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Postnatal guidance and maternal confidence Pullen, Phyllis Margaret 1983

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POSTNATAL GUIDANCE AND MATERNAL CONFIDENCE by PHYLLIS MARGARET PULLEN B.Sc.N., The University of Washington, 1972 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES School of Nursing We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1983 © P h y l l i s Margaret Pullen, 1983 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of MS / A / C~ The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date a'P/Zi'c. f 9 S ^ 3 DE-6 (3/81) ABSTRACT POSTNATAL GUIDANCE AND MATERNAL CONFIDENCE Primigravida mothers need p o s i t i v e feedback and successes i n infant care giving i f they are to learn and to continue learning about caring for the i r i n f a n t s . Maternal confidence increases as the mothers succeed and master the s k i l l s required. Confidence i s re l a t e d to good maternal-infant r e l a t i o n s h i p s . Public health nurses have opportunities to provide support and p o s i t i v e learning experiences which should increase maternal confidence. This quasi-experimental study was undertaken to evaluate the e f f e c t of an interview technique used at c h i l d health conferences, oni primigravida mothers' confidence as parents and infant care givers. The interview was constructed to focus on the mothers' successes i n infant care giving, rather than problems. A non-time equivalent pretest-posttest questionnaire or confidence measure was used to gather the data. The subjects were 34 primparous women with healthy babies from i n t a c t family s i t u a t i o n s . Sixteen mothers, r e c r u i t e d at c h i l d health conferences i n one health unit area, f i n i s h e d the study i n the control group. Eighteen mothers f i n i s h e d the study i n the experimental group. Five instructed public health nurses interviewed the experimental group subjects. Control group subjects had the regular c h i l d health conference interview. A l l subjects f i l l e d i n the questionnaire p r i o r to t h e i r f i r s t c h i l d health, conference when the i n f a n t was two months old and again a f t e r the second c h i l d health;conference when t h e i r infant was four months o l d . S t a t i s t i c a l analysis comparing the pretest and posttest scores for both groups indicated no s i g n i f i c a n t d i f f e r e n c e between the two groups on the pretest or the posttest scores. Maternal confidence, i n both groups, as indicated by the confidence measure, did increase s i g n i f i c a n t l y over the two month period from two months postpartum to four months postpartum. This was not r e l a t e d to a s p e c i f i c nursing interview technique. Implications for nursing p r a c t i c e are discussed and recommendations made for further research. i v TABLE OF CONTENTS Page LIST OF TABLES v i i ACKNOWLEDGEMENTS v i i i CHAPTER I. INTRODUCTION 1 The Problem 2 Statement of the Purpose 3 D e f i n i t i o n of Terms 3 Assumptions of the Study 4 Limitations of the Study 4 Hypothesis Tested i n the Study 5 Overview of the Remainder of the Study 5 I I . LITERATURE REVIEW - 7 Introduction 7 Cogni t i v e - F i e l d Learning Theory 7 The Need f or P e r i n a t a l Education 10 Prenatal Maternal Education 13 Early Postnatal Maternal Education 16 Later Postnatal Maternal Education 19 The Maternal-Infant Relationship and Confidence 22 Summary 25 V CHAPTER Page I I I . DESIGN AND METHODOLOGY 26 Overview 26 The Independent Variable 26 The Dependent Variable 27 The Measurement Instrument 28 The Setting 29 Human Rights and Ethic s 29 The Study Sample 30 Recruitment of the Control Group 30 Recruitment of the Experimental Group 31 Sele c t i o n and Ins t r u c t i o n of Nurse Interviewers 31 Procedure for C o l l e c t i o n of Control Group Data 32 Procedure for C o l l e c t i o n of Experimental Group Data . . . 33 Analysis of the Data 33 Summary 34 IV. ANALYSIS OF THE DATA 35 Description of the Sample 35 Analysis Related to the Hypothesis 36 Data on In d i v i d u a l Instrument Responses 41 Ad d i t i o n a l Data 42 Data on Successes and Goals 42 Summary 45 v i CHAPTER Page V. FINDINGS, IMPLICATIONS, RECOMMENDATIONS FOR FURTHER RESEARCH, SUMMARY AND CONCLUSIONS 46 Report of Findings . . . 46 Implications for Nursing P r a c t i c e 49 Recommendations for Further Research 50 Summary 51 Conclusion 53 BIBLIOGRAPHY 54 APPENDIXES A. NURSING INTERVIEW GUIDE 61 B. THE CONFIDENCE MEASURE 63 C. NURSE INSTRUCTIONS, GOAL SHEET 70 D. INFORMED CONSENT, EXPLANATION FOR MOTHERS 74 E. TABLE OF DESCRIPTIVE STATISTICS 77 v i i LIST OF TABLES TABLE page 1. SEX OF INFANTS 35 2. MOTHER'S AGE (IN YEARS) , 36 3. SUBJECT TOTAL SCORES, PRETEST AND POSTTEST GROUP SCORES, MEANS, STANDARD DEVIATION AND RANGE FOR CONTROL GROUP AND EXPERIMENTAL GROUP 37 4. EXPERIMENTAL GROUP AND CONTROL GROUP PRETEST AND POSTTEST MEAN SCORES WITH STANDARD DEVIATIONS AND RESULTS OF t-TESTS 38 5. EXPERIMENTAL GROUP PRETEST AND POSTTEST MEAN SCORES, STANDARD DEVIATIONS, MEAN DIFFERENCE WITH STANDARD DEVIATION AND t VALUE 39 6. CONTROL GROUP PRETEST AND POSTTEST MEAN SCORES, STANDARD DEVIATIONS, DIFFERENCE IN MEAN SCORES WITH STANDARD DEVIATION AND t VALUE 39 7. ANALYSIS OF VARIANCE SUMMARY TABLE OF INTERACTIONS BETWEEN OR WITHIN GROUPS WITH F RATIO 41 8. ANALYSIS OF VARIANCE SUMMARY TABLE FOR SEX OF BABY EFFECT ON THE CONFIDENCE MEASURE WITH F RATIO 41 9. SUCCESSFUL AREAS OF INFANT CARE REPORTED BY EXPERIMENTAL GROUP SUBJECTS BY FREQUENCY AT FIRST INTERVIEW AS RECORDED ON GOAL SHEET 43 10. SELECTED AREAS OF CONCERN FOR WHICH GOALS WERE ESTABLISHED BY EXPERIMENTAL GROUP MOTHERS AT THE FIRST INTERVIEW 44 v i i i ACKNOWLEDGEMENTS I wish to express my thanks to the people who made t h i s study possible: to Helen E l f e r t and Annette Stark for t h e i r p r o f e s s i o n a l guidance, patience and constructive c r i t i c i s m ; to the s t a f f of the Boundary Health Unit, espe-c i a l l y the f i v e nurse interviewers f or th e i r cooperation; to Mark Starr for h i s assistance i n the data analysis; to the mothers who p a r t i c i p a t e d i n the study; and to Susan Painter and Tannis Williams for t h e i r assistance and encouragement. 1 CHAPTER I INTRODUCTION "The public health goal of primary prevention i n c h i l d health might be most e f f e c t i v e l y achieved through a focus upon strengthening and supporting the family's r o l e i n f o s t e r i n g c h i l d development" (Shaefer, 1979:849). F a c i l i t a t i n g learning, competence and confidence i n infant care giving, providing support systems and promoting healthy parent-infant r e l a t i o n s h i p s are areas public health nurses have always been involved with and interested i n . Many parents today f e e l inadequate during the early months of their c h i l d ' s l i f e because many have had l i t t l e experience with inf a n t s . They may have some d i f f i c u l t y r e a l i z i n g that parenting i s learned and does not appear spontaneously with the b i r t h of a c h i l d . P u b l i c health nurses have considerable contact with new parents and th e i r i n f a n t s , therefore, the opportunity i s there for them to a s s i s t parents and infants to develop to t h e i r p o t e n t i a l . Assistance for parents must respect the "uniquely compli-cated, d e l i c a t e and important process that i s parenting" (Wilson, 1978:77). The neonate and h i s parents are raw and ready for learning i n the f i r s t few weeks and months aft e r the b i r t h (Brazelton and A l s , 1978). This need for continued learning by parents i n the postpartum months i s evidenced by requests for and attendance at postpartum classes, parenting groups and c h i l d health conferences. These programs for f a c i l i t a t i n g parent learning are generally based on areas of parental concerns and problems and also provide a n t i c i p a t o r y guidance regarding possible future problem areas. 2 The Problem The maternal-child i n t e r a c t i o n p r e n a t a l l y and i n the immediate post-partum period i s an area of much i n v e s t i g a t i o n and i n t e r e s t . The r e l a t i o n -ship between the infant and the mother or environment i s f e l t to be of an ongoing, i n t e r a c t i o n i s t nature which i s continuous (Richmond and Janis, 1980). The q u a l i t y of the parent-infant r e l a t i o n s h i p can be enhanced by professionals who help parents f e e l good about themselves by recognizing and backing up t h e i r strengths instead of looking for weaknesses (Brazelton, 1978). The experiences with the f i r s t b o r n are often discussed negatively with a focus on problems when there are many p o s i t i v e s (Giovanetti, 1977). Families t h r i v e on p o s i t i v e reinforcement. C o g n i t i v e - f i e l d learning t h e o r i s t s believe " i f one has a c e r t a i n l e v e l of a s p i r a t i o n and i s able to achieve t h i s l e v e l , one f e e l s good about i t . I f one at t a i n s success at one l e v e l of a s p i r a t i o n , one i s l i k e l y to r a i s e the l e v e l and continue doing so as long as one i s able to perform success-f u l l y " (Bigge, 1976:76). A mother who i s su c c e s s f u l l y managing infant care f e e l s good about her s e l f for mastering these s k i l l s . When she f e e l s good about h e r s e l f , she w i l l also f e e l good about her infant and others close to her (Mercer, 19.81)... I f health professionals do something for a c h i l d , they gain the mother's confidence, but i f she can do something f o r the c h i l d , she gains i t h e r s e l f (Williams, 1973). Confidence i n infant care giving has been shown to be c l o s e l y related to p o s i t i v e mother-infant r e l a t i o n -ships (Williams et a l . , 1979). In today's rapid, impersonal society, small nuclear f a m i l i e s often lack p o s i t i v e feedback and support from others, which would help increase maternal confidence and learning. With c h i l d care advice changing, the information they do get may confuse the new mother. Community nursing 3 interventions have provided learning opportunities for the new mothers i n areas of problems or weaknesses, which may or may not improve maternal confidence. This writer believes a more p o s i t i v e approach to providing learning opportunities for mothers might increase maternal confidence and would incur no added costs to present programs. There has been l i t t l e study of nursing interventions which, have reinforced mother's successes i n infant care giving and successes from selected goal s e t t i n g as a method for increasing maternal confidence. Statement of the Purpose The writer developed a method for interviewing and o f f e r i n g postnatal guidance at c h i l d health conferences which focused on primiparous mothers' successes i n infant care giving and successes i n reaching s e l f - s e l e c t e d goals i n areas of maternal concern. The purpose of t h i s study was to evaluate the e f f e c t of t h i s interven-t i o n on the mothers' confidence as a parent and infant care giver. A measure of confidence was developed with questions previously used i n a parent-infant study. This measure was used to compare an experimental group of mothers, who received the intervention, to a co n t r o l group of mothers who did not. D e f i n i t i o n of Terms Primipara. A woman who has had one d e l i v e r y of a v i a b l e i n f a n t . Postnatal Guidance. An i n t e r a c t i v e discussion i n which a mother re l a t e s areas of success i n infant care giving, which are rein f o r c e d p o s i t i v e l y by the nurse. Goals are established for areas of concern with suggestions for a t t a i n i n g them. 4 Mother-Infant Relationship. The extent to which a mother f e e l s her infant occupies an e s s e n t i a l p o s i t i o n i n her l i f e accompanied by p o s i t i v e f e e l i n g s , a need for continued transactions and an acceptance of imposi-tions and o b l i g a t i o n s (Robson and Moss, 1970) (their d e f i n i t i o n of "attachment"). Success. A favourable or s a t i s f a c t o r y course or r e s u l t of something attempted. Confidence. A f e e l i n g of s e l f assurance, s e l f r e l i a n c e and security i n what the mother i s doing. Infant Care Giving. Providing an infant with physical care (bathing, feeding), love and s e c u r i t y (cuddling, warmth, eye contact and s a f e t y ) , and stimulation ( t a l k i n g , changing the environment) (Wuerger, 1976:1283). Assumptions of the Study 1. Maternal-infant r e l a t i o n s h i p s develop over a considerable period of time. 2. Maternal confidence i s important for healthy maternal-infant r e l a -tionships . 