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Exploratory study of the effectiveness of the parent education conference method on child health Khairat, Lara 1970

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AH EXPLORATORY STUDY OF THE EFFECTIVENESS OF THE PARENT EDUCATION CONFERENCE METHOD ON CHILD HEALTH ky ' . LARA KHAlRAT B.A., UniversityofBritish,GoluiBbia, 1952 B.S.W., University of British Columbia, 1952 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF EDUCATION in the Faculty of Education Me accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA June, 1970 In presenting th i s thes i s in pa r t i a l f u l f i lment of the requirements fo r an advanced degree at the Un ivers i ty of B r i t i s h Columbia, I agree that the L ibrary sha l l make i t f r ee l y ava i l ab le for reference and study. I fu r ther agree that permission for extensive copying of th i s thes i s fo r scho lar ly purposes may be granted by the Head of my Department or by his representat ives. It is understood that copying or pub l i ca t ion of th i s thes i s f o r f i nanc ia l gain sha l l not be allowed without my wr i t ten permiss ion. Department of The Univers i ty of B r i t i s h Columbia Vancouver 8, Canada ABSTRACT In the study which examined the c h i l d health conference as an i n d i v i d u a l method of adult education, evaluations were made of both the nurse i n s t r u c t o r and parent-participant r e l a -tionships and the gains made by parent p a r t i c i p a n t s i n t h e i r knowledge of general health information, developmental mile-stones and mother-infant relationships during t h e i r period of attendance at the conferences. I t was hypothesized that there would be no s t a t i s t i c a l l y s i g n i f i c a n t mean equivalences be-tween the f i r s t and f i n a l t e s t scores f o r the 32 parents who comprised the study population. The hypotheses were rejected with values of t which were s i g n i f i c a n t beyond the 0.001 l e v e l . Despite the s i g n i f i c a n t gains recorded, i t would appear that a number of major factors presently l i m i t the conferences' e f f i c i e n c y i n providing optimal conditions under which learning may occur. F i r s t , an assessment of the educational needs or expectations of each parent i s not undertaken at the beginning Of each conference and learning objectives appropriate to each i n d i v i d u a l p a r t i c i p a n t are not sot up. Second, the conference does' net presently specify educational objectives i n tanas of desired behaviors and therefore, health teaching i s not only relegated a more minor r o l e , but par t i c i p a n t s aire, forced to become mere paasivet r e c i p i e n t s of information. Third, th© conference may not always reach i t s present broad goals be-cause appointments made by the nurse f o r the parent-participant to return f o r further discussions may be broken* i i i While i t was f e l t that the research instruments used in this study met; the retirements for which they were con-* structed to some diagree, theycouldundoubtedly have been much more effective measuring devices had steps been taken to increase: thoir r e l i a b i l i t y 1 , ;'Validity, ©b3©^t£vity> Comprehen-siveness and differentiation. Moreover* rating scale errors could have been minimized had nurses been trained in their proper use. TABLE OP CONTENTS CHAPTER PAGE INTRODUCTION ., .. * * * . , .. • • #• 1 purpose of the Study . . . . . . . . . . . . . 2 Hypotheses . • . . • • . • • . » • • . . • <> • 2 The Conference . . . « . . ... • • «..«..* • * • 3 Procedure.^ .. . . ... . « * « . • « . 5 Population . . . . , • , , . . * • . , « . , . . . . 5 Research Instruments . . . . . . 8 Conduct, of Conferences , ... ... . ,, . . ., .. . i i Data Analysis . . . . . . . . > . .• * • . 12 Definition of Tetfms. . * . , . . > . . . . . . * 12 II, REVIEW OF THE LITERATURE ,. . . . * . . 14 Child Health Centres i n Vancouver. . . . . . . 14 The Health Conference Method . . . . . . . . 0 17 Consultation . . . . . . . . . . . . . . . . 20 Counseling . . . . . . . . . . . . . . . . . 22 Casework . • « . • • • « * . . * . « • • • • 27 28 o o « » e e e e o e o o III. ANALYSIS OF THE DATA . . . . . . . ,' , * . . . . 32 The Parent Participant . . . . . . . . . . . . 32 AtJQ. . . » . • . . . . . . . . .' o a '. * . .. 32 Educational Backgrounds. . , , * . ... , , . . 33 Occupations of Husbands. . . . . . . . . . • 34 Murober of Children . • . . « . • . • 34 Physical Care Of Infant. . . . . . . . . . . 36 Attitude • of - Parents Toward .the Child; Health. Centre and the Public Health Nurse 37 Gains i n Learning Obtained by Parent Participants . . . . . . . . . . . . . . . . 40 The Nurse Observes? . . . . . . . . . . . . . . 51 Responsiveness to Mother . . . . 0 . . . . . 52 Communication S k i l l s . . , . » . . , . . . . 52 V CHAPTER PAGE $V. SUMMARY MFD CONCLUSIONS. . . .«, . .. .. ... * . . . * 55 Evaluation of the, ©phfereheo ' •*• '. .*... .... * .. . 56 Evaluation of the Instruments Used . . . . . . 58 BIBLIOGRAPHY • « . ... ... • ..  ..if .. !*: ... ~4 » . « . . -.» 64 APPENDIX A. Attendance Record Fom . . . . * , . . > . . . 67 B. Knowledge of General Health Information. . . . . 68 Knowledges of Developmental Miles tones. . . . . . 70 Knowledge of Mother-^Infant Relations . . . . . . 71 Physical Gat© Givein../ . ,. *. .. . ,. 4 • » * * «. • • 72 Attitude of Parent to Child Health Centre. . . . 73 Response of Parent to Gonfereiiee ..•.-..•*# • * 74 Attitude of "Parent to NUgtse, ,. ' . . . . ., . . 75 Nurse A p p r a i s a l . . . . . . . . . . . . . . . . . 76 LIST OF TABLES TABLE PAG I. Attendance and Immunization at Marpole Child.-Health Centre'.:'. '. * ".; ••; . .' . .'•.". . .' 8 '' II.' 'Percentage D i s t r i b u t i o n '&£ Par^ht-Pa>ticlf ante : by Age Groups. » . . . . . . . . . . . . . . . . 33 I I I . Percentage D i s t r i b u t i o n of Parent-Participahts •fey Highest Level o f S c h o o l i n g , v . ,: ..".' , . • 34 • IV.. '• • ©eeup^iona "Of: HuMkahds <^^e< 3 According -to •' Hollingshead Occupational Scale. . . . . . . • . 35 V. Physical Care Observed by Public Health Nurse. * 36 VI.. Attendances at' C h i l d Health Centre, . .. . ». . * 37 VII. Response of Parent to Conference as Observed by 'Public Health;l«urse.''.- -v-.5-*,.'-i>'-V . '. . . . . . •', 38 VIII. 'Attitude 1 -of' Patent 1 to''Public Health Surse -afc' • Observed ''by;. Public Health • Mtiafse.. * * . . . . . . 39 IX. Summary of the Means and Standard Deviations of • 'Scores'Obtained by Parenfc-Par^cipants on - Three • Areas Of Learning» # .« • • « • *• ». * * * ,» . * 40 X. " t " values on the Mean Differences of F i r s t and F i n a l Conference Test Scores of Parent-par t i c i p a n t s . . . . . . . . . . . . . . • • • . 42 . X X * D i s t r i b u t i o n of Scores i n Three Areas by Gains In Knowledge of Health information . . . .• . . . 43 XII. D i s t r i b u t i o n of Scores i n Three Areas by Gain i n Knowledge of Developmental Milestone, i . ^ 45 XIII. D i s t r i b u t i o n of Scores in^Th^ee Areas by Gain i n Mother-Infant Itelatiohshijp * . . . . v .' * • . • .' '46 XIV.. -Mean: Gains-: in"'Th#ee'- Areas of • Learning by Parent- • Part i c i p a n t s underand Over 25 , :. ,':* . * , , . 47 XV. Mean Gains i n Three Areas of Learning by Parehfc-P a r i i c i f a n t s with High School or Less than High School Levels of Education . . . . . . . . . . . 48 TABLE XVI. x v i i , XVIII. XXX. 3GC • v i i PAGE Distribution of Scores by Parent-Participants Grouped on the Basis of No. of Children. . . . . 49 Mean Gains i n Three Areas of Learning by Parent-Participanfcs who Attended Health Conferences for Between 2 - 4 and S - 9 Month Intervals. . . . . 50 Mean Gains in Three Areas of Learning by Parent-Participants who visited the Health Centre up to 4 and More than 4 Times . . „ , . . . . . . . 51 Responsiveness of Public Health Nurse to Mother S3 Communication S k i l l s Used with Mother by Public Health- Nurse .• # * . . . . . . . . . . . . . ». 54 Figure 1 Metropolitan Health Area of Greater Vancouver. 7 ACKNOWLEDGEMENT Grateful acknowledgement i s made "to Dr. Coolie Verner, my thesis adviser, for his help and cooperation i n the study, and to the ntemr-bers of my thesis committee, t would also like to thank Catherine Davison and Robert i 7 . Caldwell for their invaluable assistance in the statis -t i c a l analysis of data* 'Filially, grateful appreciation i s ex-pressed to the nurses in. Health Unit 2 and to Eva M» Williamson* Directoir of Public Health Nursing ,• whose cooperation and encouragement made this study possible* CHAPTER I INTRODUCTION The inspection and supervision of child health has been a major function of the public health service i n Vancouver, B.C. since that service was established. Public health nurses undertook parent education programs i n child health to enable parents to c l a r i f y their understanding of common child health problems such as nutrition, feeding, safety and accident pre-vention as well as to know the developmental milestones i n child growth and development. For the past twenty years there has been a marked Increase i n the educational content of these parent education programs. The child health conference has been adopted by the health department as a way of providing parent education i n child health. The child health conference hasi heen described as: A device for providing continuous health supervision for those children of a community whose health would not otherwise be supervised. Its purpose i s to keep well children well and promote their best possible state of health. As part of a broad public health program, i t offers to parents f a c i l i t i e s for the protection and pro-motion of the health of their children, and I t teaches parents some of the fundamentals of child care which they might have no way of learning. From the point of view of parents, i t i s a combined education and health service.1 Committee on Child Health of the American Public Health Association, Health Supervision of Young Children (New Yorks The American Public He^xW~Assn,Ihe. , 1955) , p. 96. 2 The Child Health Conferences discussed i n this study are not only for those whose health would not otherwise be super-vised , but for a l l parents and their children and i s not an alternative to, but rather complements other health care. This technique has evolved gradually over the years according to early accounts of the education of parents. I. PURPOSE OF THE STUDY The purpose of this study i s to examine the child health conference i n an effort to evaluate i t s effectiveness as an individual method of adult education by both assessing the relationships established between the public health nurse as the adult educator and the parent participant and measuring the gain i n information achieved by those parents participating i n child health conferences. II. HYPOTHESES Since this i s an exploratory examination of an individual method of adult education, the study was more concerned with analyzing the components of the instructional situation esta-blished i n the child health conference than i n testing specific hypotheses; nevertheless, the following hypotheses, i n null form, were specified: •3' 1. There i s no s t a t i s t i c a l l y significant gain on mean scores in knowledge of general health and disease prevent-ion i n children, and knowledge of developmental milestones by parents following participation i n a child health conference. 2. There i s no s t a t i s t i c a l l y significant change in mean scores on parent-infant relationships following p a r t i c i -pation i n the child health conference. III. THE CONFERENCE The conference method of adult education its an Indivi-dual instruction method as identified by Verner and involves a learner and an instructor. Ih the case of the child health conference the learner i s the parent—usually the mother—and the instructor i s the public health nurse who conducts the con-ference. In Vancouver, a l l families with newborn children are visited by the public health nurse as early as possible after the birth of the child, usually within fourteen to twenty-eight days after birth. At this time parents are often i n need of guidance on the care and nurture of the infant and welcome an opportunity to confer with the public health nurse. Although the nurse may continue regular v i s i t s to some families i f the situation in the home warrants this, ordinarily mothers come to the child health centre once a month with their infant. 