overall parenting skill scores improved for all domains from birth to 12 months. The improvement was slightly stronger in the BNG for almost all the skills except learning and knowledge (on average, 0.48 points fewer on a scale from 0 to 60, 95% CI − 3.17 to 2.21), but the improvement was statistically significant only for play and enjoyment (on average, 2.18 points more on a scale from 0 to 60, 95% CI 0.12 to 4.25). Not surprisingly, differences were only perceptible in parents of firstborns [9, 47]. Education level also affected the results: there was an advantage for BNG only for the more educated parents in all outcomes.

Written advice interventions have been shown to be effective in causing positive health behavior changes [48] but there is little evidence on the effectiveness of written advice in improving parents’ skills and health behaviors in the care of their child in his/her first years of life [45, 49‐51]. Parenting programs often are not built on a theoretical model [52]. Almost all pediatric parenting programs provide for focus groups, face-to-face sessions, and/ or advice offered in the clinical setting [52, 53] or provide home visits and group or individual sessions [9]. Few programs provide age-paced written advice sent by mail to support parenting [45, 49].

The intervention evaluated in this study, based on the parent’s self-efficacy, is affordable and sustainable. Furthermore, using email or mobile messaging apps may further reduce costs and possibly increase the spread of the intervention [49]; even if equity is a challange for technology-based parenting interventions [54, 55]. The Baby Newsletter allows all parents to receive written pediatric anticipatory guidance that would otherwise not be received and extends the pediatrician’s contact with the family [25, 56‐58].

Finally, written guidelines issued by health authorities may play a fundamental role in the internet era, when free access to information is available to all without any verification of the source. The written messages in our newsletter are qualitatively reviewed and may help contrast poor quality information [31, 59, 60].

Written guidance on child development and on activities that parents can do with their child in the first year of life is associated with an increase in the parents’ self-confidence and self-efficacy in playing with the child and enjoying parenthood. In the subgroup with a low education level, however, there is an increase in stress and low control of emotions. Anticipatory guidance, even when designed for parents with a low education level, could have adverse effects in those parents, making equity the main challenge in interventions to improve parenting skills.