3. Parenting s k i l l s are learned. 4. Success, feedback and confidence are instrumental to learning. Limitations of the Study The study was subject to the following l i m i t a t i o n s : 1. The study was l i m i t e d to a small sample of volunteer mothers i n both experimental and control groups from one geographical area. 2. The sample was l i m i t e d to women from i n t a c t - f a m i l y s i t u a t i o n s . 3. The material discussed i n the interview depended on the mothers' 5 r e c a l l and s e l f - r e p o r t i n g and the interviewing nurses' compliance with following the interview guide. 4. Fathers, who play an important r o l e i n in f a n t care giving, were excluded from the study due to time l i m i t s . 5. The control group were f i r s t interviewed from early January to early February as they attended c h i l d health conferences. The experimental group were f i r s t interviewed from l a t e February to early J u l y , therefore, there could have been some seasonal f a c t o r biasing the r e s u l t s . 6. The sample was selected from attenders at c h i l d health conferences and could have been d i f f e r e n t from non-attenders. 7. The mother's age, support systems, c h i l d care experience, and sex of i nfant were not controlled f o r . 8. The mixture of questions used f o r the instrument came from three d i f f e r e n t questionnaires used previously but not together on one question-naire. Hypothesis Tested i n the Study The following hypothesis was tested i n the study: The mothers i n an experimental group who are encouraged to discuss t h e i r successes i n infant care giving w i l l have a s i g n i f i c a n t l y lower posttest t o t a l mean score on a confidence measure than w i l l a control group of mothers who w i l l not be s p e c i f i c a l l y encouraged to discuss successes.* A lower score indicates a higher degree of s e l f confidence. 6 Overview of the Remainder of the Study Chapter II i s a review of the l i t e r a t u r e with a focus on maternal p e r i n a t a l education using c o g n i t i v e - ^ i e l d theory of learning as the con-ceptual framework. The maternal-infant r e l a t i o n s h i p , infant care giving and maternal confidence are discussed b r i e f l y . Chapter I II i s a d e s c r i p t i o n of the design and methodology of the study. Chapter IV i s an analysis of the data obtained i n the study. Chapter V i s a summary of the findings of the study with implications for nursing p r a c t i c e and suggestions for further research, a summary of the study and conclusions. 7 CHAPTER II LITERATURE REVIEW Introduction P e r i n a t a l education has been a subject of much i n t e r e s t and challenge i n the l a s t two decades as health care providers t r i e d to meet the demands and changes of a mobile, questioning society. This l i t e r a t u r e review examines studies and theories which determine the need f o r p e r i n a t a l education as well as studies related to educational programs offered to mothers i n the prenatal period, the early postnatal and l a t e r postnatal periods. C o g n i t i v e - f i e l d theory of learning w i l l be discussed as the conceptual framework for th i s study. According to t h i s learning theory and p r i n c i p l e s of learning, success and confidence are c l o s e l y related to learning. Studies examining the maternal-infant r e l a t i o n s h i p , success i n infant care g i v i n g and maternal confidence w i l l be focused on i n the l a t t e r part of thi s review. Cognitive-Field Learning Theory Cognitive^-field theory of learning i s a "g o a l - i n s i g h t " theory. The psychological model used i n t h i s theory describes a person within a world pertinent to h e r — t h e t o t a l i s termed l i f e space. L i f e space contains, besides the person, the goals she i s seeking, the negative goals she i s t r y i n g to avoid, b a r r i e r s which r e s t r i c t psychological movement toward goals and p o t e n t i a l or actual paths to her goals. Actual paths are the 8 paths she must follow to get what she wants. L i f e space i s the environ-ment as i t a f f e c t s a person's behavior (Bigge and Hunt, 1978; H i l l , 1977; Hergenhahn, 1976). Cognitive theory explains how people gain understanding of themselves and t h e i r environment. F i e l d theory focuses on the idea that psycholog-i c a l a c t i v i t y occurs i n a t o t a l i t y of factors which are interdependent. An i n d i v i d u a l ' s understanding of her f i e l d i s her grasp of in s i g h t i n t o her l i f e space or the cognitive structure of her l i f e space. The cog-n i t i v e structure means the ways she perceives the psychological aspects of her t o t a l world in c l u d i n g h e r s e l f , her b e l i e f s , expectations, facts and concepts. To perceive something means i t i s also valent and includes besides f e e l i n g and sensing, some ideas of what to do about i t . Every-thing i s perceived i n r e l a t i o n to other things and i s affected by a per-son's needs, a b i l i t i e s , purposes, i n s i g h t s , as well as what the person's l i f e space contains at a given time i n r e l a t i o n to her past, present and future. I n t e l l e c t u a l processes and learning are goal directed. Goals may be i n the future or may not occur. Person-environmental r e l a t i o n s h i p s are viewed by constructs which are interdependent. Within t h i s c o g n i t i v e - f i e l d theory, learning i s "a process within which a person develops new in s i g h t s or cognitive structures or changes old ones" (Bigge and Hunt, 1978:405). When a need occurs, a tension e x i s t s i n an in d i v i d u a l ' s l i f e space and she i s motivated. When the need i s f u l f i l l e d , the tension disappears. This may be achieved through reaching a goal or re s t r u c t u r i n g one's l i f e space which i s learning to see things d i f f e r e n t l y . Learning i s a dynamic, purposeful, i n t e r a c t i v e process. Insights may be verbal, preverbal, or non verbal, and they derive from the i n t e r p r e t a t i o n the i n d i v i d u a l makes of what comes to her. Learning or 9 i n s i g h t r e s u l t s i n b u i l d i n g "traces" which are the r e s u l t s of previous l i f e spaces and which contribute to future l i f e spaces (Bigge, 1976; H i l l , 1977). Changes i n cognitive structures of l i f e spaces occur by d i f f e r e n t i a -t i o n , g e n e r a l i z a t i o n and r e s t r u c t u r i z a t i o n . D i f f e r e n t i a t i o n means learning to discern more accurately the s p e c i f i c aspects of oneself and one's environment. Generalization i s a formulation of concepts by categorizing or i d e n t i f y i n g groups of ideas or objects. Restructurization i s defining or redefining d i r e c t i o n s i n one's l i f e space by separating or connecting regions. Bigge and Hunt (1968:416) summarize a c o g n i t i v e - f i e l d theory of l e a r n -ing as learning through d i f f e r e n t i a t i o n , generalizing and r e s t r u c t u r i n g of a person and her psychological environment i n ways through which she can change i n s i g h t s or meanings, or obtain new ones. These i n turn can change motivation, r e l a t i o n s h i p s , ideologies and time perspective. A l l help her gain c o n t r o l of h e r s e l f and her world. Some p r i n c i p l e s of learning which are accepted by c o g n i t i v e - f i e l d learning t h e o r i s t s are: 1. I n t r i n s i c motivation a r i s i n g from tension provides i t s own reward when the task i s mastered. 2. When motivation i s e x t r i n s i c , understanding and retention i s l e s s than when i t i s i n t r i n s i c . 3. F a i r l y regular success i s a must i n learning. 4. Feedback i s e f f e c t i v e i n promoting learning (Bigge, 1976:305-307). Bruner (1966), a cognitive psychologist, suggests i n the absence of a reward, a learner must have a continually a v a i l a b l e knowledge of r e s u l t s and progress. Knowledge of r e s u l t s must provide information of success of of an act or whether i t i s leading toward a goal one wishes to achieve. 10 5. When a person i s ready f o r new learning, i t i s because she sees the new learning as the next l o g i c a l step to take (Bigge, 1976:310). Bruner (1966b: 118-119) claims that one purpose of education., should 1 be development of learner's confidence i n the s o l v a b i l i t y of problems by developing understandings. He thinks, "the one most pervasive thing that prevents man from reaching h i s f u l l p o t e n t i a l i s a lack of confidence not only i n h i s own capacities but also i n the a b i l i t y to develop them further." He f e e l s confidence comes from mastery. Opportunities for new mothers to learn from r e l a t i v e s and the community are greatly reduced today. Large amounts of educational material are a v a i l -able informally i n various media forms, but may be unintegrated and r e s u l t i n uncertainty. The Need for P e r i n a t a l Education_ A mobile society often leaves f a m i l i e s i s o l a t e d from r e l a t i v e s and f r i e n d s . The need for s o c i a l networks to improve a mother's sense of com-petence was demonstrated by Abernethy (1973). Women i n loose networks suffered from i n s u f f i c i e n t feedback, were l i k e l y to be exposed to too many theories of c h i l d - r e a r i n g which diminished confidence i n any one technique and could r e s u l t i n inconsistent maternal behavior and frustrated goals. Lack of p r a c t i c a l assistance for new mothers, emotional support and encouragement appears to be r e l a t e d to continuing emotional d i f f i c u l t y l a s t i n g at l e a s t s i x months. Mothers who learn the s k i l l s of c h i l d care, and obtain p r a c t i c a l and dependable a i d , adjust well i n the postpartum period and for years (Gordon et a l . , 1965). Yet large numbers of young mothers face motherhood with inadequate s k i l l s and s e l f confidence to meet t h e i r infant's needs. Parents look to nurses for support and guidance but 11 more important than these, for feedback which can v e r i f y t h e i r successes i n mothering (Carlson, 1976; Clark, 1966). Walker (1974) f e e l s one problem seen i n maternity services i s a lack of preparation for and confusion about parenthood. The possible explana-t i o n for t h i s i s that mothers r e j e c t t h e i r own upbringing as the way they want to rear t h e i r c h i l d . They f i n d i t d i f f i c u l t to f i n d and follow a new pattern. They need p r o f e s s i o n a l guidance and support i n carrying out t h e i r r o l e , but how a young woman:adjusts to the mothering r o l e depends l a r g e l y on the mothering she received. Residual memory and l i f e experiences color how she w i l l react as a mother (Brazelton, 1966). C o g n i t i v e - f i e l d learning theory explains that she l i v e s i n the present and the past i s past-present, which we c a l l memories. The memories of past events influence present behavior only i f factors i n the present are i d e n t i f i e d as past or are traces i n her l i f e space (Bigge, 1976). Education to increase mothers' knowledge and s k i l l s must be c u l t u r a l l y acceptable to be e f f e c t i v e (Marecki, 1979), and i t i s important that infant care techniques are taught (Swanson, 1978) ,.since:: onceL/the s k i l l s are learned and s u c c e s s f u l l y employed, the mother's