2 Coolie Verner, Adult Education Theory and Method, A Conceptual Scheme (Washington; Adult EducatioiTAssocLitiQn of the U.S.A., 1962), p. I 3 r l 4 -4 At this conference a mother w i l l talk to a public health nurse for 20 minutes about her infant and his care, and ask ques-tions or request information on -.feeding; immunization and other aspects of child care or for c l a r i f i c a t i o n about a stage of development. The, immisnizatlons f a l l into a four-week Schedule and i n situations where a l l i s well between mother and child the appointments i n the child health centre tend to Occur monthly on a regular basis. A mother having considerable d i f f i c u l t y with her child may attend every two weeks or may attend irregularly. Parents of infants having long term and serious health problems are Visited in their homes on a regu-lar basis by the public health nurse. The desired outcomes of such an education program would include an increased understanding by the parent of the health and the growth of the child. The parent should understand how to prevent i l l health and disease through effective use of immunization against infectious diseases such as diphtheria, pertussis, smallpox, poliomyelitis and tetanus. She should also have an understanding o f t h e growth of the child includ-ing some knowledge of the developmental milestones through which a l l infants pass as they mature. A parent with this i n -formation i s thus i n a better position to anticipate and meet the needs of his child more adequately, '• ' An evaluation of the-effectiveness of the conference method would include not only measurement of the specific i n -formation acquired by the learner, but also measurement of the 5 attitudes developed by the parent as shown by changes in mother-infant relationships. It should also include a measure-ment of both the response of the instructor to the needs of the parent i n the conference and the communication s k i l l s used by the instructor i n the conference. , : IV. PROCEDURE The data for this study were based upon participant observation using structured instruments to record the data. The population studied and the nature and characteristics of the specific instruments used are discussed below. Population Parent Population. The population for this study con-sisted-';: of a l l parents who' attended the Marpole Child Health Centre for the f i r s t time during the six month period from November 20, 1967 t© May 19, 1968. This population consisted originally of thirty-four mothers and infants of whom two moved from the region so that the f i n a l population consisted of thirty-two. l i v e fathers regularly accompanied the mother and Infant to the child "health^ centre and participated in the con-ference but these were not included in the study. /: The-.child, .health -cent#e;' ilsed In "the' etudy was located in a United Church Education Centre at 67th Avenue and Selkirk Street i n the Marpole area of Vancouver. The parents who attend this child health centre l i v e i n the geographic area 6 bounded by Marine Drive on the south, 59th Avenue on the north and from Granville Street on the west, thence east to Gamble Street (Figure- 1). Marpole d i s t r i c t has a large migratory peptiiation due to the number of young families l i v i n g i n apartments of moder-ate rents which w i l l accept small children. Continuity of service on a long term basis i s not always as possible as i t might be i n a more settled residential area. Attempts to follow up those who had broken appointments revealed that most of them had moved out of the d i s t r i c t . The number of immunizations provided to the infants of the study population on each v i s i t to the Child Health Centre, Is as follows-... ' Eight infants, twenty-five- percent' of the sample, were immunized oh each V i s i t to the Child Health Centre. The immunization was administered fjry the public health nurse as part of the health conference. Seventy-five percent or twenty^four infants who attended did not receive an immuhizatlon on each v i s i t , ©ne could conclude that the parents of these infants attended the: Centre to confer- -with- the public health nurse and to receive counseling oh health and child care (Table I ) . Nurse Observers, Four public health nurses who were regularly assigned to this child health centre conducted the conferences and made the observations that provided data for the analysis, TWO nurses were graduates of degree programs in Figure 1 M e t r o p o l i t a n H e a l t h A r e a of G r e a t e r V a n c o u v e r 8 TABLE % ATTENDANCE AND IMDWJNIZATION AT MARPOLE CHILD HEALTH CENTRE Number Times Attended Immunization per Infant I 2 1(0 Im.) 2 3 2(0 1m.) 5 4 3(3 Im.) 1(2 Im.) 1(P Im.) 8 5 6(4 Im.) 1(3 Im.) 1(2 Im.) 4 6 2(5 Im.) 1(4 Im.) 1(3 im.) 3 7 2(5 Im.) 1(2 Im.) 1 8 1(6 Im.) Total 24 17 4 3 nursing. Two were graduates of the same hospital school of nursing, and had undertaken additional study In public health nursing at the University of British Columbia. Research Instruments Participant-observation Instruments. Since the data were collected by the participant-observer technique, instru-ments were constructed to f a c i l i t a t e recording observations i n the categories of the behaviour observed. The instruments used by the nurse were as follows s 9 1, Knowledge of General Health Information. At the end of the f i r s t and, last conferences between parent and nurse, data were collected on knowledge of general health information by asking the mother to explain the meaning of twenty words and phrases chosen because of the frequency with which they are used i n discussions with parents i n child health centres. In evaluating knowledge of general health information, a score was assigned to each of the twenty questions answered on the basis of the use of the words i n context and on the con-tent and meaning of the answers. Responses to each question were graded on a seven point scale With (1) no knowledge a Score of 0; (2) imperfect knowledge, a score of 0? (3) some knowledge, a score of 1; (4) f a i r l y good knowledge, a Score of 2? (5) good knowledge, a score of 3; (6) very good knowledge, a score of 4; (7) excellent knowledge, a score of 5 (Appendix B). . 2. Knowledge of Developmental Milestones. Knowledge „ ©f developmental milestones was gathered from the discussions during the conference without direct questions posed to the parent* Developmental milestones as indicators of motor and behaviour maturity were based on the findings of Gesell and 3 I l g . In evaluating knowledge of developmental milestones one 3 Arnold Gesell and Prances L. I l g , Child Developments An Introduction to the Study of Human Growth-(New Yorks Tfarper and i f others, 194"$) , p * * ^ 7 5 . 10 point was given for awareness of each of twenty-five mile-stones (Appendix B) , 3. Mother-infant Relationships, Evidence of mother-infant relationships was gathered from observations of the mother and infant i n the conference, by listening to what the parent said i n describing the infant, and by the feelings ex-pressed about the infant. Mother-infant relationships were assigned points on the basis of what the public health nurse heard the parent Say to and about the child, as well as what the nurse observed of parent-infant interaction. Five regarding the depth of the relationship were examined for parent-child interaction and points were assigned accordingly (Appendix B). 4. Physical Care Given Infant. The description of physical care given was assessed on a seven point scale by the public health nurse immediately after completion of the con-ference. This was done at the f i r s t and f i n a l conferences (Appendix B). 5. Attitude of Parent to Child Health centre. The attitude of the parent to the Child Health Centre was evaluated on the basis of persistence of attendance at the conferences (Appendix B). 6. Response of Parent to the Conference. A nine point scale rating interest, i n i t i a t i v e , and responsibility for discussion was used to assess the responses of parents during 11 the conference. The nurse assessed this response at the f i r s t and last conferences " 7. Attitude df Parent to Public Health Nurse* A five point scale was used to assess the attitude of the parent to the public health nurse during the conference. This was mea-sured : at 'the f i r s t 'and' 'final conferences ' (Appendix B). Nurse Appraisal. A crucial aspect of the health confer-ence i s the t©ap©naiven@ss to the parent of the nurse conduce ting the conference. Instruments were constructed to appraise tne nurses conducting the conference with respect to their res-ponse to tine needs of the parent and t h e i r f a c i l i t y i n communi-cating' with the; parent 'partielpanfe, ' Observations' o'f" the "hurse. participant were made by the author of the study who was present i n the Child Health Centre during each conference. The assess-ment of the nurse was based on a nine point scale which was completed after listening to and Observing one conference between a nurse and each of the mothers (Appendix B). Conduct of Conferences The normal routine of service to parents of infants new to Marpole Child Health Centre was net affected by the research. The conferences were conducted by -the-nurses: regularly•'.assigned to this duty with additional time being taken at the end of the conference to complete the research;'instruments.. 12 Data. Analysis^ •- > The data' Were 'analysed by s 1. Simple' frequency distributions tabulating certain sdeio^eebnoM 2. '''Biva^la^''tabiila^0nis' collaring parent-participant and nurse-observer characteristics with gains i n general health knowledge,^ ifenowlfedge of developmental milestones and;mother -i h l a^tVreiationships^'' 3. " t " tesiis to measure the significance of gains i n three areas of learning and differences among groups* V. BEFlNITiONS OF TERMS t% ,Cliil^..^SJa^^-,qe^tyg i s the, place i n which health supervision for well. infa>*tS;;®ild. •pfesoh^ A Qhild Health Conference i s that part of a public health pro-gram which offers health supervision for.well young children and i s .,not an a l t e r a t i v e to, but rather complements other h#alt&..ear@.,./ ;.,, ,.,./. :'.:',.,- -v,:.. •••••<:.. Development i s defined as growth to f u l l size or maturity; progress of an egg to the adult state.. De^lopmefttal milestones are stages and states that the human infant and. child goes through as he becomes less immature and these/stageS' :'a&e;'vialfcie.' of activity' i s 'observable. Regular attjBiidjef a axe -th'oae who attend the. child-health, centre approximately once a month, (If attendance i s nbfe regular the 13 immunization schedule i s interrupted and series sequence may need to be repeated.) Irregular; attenders are those who attended child health centre either\l#ss or mo£e frequently than once a month. If a par-ent has ne^d for additibhal help withthe baby more frequent attendance than oncea month i s encouraged* A parent who attends less often than th© interval i s not making optimum use -of th# service. -: An I n t e r v a l s t a t e d i n months, i s the time between the f i r s t and f i n a l confereihc#s* CHAPTER I I REVIEW OP THE L ITERATURE This review of literature w i l l examine some of the historical'origins' of the child health conference as well as the method of adult education Used i n the child health con-ference.' Some of the origins of the Child Health Conference ideas can be traced to the French obstetrician, Budln, who i n the latter part of the 19th century initiated the novel practice of asking the women he delivered to return i n six months. He wa& shocked at the number w-who came back without their babies. In those days i n * fant deaths were appalling especially in the summer months. Bacteria as a cause of disease was just then the new knowledge. The importance of "clean* milk was Only beginning to be grasped. In 1892 Budln established the 'Consultations des Nourrissons' which presently became the .'