self-concept improves and she begins to f i n d pleasure i n her i n f a n t . There i s agreement that infant care i s learned and more preparation and education are needed for c h i l d rearing i n today's society (Crohenwett, 1976; Hrobsky, 1977; Huber and Lynch, 1978; Smoyak, 1977). A small study of s i x primigravida mothers found three mothers' main concern i n the postpartum period was a t t a i n i n g competency i n infant care. New mothers have an acute desire to l e a r n and succeed, and education on infant care as well as encouragement that they are doing the r i g h t thing i s e s s e n t i a l (Sheehan, 1981). Several studies have documented parents' desire for more learning opportunities. A l o n g i t u d i n a l study by T. M. Williams et a l . (1979) found 50 percent of mothers questioned f e l t the need for or had attended parenting classes. J . K. Williams (1977) reported on a questionnaire given to 39 couples who were graduates of her prenatal classes. Eighty-two percent believed a small group class on infant care and behavior would have been h e l p f u l during the period from h o s p i t a l discharge up to three months postpartum. Several studies have led professionals to believe there i s a need for parent education. A survey by Sumner and F r i t s c h (1977) documented parental concerns which were phoned to the f a c i l i t y i n which t h e i r baby was born. Eighty-eight percent of the primiparous women, and 25 percent of the multiparous women who were e l i g i b l e to c a l l , did so. Most of the enquiries were about feeding and c o l i c . Linde and Englehardt (1979) examined new parents' knowledge of infant developmental milestones before the mother and baby were discharged from h o s p i t a l . Their r e s u l t s showed that parents knew less than h a l f of the developmental milestones, and they suggested that t h i s knowledge i s needed for e f f e c t i v e parenting. Eighty-s i x mothers from age f i f t e e n to twenty-one expected too much from t h e i r babies too soon and sometimes used punishment i f babies did not respond appropriately. They modeled th e i r c h i l d rearing on experience and obser-vations which generally came from t h e i r own fa m i l i e s where often punitive ( J a r r e t t , 1982). Another l o n g i t u d i n a l study correlated high expectations i n w e ll educated mothers with accelerated infant development (Snyder et a l . , 1979) . These studies have shown that both parents and professionals have f e l t a need for p e r i n a t a l education. 13 Prenatal Maternal Education Preconception classes, high school classes on c h i l d care and workshops on parenting have been taking place for the l a s t few years, but no evalua-t i o n of outcomes was found i n the l i t e r a t u r e . MacLachlan and Cole (1978) describe the Salvation Army Education f o r Parenthood program. This program offered information and pr a c t i c e i n c h i l d care as we l l as goals and values to 750 teenagers. Leaders f e l t teenagers changed t h e i r attitudes because of t h e i r successes i n t h i s program and because of feeli n g s of competence as po t e n t i a l parents. Subjects who f i l l e d i n a questionnaire offered to mothers regarding the i r experiences i n prenatal classes reported most frequently a lack of adequate coverage of infant care i n prenatal classes (Painter, 1978). In another study of 419 women questioned a f t e r d e l i v e r y , only 199 women had attended prenatal classes. Of these, 87 percent gave as t h e i r reason for attending, breathing, r e l a x a t i o n , labour and del i v e r y . Only 4 percent attended to get information on in f a n t care. Eight percent of the p r i m i -paras reported i n f a n t care as the most us e f u l class while 77 percent reported labour, d e l i v e r y and exercises as most u s e f u l , although 35 percent f e l t they did not receive enough information on infant care. There was no diff e r e n c e i n atti t u d e s or concerns regarding c h i l d care between the attenders and non-attenders (Stark, 1976). Another study found labour, d e l i v e r y and exercise classes the most u s e f u l for primiparous women (Thordarson and Constanzo, 1976). Speculating on the most appropriate time to teach i n f a n t care i s f r e -quently done by health professionals. Kruse (1976) studied couples post-n a t a l l y to determine i f s p e c i f i c education for the postnatal period could be taught prenatally to a l l e v i a t e some of the c r i s i s experienced by couples 14 with f i r s t babies. The couples were sent questionnaires at two to four weeks and four to eight weeks postpartum. Results showed that 50 percent of wives and 25 percent of husbands showed some degree of c r i s i s , from moderate to severe, i n the f i r s t time period, 25 percent of wives and 37 percent of husbands i n the second time period. When couples l i s t e d areas they wished they had been better prepared f o r , mothers mentioned schedul-ing time and a crying baby, while fathers l i s t e d baby care, growth and development. Kruse suggested that a n t i c i p a t o r y guidance during prenatal classes should be replaced by postnatal groups which would supply emotional support and information. Petrowski (1981) elected also to f i n d the best time to teach postnatal content. She used a random sample of primiparous women who were assigned to one of four treatment groups. Half the subjects, two groups, received an i n s t r u c t i o n a l package i n the l a s t trimester. A t h i r d group received t h i s package i n the h o s p i t a l . One of the f i r s t groups received the package again i n the h o s p i t a l , while the fourth group received none. A l l mothers were tested f o r retention of the material during the second week postpartum. There was no s i g n i f i c a n t d i f f e r e n c e between any of the groups, although the group who had the postnatal i n s t r u c t i o n scored the highest. Timm (19.79) divided pregnant women between prenatal classes, k n i t t i n g classes and no classes. She reports that l e s s medication was needed during labour f o r the group who attended prenatal classes. Differences i n b i r t h -weight between groups were not found to be s i g n i f i c a n t . She f e e l s better mother-infant r e l a t i o n s h i p s r e s u l t from the use of less medication, but th i s was: not tested. Other researchers (Huttel et a l . , 1972; Shapiro and Schmitt, 1973) found that prenatal class attenders use less medication during labour and have shorter labours but Stark (1976) found attenders experienced longer labours and no decrease i n medication. Fillmore and Taylor (1976) reported prenatal class attenders expressed increased con-cerns p o s t n a t a l l y . Mothers with Lamaze t r a i n i n g and c h i l d b i r t h education showed increased awareness postnatally which i n turn increased t h e i r p o s i -t i v e f e e l i n g s toward t h e i r infants (Doering and Entwisle, 1974). Psychosocial i n s t r u c t i o n for the motherhood r o l e , when added to ante-n a t a l classes, resulted i n happier, h e a l t h i e r and better adjusted mothers for the followup time of s i x years. Continued guidance and counselling proved more e f f e c t i v e from a mother's family doctor or nurses than from a p s y c h i a t r i s t (Gordon et a l . , 1965). The Vancouver P e r i n a t a l Health Project included two programs, Parent's Choice and Healthiest Babies Possible. Parent's Choice provided prenatal education, i n d i v i d u a l evaluation, h o s p i t a l and home v i s i t s f o r support. Healthiest Babies Possible was an out-reach program for non-attenders of prenatal classes. I t provided monthly home v i s i t s f o r counselling on n u t r i -t i o n , community resources, budgeting, minor concerns and support by aides for f i v e language groups. Both demonstrated that increasing the l e v e l of p e r i n a t a l care r e s u l t s i n increased health of the babies and mothers (Bradley et a l . , 1978). Teaching, support and the use of feedback may have increased the learning of the mothers. Prenatal classes that focused on e s t a b l i s h i n g and strengthening sup-port systems, parenting, infant care and c h i l d development r e s u l t i n some increase i n knowledge of c h i l d development and a s e l f report of more secure, confident parents. Volunteers were used to make contact and to support the parents (Smith and Smith, 1978). Prenatal education should be most h e l p f u l f or primiparous mothers as there i s a high c o r r e l a t i o n between fear for s e l f and baby prenatally 16 and fear and concern for the baby and need for assurance i n the postnatal period. Primigravidae are more f e a r f u l , dependent, need more reassurance prenatally and postnatally than multigravidae (Shaefer and Manheimer, 1960). One explanation for t h i s could be the primigravidae's psychological f i e l d or l i f e space does not contain information on the event. Prenatal education studies reveal that although mothers are not spe-c i f i c a l l y interested or ready to learn about infant care prenatally, they do wish postnatally they had been offered more teaching on the subject. A p r i n c i p l e of learning explains that mothers w i l l learn what they see as the l o g i c a l step when the r i g h t psychological time comes. Early Postnatal Maternal Education Rooming-in i s one form of parent education which combines i n s t r u c t i o n and p r a c t i c e . Jordan (1973) evaluated a family-centred maternity care pro-gram and a t r a d i t i o n a l maternity care program. Families were divided between the two programs. Jordan affirmed that parents r e c e i v i n g prenatal education had le s s fear of labour, were more interested i n the baby and more confident i n t h e i r a b i l i t y to care for the baby. Parent-child r e l a -tionships were stronger i n the experimental group i n the h o s p i t a l but not l a t e r at home and the experimental group had more concerns at home. Eighty-s i x to 91 percent of the p a r t i c i p a n t s f e l t some postnatal discussion at two weeks would have been h e l p f u l and the majority wanted more knowledge on normal growth and development at eight weeks postpartum. Rooming-in,as an educational method to increase mothers' competence i n infant care, confidence and fee l i n g s of closeness to t h e i r i n f a n t s , i s successful i n the h o s p i t a l s e t t i n g (Greenberg et a l . , 1973; Schroeder, 1977). The l o n g i t u d i n a l e f f e c t of rooming-in when„mea'sur.'ed; (at-.onei-month 17 postpartum i s more confident mothers who are more competent i n infant care (Shea et a l . , 1952). D i f f e r e n t methods of baby care counselling for mothers i n the postpar-tum period i n the h o s p i t a l were evaluated (Kleinberg, 1977). One group of mothers received one d a i l y p e d i a t r i c i a n contact, the second had one d a i l y contact by a p e d i a t r i c trained public health nurse and the t h i r d group had counselling on the day of discharge by a d i f f e r e n t p e d i a t r i c i a n . The f i r s t two groups demonstrated less anxiety, signs of postpartum depression and feeding problems than the t h i r d group. At two weeks, more mothers i n group three had breast feeding problems. Personal contact and supporting the mothering r o l e on an incremental b a s i s , i s f e l t to be e s s e n t i a l . The use of t e l e v i s i o n as a medium for providing a n t i c i p a t o r y guidance fo r primiparae was evaluated by Broussard (1976). A ser i e s of three video-taped programs were offered to three experimental groups of mothers i n the h o s p i t a l , describing mothers' f e e l i n g s and changes i n the family, the new-born and i t s care, and infant behavior, with extra reassurance for mothers. Mothers' perceptions of t h e i r i nfants were measured at one month postpartum. Mothers who viewed one or more t e l e v i s i o n programs showed a s i g n i f i c a n t increase i n how they rated t h e i r babies at one month, from the r a t i n g p r i o r to the viewing. Those who did not view any programs showed no increase. Children whose mothers viewed them as above average,, exhibited le s s psycho-pathology at age four and one-half. I t was concluded that t e l e v i s i o n was an e f f e c t i v e postnatal education method for new mothers. Primary concerns of f i r s t time mothers on the t h i r d postpartum day and a f t e r one week at home were re l a t e d to s e l f and infant behavior and remained the same from h o s p i t a l to home ( B u l l , 1981). Adams (1963) found the main concern of primigravidae during the month aft e r t h e i r i n f a n t ' s b i r t h was 18 feeding f i r s t , with crying the next most important concern. The recommenda-t i o n was made that teaching about i n f a n t care would be most e f f e c t i v e i n the postnatal period. Teaching new, middle class parents the i n t e r a c t i v e and ph y s i c a l a b i l i -t i e s of t h e i r infants by using the Brazelton Neonatal Behavioral Assessment Scale was the basis of a study by Myers (1982) to improve parental f e e l i n g and behavior. A group of mothers only, and a group of fathers only, were taught to administer the assessment between the second and fourth h o s p i t a l day. Parents exposed to the teaching sessions demonstrated more knowledge of i nfant a b i l i t i e s than a control group and r e c a l l e d most of the informa-t i o n again at four weeks. Fathers who received the teaching session were more involved with infant care a c t i v i t i e s at four weeks than untrained fathers. Generally, a l l parents f e l t f a i r l y confident as care givers and the Brazelton t r a i n i n g had s l i g h t e f f e c t on confidence and s a t i s f a c t i o n . Anderson (1981) used the same assessment scale with two groups of new mothers and measured maternal-infant r e c i p r o c i t y at ten to twelve days postpartum. The group of mothers who observed the assessment and had an explanation of the r e s u l t s , evidenced enhanced responsiveness. In another study of f i v e experimental and s i x control couples by Kang (1974), the experimental group were involved i n a teaching session at two weeks post d e l i v e r y about t h e i r infant's behaviors. A l l infants were assessed at two to three days postnatally i n the h o s p i t a l and at one month i n the home. At one month, the experimental group of mothers scored th e i r infants more pos-i t i v e l y on the Broussard Neonatal Perception Inventory and the experimental group of babies were more a l e r t at one month. Similar r e s u l t s on mother's perceptions were obtained by H a l l (1980). Her intervention was a s p e c i a l teaching session on infant behavior at two to four days post discharge. 19 Mothers were tested i n the h o s p i t a l and at one month. Davidson (1978) v i s i t e d mothers i n the h o s p i t a l and made arrangements for a home v i s i t one week post discharge for both parents, i n an experimental group for a teach-ing i ntervention. Parents were taught about t y p i c a l i nfant behavior pat-terns and shown responses and refle x e s on t h e i r infant based on the Brazelton Neonatal Assessment Scale. Control and experimental group mothers were contacted at one month following the b i r t h . Experimental group mothers perceived t h e i r babies as s i g n i f i c a n t l y better than average on the Broussard Neonatal Perception Inventory and reported fewer negative aspects of c h i l d rearing. I n d i v i d u a l counselling, t e l e v i s i o n , the use of assessment as a maternal teaching t o o l i n the h o s p i t a l or the early postnatal period has demonstrated a p o s i t i v e e f f e c t on early mother-infant r e l a t i o n s h i p s , possibly because mothers have had successes from the interventions taught to them and f e e l more confident i n caring for t h e i r i n f a n t . Later Postnatal Maternal Education Education and support for. mothers regarding well c h i l d care over the f i r s t years of the c h i l d ' s l i f e i s important for the promotion and mainte-nance of good mother-child r e l a t i o n s h i p s . Roberts and Rowley (1972), i n a study of 197 mother-infant p a i r s over a two-year period, found an associa-t i o n between infant development and mother-child contact, maternal compe-tence and t r a i n i n g i n independence. Peters and Hoekelman (1973), who devel-oped a measure of maternal competence, came to the conclusion that "the most important component of c h i l d care i s probably emotional and a f f e c t i v e rather than cognitive and i n t e l l e c t u a l " (Peters et a l . , 1973:526). To be able to give her c h i l d the emotional support he needs, a mother 20 i n turn, must be r e c e i v i n g support as well as knowledge. This i s confirmed by Gutellus et a l . (1972) who studied well c h i l d care provided for three years to an experimental group of s i n g l e , black primiparas with some added infant stimulation counselling. The experimental group of chil d r e n had higher I.Q.s than the control c h i l d r e n at three years. The researchers f e l t that the success of the program was l a r g e l y due to the increased f e e l -ings of personal worth and self-confidence b u i l t up i n the mothers which resulted i n p o s i t i v e mother-infant r e l a t i o n s h i p s . P e d i a t r i c i a n s ' well c h i l d v i s i t s were also studied with regard to the re l a t i o n s h i p between teaching mothers about c h i l d development and various outcomes (Chamberlin et a l . , 1979). Results affirmed that mothers who were provided with counselling and guidance at well c h i l d v i s i t s reported more p o s i t i v e contact with t h e i r c h i l d r e n , more knowledge of c h i l d development and, most important, f e l t more supported i n c h i l d rearing. They suggested education and emotional support could be given i n the home by health v i s i -tors of some sort. Nurses could and do provide the support, but Gruis (1977) reported that mothers do not ask nurses for t h i s support. At one month-postpartum, they turned to t h e i r husbands who were also experiencing an adjustment. Major concerns were about s e l f , f i g u r e , tension, fatigue and time, with, concerns for the infant next i n importance. Infant crying was a major concern of 35 mothers at one month postpartum i n a study by Harr i s (1979), while lack of sleep and time were concerns i n a study of 37 primiparous women by Pellegrom and Swartz (1980). The effectiveness of public health nurse v i s i t s was the subject of a study by Brown (1967). At four weeks postpartum, mothers with v i s i t s from nurses indicated more concerns i n a l l areas except feeding than a control group. Crying was the major concern and a l l mothers ranked husbands as being the most h e l p f u l to them. Group v i s i t s to c l i n i c s by parents with babies of s i m i l a r b i r t h dates, or c l u s t e r c l i n i c s , has been one attempt to meet the needs of new parents. In one area, infants are examined at two weeks of age and parents attend a group educational session where normal infant behavior, ref l e x e s and care are discussed with a nurse p r a c t i t i o n e r and: experiences shared with the group (Hancock, 1979). Parents report they f e e l more confident and capable, but no formal evaluations have been done. In another area, c l u s t e r c l i n i c s are offered where) babies are two weeks, four and s i x months old. Teaching as well as screening i s offered and there i s group discussion. Ninety per-cent of respondents to a questionnaire indicated they preferred i t to the t r a d i t i o n a l w e l l baby v i s i t s (Cronin, 1979). Peer teaching was t r i e d i n one l a r g e l y Spanish-speaking area, but was not evaluated (Johnston et al.., 19.77). Groups for mothers and fathers have been offered, because of parent need and because of lack of p r o f e s s i o n a l s t a f f a v a i l a b l e , to increase parents' s k i l l s , knowledge of c h i l d development and confidence. They have not been evaluated (Cooper,- 1974; M i l l e r and Baird, 1978; Post and Robinson, 1980; Shaw, 1974). Parent-infant classes i n a college s e t t i n g have been reported to be successful, allow for a great amount of parent sharing of information and support, and are held weekly for three consecutive college quarters (Charnley and Myre, 1977). What i s apparent from the l i t e r a t u r e on the education for mothers i n the early months and years of the c h i l d ' s l i f e i s the importance of emotional sup-port. Also important i s the r e i n f o r c i n g of mothers' f e e l i n g s of s e l f worth 22 as w e l l as increasing t h e i r confidence i n t h e i r a b i l i t y to understand and respond w e l l to the needs of t h e i r i n f a n t s . The Maternal-Infant Relationship and Confidence The mother-infant r e l a t i o n s h i p has been under considerable scrutiny the l a s t few years, p a r t i c u l a r l y since Klaus and'' Kennell (1978) released t h e i r theory of a s e n s i t i v e period soon a f t e r b i r t h when bonding or attachment occurs between a mother and in f a n t . Svejda et a l . (1980) f e l t there were problems with the theory and studied 15 primiparous women who had early and extended contact with t h e i r infants as compared to f i f t e e n who had the routine h o s p i t a l care. No differences on maternal behavior were obtained. In an e a r l i e r study, Robson and Moss (1970) rel a t e d the findings from interviews with 54 primiparous mothers when the i r infants were three and one-half months old. The three s p e c i f i c questions asked were: "When did she f i r s t experience p o s i t i v e f e e l i n g s and love toward the baby? When did he f i r s t become a person to her? When did he f i r s t seem to recognize her?" (Robson and Moss, 1970:77). The modal answers were that they b r i e f l y f e l t p o s i t i v e f e e l i n g s at the beginning of the t h i r d week of l i f e which were re l a t e d to responses in;'the i n f a n t . By four to s i x weeks, mothers were f e e l i n g p h y s i c a l l y better, more confident with infant care and schedules were more regulated. They started thinking of the baby as a person. At seven to nine weeks, the mothers f e l t they were being recognized and strong attachment was formed by the end of the t h i r d month. The authors f e l t attachment must be maintained over years with varying i n t e n s i t y . The i n f o r -mation they obtained was by retrospective reporting of the mothers only and could also be questioned. Attachment has been suggested as a pattern of i n t e r a c t i o n between two human beings and not as a one time "thing" 23 (Rosenthal, 1972), and i t r e f l e c t s the current status of the mother-infant i n t e r a c t i o n (Thompson et a l . , 1982). P o s i t i v e mother-infant r e l a t i o n s h i p s r e s u l t from mutual f e e l i n g s of e f f i c a c y of the infant and mother and are supportive of infant development. I f the infant responds i n a desirable way i n r e l a t i o n to the mother's goals i n s p e c i f i c i n t e r a c t i o n s , she f e e l s she i s an e f f e c t i v e parent. The f e e l -ings of e f f i c a c y should be enhanced for both mother and inf a n t . Any prob-lems with the dyad should be helped i f the mother's s k i l l s i n understanding her infant are improved and i f the infant i s competent. I f not, then both need help (Brazelton and A l s , 1978; Goldberg, 1977). Intervention can reverse an unstable r e l a t i o n s h i p between mother and infant as demonstrated i n a study of 267 primiparous women. I t found that when the infants, were between 12 to 18 months ol d , there was a move by the poorly attached mothers and infants toward better attachment (Egeland and Sroufe, 1981). This move began af t e r some changes i n l i f e events had occurred or interventions of a supportive nature had taken place for the mother. A woman's pers o n a l i t y can indic a t e her i n t e r a c t i o n with her infant dur-ing the f i