(Soufctes'des Lait* or' '-Milk Stations'* 'These early stations encouraged breast-feeding and provided safe cow's milk.. They-'were 'so successful i n reducing infant diarrhea that the pattern began to spread around the world* New york City's program s o r t e d before the turn of the century. From concentrating on milk, Child Health conferences' soon became'* sources of information about ehiidren'S health. 1 I i CH ILD HEALTH CENTRES IN VANCOUVER Dr. Underbill, then medical health officer of Vancouver, writes in the Annual Report^of 1912 of his concernfor the Committee On;Child Health of the American Public Health Association, Health Supervision of Young Children (New York? The American Public Health Association Inc., 1955), p. 95. 15 need f o r a day nursery of creche vfere 151 d e s t i t u t e mothers could leave childr e n while they sought employment. In the ; Annual Report of 1913 he reports the establishment of such a day nursery. Part V I I I of the C i t y of Vancouver Health By-Law 949 i n r e l a t i o n to the Infants Protection Act was passed i n 1913 and t h i s then necessitated the appointment of a Lady Health Inspector i n 1913. Such provisions demonstrate the concern f e l t even at that time f o r the health and care of infants and children* In 1916 the f i r s t C h i l d Health Centre or the Well Baby C l i n i c was established at the Infant's Hospital and i n 1917 when the D i v i s i o n of C h i l d Hygiene was developed, c h i l d health centred or w e l l baby c l i n i c s commenced to function on a regu-l a r b a s i s . The chief aim of these c l i n i c s was as f a r as possible, to have every baby breast fed. In addition, the C i t y of Vancouver provided a fund to make availa b l e extra milk f o r mothers who were unable to buy s u f f i c i e n t amounts. In 1919, i n cooperation with the V i c t o r i a n Order of Nurses, a second c h i l d health centre or Well Baby C l i n i c was opened f o r the east end of Vancouver i n the Vancouver Community House at Campbell Avenue and Georgia Street. By 1921 a t h i r d c h i l d health centre or Well Baby C l i n i c had been opened at the Sixth Avenue Church i n K l t s i l a n o . Attendance at these c l i n i c s gradually increased over the years from the average of eight babies who attended the f i r s t c h i l d health centre# Medical Health O f f i c e r ' s Annual Report f o f C i t y of Vancouver, 1912*1913,1917,1919, C i t y of Vancouver. 16 In the Medical O f f i c e r ' s Report f o r C i t y of Vancouver i n 1921 one reads that: In every c i t y there are babies brought i n t o the world to mothers who do not understand how to cafe f o r tljem properly. To help these mothers and to im-prove the general conditions under which children are feared, i s the chief object of t h i s D i v i s i o n , with t h i s f o r a motto; 'Keep w e l l babies w e l l ' . 3 He then elaborates upon the advantages of educating mothers i n the preparation of feeding as well as the provision of milk t i c k e t s up to the age of two years. By June 1937, s i x months a f t e r the Metropolitan Health Committee had been established, eighteen c h i l d health centres wefe operating i n Vancouver, The Increase i n attendance at these c h i l d health centres may have been due to the v a r i e t y of services offered to the parent and c h i l d . Among the services provided were (1) a health appraisal of the c h i l d including h i s t o r y taking, p h y s i c a l examinations, growth assessment, and v i s u a l and auditory screening t e s t s ; (2) preventive immuni-zation procedures; (3) counseling f o r mothers about a l l aspects of her c h i l d ' s health and c l a r i f i c a t i o n of common childhood health problems of feeding and n u t r i t i o n , behavior disorders, accident prevention; (4) r e f e r r a l s f o r i n v e s t i g a t i o n and sp e c i a l services offered by the health u n i t such as dental c l i n i c s , consultants, and r e f e r r a l s to the appropriate com-munity services outside the health u n i t including private Medical Health O f f i c e r ' s Annuai Report f o r C i t y of Vancouver 1921,City of Vancouver, p, 17. 17 physicians, nursery schools, family social agencies; (5) home v i s i t s made by the public health nurse as needed.4 Thus, i n the thirty-year interval child health centres had doubled i n number from eighteen to thirty-sijc, II. THE HEALTH CONFERENCE METHOD A method of adult education i a defined by Vemer "as the relationship established by the institution with a poten-t i a l body of participants for the purpose of systematically diffusing knowledge among a prescribed but not necessarily f u l l y identified publico" The child health centre, which i s ai» administrative function of the health department* may be considered to be the institution involved in adult, education* The conference i s the method of adult education employed by the institution and the public health nurse i s the adult edu-cator- i n this context. Adult education may take place by individual, group or community methods. "Individual methods are those i n which the relationship established by the Institution with the potential g learner Is on a one-to-one basis." Four-methods within this ^Committee on Child Health of the American Public Health Association, Health Supervision of Young Children (New York? The American f u l i l l H ^ p> 97, 5 verner, oj>. c i t . , p. 9. ^jbidw/.p* 13.* 18 class are correspondence study, apprenticeship, internship and directed individual study. Traditionally* the child health conference has been organized i n a direct public health nurse to parent relationship and i s , therefore, an individual method of adult education under the classification of directed Individual study ^  This review w i l l thefefojfe further examine directed individual study. i n 'directed. ..individual 'Study "a ^ relationship- i s esta-blished with the learner that involves semes direct personal contact between th© learner and the agent so that personal 8 supervision of the learning process can be assured*' "In many respects* this method i s a form of adult counselling with an instructional rather 'than1 therapeutic orientation* M - -In reviewing research on parent education. Brim notess Educational techniquesare those directed to the conscious (and neer-conscious) aspects of th© individual personality, and exposure to educational programs ideally should arouse only conscious beliefs and conscious motives. In contrast* therapeutic technigues are d i r -ected to unconscious motives* 0xp®ctafeioni and attitudes* and - the instrumental goal Of therapy i® to make the individual ready to p r o f i t from subseguejat educational experiences.19 -Ibid.', p„ 14. 8 Verher* loc, clt> ^Goolie Vernek and Mian Booth, Adult Education (Hew York's' Th® Center for" Applied' Research In Mucatloii Inc., 196 4) * 71, 1 O 0 r v I l l e Brim* Education for Child Rearing (New York; The Free tress *; 1965) '.* p. 21..;. • . 19 He c l a r i f i e s this further by stating that education avoids pressing forward;where the person i s resistant, on the assump-tion that the resistance arises from strong defenses which, i n turn,arise>from unconscious motives, There i s no implication that education does not examine why a person feels as he does. To the extent that the "why" i s under conscious control, i t i s suitable subject matter for the educational procedure .• Changes resulting from education .wl11 comprise minor changes i n the perjson'S character, when compared to the major person-a l i t y reorganization held to result from successful therapy. Education is, oriented toward the healthy factors of the per-sonality and appeals to the a b i l i t y to judge, to gain under-: standing,. ..it©,, learji to use one's, .e^,eriene?e for-new and, d i f f e r -ent situations, to plan, to make, choices, to adapt to changing circumstances, and to add new experiences. In addition, education oeui fosterthet estai>lishment of an (aJfectiVe, warm, and personal relationship with the pupil. Such warmth would bis every b i t as conducive to,the success of education as i t i s to that of therapy. In other words, education i s the attempt to influence a person by appeal to those, motives and 11 beliefs which are under, conscious control. This relation-ship and i t s instructional aspect are components of consul-tation, counseling and.casework. ^ I b i d , , pp. 21-23. 2G Consultation In a review of the literature on the" instructional'' orientation of consultation, one discovers that "eonsoltation * , . i s not a single unified. Standardized procedure but i s delineated and practiced i n a wide variety of ways," The core theme of consultation i s helping but consultation has no par-ticular process with i t s own pure: and specific features which 12 receive general accord as a single entity. n I t i s an egalitarian relationship i n which the responsibility for i n i -13 . . tiatlng change rests with the consuifcee*" Fiv<§ maijor divisions of the continuum of consultation. ar& eeen- to ho,: direct Service, advising, teaching, resource and supported The general goal or aim of consultation,, i s to strengthen •*'"V • the individual and education also has this goal,- Th^ method of consultation basically consists of working with the con-sultee on the solution of a particular problem which he brings for consultation and helping him to continue his wofk i n the face- of that problem- which i;e -marring' -his.' a b i l i t y to carry 12 Hanna Fonseca and Gerald Caplan, Consultation L i t e r - ature Review (Boston: Harvard University,"T^Ff)> p. 1. ^33oan Web©, "The Specialist Consultant i n a Public Health Agency," Canadian Journal of public Health;* 59 (April, 1968)* p. 156.. • - '"' 14 Fonseca and Caplan* c i t * $ pp. 10-15. 21 out h i s r e s p o n s i b i l i t y to h i s f u l l e s t capacity, "Education i s systematic i n contrast to the ad hoc o f opportunistic char-acter of consultation, i t focuses on long-range general l e a r n -ing i n a subject area and imparts a basic body of knowledge - • • 'IS' .father 'than solving, specific" i n d i v i d u a l problems, *' The phases Of process o f consultation are stated by Maddux to be request for assistance, development of rapport, i s ' ' diagnosis, working thfCugh and tefmihation, Fonseea; and Caplan describe seven phases which represent ideas of change i n th© developj^iit of- consultation* These', are development of a need f o r change* establishment of a change r e l a t i o n s h i p , ' diagnosis' of ' the .problem:, establishing; goals; and intention of action, i n i t i a t i o n of change e f f o r t s , generalisation and s t a -1 7 b i l i z a t i o n of change and achieving a terminal r e l a t i o n s h i p , That consultation should be evaluated i s not t o t a l l y ignored, but neither i s any r e a l scheme f o r doing so presented i n the l i t e r a t u r e * Most mentions of evaluation simply state that consultant and consultee both should take a look from time to time to see how they are progressing toward the goal 18 they have set. * 5 I b i d . , -p.' 35.,- -• James Maddux, "Consultation i n Public Health," Amefican Journal o f 'Public Health, 45 (November, 1955), pp, 1426-1427. '' " '•' 17 Fonseca, op. c i f r , , p. 39. 