r s t s i x months postpartum. Self confidence and nurturant q u a l i -t i e s c o r r e l a t e with good maternal functioning (Shereshefsky et a l . , 1973). Separation of mother and infant a f t e r b i r t h with the r e s u l t i n g decrease i n maternal-infant i n t e r a c t i o n has a negative e f f e c t on s e l f confidence i n primiparous mothers and i n multiparas low i n s e l f confidence. Mothers per-mitted early contact with i n f a n t s , increase i n s e l f confidence (Seashore et a l . , 1973). The self-concepts of mothers are re l a t e d to the self-concepts of t h e i r c h i l d r e n (Tocco and Bridges, 1973), and maternal self-acceptance i s r e l a t e d to c h i l d acceptance (Medinnus and Cu r t i s , 1963). A study of p a r t i c u l a r i n t e r e s t by Painter (1978), as part of a larger 24 l o n g i t u d i n a l study by Williams et a l . (1979), investigated maternal-infant bonding i n a core group of primiparous mothers both prenatally and post-n a t a l l y . The purpose was to develop instruments f o r studying maternal attachment. The time period studied was from the l a s t month of pregnancy u n t i l the end of the f i r s t month of the infant's l i f e . A l l instruments and d i a r i e s used i n the study were developed by the author. She found that prenatal predictions of parent-infant attachments were rel a t e d i n the post-partum period to how the mother perceived the r e l a t i o n s h i p . The mother's s e l f confidence i n her a b i l i t y to understand her infan t ' s signals and her competence i n infant care were r e l a t e d to her predictions p r e n a t a l l y . One of the emotional f e e l i n g s , elation-depression, also correlated across time. Other predictions of l i f e with the new baby were not rela t e d to the actual experience. She concluded that parent-infant r e l a t i o n s h i p s begin p r e n a t a l l y and should be studied l o n g i t u d i n a l l y . In the larger study, Williams explained that a mother's p r e d i c t i o n of her competence to care for her baby was strongly r e l a t e d to attachment, con-fidence and emotional f e e l i n g s i n the postpartum period and postpartum emo-t i o n a l f e e l i n g s were strongly r e l a t e d to postpartum attachment and c o n f i -dence. Confidence i n infant care giving, which can respond to intervention, showed the most consistent r e l a t i o n s h i p to postpartum attachment and p o s i -t i v e emotional f e e l i n g s at one month postpartum. Education programs should not make mothers f e e l inadequate or g u i l t y but should help b u i l d mothers' confidence i n the q u a l i t y of parenting they are providing f o r the i r children (Joy et a l . , 1980). Summary This l i t e r a t u r e review included an i n v e s t i g a t i o n of the need for p e r i -natal education, studies of parent education i n the prenatal period, the early postnatal period, and the l a t e r postnatal period. Selected studies on maternal-infant r e l a t i o n s h i p s and maternal confidence i n care giving were reviewed. The c o g n i t i v e - f i e l d theory of learning and the studies strongly postulate that success and confidence are necessary for learning to take place and to continue. Confidence w i l l increase with success from learning. The Painter and the T. Williams et a l . studies, i n p a r t i c u l a r , suggest that the r e l a t i o n s h i p of confidence to good mother-infant r e l a t i o n -ships i s one which can be f a c i l i t a t e d by appropriate nursing interventions. Mothers' successes i n learning infant care can be reinforced by nurses which, i n turn, w i l l strengthen the f a m i l i e s ' r o l e i n f o s t e r i n g infant development. 26 CHAPTER I I I DESIGN AND METHODOLOGY Overview The purpose of th i s study was to evaluate the e f f e c t of a nursing intervention on mothers' confidence as a parent and infant care giver. The intervention was an interview constructed to focus on mothers' successes i n i nfant care giving: rather than problems, which was given at c h i l d health conferences. The research design was quasi-experimental using a non-synchronized or non-time equivalent, two group pretest-posttest question-naire ( P o l i t and Hungler, 1978:165) to obtain the necessary data for t e s t -ing of the hypothesis. The subjects assigned to the experimental group were interviewed following the c o l l e c t i o n of the f i r s t data from the control group to prevent contamination by the control group interviewers using the technique taught to the experimental group interviewers. The control group received the regular c h i l d health conference interview or the old method ( P o l i t and Hunger, 1978:153). A study by T. M. Williams et a l . (1979) was used as the foundation for t h i s study. Data were analyzed using the S t a t i s t i c a l Package for the S o c i a l Sciences (1980). The Independent Variable The independent v a r i a b l e was an interview technique which focused on the mothers' successes i n infant care giving as she re l a t e d them and a s s i s t i n g with selected goal s e t t i n g for areas i n infant care giving where the mother f e l t improvement was needed. A general o u t l i n e for the interview 27 was drawn up by the investigator (see Appendix A). The interviews were con-ducted by f i v e nurses who were given an explanation on how to proceed. The interviewer commenced the interview by asking a general question such as, "How are things going?" She next asked about areas the mother f e l t good about i n caring for the i n f a n t . P o s i t i v e feedback was given for suc-cesses. Areas of concern were e l i c i t e d next by asking i f the mother had an area or issue she would l i k e to improve on by the next appointment. Goals were established with the mother and an i n t e r a c t i v e discussion was held on methods to meet the goals. P o s i t i v e feedback was given on how the mother was progressing. Successes and goals were written on a form kept i n the health record for the second interview (see Appendix C). This interview d i f f e r e d from the usual interview which commenced with a general question followed by asking the mother i f she had any problems she would l i k e to discuss. P o s i t i v e feedback may or may not be given. The second interview, two months l a t e r , opened again with a general statement or question. Discussion was held regarding the goal. P o s i t i v e feedback was given i f the goal was reached. Goals were set again and p o s i -t i v e feedback was given on infant care. The second and fourth month postpartum were chosen to coincide with c h i l d health conference immunization schedules and also because the infant would not be mobile at that time which could present d i f f e r e n t d i f f i c u l t i e s for the mother. The Dependent Variable The dependent v a r i a b l e , maternal confidence, was measured by a question-naire composed of questions developed by Dr. Susan Lee Painter for her research studies (1978; 1980). 28 The Measurement Instrument The measurement instrument was a questionnaire composed of 36 ques-tions suggested by Painter, selected from three questionnaires used i n her research. These were: The Postnatal Questionnaire (1978) , The Question-naire for Mothers of Toddlers and the Parenting Inventory for Fathers of Toddlers (1980). The questions covered/three subjects or concepts that Painter (1978) found to be i n t e r r e l a t e d : (a) Mother's s e l f confidence i n care giving. (b) Mother's report of her r e l a t i o n s h i p with her i n f a n t and her husband's r e l a t i o n s h i p with the i n f a n t . (c) The p h y s i c a l and emotional fee l i n g s of the mother. Seventeen questions were i n the form of f i v e - p o i n t L i k e r t type scales, while nineteen were six-point L i k e r t type scales (see Appendix B). Ques-tions on the measure were scored from one to f i v e , or one to s i x . The questions were scored together because of t h e i r r e l a t i o n s h i p ( P o l i t and Hungler, 1978:364). A range of high scores denoted problems with c o n f i -dence. Scores could range from 36 to 199. The questionnaire was p i l o t tested on three subjects referred to the investigator by other nursing s t a f f , to test for v a l i d i t y . The nurses f e l t one subject to be very confident i n i n f a n t care giving, one not confident at a l l , and one becoming more confident a f t e r having not been confident at a l l . The r e s u l t i n g scores demonstrated t h i s d i f f e r e n c e . They were 41, 104, and 72,. r e s p e c t i v e l y . The questionnaire was repeated one week l a t e r to test for r e l i a b i l i t y on the subject with the highest score. An even higher score of 110 was obtained the second time and t h i s mother claimed she had l o s t confidence i n her a b i l i t y to meet her baby's needs. No items were changed af t e r the p i l o t t e s t i n g . The scale was f a i r l y e a s i l y understood by subjects and e a s i l y scored. The Setting This study took place i n one large health unit comprising two munici-p a l i t i e s and one small c i t y i n the lower mainland of B r i t i s h Columbia with a t o t a l population of 235,674 (Boundary Health Unit Annual Report, 1981). Although s i x o f f i c e s are i n the health u n i t , the three with the highest number of b i r t h s per year were used. The largest o f f i c e had 1369 b i r t h s registered i n 1981, one had 699 b i r t h s , and one had 584 b i r t h s (Boundary Health Unit S t a t i s t i c s , 1981). This highly populated, r e s i d e n t i a l area of rapid growth has a large proportion of the population aged f i f t e e n to t h i r t y - f o u r , the c h i l d bearing years (Greater Vancouver Regional D i s t r i c t Newsletter, 1981). The research was done at c h i l d health conferences i n the three o f f i c e s . Parents are i n v i t e d to attend c h i l d health conferences f o r immunization and discussion on infant care giving, n u t r i t i o n , and normal growth and develop-ment when babies are two, four, s i x , twelve, and eighteen months o l d . The i n v i t a t i o n i s given by public health nurses who v i s i t a l l new mothers at home when the infant i s from one to two weeks old. An average of 45 percent of mothers with new infants attend the c h i l d health conferences i n the three health unit o f f i c e s ( V i t a l S t a t i s t i c s Printout - Pub l i c Health Nursing Systems, 1982). Human Rights and Ethic s A written explanation of the study was given to a l l subjects as well as a verbal explanation (see Appendix D). A signed consent was obtained 30 from a l l p a r t i c i p a n t s (see Appendix D). C o n f i d e n t i a l i t y and anonymith were stressed as well as the r i g h t s of the subjects to refuse to p a r t i c i -pate without jeopardizing present or future services from the Boundary Health Unit. Subjects were given an i d e n t i f y i n g number to ensure anony-mity. The Study Sample Subjects i n t h i s study were primiparous women with healthy babies from i n t a c t - f a m i l y s i t u a t i o n s . Forty was the number of subjects decided on. They were able to speak and understand the English language. Recruitment of the Control Group Publ i c health records of mothers attending t h e i r f i r s t c h i l d health conference when t h e i r infant was two months o l d , were examined using the above c r i t e r i a . E l i g i b l e subjects were approached by the i n v e s t i g a t o r , sequentially by appointment time, when they arrived at a c h i l d health conference i n one of the three o f f i c e s . They were given an explanation of the study and i n v i t e d to p a r t i c i p a t e . I f they agreed to p a r t i c i p a t e , they were given a written explanation of the research and a signed con-sent was obtained. Nursing interviews and interventions for problems i d e n t i f i e d at the c h i l d health conference would continue as usual. Twenty subjects volunteered to take part In the study. Of these, s i x -teen completed both interviews. Four subjects were dropped from the study; one because the father came to the second interview for the mother who was s i c k , another because the grandmother came f o r the mother who was working. One p a r t i c i p a n t was given the questionnaire at the t h i r d interview instead 31 of the second, and one questionnaire disappeared. The recruitment of the control group took from the beginning of January u n t i l the beginning of February. Recruitment of the Experimental Group The p a r t i c i p a n t s i n the experimental group were re c r u i t e d i n a s i m i l a r manner to the control group subjects. They were r e c r u i t e d by the f i v e nurse interviewers. Signed consents were obtained. The subjects were not aware of any differ e n c e i n the c h i l d health conference as i t was t h e i r f i r s t v i s i t to the health u n i t . This helped to - ensure i n t e r n a l v a l i d i t y ( P o l i t and Hungler, 1978:259). Eighteen of the 21 subjects who volunteered for the experimental group f i n i s h e d the study. One subject asked to be taken o f f the study, one did not return, and one returned, but the instructed nurse interviewer was not at the c h i l d health conference. The s e l e c t i o n of the experimental group took from the end of February u n t i l the middle of July. This was because the instructed nurses had to match with a mother who met the c r i t e r i a for the study at the c h i l d health conferences that these nurses were r e g u l a r l y assigned to each month. Se l e c t i o n and In s t r u c t i o n of Nurse Interviewers A t o t a l of 25 pu b l i c health nurses s t a f f e d the c h i l d health conferences i n the three o f f i c e s picked f o r the study. In order to ensure two nurse interviewers i n the two o f f i c e s with the highest number of b i r t h s , the names of the nurses were put into a container, separately f o r each o f f i c e . Two names were then drawn from the container for each of the higher b i r t h rate o f f i c e s and one name was drawn for the t h i r d o f f i c e . This was f e l t to be 32 random assignment of ins t r u c t e d nurse interviewers within each o f f i c e ( P o l i t and Hungler, 1978:155). The in v e s t i g a t o r met with two of the nurse interviewers one day, and with the three remaining the following day, to explain the study. They were each given a package containing questionnaires, consent forms, explana-tions of the study for the mother, goal sheets, an interview guide for the f i r s t and second interviews, and a supply of turquoise l a b e l s . Each nurse interviewer was also given a written explanation of the c r i t e r i a f o r s e l e c -t i o n of subjects and an explanation of how to proceed through both of the interviews (see Appendix C). Each instru c t e d nurse interviewer was asked to r e c r u i t four subjects. The s i n g l e nurse interviewer from the o f f i c e with the lowest number of b i r t h s sustained an i n j u r y s h o r t l y a f t e r the c o l l e c t i o n of the experimental group data began. She d i d not return to work u n t i l nearly the end of the study. Another interviewer was chosen by draw. This nurse had her vaca-t i o n shortly a f t e r being instructed regarding the study. Another nurse was then drawn and t h i s nurse interviewed the subjects. The time taken for the c o l l e c t i o n of experimental group data was lengthened somewhat by these i n c i -dents. One nurse interviewer i n the o f f i c e with 699 b i r t h s was asked to r e c r u i t a f i f t h subject, i n case four were not c o l l e c t e d i n the o f f i c e with the s i n g l e interviewer. As four subjects were f i n a l l y r e c r u i t e d , the t o t a l of the experimental group recruitment was twenty-one. Procedure for C o l l e c t i o n of Control Group Data The control group questionnaires were c o l l e c t e d before the experimental group to t r y to a l l e v i a t e any contamination of the c o n t r o l group by communi-cation among the nurses about the nursing intervention. A questionnaire was given to each control group subject to be f i l l e d out p r i o r to t h e i r p a r t i c i p a t i o n i n a regular c h i l d health conference. The health record was i d e n t i f i e d with a bright orange l a b e l marked with the information that the subject was i n the study. Nurses i n the three o f f i c e s were asked to give the mothers the questionnaire at the end of the second c h i l d health confer-ence. A blank questionnaire was put i n the health record with v i v i d :'. i n s t r u c t i o n s that i t was to be given at the end of the second v i s i t to the c h i l d health conference when the infant was four months old. The nurse who interviewed the subjects at the second c h i l d health conference returned the second questionnaire to the i n v e s t i g a t o r and the l a b e l was removed from the record. Procedure for C o l l e c t i o n of Experimental Group Data The questionnaire was administered to the p a r t i c i p a n t s before the f i r s t interview and following the second interview by the same instructed nurse. These nurses made the appointments f o r the second c h i l d health conferences to ensure the p a r t i c i p a n t s returned to them. Family records fo r the experimental subjects were i d e n t i f i e d with turquoise-colored l a b e l s to d i s t i n g u i s h them from the c o n t r o l group.subjects. These l a b e l s were removed following the second interview. Analysis of the Data The data, including the age of the mother and sex of the i n f a n t , were coded using Fortran Coding Forms. The data, using the p a r t i c i p a n t s ' i d e n t i -f y i n g number, were analyzed at the U n i v e r s i t y of B r i t i s h Columbia Computing Centre. The S t a t i s t i c a l Package for the S o c i a l Sciences was used for the a n a l y s i s . Descriptive and i n f e r e n t i a l s t a t i s t i c s were used. The d e s c r i p t i v e 34 s t a t i s t i c s were Chi-square test f o r homogeneity. I n f e r e n t i a l s t a t i s t i c s were Student's t-Test f o r independent samples and for paired measures and mult i f a c t o r analysis of variance or the Anovar procedure. S t a t i s t i c a l analyses were tested against an alpha c r i t e r i o n of p<.05. Summary This chapter has described the design and methodology of the study with an explanation of the v a r i a b l e s and a d e s c r i p t i o n of the instrument to -measure maternal confidence as well as a small pretest of i t s i n t e r n a l v a l i d i t y and r e l i a b i l i t y . Recruitment of subjects, i n s t r u c t i o n and r e c r u i t -ment of nurse interviewers, data c o l l e c t i o n , and data analysis methods were described. 35 CHAPTER IV ANALYSIS OF THE DATA Analysis of the data w i l l be discussed i n t h i s chapter i n r e l a t i o n to the hypothesis following a short d e s c r i p t i o n of the sample. A d d i t i o n a l data describes the areas of success and concern i n infant care giving and the goals f o r the experimental group. Description of the Sample Id e n t i f y i n g data were obtained from a face sheet attached to the ques-tionna i r e (see Appendix B) for both the control and the experimental groups. Sex of the infants i s shown i n Table 1. Male female r a t i o of the infants i n the c o n t r o l and experimental groups were analyzed using Chi-square test of homogeneity (Brown and Hollander, 1977:180). TABLE 1 SEX OF INFANTS Sex Control Experimental .Totals N = 34 Group Group Male 4 13 17 Female 12 5 17 Totals 16 18 34 X 2 = 7.56 p = <v05..-The r e s u l t indicates there was a s i g n i f i c a n t d i f f e r e n c e between the two groups i n regard to sex of the inf a n t . The r a t i o could be due to the small number i n the sample.. There was no systematic s e l e c t i o n of the sample (Brown and Hollander, 1977:74-80). The obvious diff e r e n c e w i l l be discussed l a t e r i n t h i s chapter i n r e l a t i o n to i t s e f f e c t on the confidence measure. The mean, range, and standard deviation of age of the mothers i n the two groups are shown i n Table 2. The mean age of the mothers i n the control group and the experimental groups as shown i n Table 2 were compared. They were analyzed using the Student's t-Tests for independent samples (Brown and Hollander, 1977:90). TABLE 2 MOTHER'S AGE (in years) Group Range Mean s.d. t . P Control N = 16 10 24.813 2.344 1.472 n.s. Experimental N = 18 14 26.389 3.664 There was no s i g n i f i c a n t d i f f e r e n c e i n the mean age of the mothers i n the two groups at the .05 l e v e l of s i g n i f i c a n c e . Analysis Related to the Hypothesis The hypothesis stated that the mothers i n an experimental group who were encouraged to discuss t h e i r successes i n infant care giving would have a s i g n i f i c a n t l y lower posttest t o t a l mean score on the confidence measure than would a control group of mothers who would not be s p e c i f i c a l l y encour-aged to discuss successes i n infant care g i v i n g . The experimental group 37 of mothers, therefore, should have f e l t more confident with infant care giving. Table 3 shows the i n d i v i d u a l pretest and posttest scores with t h e i r group means, standard deviations, and range. Three high scores i n the control group pretest were notable. These were 107, 110, and 117. These scores dropped considerably i n the posttest to 67, 72, and 78. TABLE 3 SUBJECT TOTAL SCORES, PRETEST AND POSTTEST GROUP SCORES, MEANS, STANDARD DEVIATION AND RANGE FOR CONTROL GROUP AND EXPERIMENTAL GROUP Subject Control Group Subject Experimental Group number pretest posttest number pretest posttest 1 79 73 17 65 62 2 65 66 18 58 60 3 107 67 19 73 68 4 53 57 20 60 58 5 53 53 21 85 56 6 81 71 22 69 68 7 63 65 23 54 44 8 58 54 24 67 56 9 51 61 25 95 81 10 51 50 26 57 47 11 110 72 27 56 53 12 117 78 28 59 . 59 13 56 49 29 82 64 14 71 68 30 43 41 15 56 55 31 87 80 16 74 71 32 76 70 33 71 63 34 66 58 N = 16 1145 1010 N = 18 1233 1088 X = 71.563 X = 63.125 i = 67 .944 X = 60.444 s.d. = 22.012 s.d. = 9.084 s.d. = 13 .326 s.d. = 10.766 Range = 66 Range' = 29 Range = 52 Range = 40 38 Four scores in^the control group and one i n the experimental group did become s l i g h t l y higher on the posttest. Two scores, one i n the experi-mental group and one i n the cont r o l group, were the same i n both the pre-test and the posttest. Table 4 shows the pretest and posttest mean scores and standard devia-tions for the cont r o l group and the experimental group. The analysis of these independent mean scores was done by using the Student's t-Test for independent samples (Brown and Hollander, 1977:116-118). TABLE 4 EXPERIMENTAL GROUP AND CONTROL GROUP PRETEST AND POSTTEST MEAN SCORES WITH STANDARD DEVIATIONS AND RESULTS OF t-TESTS Pretest Posttest Group mean s.d. t P mean s .d. t P score score Experimental 67.9444 13.326 60.444 10 .766 N * 18 0.59 0.561 0.78 0.442 Control 71.5625 22.012 63.1250 9 .084 N = 16 The r e s u l t s i n d i c a t e there was no s i g n i f i c a n t d i f f e r e n c e at an alpha c r i t e r i o n of .05 between the experimental and the control group posttest mean scores. The hypothesis was rejected. The analysis of these data also indicated there was no s i g n i f i c a n t d i f -ference between the pretest mean scores of the experimental and the control groups. Table 5 shows the pretest and posttest mean scores, standard deviations, mean differe n c e with standard deviation, and t-value for the experimental 39 group data. Data were analyzed using the Student's t-Test f o r paired measures ( P o l i t and Hungler, 1978:350). TABLE 5 EXPERIMENTAL GROUP PRETEST AND POSTTEST MEAN SCORES, STANDARD DEVIATIONS, MEAN DIFFERENCES WITH STANDARD DEVIATION AND t VALUE Test N Mean s.d. (Difference) s.d. t P Mean Pretest 67": 4444 13.326 18 7.5 7.43 4.28 0.000 Posttest 60.4444' 10.766 The r e s u l t s i n d i c a t e there was a s i g n i f i c a n t d i f f e r e n c e between pretest and posttest scores f o r the experimental group. Pretest and posttest mean scores, standard