22 In a review of the literature on the instructi^hal orientation --of ,qo^selin# i t ' I s etated-.that •"oouhBeiinf.ie one of the personalized and Individualized processes designed to aid the individual to leam school subject matter, citizenship t r a i t s , social and personal values and a l l the other habits, skills^-, .attitudes,;and..beliefs which go to, make, up a hdrjaaliy adjusting human being." Arbueklesees counseling as a re-lationship which exists between two persons, one of whom i s 20 assisting the other i n a proceiss of growth and insight. Jinks isolated and determined .six basic principles of counseling by analysing the content of twenty-two textbooks concerned with counseling the and practice, published from 1950 - 1965* J^ose prinM weres the client seeks counseling because of some impediment to his progress; the; objective of counseling i s responsible self** direction for the client; counseling i s a learning process; the primary ,. cc^cerjfc of. counselor' i s . the'.welfare of ' the'.' client? the counselor recognizes Individual differences among clients; and the clie n t has the capacity to achieve responsible self 21 direction. Williamson cl a s s i f i e s counseling techniques E.G. Williamson, Oounseling Adolescents C^ ®** #OX}L» MeGraw Hi11 Book Co., 1950), pV2; Pugald Arbuckle, Couhaelihg Philosophy, Thgtbry and  Practice '(Bostons' • Mlyn- all^Bacon • fne^ '> • 065),'pV 72* 21 ' Lydia: tJink's.,, A Content Analysis of Selected Books Related to Principles of ''Couhselino;, 'Wrversl%1 olT^.!i^oiaa.f 1966. 23 under five headings including establishing .rappbri, c u l t i -vating ' :self-uh^rstahding #' advising/ or'- |>Iannini:i a" program' of '' -action.,:: carrying' but.' thfe' plan:, 'r#f e'rrih|f stUdbhfc''' to another' personnel:1 worker for additional assistance* •' Brim;'-states''that individual counseling not only"'presents facts' as' well' as' ..other'-'itte^bd'S;/ but' i s a' !faee-to-.face inter'-action situation v;hich rasearch from other fields'' Indicates i s more" effective.'' in' bhanging' • attitude's • and motives^; correcting Msinfbrmatlbh, alleviating anxiety and adapting content to specif i c ' i i t u a t i b h s . * * - : V •"' Individual' counseling ranks second to mass' media' 'and' ahead'of gfbup: discussion i n the. number of parents i t reaches. 2 4 .In'Vpfoir'ams' .for Ari&ed''Serviced:;in/World;.War';II..* ". . . theneed f or''counse'liiig 'and guidance' ambng "adults of'ittiiitary^ age''was great i n terms of helping them to both analyze their educa-tional •' .needs. • and' • to select' the'- ''most hblpfui learning "experience*•1 '  vBrik: -arepbf ts' bh -three 'studies' o f evaluation of results on individual -ce^aeiihg.! in'parent ^education.* • One -study showed changes i n parent and child feehaviot *1 another^ showed Improvement; in children's behavior, another that counseling increases the 2-2 '-.•'•'• Williamson, op> git* * .p-.. -224. -• '23 ',••;•'.•''••'.••*''•.''••••'. Brim* og* b i t * , pi 201* 2 4 |bjd* .* p« 189* :• ^Edmund Bruhiief * An ©jterview bf;• Adult-': gducatj^ bn:' -Itesbarbh (Chicago: Adult Education '• Assoclaid'bh' .A^L959)V>p*; 24 number of problems one perceives he has or i s willing to report. However, he believes that the data delinate no clear conclu-s i o n s * ^ A study on the method of individual counseling i s also reported by Brim showing changes i n both parent and child be-havior, although the number of persons changing were few* and the study used no controls. The study was concerned with change i n a child-rearing practice on the part of 57 mothers attending a child health centre. The Innovation selected Mot study was permissive behavior on the part of mothers i n handling food refusal of her children. Significant relationships between a number of factors and behavioral change were set forth. These included the prestige rating of doctors; the relative satis-faction to be gained from the change; the degree ©f dominance characterizing the mother's child-rearing; the exposure to favorable or unfavorable advice concerning the change; the encouragement and approval received from husbands; and the actual results obtained from employment of the new behavior pattern,. Although change was influenced by the amount of pres-tige accorded to doctors, this influence acted chiefly upon i n i t i a l t r i a l s of the new; pattern., and was not important i n •Brim* oj>, c i t , , pp* 311-312, 25 continued perf ©rmtoee. Such a finding supports the idea that i n instances of behavioral change where t h i s f a c t o r alone i s present* change w i l l take the form of many t r i a l s but l i t t l e net r e s u l t s w i l l be derived. The other point i s that i n under-taking novel behavior f o r which the s a t i s f a c t i o n s are delayed* i t i s necessary that the performance be supported and sustained in.some manner,. - The-evidence•'oofecernihg"•the influence' Of the sources of information drawn upon i n the t r i a l period* together with the influence of the husband's reactions,, suggests; • that-one important source of support i s a favorable group context f o r the i n d i v i d u a l . The ffroup not only sustains the i n d i v i -2 7 dual's expectations„ but rewards him at the same time. '• Cooper reports- on a study undertaken as an effort- to estimate the value of the Mother's Advisory Service conducted by the Mental Hygiene Study of the Johns Hopkins School of Hygiene and Public Health i n cooperation with the C h i l d Hygiene C l i n i c s i n the Baltimore C i t y Health Department. The group studied consisted o f 100 normal childre n and 81 contro l s . A method was devised f o r the graphic presentation of behavior items which could be re a d i l y translated i n t o numerical scores and which f a c i l i t a t e d a c l e a r understanding of the c h i l d ' s 27 O r v i l l e Brim, "The Acceptance ofNewBehavior i n C h i l d Rearing," Human Relations * v l ! '-(November•*'.'.%9.54)/••pp.!-473-491* "•' ; -V V v.-"": ' 26 status at any given time. According to this method a s i g n i f i -cant advantage on behavior status was seen i n patients over the control group regardless of sex and color* Moreoverr this advantage was not related to the intelligence of the mother as Indicated by school achievement. Cooper concluded that such a service could be effectual i n such a setting and was fea-s i b l e . 2 8 Klatskin found i n a study of 229 parents that parental child care practices are capable of modification through i n -struction, and that i t i s possible to alter the influence of 29 social class membership on child care* Leonard, Vandeman and Miles state that "successful coun-seling helps the parent see his Or her child more objectively, recognize his own attitudes toward his child and understand h i t problems a l i t t l e more clearly* This may* however, be a long time process, not even accomplished i n several confer-ehces *" . 28 • -;- *^Marcla. Cooper* "Evaluation .of Mother'a'Advisory Service*" i n Monographs of Society for Research on Child  Development, XII (1947), p. 42, 29. EthyIn Klatskin, "Shifts i n Child Care Practices i n Three Social Classes Under an Infant Care Program of Flexible Methodology,n American Journal of Orthopsychiatry, XXII. ttfanu.ar3p, 19S2) * p* 611. Edith Leonard, D, Vandeman and L. Milea, Counseling with. Parents* i n Early CMldhoed 'Education' (New York; MacMillan CO., 1954), p.; 70* 27 Casework In describing the casework method, Hamilton l i s t s use of relationships* the interviewing process, Use of social re-sources and the l i v i n g experience, and requirements of agency practice as part of the process* * Some attempts have been made to evaluate the effec-tiveness of casework * "A. study by the Family Service of America was conducted with 33 families from which i t was Con-cluded that the gains occurring during casework Contact tend to be sustained* and there was f a i r l y strong implications that 3:2 some of the gains were a result of casework* An evaluation of the one individual approach to teach-ing families a different way of functioning has been carried but i n Vancouver* The project was established i n 1964 to develop new methods of providing services to these families* The assumptions underlying the programs were that an approach which integrated services through one worker and focused on the whole family was more effective than programs providing these : services: thfough various, iagbhcies; and that an approach which viewed the neighborhood as a focus of service could • 31 . Gordon Hamilton, Theory and Practice of Social Work • yofk? Columbia university Press, 195I), p. 26. ' 32' - IteohafdKogan 'e]tv;al,.,j A follbwrUp-•• Sjudy:of..Results.of,  |ociai Casewbrk.- (Newborn? J •" • Fam£ly.--Servic© Association of "" " America, 1953), p. 66. 28 change neighborhood conditions a f f e c t i n g family functioning* The procedure was to study an incoming group possessing cer-t a i n population c h a r a c t e r i s t i c s f o r whom something i s done which, i n turn, produces a desired change* Both experimental and c o n t r o l f a m i l i e s w i l l be followed by a se r i e s of family functioning ratings f o r f i v e years, with f i n a l measurement 33 during 1972-73, interview Xn consultation, counseling and casework, the interview has been described as a basic t o o l f o r e s t a b l i s h i n g a r e l a t i o n -ship between the agent and the c l i e n t ; consequently, i t i s the p r i n c i p a l i n s t r u c t i o n a l technique. "Regardless of i t s s p e c i f i c purpose, form or content, the interview i s e s s e n t i a l l y a method of c o l l e c t i n g informa-t i o n * The purpose f o r which the information i s sought varies with both the seeker and the respondent." Fenlason describes the interview as a professional method* based upon a simple but d e f i n i t e structure; i t accomplishes i t s purpose by the employment of processes 'and techniques; Its dynamics are the in t e r a c t i o n between the interview and the interviewee. 33 Larry Bell,and Beverly Ayres, Area Development Project  Research Monograph (Vancouver! United' Community Services.,. 1968), p p . 1^8. 34 .....•>• ; ' Bptiphmn Richardson and B. Dohrenevend and D„ Klei n * Interviewing* I t s forms and functions (Hew YOrks Basic Books Inc., 1965)* p. 7. Anne- Fenlaaon, - Essentials; of Interviewinf i' (New York: Harper and/Brothers'-.-,'. 195-2), p. i s s . 29 Tyhurst indicates that the interview c h a r a c t e r i s t i c a l l y Involves two people who are l i s t e n i n g to and responding to one another* He states that to understand and use t h i s r e l a t i o n -ship i t i s necessary to have Ways of r e f e r r i n g to what goes on i n the interview; t h i s he describes as the concept of cue, ©f s e l e c t i o n * •••©!? d i f f e r e n t i a l response>.©f relevahce' of coh-36 t e s t , ©f r o l e . The required techniques for good interviewing are seen t© be; s k i l l i n observation, i n use. of s i t t i n g * i n e s t a b l i s h i n g rapport, In meeting resistance, i n use of ques-3 . 7 tions and silence.*.'' Garrett, i n describing how to interview* lays stress on observation* on l i s t e n i n g and beginning where the respondent i s , on questioning, on leadership or d i r e c t i o n i n the interview. Some of the concrete d e t a i l s of good i n t e r -viewing she l i s t s as physical s e t t i n g where the interviewer i s able to give undivided attention to the interview* time set . aside immediately, a f t e r each interview.for recording, some. assurance to the interviewee of the c o n f i d e n t i a l nature of the interview, a general 'body of background knowledge possessed by th© Ihterviewer*^ 8 The literature; review does point out the- tremendous edu-c a t i o n a l strength found i n the r e l a t i o n s h i p established i n di r e c t e d i n d i v i d u a l study. This r e l a t i o n s h i p and i t s i n s t r u c -t i o n a l aspect are components of the conference between parent 36 3VS. Tyhurst, ln%e:rviewing; ( v i c t o r i a : j^ept. .of Health Services' .and Hospital 2Snsurance> i960). * pp. :3?-5> ' 3 7FehlajtOh, ••©£>-- c i t y * ppv ,111*134.*. go •,—J—' j ./ ... „ . Annette, -'G^ rre>tt*. I^epriewlhg,* ;|ts^:P.ifij£iclp3^^wd Methods (New y o r k s,' i W ^ ^ ^ : ^ e m m ' ^ ~ m m » m 'MmtlpaTi^Zff^ 'pp. •,34-59. *•'' 30 and public health nurse i n the child health centre where the nurse may be counseling or i n consultation with a parent* Personal communication i s stated by Rogers to be most impor-tant at the evaluation stage i n the adoption process where mental judgntent of the imiovatibh i s made, for later adopters tatheje 'i&an-oarly iad!op^era.