deviations, d i f f e r e n c e i n mean scores with the standard deviation and t value f o r the con t r o l group are shown i n Table 6. TABLE 6 CONTROL GROUP PRETEST AND POSTTEST MEAN SCORES, STANDARD DEVIATIONS, DIFFERENCE IN MEAN SCORES WITH STANDARD DEVIATION AND t VALUE Test N Mean s.d. (Difference) s.d. t P Mean Pretest 71.5625 22.012 16 8.4375 16.849 2.13 0.000 Posttest 63.1250 9.084 The r e s u l t s i n d i c a t e there was a s i g n i f i c a n t d i f f e r e n c e i n the pre-test and posttest scores for the control group also. The Anovar procedure or mul t i f a c t o r analysis of variance was used to analyze the data f o r any in t e r a c t i o n s between or within groupings (Kitay 1980; P o l i t and Hungler, 1978). Table 7 i s a summary of the r e s u l t s of the analysis of variance. TABLE 7 ANALYSIS OF VARIANCE SUMMARY TABLE OF INTERACTIONS BETWEEN OR WITHIN GROUPS WITH THE N = 34 F RATIO Source Sum of Squares d.f. Mean Squares F Ratio P Between control and 168.022 1 168.022 experimental groups 0.483 0.0492 Within 11141.938 32 348.186 Between pretest and 1075.831 1 1075.831 posttest .combined 14.630 0.0001 Within 2353.188 32 73.537 The r e s u l t s i n d i c a t e no s i g n i f i c a n t d i f f e r e n c e between or within the scores of the experimental and control groups. The di f f e r e n c e between the pretest and posttest scores was s i g n i f i c a n t at .001. This r e s u l t and the r e s u l t s of the Student's t-Test for paired measures show that the mothers did improve t h e i r f e e l i n g s of confidence i n in f a n t care giving from the c h i l d health conference when the i n f a n t was two months old to the c h i l d health conference when the infant was four months old, regardless of program. The Anovar procedure was used to analyze i f there was a male, female e f f e c t on the confidence measure because of infant sex di f f e r e n c e i n the experimental and control groups. Table 8 i s a summary of the analysis of variance f o r male, female e f f e c t . TABLE 8 ANALYSIS OF VARIANCE SUMMARY TABLE FOR SEX OF BABY EFFECT ON THE CONFIDENCE MEASURE WITH F RATIO* N 34 Source Sum of Squares d.f. Mean Squares F Ratio P Sex of babies 367.094 1 367.094 1.073 0.308 Pretes t -posttest scores 1072.063 1 1072.063 14.750 0.001 Sex of baby and pretest-posttest scores 31.145 1 31.145 0.429 0.517 See Table 1, page 35. This tabulation indicates there was no s i g n i f i c a n t male, female e f f e c t on the score r e s u l t s due to the s i g n i f i c a n t d i f f e r e n c e i n the babies sex found i n the control group and the experimental group. Data on Ind i v i d u a l Instrument Responses Several i n d i v i d u a l questions on the instrument showed high mean scores (see Appendix E). The statement which had the highest scores was worry about handling things that might come up with, the c h i l d i n the future. The high scores denoted considerable worry by mothers over the future. 42 , The question with the second highest scores was the question about l o s -ing confidence when faced with c h i l d r e a r i h g problems the mother was unsure of. This r e s u l t indicated a loss of confidence when mothers are not sure how to handle c h i l d rearing s i t u a t i o n s . The t h i r d highest scores were on a depression-elation question. F i f t y -four percent of the scores were marked "average for me", the midpoint of the question (see Appendix B). Two questions with f a i r l y s i m i l a r high scores were a question which dealt with being bothered when c h i l d r e a r i n g opinions are d i f f e r e n t from other parents and the second was a statement about not being patient with the baby. The questions pertaining to tiredness and anxiety also had f a i r l y high scores. This could p a r t l y be accounted for by the midpoint of the L i k e r t type scale previously mentioned. Thirty-seven percent of the tiredness question were marked i n the centre. Twenty-eight percent of the anxiety question were marked i n the centre. Tiredness and anxiety were scored moderately highly by the mothers. The questions with the lowest scores were the questions on the mother's f e e l i n g s of closeness to the i n f a n t , her fe e l i n g s of s a t i s f a c t i o n with her re l a t i o n s h i p with her baby, and her contentment with her own warmth and a f f e c -t i o n f o r her c h i l d . These r e s u l t s indicated mothers f e l t they had a good mother-infant r e l a t i o n s h i p . A computer r e l i a b i l i t y analysis of the scale showed the t o t a l scale was r e l i a b l e at an alpha c r i t e r i o n of .05. Add i t i o n a l Data Data On Successes and Goals The areas i n infant care giving which mothers f e l t had gone well were 43 tabulated i n Table 9 by frequency of reporting at the f i r s t interview, as recorded on the goal sheet (see Appendix C). TABLE 9 SUCCESSFUL AREAS OF INFANT CARE REPORTED BY EXPERIMENTAL GROUP SUBJECTS BY FREQUENCY AT FIRST INTERVIEW AS RECORDED ON GOAL SHEET N !» 18 Successful areas i n infant care giving reported by experimental Frequency group mothers at f i r s t interview reported Feeding 14 Sleeping 12 Happiness, contentment and enjoyment 5 Bathing 3 A l l areas 3 Infant growing w e l l 2 Responsiveness 1 Handling infant 1 Taking infant out 1 Reduction i n anxiety 1 44 Feeding and sleeping were mentioned the most frequently. Four areas of successes were mentioned by 18 subjects. A l l subjects reported successes. The selected areas of concern f o r which goals were established by the experimental group subjects at the f i r s t interview were tabulated i n Table 10 by frequency of reporting. 44 TABLE 10 SELECTED AREAS OF CONCERN FOR WHICH GOALS WERE ESTABLISHED BY EXPERIMENTAL GROUP MOTHERS AT THE FIRST INTERVIEW N = 18 Selected areas of concern f o r which goals were established Frequency at the f i r s t interview reported Introducing s o l i d food 4 Cradle cap or dry scalp 3 D i f f i c u l t y s e t t l i n g baby i n the evening 1 Schedule and sleeping 1 Infant favouring one side 1 Constipation and c o l i c 1 Too much l i q u i d and s p i t t i n g up 1 Weight gain 1 Unhappy bath time 1 Baby s i t t i n g 1 Weaning 1 16 No concerns, no goals 3 Introducing s o l i d food, the concern mentioned four times, had the highest frequency. Cradle cap, mentioned three times, had the next highest frequency. A l l other concerns were mentioned only once. There were a t o t a l of 16 concerns compared with 44 successes i n infant care giving. Three subjects stated that they had no concerns and established no goals. A l l goals were reached by the second c h i l d health conference. 45 Summary The analysis of the data, characteristics of the experimental and con-t r o l groups, and additional data were presented i n this chapter. The data related to the hypothesis were analyzed using the Student's t-Test for independent samples. This revealed there was no si g n i f i c a n t d i f -ference between the experimental and the control groups posttest mean score on the confidence measure. The hypothesis was rejected. The Sign test indicated the four higher scores i n the control group were s i g n i f i c a n t . There was no s i g n i f i c a n t difference when the signs were compared for the two groups using Chi-square. The Student's t-Test for paired measures and the multifactor analysis of variance showed a s i g n i f i c a n t difference between pretest and posttest scores for both the experimental and control groups. The multifactor analy-s i s of variance showed the s i g n i f i c a n t difference i n the sex of the baby between the experimental and the control groups was not s i g n i f i c a n t l y related to the confidence measure. A description of ind i v i d u a l questions on the instrument which yielded high and low scores followed. The question regarding worry about handling things that might come up i n the future with the c h i l d had the highest score. The question about the mother's closeness to her infant had the low-est scores. Mothers generally f e l t very close to thei r infants. The additional data included l i s t i n g s by frequency of successes i n infant care giving and selected concerns for which goals were established, s e l f reported by the experimental group mothers at the f i r s t interview. Discussion, of findings, implications for nursing practice, recommenda-tions for further research, summary and conclusions are presented i n Chapter V. 46 CHAPTER V FINDINGS, IMPLICATIONS, RECOMMENDATIONS FOR FURTHER RESEARCH, SUMMARY AND CONCLUSIONS Report of Findings The findings w i l l be discussed i n r e l a t i o n to the hypothesis, the d i f -ference i n pretest and posttest scores, c h a r a c t e r i s t i c s of the sample, the confidence measure questions, and the a d d i t i o n a l data. To test the hypo-th e s i s , the experimental and control group posttest and pretest scores were analyzed using the Student's t-Test for independent samples. There was no s i g n i f i c a n t d i f f e r e n c e found between the groups on the confidence measure. The nursing intervention did not make a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e to the mothers' f e e l i n g s of confidence as a parent and infant care giver. Joy et a l . (1980) concluded t h e i r review of p e r i n a t a l education with the observation that s e l f reported maternal confidence does not always corre-spond with behavior. The d i f f e r e n c e between the pretest and posttest scores was analyzed using the Student's t-Test for paired measures and m u l t i f a c t o r analysis of variance. The d i f f e r e n c e was s i g n i f i c a n t for both the experimental and c o n t r o l groups. This would i n d i c a t e maternal confidence increased i n the two-month period between the c h i l d health conferences. Robson and Moss (1970), as stated e a r l i e r , f e e l the mother-infant r e l a t i o n s h i p becomes well established by the t h i r d month of infancy. Mothers i n t h i s study generally reported f e e l i n g very close to t h e i r infants at two months postpartum. I t could have been that confidence increased as the maternal-infant r e l a t i o n -ship became more established. I t may be that the maternal-infant 47 r e l a t i o n s h i p i s c e n t r a l to confidence and emotional f e e l i n g s rather than confidence being c e n t r a l as mentioned by Williams et a l . (1979). Many factors possibly change mothers' feel i n g s of confidence i n care giving. Williams et a l . (1979) suggest the increased f a m i l i a r i t y with the c h i l d during the f i r s t few months could have some e f f e c t on increased con-fidence. C o g n i t i v e - f i e l d theory of learning would appear compatible with the f a m i l i a r i t y suggested by Williams i n that one does not ne c e s s a r i l y learn by doing unless i t contributes to one's change i n cognitive structure. R e a l i z a t i o n of the consequences as well as doing i s necessary for learning to occur. Learning, therefore, i s the r e s u l t of experience (Bigge and Hunt, 1968:446). The learning opportunities for mothers at c h i l d health conferences could have contributed .to increased confidence, but one must be cautious about assuming t h i s . Several of the instructed nurse interviewers found the mothers reacted well to the p o s i t i v e feedback. One began to use t h i s technique on routine postnatal home v i s i t s . In response to the interview, the mothers who were v i s i t e d at home stated they f e l t the nurse to be extremely h e l p f u l . Two of the nurse interviewers claimed they usually used s i m i l a r methods of giving p o s i t i v e feedback. I f t h i s i s true, t h i s might be one reason f o r the experimental and control groups not being s i g n i f i -cantly d i f f e r e n t . One nurse had not thought of giving p o s i t i v e feedback. There was a s i g n i f i c a n t d i f f e r e n c e between the con t r o l and experimental groups for sex of in f a n t , although t h i s was not s i g n i f i c a n t f o r the c o n f i -dence measure when analyzed by analysis