*'and in''Unclear situations rather than clear-cut situations. He gives as reasons for this state-ment that personal communication (1) allows a two-way exchange of ideas which assists i n c l a r i f i c a t i o n (2) i s l i k e l y to i n -fluence behavior as well as transfer ideas (3) provides greater accessibility 'and' Credibility (4)' has greater'effectiveness i n the face Of resistance or apathy. Rogers further states that personal influence functions moire effectively than mass madia i n overcoming resistance to change or to new ideas. He fives an explanation for this on the basis (1) that people expose themselves to communications that agree with' their ex-isti n g opinions and exposure to personal influence i s less selective than exposure to mass media as person does not know i n advance what w i l l be discussed (2) that people select perception and when an individual misinterprets what i s said, hie misunderstanding i s grasped .and attempts made to correct him (3) that due to selective retention i t may be possible to remind m i n d i v i d u a l about an innovation on , , v e r a l o c c a , i c n S . J 3 9 •• • • .Everett H,# Rogers-, piffusion of innovations (New Yorks-Who 'Pre©' P*ess,>i962)'/ po. 99, -^p^-^S^-^sS-*^' 4 Q I b l d . , p. 225. m He- • looks -tlpo-h' public health hus?$es : 'ehahge- ageh-fes- -who- attempt to influence adoption decisions i n a '•directionthat the public health 'nurse- .feele • i s ; desirable * '•:$© 'U£ge» •chahgb agents- to fee-more^ concert eojapetence of those., .they-:-' eonfer-tfith ;itt^ie^luati^''n^'''iae'a^ and leas- with Mraply pre^ CHAPTER III ANALYSIS OF THE DATA The experimental evaluation of the child health Con-ference as ah individual method Of adult education was con-cerned f i r s t with the appraisal of Changes and development that occurred i n the parent-participant with respect to certain aspects of Child health and then With the role of the public health nurse acting as an adult educator* I. THE PARENT PARTICIPANT Thirty-two mothers with infants were the parent-participants i n the child health conferences Conducted i n the Marpole Centre and these mothers constituted the popula-tion for the study* The gains they obtained i n their know-ledge of general health information and developmental mile-stones and in their mother-infant relationships as a result of participating i n these health conferences provided the basic data for this study. Age The age distribution of the mothers ranged from eighteen to thirty-eight with fifteen mothers (46.9 per cent) in the eighteen to twenty-five year old group and seventeen 33 mothers (53.2 per cent) between twenty-six and thifiy-eight years of age (Table I I ) . ...... TABLE II. PERCENTAGE DISTRIBUTION OF. PARENT-PARTICIFAHTS BY AGE GROUPS • . Age Number Percent 18 - 21 4 *. S 22 - 25 11 34.4 26 - 29 " ' !" 11 34.4 30-38 18.6 Total 32 100.0 Educational Backgrounds In terms . of. thei*'' educational .levels,. the itothers .were* slightly above the median for the population of the census tract i n which the Marpole Centre i s situated. None of the mothers participating in the health conferences had less than some high school education. As shown in Table III, eight mothers (25 per cent) had attended high school between one and two years while fourteen mothers (44 per cent) were high school .graduates'.Thirty-one ;per.'ceiit of. the .mothers reported some university experience. 34 • TABLE. I H ..... . PERCENTAGE DISTRIBUTION OF PARENT-PARTIGIPANTS BY HIGHEST LEVEL OF SCHOOLING Highest Level of : Sehooling- Number \ .Per- cent;., 1 - 2 years high school 8 25.0 High School Graduation 14 44,0 Some university experience 10 31.0 Total 32 100.0 Occupations of Husbands . . The occupational categories of the husbands were c l a s s i -• l fled according to the Hollingshead Occupational Scale. Table Iv shows that 38 per cent were classified as administrative personnel and 4? per cent as s k i l l e d manual workers or i n sales positions» Number of Children Participants in the health conferences were evenly divided between those with one child and those with two or August''Hollingshead, Two/Fecter Index of Social,  Position (New Haven: Mimeo) , pp*:"'3~81',' \ 33 TABLE I V OCCUPATIONS OF HUSBANDS GRGJJEgD ACCORDING TO HOLLINGSHEAD OCCUPATIONAL SCALE Holiingshead QGCU Scale patiohai No, • of \F:ath4rs ,,Per .cent ^  Students ' o • ' ...... 2 6.0 Unskilled 7 ' 0 0.0 Semi-skilled : ;' 6 ; ' 6.0 Skilled manual 5 8 2S.0 Sales 4 7 22.0 Administrative Personnel 3 • 12 • 38.0 Business Manager 2 .• • • 3.0 Higher "Executive • • •> 0.0 Total' 32 100.0 more children. Seventeen mothers' :'(5l3*2 pe^Oeht)''were1 atten-ding the conference with their f i r s t Child* thirteen mothers (40.6 per cent) had one other child and two mothers (6.3 per cent) had two other children. Their infants, whom they were bringing to the conferences, ranged i n age from two to eleven months; twenty-three (71.9 per cent) were under six months of age, while nine (28.1 per cent) wet© between six and eleven months old. Physical Car® of/-Infant • • • . The physical care of the infant was observed by the public health nurse at the f i r s t and f i n a l conferences and assessed ©n a seven point scale i Twehty~six infants (81 per cent) were found to be well cared for and there was ho change observed between the f i r s t and f i n a l conferences (Table V)... • • '• M • -.•'.} TABLE V ' PHYSICAL mmOBSERVED^:.jWvf^fiI-C:•l^BA^TH^•iHj^fi. Description of Gare •m' -First.' Visit' to C.HrG,f : Fihal V i s i t • to G.HiG, •" Bruiaed -; and i n j ured o ; , - . : . ' . , . / 9 Malnourished - diet poor 0" o ' Unclean and unkept o Inadequately clothed '.0. :'-'.«.':;'""'•' ' Appropriately clothed '•'' 6 " Well nourished o : Well cared for ' 26' ""' '•' 26 Total'- . ; ,.', 37 Attitude of Parents Toward the Child Health Centre  and the Public Health Nurse The attitude of the parent-participant to the child health conference was evaluated on the basis of the persistence of attendance at the conferences on the assumption that the parent would not participate i f she did not feel that the con-ferences were of some value to her* Nineteen parents (59 per cent) displayed a keen inter-est i n the health conferences by attending the Child Health Centre on a regular basis* Six parents (19 per cent) broke one appointment while seven parents (22 pet cent) broke two or more appointments * Failure to attend two or more confer-ences constituted irregular attendance, which tends to disrupt the immunisation schedule and may even necessitate repeating immunizations (Table VI)* TABLE VI ATTENDANCE AT CHILD HEALTH CENTRE Attendance of Parent and c h i l d Number Per cent Irregular Attendance 7 22.0 One Broken Appointment 6 19,0 Keeps Appointments suggested 11 34.0 Requests Appointments and keeps them 8 25.0 Total 32 100.0 38 A favorable attitude toward the conference was also reflected by the way i n which the parent participated i n the conduct of the conference. As noted i n Table VII, there was an increase i n the assumption of responsibility by the parent between the f i r s t and last conference* At" the f i r s t confers ence 19 per cent of the parents assumed responsibility for topics to bo discussed and by the last conference this had increased to 32 per Cent, TABLE VII RESPONSE OF PARENT TO CONFERENCE AS OBSERVED BY PUBLIC HEALTH NURSE Fi r s t Conf. -'Final .Cohf. Description of Response of Parents- No, '"'' '. % No* 1* Passive and Indifferent Inappropriate responses to questions Talks but does not li s t e n Listens but does not discuss or . question 1 3*0 Passive but some attempt at response 1 3.0 interested i n discussion but has d i f f i c u l t y finding words 3 9.0 4 13*0 Enters easily into discussion and responds to interviewer and questions 12 38*0 11 36,0 Took i n i t i a t i v e i n i n i t i a t i n g dis-cussion and good response to interview 9 28,0 6 19*0 Prepared with questions and f u l l y responsible for areas of discussion 6 19.0 10 32,0 Total 32 100.0 31 100.0 39 A five point scale was used to assess the attitude of the parent toward the public health nurse. It was noted that twenty parents came to the f i r s t and twerity-bne to the f i n a l Conference ready with questions requesting information on specific areas of health and child care, These latter parents indicated by this response some awareness of the role of the public health nurse i n parent education on child health, The remaining parents Indicated alertness and interest i n the conference (Tablet V l l l ) , TABLE VIII ATTITUDE OP PARENT TO PUBLIC HEALTH NURSE AS OBSERVED BY PUBLIC HEALTH NURSE Response First; Conference No. % Final Conference No. % indifferent Hostile Alert 11 34.0 • 9 29.0 Questions indicate heed for approval 1 3.0 •'" i 3.0 Questions indicate need for Information 20 63.0 21 68.0 Total 32 '•: 100,0 3i- 100.0 40 It . GAINS IN LEARNING OBTAINED BY PARENT PARTICIPANTS As stated;- previously-, at the- end of'-the first- and last conferences between the parent and nurse, data were collected On knowledge of general health information, know-ledge of developmental -milestone's' and, evidehce. of mother-* infant relationships* Table IK shows the mean and Standard Deviation of scores obtained by the parent-participants following their f i r s t and l a s t conferences, as well as the mean gain i n scores between these two conferences* TABLE XX • • " ••' SUMMARY OP THE MEANS AND STANDARD DEVIATIONS OF SCORES OBTAINED BY PARENT^PARTIGlPANTS ON THREE AREAS OF LEARNING , , ^  , . . . . . _ Mean Area of Learning F i r s t Conference Last Conference Gain General Knowledge M* 60.03 M. 73*90 13.56 S *D * 4*79 S.D* 11.39 Developmental Mile- M. 4*25 M. 10.40 6*13 stones S.D* 3.72 S*D* 5.25 Mother-Infant M. 54.20 M. 76.72 22,07 Relationships S.D. 17.92 S.D. 13.11 These measurements indicate a wide dispersion i n the scores obtained* On the general health knowledge test admin-istered following the f i r s t conference, scores ranged from 35 41 to 35; after the f i n a l conference, the range was between 53 and 92* Scores obtained on knowledge of developmental mile-stones ranged from 0 to 21 aftei? the f i r s t conference and •from ;3- 'to: 2S; fbilcWing the final'conference^ 1 While/evidence' of mother-infant relationships range of 15 to 85 following the f i r s t conference and 55 to 100 following the f i n a l eohferenc%i ; Factors wnieh-may have contributed to this score dispersion are discussed later i n this chapter. ; - ;Because'•the ''major purpose' of this atudy was- to evalu-ate the effectiveness of the health conference as an i n d i v i -dual method of instruction, t-tests on the mean, difference of the f i r s t and f i n a l conference test scores of participants were administered to determine whether any significant gains i n learning had occurred. Oh general knowledge- scores, the t value for mean differences b&ime&n f i r s t and f i n a l confer-ence test scores was 12.80 which i s significant beyond the 0,001 level; oh mean differences on developmental milestones test scores a t value of 6,72 was obtained. This value i s also significant beyond the 0,001 level* The mean difference in scores measuring the existence of mother-infant relation-ships showed a t value of 6.83, again significant beyond the 0.001 level* Table X presents a summary of these calcula-tions* Since a l l of the- above values of " t " are significant beyond the 0.001 level, the hull hypotheses that there are no s t a t i s t i c a l l y significant differences between f i r s t and 42 TABLE X " t " VALUES ON THE MEAN DIFFERENCES OF FIRST AND FINAL CONFERENCE TEST SCORES OF , PARENT-PARTICIPANTS Area of Learning Value of wt«* •Level' of Significance General knowledge 12*80 29 0.001 Developmental Milestones 6.72 29 0.001 Mother-infant Relationships . 6 ,'83 29 0*001 f i n a l conference test scores Onknowledgeof general health and disease prevention i n children, on knowledge of develop-mental milestones, and on the existence of mother-infant relationships, may be rejected and the alternative hypothesis that significant gains i n learning did occur i n a l l three areas i s accepted* A detailed analysis of gains in knowledge of general health information shows that a l l participants increased their knowledge about the subject which was covered i n 'twenty ques-tions'* • Moreoverparents with- the.'greatest gains in their knowledge of general health information also showed the greatest gains i n their knowledge of developmental milestones (Table XI)* : TABLE XI; DISTRIBUTION OF SCORES IN THREE AREAS BY QAINS IN KNOWLEDGE OF HEALTH INFORMATION : Points--' Gained la".' ' Number Knowledge of Health of Information '•Knowled^ fe of-Geh©ra"If^ Moi^ ieri;.;aj»'d -Infant ^ e a i t & A l - n ^ ^ •'.'RSIationshipe -lst,~ .Final' is t ^ . / F ^ i M t l . ^ ;' - ^-'ls^'?'3Final' ".• '•. Conf. Gonf, Av,. C c i f . ' ^ Av. Av; Gain Av. Av, ; Gain Av. Av. Gain 3 - 10 11 6S.3 73.0 6.7 4.1 9.5 ' 5.4' 63 ,0 80. 0 17.0 12 - 17 10 56.2 70.9 ' 1-4*7 3.6 8.3 4.7 44.0 75.0 31.0 18 - 24 11 57.3 77.5 20.3 4.9 13.0 8.1 54;0 74.0 20.0 1$. The gains i n knowledge of developmental milestones were assessed by examining the content of discussions i n the con-ference :• since. direct- questions '.-were - hot-posed' 'to • the' parents*. For example, a parent would state that the child had no teeth even though.* he had reached nine months of age; The nurse would- then supply • the- appropriate- infofinatioh related to developmental knowledge since the parent realized that her baby should have begun teething* The nurse and parent would discuss the' .'fact / that. central :iiiOiso'rs, erupt from approximately six months of age and general Information on teething would naturally follow* Analysis of data On gains i n knowledge of developmental milestones again indicates that a l l parent-participants made some', increase. In .addition* -as Table.-Xll shows, parents.with the highest gains on knowledge Of developmental milestones also had one of the highest average gains on mother-infant relation-ships* Changes i n mother-infant relationships were examined throUgh observations made by the public health nurse of the reaction between child and parent and on '#efbal statements made by the parent about the child* The parents with the highest gains oh mother-infant relationships were also the highest i n the average gain on general health information (Table XIII)* Of th© thirty-twO parent-participants, three; displayed no change between their f i r s t and f i n a l Conference scores i n this area of learning. TABLE XII DISTRIBUTION OF SCORES IB THREE AREAS BIT GAIN IN KNOWLEDGE OF DEVELOP-MENTAL MILESTONES Developmental Knowledge Knowledge of Gen.Health Infor. Points Gained on 1st Final 1st Final Knowledge of Number Conf. Conf. Av. Conf. Conf. Av, Developmental Milestones Av. Av, Gain Av. Av, Gain Mother and Infant Relationships 1st Final Conf. Conf, Av. Av. Av. Gain 1 - 10 6 6.1 8.4 2.3 62.0 77.0 15.0 49.0 65.0 16.0 3.1 7.3 1.2 56.6 71.0 14,4 45.0 65.0 20.0 6 7 - 23 9 4,3 10,3 6.0 62.4 73.5 11.1 64,0 83.0 19.0 7 2.4 15.8 13.4 56.8 72.3 15,5 55.0 75.0 20.0 tn TABLE x l i i DISTRIBUTION OP SCORES I N THREE AREAS BY GAIN I N MOTHER-INFANT RELATIONSHIP Mother and Infant Knowledge of General Relationships Health Information Points Gained on Mother 6 Infant Number 1st Final Conf,. Corif. Av. Av. Gain 1st Final Conf. Goaf. Av* Av. Av. : Gain Developmental Mile-stones Knowledge 1st Final Conf* Confv Air. -AV.." Ave.' Gain 0 - s 15 - 25 30 - 60 8 69,3 71.8 2.5 58.7 70*6 11,9 11 56.0 76.0 20.0 60.0 72.0 12,0 10 40.5 81*5 41,0 60.6 75.9 15.1 3,5 11.5 8,0 4.5 11.0 6.5 5.0 10.0 5.0 47 To ascertain whether different rates of growth occurred among the parent-participants, the population was grouped on the basis of age, education, number of children, period of attendance at the Health Centre and number of v i s i t s to the Centre. While none of these groupings produced significant differences when the t test was applied, they do show some interesting trends which w i l l b# brie f l y discussed. Table XIV presents a summary of the mean gains obtained by parent-participants who were'-under and over 25 years of age. As may be seen, i n a l l throe areas of learning the younger mothers had higher rates of gain. TABLE XIV MEAH GAINS;IN THREE AREAS OF LEARNING BY PARENT* PARTICIPANTS UNDER AND OVER 25 Age Category No. Gen.Knowledge Dev.Milestones Mother-Infant Relationships Mean Gain Mean' Gain Mean Gain Under 25 17 * l 7.242 23.82^ OVer 25 15 12.00 4.87 19.58 —... —....—•,•,„••„.; — _ * — ; „ „ . „ . . , . • . , • — _ — - . •. ~ — , — . . . ^ . . r , , . , — j , . . . , , , t ¥ 1.68 m t « 1.40 NS t * 0.70 NS 43 Since the study population for the most part had similar educational backgrounds, i t was not expected that significant differences In their rates of gain would be observable,' Yet, Table XV shCws that parent-participaiits with less education had higher mean gains on their knowledge of developmental milestones and the existence of mother-infant relationships than those reporting high school graduation or some university experience, TABLE XV MEAN GAINS IN THREE AREAS OF LEARNING BY PARENT-PARTICIPANTS WITH HIGH SCHOOL OR LESS THAN JgtGH SCHOOL LEVELS OP EDUCATION .. . - • ' . . i n . , ..... .... ... . . . , i. . i . i . Education Category NO, Gen•Knowledge Mean Gain Dev * Miiestones Mean Gain Mother-Inf* ant Rel. Mean Gain less than high school 8 12,OO1 7.132 24.383 high school graduation 24 14.46 5,79 21.19 * t » ,933 NS 2 t » .553 NS 3 t ¥ .515 NS 49 Previous experience i n raising a child should influence a parent's knowledge of developmental milestones. However., a grouping of the parent-participants by their number of children shows that following the f i r s t conference parents of more than One child had ah average score of only 0,5 above that of par-ents of only one child, and while their mean gain between con-ference intervals was somewhat higher, the difference was not significant (Table XVI), Alternately, mothers of only one child had higher average scores on general knowledge and mother-infant relationships f©llbwing the f i r s t conference and also made higher mean gains, but again the differences were not significant, TABLE XVI DISTRIBUTION OF SCORES BY PARENT-PARTICIPANTS GROUPED m- THE BASIS OF NO, OF CHILDREN Gen.Knowledge Dev.Knowledge Mother-Infant Re1. M « * H * a » . e M« Is*- Final 1st Final 1st Final Eiotners wo, G e ^ f , e G ^ f . j ^ . eonf.GOnfi Av. Conf * «Ohf s Av. Av. Av, Gain Av. Av* Gain Av. Av, Gain child 17 63,«2 27.4 14*!1 4.1 9.5 5*62 55*0 78*5 22.S3 More than one child 15 56*4 70.0 12*9 4*6 11.4 6.7 53*3 75.0 21.7 i t « ,634 N S . '• f t = .701 NS 3 t » .667 NS 50 It was expected that the paxent-participant's period of attendance at the health Conference might produce s i g n i f i -cant differences i n the mean score gains on knowledge of developmental mileistohesi sincO their infants would have passed through:'mo^fe "Stages* ' ft: grouping'.Of parents, by 'those who were in attendance from 2 - 4 months and those from 5 - 9 months shows a marked similarity i i i mean score gains on general know-ledge, of health information and knowledge of developmental milestones, but parents who attended for a shorter period of time. displayed, e l ^ ^ evidence' of an increase i n mother-infant relationships than did those whose period of attendance at the conference covered a longer time span (Table x v i l ) . '. TABLE XVII MEAN GAINS IN THREE AREAS OF LEARNING BY PARENT-FARTIGIFANTS WHO ATTENDED HEALTH CONFERENCES FOR BETWEEN 2 - 4 AND 5 - 9 MONTH INTERVALS Interval Gen.Knowledge Dev.Milestones Mother-Infant Rel. Category No. Mean Gain Mean Gain Mean Gain 2 - 4 mos. 16 4.62 26 . 5 3 5 - 9 1 O 0 . 16 13.1 6.3 18.8 A t * .147 NS 2 t « .256 NS 3 t =1.91 p > .10 51 The parents who had the longest Interval between their f i r s t and last v i s i t s to the Health Centre also made the greatest number of Visits*• However, as Table XVIII shows, an increase i n the number of v i s i t s produced only slight d i f f e r -ences between parent-participants. '. •'' '• TABLE 3CVIII MEAN GAINS IN THREE AREAS OF LEARNING BY PAREtJT-FARTICIFANTS ViK® VISITED ^ 4 AND MORE THAN 4 TIMES Interval Gen.Knowledge Dev.Milestones Mother-Infant Rel. Category No. Mean Gain Mean Gain Mean Gain Up to 4 16 14.62* 5.002 25.663 more. •'• |jj ••': • 13.12 • "! 7.25 ••' 18.33 * t =» 1,50 NS 2 t 1,27 NS 3 t a 1.20 NS III, THE NURSE OBSERVER ...The public health'nurse acted as a participant observer in the conduct of the conferences. As a participant the nurse f u l f i l l e d the role of an adult educator i n conducting the con-ference and i n supplying the information required by the mothers. As an observer* the nurse was responsible for making the.'.'3'Uagemeh.ts- about the parent required ;to. .provide.' the:-data for the study. A supervising nurse observed the conduct of certain health Gonferehcea arid appraised the communication s k i l l s of the n«rs^ as well as the quality of the interaction 'between- the. .nurse' and' the ^ participant. „ . ... Responsiveness to Mother-A l l of the public health nurses were responsive to mother and baby In each conference. In ten of the health conferences the public health nurse emphasized both the heeds of the baby and the needs of the mother.. In twenty-two health conferences the public health nurses 8 emphasis was on both the needs of the mother and U t i l i z i n g the mother's .V' strengths to find answers to her questions'(Table XIX). Communication .Skills • -The public health nurses were judged as able to com-municate effectively with the mothers i n eleven of the health conferences observed, Iii nineteen conferences the nurses .usually expressed, their ideas clearly and- were, reasonably' con-vincing 0 In two conferences two different nurses expressed themselves• ad#fuat#iy''but. 'n^'f^t^fully^tTatol* XX)^ • TABLE XIX RESPONSIVENESS OF P0BLIG HEALTH 'NURSE. T0>MOTHER Responses •, Per of PHN-' .' eeht. 0 0 0 Focus On needs of baby - rather than mother and impersonal 0 Focus on needs of baby - rather thaji On mother and warm 0 •Fooias bh • heeds--. Of bahy^ahd; later; i n interview on mother and impersonal 0 Focus on needs of baby and later i n interview on mother and not impersonal 10 31.0 Focus on mother and her heeds and u t i l i z e s '-mother's• ©tfer^ths 14 44.0 Focus on mother and her needs and uti l i z e s tether?© strengths' and assists-her i n finding answers 8 25.0 Total '-;:'''rT. 32 100.0 ,.!»«»«;j^ ay.iti- m,,;*.'.-,- ^.,1....,r,,.,,r,y,^,;;i.i„.^^_^.,..»,..,, ^^nn^^mm,,)^^^).-^^ •• 5 4 • • • • -TABLE.1 .XX • [mmmsinhTiQ® S K I L L S USED• WITB;;MOTHER--BY--;ROTLXC-: HEALTH NURSE . .. .. . . NO., Per Cent g'oox'ih Comma^ ''-^  0 Of ten patia.es , for; /Words,.' Unconvincing 0 Often pauses for words or has to repeat to c l a r i f y 0 Can express s e l f but often pauses for words 0 Can express >self ^ adequately: but hot forcefully 2 6«0 Usually expresses ideas clearly but hot forcefully 0 Usually expresses ideas clearly. "Reasonably ' •• •eo^vxhoihf'-'-i:-': •'• :V: 19 60.0 $^^8'.clearly,reasonably ^CohvinCing'-- 0 Sp^afes-'bleariy'' * -makes- ;me'ahing oIear ;by' pjrecis©.-' ." Use' of words- 11 34,0 Total 32 100.0 CHAPTER IV SUMMARY AND CONCLUSIONS The purpose of this study was to examine the child health conference i n an effort to evaluate i t s effectiveness as an individual method of adult education. An assessment was made of the relationship established between the public health nurse as the adult educator and the parent participant as a learner, and gains made by the parent participants i n their knowledge of general health information and developmen-t a l milestones and i n their mother-infant relationships were evaluated through tests administered following th© f i r s t and f i n a l conferences. The study population consisted of 32 parents who attended the Marpole Child Health Centre for the f i r s t time during the six month period from November 20, 1967 to May 19, 1968, Th© mothers ranged i n age from 18-38 with 68,8 per cent between 22 and 29 years of age; a l l had at least some high school education. Seventeen mothers (53.2 per cent) were attending the conference with their f i r s t child, thirteen mothers (40.6 per cent) had one other child and two mothers (6,3 per cent) had two other children. Their infants, Whom they were bringing to the conferences, ranged i n age from two to eleven months with the majority (71.9 per cent) 56 under six months of age. Seventy-eight per cent of the mothers attended the conferences regularly, keeping the appointments scheduled for them. I, EVALUATION OF THE CONFERENCE How effective, then, was the child health conference as an individual method of instruction for these parent-participants? I t was hypothesized that there would be no s t a t i s t i c a l l y significant mean equivalences between f i r s t and f i n a l conference test scores on knowledge of general health and disease prevention in children, on knowledge of develop-mental milestones and on the existence of mother-infant rela-tionships. These hypotheses were rejected with Values of t which were significant beyond the 0,001 level and the alternative hypotheses that significant gains i n learning did occur in a l l three areas was accepted. Since this study was primarily an exploratory One, i t i s i n order to examine the conference i t s e l f to determine why i t may or may not have been effective as an individual method. The conference's primary orientation i s toward counseling a mother and equipping her with knowledge or information and s k i l l s to assist her In caring for her infant. Because the nurse i s i n an assured position to give direct personal supervision to the parent participant, to act as a confidant and to function as a reality check On the facts and opinions 57 that a mother wishes to share with her, the conference has excellent potential to be an effective instructional method. In examining this particular health conference, i t would appear that a number of major factors presently limit i t s efficiency i n providing ''optimal' Conditions under which learningmay occur. F i r s t , an assessment of the educational needsv''or expectations' of"each 'parent ; i s : not undertaken-at the beginning of 'each''conference,' Ideally* such an appraisal should be carried out and learning objectives appropriate to each individual parent-participant set up. As the conference ir-presently • strnetured; b^ad'''goals';gtiide ''the'' learning' activity but a closer examination of the gains made by .'parent-' 'participants''on'; general and developmental knowledge and mother-infant relationships Wonld 'appear to indicate that such ;a-;'p"reeMure:'' actually • limits'' the :'potential deveiopmeht'' of the participants, and their gains are probably hot as great as they could be, ' ,; 1 By "specifyi'ag e'dueati.ohai 6b|(3'Ctiyes"'in terms of be-haviours, a more meaningful and powerful means of analysing the instructional process would be available* The public health ; nurse*; would'' thus be'' forced to examine! her own ihten- ' tions and make her teaching a .'professional decision-making function rather than an addendum to the screening process as i a ''presently 'the''' Case* : 'Moreover, •'through • the^ active'' involve-ment of the parent participant i n setting her own objectives 58 for the conferences, she would be more li k e l y to internalize the behaviours basic to positive health attitudes than i f she were merely a passive recipient of information* Finally, the extent and duration of participation by the parent i n the learning process i s logically related to the efficiency of the conference i n bringing about behavioural change. In this respect the conference may not always reach Its objectives because appointments made by the nurse for the parent participant to return for further discussions may be broken. While the public health nurse has ho control over attendance i t i s possible, however, that increased involvement Of the- pareht-participant could at least partially - eliminate this problem, II, EVALUATION OF THE INSTRUMENTS USED The test of the mother's knowledge of general health information consisted of 20 words or phrases chosen on the basis of the frequency with which they had been previously used in discussions with parents i n the child health centre. While some incidental learning Obviously occurs as a result of discussions with neighbours, friends and relatives or from mass media presentations, at least 14 of the 20 words and phrases used in this test could probably be learned only through a child health centre Conference, A mother who has an interest In, or access to, s c i e n t i f i c literature might 59 locate this information but previous experiences at the child health centre have not shown this to be the case. To evaluate the mother's knowledge of the 20 words and phrases before the conference and her gain i n knowledge follow-ing the f i n a l conference a seven point rating scale was used. Because the score a mother obtained was entirely, dependent upon just one nurse's perception, i t may not have been a totally accurate assessment of her actual knowledge. In addition, a number of common rating errors may have occurred. The f i r s t of these i s the "error of central ten-dency." The investigator who later assigned ratings to each mother may have tended to group the ratings close to the centre of the scale because she hesitated to give either an extremely high or extremely low rating on the basis of the information collected by the public health nurse. The second error which may have occurred i s known as the "error of halo," The nurse's perception of the mother's knowledge may have been influenced by the favourable or un-favourable impression the mother presented to her. Obviously this error i s almost impossible to overcome i n an evaluation tool used by a single rater, as even When the error can be identified i t s reappearance cannot be accurately predicted. The, mother's knowledge ©f developmental milestones, which were based on the finding© of Geselj, & llg,,,, was assessed from the discussions during the conference without direct questions being posed to the parent. One point was 60 given for the mother's awareness of each of twenty-five milestones. Since a child's development i s a seemingly popu-la r topic of conversation for the mother with her friends and neighbours, she could have gained a substantial amount of information on developmental milestones outside of the health Conference. I t should be stated, however, that parents do verify the information they have obtained from these inciden-t a l discussions with the public health nurse. Moreover, because the child's development i s of prime importance to the public health nurse, developmental milestones are discussed In depth at most conferences although the width of discussion with each mother varies according to the progress of her child. This latter fact undoubtedly accounted for the range of scores obtained by mothers i n this study. Evidence of mother-infant relationships was gathered by the public health nurse from observing the mother and i n -fant i n the conference, by listening to what the mother said in describing the infant and by the feeling she expressed about the infant. The nurse assigned points to each mother on the basis of her awafehess of the infant's needs, mother-child compatability, her degree of respect for the infant's indepen-dence, her degree of acceptance of the infant and the kind and amount of contact offered. It was assumed that this instru-ment would measure behaviour resulting from increased know-ledge of general health information and developmental voile-stones. After using this instrument with the 32 mothers, 61 however, for several Reasons i t was f e l t that a rating form offered l i t t l e helgi i n evaluating the kinds of observable, measurable behaviour that should have been demonstrated because of the mother's -'increased knowledge * This instrument was similar 'to'the' .one used to assess the''mother's general 'knowledge-in! that i t 1 may have: • tof le'etad errors of both "central tendency0 and "halo effect.* 1 In addition because the piiblic heal her own mental standard on which to fudge the mother-child relation^ •ship," i t i s feasible 'that thero'were as "-many'different 'Stan-dards as there were nurses assigning the ratings. Moreover the nurses may have given similar ratings to items which do hot necessarily go together. FOr ©karapl©* a mother who was rated as highly compatible with her child may also have bean rated as highly accepting Of h©r ©hiId when, i n actual fact, a mother who appears congenial may not fas at a l l accepting of her'child. A description of the physical care given the infant was assessed on a seven point Scale by the public health nurse immediately following the bbhforencO. This seal© showed some ©Videne© of a rater halo effect, which could ' probably h© 'easily - ©vorcbia® through th©; provision'bf mbr© • precise descriptions of the car© of the infant. Three measures were used to assess the attitude Of the parent toward the child health centre conferences and 62 toward the nurse observer conducting these conferences* Since seventy-five per cent of the infants did not receive immunization on each visit,, the mother's persistence of attendance was assumed to reflect a favorable attitude toward the child health centre and the conferences. Perhaps a more accurate indicator could have been used since extraneous c i r -cumstances such as an illness in the family could have pre-vented the mother from keeping her appointments* The response of the parent to the conference was assessed on a nine point scale which rated the degree to which the mother participated i n discussions with the nurse observer. Again, the "error of halo" may have affected the ratings given to each mother. It may a l i o have affected the ratings assigned to the mother's attitude toward the nurse observer, which was based on a five point scale. Since Crucial aspects of the health conference are the nurse's responsiveness to the parent and her s k i l l in com-munications, instruments using nine point scales were con-structed to evaluate nurse observer performance i n these two areas* The common errors of rating previously discussed may also have affected the scoring on these instruments. In addition, i t i s f e l t that the investigator did hot examine the nurse observer i n enough areas. While i t i s f e l t that a l l of the instruments which have been described met the requirements for which they were con-63 structed to some degree, they could undoubtedly be much more effective measuring devices i f steps were taken to increase their r e l i a b i l i t y , v a l i d i t y , objectivity, comprehensiveness and differentiation. Moreover, rating scale errors could have been minimized had nurses been trained i n their proper use, Despite the limitations imposed by this present study, there appears to be great potential for health education that could be u t i l i z e d more f u l l y through the child health confer-ence as an individual method of instruction. While this study did show a growth i n parent-participants as a result of their involvement i n the conferences, i t appears doubtful that the gains made under the present structure of the Con-ference, were as great as they could have been had the objec-tives been centered around the participants rather than the nurse. Assuming that the suggestions put forth earlier in this chapter are incorporated into the instructional compon-ent of the health conference and a more rigorous evaluation i s conducted one might expect a f u l l e r realization of the conference's potential. BIBLIOGRAPHY Arbuckle, Dugald. Counseling, Philosophy, Theory and Practice. Bostons Allyn and Bacon Inc., 1965, p. 4T5. Be l l , Larry I* and Beverly Ayres. Area Development Project-Research Monograph* Vancouver! Onited Community Services,"*1968','' p. 58. Brim, Orville G. J r . Education for Child Rearing. New York; The Free Press, 1965, p. J^Si Brim, OrVille G. J r . "The Acceptance of New Behavior i n Child-Rearing," Human Relations, Vol. 7, November, 1954, pp. 473-49T7 Brunner, Edmund de S. and Associates. An Overview of Adult Education Research * Chicago? Adull Education Associ-ation of U.S.A., 1959, p. 279. Committee on Child Health of the American Public Health Association. Health Supervision of Young Children. New York: The American Public HeaTth Association, Inc., 1955, p. 179. Cooper, Marcia Mann. "Evaluation of Mother's Advisory Service. Monographs of the Society for Research i n Child  Development, vol, X2, 1947, pp. 11-42. Dominion Bureau of Statistics. Population by Year and Housing  Characteristics Bulletin, C.T.22, I96T, Census of Canada. Dunn, Olive Jean, Basic Statisticss A Primer for Biomedical  Sciences. New YOrk": John Wiley & Sons, 1964, p. 184, Evaluating in Air Force Instruction. Academic Instructor Course, vol. II, Alabama: Air University, Air Command Staff School, Maxwell Air Force Base, June, 1952. Fenlason, Anne. Essentials of Interviewing, New York: Harper and Brothers, l9~52, p 7~352. Fonseca, Hanna R. and Gerald Caplan* Consultation Literature  Review. Bostons Harvard University, 1963, p. 52 (mimeo.). 65 Gagne, Robert M. The Conditions of Learning. N©w York: Holt Rinehart & Winston Inc., 1965, p. 308. Garrett, Annette. Interviewing,.Its Principles ahd Methods, New York: Family Service AssocTation of America, 11942* p. 123. ..--•,,."' . ., , Gesell, Arnold and Frances L. I l g . Child Development5 An • Introduction to th© Study • of Human •*lrj&wth:l;1' New York,: Harper and Brotbers, 1949, p.* 475. Gotham, William A. .'Methods forMeasuring Staff Nurse Per-formance," Nursing RgsearehV :vbl. 12', no. 1 ;|wint©r '•' 1963), pp. 4-11-, , Hamiitohj Gordon. #h©bry.artd practice:'of SQCial^:Wiirk* - -N.@w ; • York-: Columbia University Press,' 1951, !p*-"' 328*-Hi11,. Bradford... • Principles of., Medical. Statistics. London;: -The Lancet, I9~53 , p. 28"9. ' "• "~~r~: ' • ' -';''."'' .". \,\:i'' Hollingshead, August B. Two Factor Index of Social Position. • New Haven, •.p* 11 (Mimeo.). : > : •''-:'. Infant' and J^reschoOi. Child,'' Vancouvers'''Metropolitan' H©aitn - Seirvic©/ of'.^rOater Vancouver.,. .196.2 *.. p-.*:, 87 Jinks, Lydia Henson; A Content;- AhaiySla - Of'Selected'..-Books, Related to Prlnciples'"of Counseling. 'University of Oklahoma, 1966, • , • , . , ' . ' . n,.-. Klatskln, Ethelyn Henry. "Shifts i n Child Care Ptacticos in Three Social Classes under an Infant Care Program of '" Flexible' Methodology," ' American Journal" of ; Oriihopsy-- Chiatry, vol. 22 (January, 1952) , pp. 5 * Kogan, Leonard, J . Hunt, P. Bartelem.A Follow-Up 'Study.'.'of Results of Social Casework> New York: Family"Service Association of America, 1953, p. 115. Leonard, Edith, Dorothy Vandeman, L i l l i a n Miles. Counseling  with Fareats i n gariy Chi|dh©od Education. 'New'Yorkt MacMillan Co.," 1$5" Aw,.'.p•" 330 K 66 Maddux, James, "Consultation i n Public Health," American  Journal of Public Health, vol. 45 (November, 1955)'* Medical Health Officer's Annual Report. City of Vancouver, 1912, 1913, 1917, l9i£, iSIX! Richardson, Stephen and S. Dohrenwend and D, Klein. Interview- ing Its Forms and Functions. New YOrks Basic Books Inc., 1965, p. 380, Rogers, Everett M. Diffusion of Innovations. New Yorks The Free Press, 1962, p. 367. Tate, Barbara L. "Evaluation of C l i n i c a l Performance of the Staff Nurse." Nursing Research, vol. II, no. 1 (Winter, 1962), pp. 7-9. The School of Nursing. U.B.C, Calendar. Vancouver? U.B.C. Press, 1965, E, p. 28* T^hurst, J.S. Interviewing. Victoria: Department of Health Services and Hospital Insurance, 1960, p. 30. Verner, Coolie. Adult Education Theory and Method, A Concep-tual Scheme. Washington: Adult Education Association of the U.S.A., 1962, p. 34. Verner, .Coolie, Allan Booth. Adult Education* New York? The Center for Applied Research i n Education Inc.* 1964* p. 118, Webb, Jean. "The Specialist Consultant in a Public Health Agency," Canadian Journal of Public Health, vol. 59, t (April, 1968), pp. 155-15*8*: Williamson, E.G. Counseling Adolescents. New York: McGraw-H i l l Book CO*, 1950, p* 548* pp. 1424"-T43"0~: 67 APPENDIX A ATTENDANCE RECORD FORM Name: Address: Children's Name Dates of •Ci-Hj»-Cj» Attended Age ^ srheh started Reason for each V i s i t to C.H.C. APPENDIX B 68 KNOWLEDGE OF GENERAL HEALTH INFORMATION Scale No* 1 Name Occupation Education pjrevious' Occiapatibn. i f housewife HUsband's Occupation ...  Please c i r c l e meaning mothers of the following words as indicated by Communicable disease -Immunization Reirvf brei'il'g > Immunization Smallpox Pertussis Diphtheria Tetanus Poliomyelitis Primary teeth Permanent teeth transmitted; diseases cdhtagious, catching, infectious, children's disease, named the communicable diseases protection by use of antigen against certain disease protection from disease by helping to build own defenses booster, increase strength or force of protection, stimulates body to produce more protection serious communicable disease, infectious. Can be prevented by Vaccination wheoplhfcoughInfections ''Cough* • • Can :be.'''pre^ nted'!by .liDaiaunisation^1'''- . false membrane i n throat, acute infec-tious disease, can be prevented by immunization' lockjaw, infectious s o i l borne organism, prevented by immunization infantile paralysis, infectious, oral vaccine used. 20 f i r s t teeth* erupt from 6 months and complete by 2 years 32 second set of teeth, f i r s t permanent molars around 6 yeara 69 Child Health Centre Nutrient Behavior Emotional;Security Self-reliance Toilet training Canada Food Guide yitaiftin D Vitamin C Responsibility - Centre which is; government or city operated for health supervision of children - nourishing, needed by body for growth and'tissue- repair-- how child acts, what child does - -,-safe-'wit&vmother< - --mature.,and ijelf-. .reliance f©r age.. - content t© play with toys, is. able to ;plaf::'happ|ly> wants to dress'- himself and do for himself f learns to ask to go to t o i l e t instead •' of •eoiliiig -pants.; - prepared by o f f i c i a l nutrition group to . assist one In. choosing adequate diet for family,. -Official, guide ,;t© what: we should ;:eat ? to be, healthy' - 400 International Units daily* In Cod LlVeir O i l , added to Ik hy dairy - In '©.r^ jiiiie •>juice -.. in-/tomato • juice -and vitaMnize>3 apple juice? 30 mgifts. daily requirement - able 1 to do- as mother • asks.,-.- ©r as\. required of.;, him-: "and Can,' be. depended upon to carry ••'•', 'through ' requests. • '•'"'•"'"'" (Score ©f 5 assigned to each questions of 100) 70 KNOWLEDGE OF DEVELOPMENTAL MILESTONES Scale No. 2 Score, Check i f mother displayed knowledge of the following i Teething : Central incisors erupt 6*8 months ) Lateral incisors erupt 8-12 months ) About 8 teeth - 1 year ) 5 20 primary teeth - 2-2-1/2 years ) F i r s t permanent molars - 6 years ) Motor Skillsy Holds head up without support by 3 months ) Grasps and releases objects by 1 year ) Sits alone without support by 8 months ) creeps, stands, walks by 1 year ) 8 Toddling, throws objects, scribbles, 15 months ) Walks backward, runs, climbs onto chair 18 months ) Climbs stairs, 2 years ) USes each hand independently, 2 years ) Visions \ Follows moving object with eye, 6 weeks ^ 2 Ocular balance, 8 months ) Hearings Turns head to sound by 3 months ) 2 Recognizes human voices by 4 months ) Speechj Babbles, smiles, coos by 4 months ) Repetition of syllables around 6 months* ma-ma,da-da ) 4 Says single words, 1 year ) Says 2 or 3 words together, 2 years ) Weane Thy 9 months Attempts to feed s e l f , uses cup and spoon, 1 year Eliminations Bowel control, 2 years Bladder control, 2-44/2 years 25 71 KNOWLEDGE OF MOTHER-INFANT REiLATlONS Scale No, 3 Please note evidence of Mother-Infant Relationships - Use descriptive phrase for i l l u s t r a t i o n Score 1) Awareness of baby's needs shown bys Changing expressions on the face of the mother ir, .mi a 5 Body movements i n response to stirrings of baby ... .. b 5 Way .she answers any indications' of discomfort .' c 5 Withdrawal from baby . .. , d -5 2) Mother-child compatibility(congenial,harmonious) 5 3) Degree of respect for baby's independence, s e l f -determination, autonomy Degree of a b i l i t y to accept child as a developing and differentiating organism a 5 -way she holds infant .'.'r' ^ •' D 5 -way- she: talks about Infant c 5 -way she permits infant to choose when choice """"" i s possible .  ^ d 10 4) Degree of acceptance of the infants -way she holds infant ; • . a 5 •*her voice and expression. i V . . " ' , . •,. b S -way she talks about i n f a n t ' . r. c 5 -inattention to needs .of baby \ M i d' -5 -isolation of baby - .. . ; ....... . . e -5 ' 5) Kind and amount of contact offereds -new lavements in i t i a t e d by baby are supported 'and encouraged by 'mother i ', • ... ' a 10 -acquisition of new sk i l l s ' Is part" of~Eis play "• •with his_mother . . .••-••,.. . .n... .b 5 ' -empathetiC response to his emotional needs .; \T. © 10 -balance between adequate Stimulation and '" potentially overwhelming new experiences ..,..„ & 5 -giving and withdrawing support as needed , e 10 100 72 PHYSICAL CARE GIVEN Scale No. 4 P.H.N, please check appropriate description Score Bruised and injured -60 2. Malnourished appearance and diet poor -15 3, Unclean and unkept - neglected appearance -15 4, Inadequately Clothed for age and activity -10 5. Appropriately clothed for age and activity •20 6. Well'nourished - diet adeguat© - +20 7. Well eared for.and appears content +60 100 ATTITUDE OP PARENT TO CHILD HEALTH CENTRE Scale No- 5 Circle indication of Attitude to Child . Health.- Centre; 1) Irregular attendance 2) 2 broken appointments 3) 1 broken appointment 4) Keeps appointments suggested to her 5) Requests appointments and keeps them \ 74 RESPONSE OF PARENT TO CONFERENCE Scale No* 6 Score 1. Passive and indifferent s -5 2. Inappropriate responses to questions -5 3. Talks but does not listen . 25 4. Listens but does not discuss or question 35 5. Passive but Some attempt at response 40 6. Interested in discussion but has d i f f i c u l t y i£ndi>nq 'WQ%&&\ 50 7. Enters easily into discussion and responds to interviewer and questions 60 3. Took Initiative i n i n i t i a t i n g discussion and good response to interview 70 9,. 'prepared with, questions 'and'.fully responsible for'areas of discussion 85 Scale No. 7 75 ATTITUDE OP PARENT TO NURSE Circle Indication of Attitude to Public Health Nurse; Score 1} indifferent to interviewer -10 2) Hostile to interviewer -10 3) interest indicated by alertness 10 4} Asks questions indicating need for approval 30 5) Asks questions indicating need for Information 60 100 76 NORSE APPRAISAL Scale:: No. 8 Name of Public Health Nurse • • : • • ' '• Name of Mother ', ......... ..... . a) Teaching,should be acceptable and non-threatening to parents b) Discussion should a r i i e from mutual recognition of some aspect of baby's general development c) fie meaningful to parents. ,i^$poi|s:ivenosa' to mother rs needs Score 1. Uses CHC record aS a focus rather than mother or baby 10 2. Tends to be didactic teacher to student and impersonal 20 3. Tends to bo didactic - teacher to student and warm 40 4. Focus on needs of baby rather than on mother and impersonal 50 5. Focus en needs of baby rather than on mother and warm 60 6. Focus on needs of baby and later i n interview, on mother and impersonal 65 7. Focus oh heeds of baby and later i n interview, On mother and warm 75 8. Focus on mother and her needs and u t i l i z e s the mother's strengths '•'• >••':•' •••>; • 85 9. Focus on mother and her needs and ut i l i z e s strengths of mother and assists her In finding answers. (An al l y rather than authority figure.) 90 Communication s k i l l s - with mother explanation of terms and Concepts 1. Poor i n command of words, enunciation, grammar, un convincing 20 2... Often pauses for words, unconvincing 30 3. ' Often pauses for words or has to repeat to c l a r i f y , often has tb rephrase remarks 40 4. Can express herself, often pauses for words 50 5. Can express herself adequately but not forcefully'. 60 6. Usually expresses ideas clearly but hot forcefully 65 7. Usually expresses ideas clearly. Is reasonably convincing 75 8. Speaks clearly, reasonably convincing 80 9. Speaks clearly, makes meaning clear by precise use of words and apt illustrations 90 77 Literature Score 1, Given tp reinforce teaching 10 2. GiveV/ilio^^a©naliy^ 5 3* What iiterature given 

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