of variance. The findings of the high pretest scores when the infant was two months of age, p a r t i c u l a r l y the three highest scores i n the control group, may represent a small group of mothers who need more help than others. Adams 48 (1963) believed that by one month postpartum, mothers had generally solved most of t h e i r d i f f i c u l t i e s . Sumner and F r i t s c h (1977) found c a l l s to the h o s p i t a l regarding infant concerns had dropped d r a s t i c a l l y by s i x weeks postpartum. Findings r e l a t e d to question 21 on the instrument showed a consider-able amount of worry regarding the future with the c h i l d on both the pretest and posttest. This could be at t r i b u t e d to the lack of traces or -memory of past experiences which would be s i g n i f i c a n t i n the future handling of the c h i l d . The other highly scored questions shown (see Appendix E) w i l l be discussed under Implications for Nursing P r a c t i c e . The questions with the lowest scores were regarding the closeness of the mother to the i n f a n t . Mothers reported f e e l i n g very close to t h e i r i n f a n t s . The findings related to areas of concern are f a i r l y consistent with c o g n i t i v e - f i e l d theory of learning. People learn only when they desire to learn (Bigge and Hunt, 1978:447). Some of the experimental subjects did not have any concerns and d i d not wish to set any goals. These mothers did not want assistance with learning at t h i s time. The number of concerns was small with the number of successes much higher i n number. The concerns were s p e c i f i c rather than general, while the successes were more general. C o g n i t i v e - f i e l d theory of learning explains the s p e c i f i c i t y as d i f f e r e n t i a t i o n , the general concern as generalization. Areas that heretofore were vague and unstructured regions of a l i f e space become c o g n i t i v e l y structured and more s p e c i f i c (Bigge, 1976), while other areas which become f a m i l i a r are grouped i n t o concepts or generalized. 49 There were inherent l i m i t a t i o n s to t h i s type of study. The sample was chosen from the c l i e n t e l e of one health unit from i n t a c t family s i t u a t i o n s which l i m i t s the g e n e r a l i z a b i l i t y of the study. The Material discussed i n the interview depended on mothers' s e l f reporting and nurses' adherence to the interview guide. Observation was not used. The interviews took place i n d i f f e r e n t o f f i c e s of the health u n i t , at many d i f f e r e n t times. Because of work commitments, the invest i g a t o r was unable to monitor the interviews. Seasonal changes took place during the data c o l l e c t i o n period. The nurses not instructed for the study continued to provide regular nursing i n t e r -views and interventions f o r the con t r o l group. Nurses instructed f o r the study would not a l l have the same degree of enthusiasm for using the i n t e r -view guide. They were selected by l o t t e r y and did not volunteer. The c o l -l e c t i o n of experimental group data took so long the nurse interviewers could have developed many p o s i t i v e or negative fee l i n g s about the study. They also might have forgotten some of the i n s t r u c t i o n s on the guide, although they did have a copy of i t . While there are l i m i t a t i o n s , the study has brought to the fore some implications for nursing p r a c t i c e . Implications for Nursing P r a c t i c e Public health nurses have many opportunities to help parents with t h e i r learning needs. The findings of t h i s study have implications for public health nursing p r a c t i c e which are: 1. Concerns reported by the sample of primiparous mothers were s p e c i -f i c rather than general at two months postpartum, therefore, c h i l d health 50 conferences should be an e f f e c t i v e way to address the s p e c i f i c concerns of new mothers on a one-to-one basis. 2. The sample of new mothers showed more fe e l i n g s of lowered c o n f i -dence, tiredness, and anxiety at two months postpartum than they did at four months postpartum. Nurses at c h i l d health conferences should be cognizant of t h i s p o s s i b i l i t y when interviewing. 3. The interview with the p o s i t i v e approach was not re l a t e d to any s i g n i f i c a n t change on the confidence measure. Reports by a nurse i n t e r -viewer on the study gave an i n d i c a t i o n that mothers re c e i v i n g the p o s i t i v e approach reported they f e l t they had been helped considerably. Nurses, therefore, should keep i n mind the use of p o s i t i v e feedback when i n t e r -viewing . Recommendations for Further Research Based on the findings of the present study, the following recommenda-tions for further research are made: 1. Further research on d i f f e r e n t methods of interviewing used at c h i l d health conferences with mothers r a t i n g how they f e l t about the help they received. 2. Comparative research of confidence i n mothers r e c e i v i n g well baby care from various sources measured by observations as well as s e l f report-ing. 3. The research could be repeated using a larger sample, a greater degree of i n s t r u c t i o n with observations of the nurse interviewers, and o f f e r i n g the questionnaire once or twice more during the f i r s t postpartum year. 51 Summary The problem i d e n t i f i e d f o r th i s research was that i n order to learn and to continue learning to provide care to t h e i r i n f a n t s , new mothers must have p o s i t i v e feedback and successes i n infant care giving, which i n turn can increase maternal confidence. Confidence i s c l o s e l y r e l a t e d to good maternal-infant r e l a t i o n s h i p s . Nurses can provide p o s i t i v e learning exper-iences which should increase maternal confidence. The study was designed to evaluate the e f f e c t of an interviewing technique on mothers' confidence as a parent and infant care giver. The technique, which focused on primi -parous women's successes i n infant care giving and successes from achieving s e l f selected goals, was evaluated using a confidence measure. A quasi-experimental design was used with a non-synchronized, two group pretest-posttest questionnaire to obtain the data for t e s t i n g the hypothesis. The instrument, a confidence measure, was a questionnaire composed to meas-ure three concepts which are c l o s e l y r e l a t e d . They are maternal confidence i n care giving; maternal-infant, paternal-infant r e l a t i o n s h i p s as viewed by the mother; and p h y s i c a l as well as emotional f e e l i n g s of the mother. The answers were se l f - r e p o r t e d by the subjects. The hypothesis tested for t h i s study was: The mothers i n an experimental group who are encouraged to discuss t h e i r successes i n infant care gi v i n g , w i l l have a s i g n i f i c a n t l y lower post-test t o t a l mean score on a confidence measure than w i l l a c o n t r o l group of mothers who w i l l not be s p e c i f i c a l l y encouraged to discuss successes. The l i t e r a t u r e review included a discussion of c o g n i t i v e - f i e l d theory of learning as the conceptual framework of the study. I t included a d i s -cussion of studies examining the need for p e r i n a t a l education, programs 52 offered i n the prenatal and the postnatal periods, and the r e l a t i o n s h i p of maternal confidence i n infant care giving to mother-infant r e l a t i o n s h i p s . The s e t t i n g for the study was one health unit i n a large, r a p i d l y growing, mainly r e s i d e n t i a l area. The nursing intervention took place at c h i l d health conferences i n three d i f f e r e n t o f f i c e s of the health u n i t . The subjects were 34 primiparous women with healthy babies. Sixteen mothers were i n the control group, eighteen were i n the experimental group. The subjects completed the f i r s t questionnaire when the in f a n t was two months old i n accordance with c h i l d health conference schedules. The sec-ond questionnaire was completed when the infant was four months of age. The f i r s t c ontrol group data were c o l l e c t e d from the mother by the investi g a t o r before the c h i l d health conference. The second were c o l l e c t e d by d i f f e r e n t nurses following the second c h i l d health conference. The experimental data were c o l l e c t e d from the subjects before the c h i l d health conference by f i v e nurse interviewers instructed on how to perform the interventions. They c o l l e c t e d the posttest data following the second c h i l d health conference. The data were c o l l e c t e d over a period of nine months. To test the hypothesis, the data were analyzed using the Student's t-Test f o r independent samples, paired measures, and mu l t i - f a c t o r analysis of variance. Data r e l a t i n g to one c h a r a c t e r i s t i c of the experimental and control groups, differences i n maternal age, were analyzed using the Student's t-Test for independent samples. Data r e l a t i n g to d i f -ferences i n the groups by sex of infant were analyzed using Chi-square test for homogeneity and mul t i f a c t o r analysis of variance f o r e f f e c t on the con-fidence measure. The experimental findings of t h i s study showed no s i g n i f i c a n t d i f f e r -ence between the con t r o l and experimental groups on the confidence measure at an alpha c r i t e r i o n of .05. The hypothesis was rejected. 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Shapiro, Howard I., and Leonore G. Schmitt. "Evaluation of the Psychopro-p h y l a c t i c Method of C h i l d b i r t h i n the Primigravida." Connecticut  Medicine, 37 (July 1973): 341-343. Shaw, Nancy R. "Teaching Young Mothers Their Role." Nursing Outlook, 22 (November 1974): 695-698. Shea, N i l d a , E. H. K l a t s k i n , and E. B. Jackson. "Home Adjustment of Rooming-In and Non-Rooming-In Mothers." The American Journal of  Nursing, 52 (January 1952): 65-71. Sheehan, Franci. "Assessing Postpartum Adjustment." JOGN, 10 (January/ February 1981): 19-23. Shereshefsky, Pauline M., Beatrice Liebenberg, and Robert F. Lockman. "Maternal Adaptation." In Psychological Aspects of a F i r s t Pregnancy  and Early Postnatal Adaptation. Eds. P. M. Shereshefsky and L. J . Yarrow. New York: Raven Press, 1973, pp. 165-180. Smith, Dianne, and Howard L. Smith. "Toward Improvements i n Parenting: A Description of Prenatal and Postpartum Classes with Teaching Guide." JOGN, 7 (November/December 1978): 22-27. Smoyak, S h i r l e y A. "Symposium of Parenting: Introduction." Nursing  C l i n i c s of North America, 12 (September 1977): 447-455. Snyder, Charlene, Sandra J . Eyres, and Kathryn Barnard. "New Findings About Mothers' Antenatal Expectations and Their Relationship to Infant Development." American Journal of Maternal Child Nursing, 4 (November/December 1979): 354-357. Stark, Annette J. "Styles of Health Care Offered to Pregnant Women and Mother-Child Health Outcomes." Ph.D. d i s s e r t a t i o n , ^ U n i v e r s i t y of North Carolina, 1976. S t a t i s t i c a l Package f o r the S o c i a l Sciences. Computer Centre: University of B r i t i s h Columbia, 1980. Sumner, Georgina, and Joseph F r i t s c h . "Postnatal Parental Concerns: The F i r s t S ix Weeks of L i f e . " JOGN, 6 (May/June 1977): 27-32. 60 Svejda, Marilyn J . , Joseph. J . Campos, and Robert N. Emde. "Mother-Infant 'Bonding': F a i l u r e to Generalize." Child Development, 51 (1980): 775-779. Swanson, Jackie. "Nursing Intervention to F a c i l i t a t e Maternal-Infant Attachment." JOGN, 7 (March/April 1978): 35-38. Thompson, Ross, Michael Lamb, and David Estes. " S t a b i l i t y of Infant-Mother Attachment and I t s Relationship to Changing L i f e Circumstances i n an Unselected Middle-Class Sample." Child Development, 53 (1982): 144-148. Thordarson, L., and G. A. Costanzo. "An Evaluation of the Effectiveness of an Educational Program for Expectant Parents." Canadian Journal  of P u b l i c Health, 67 (March/April 1976): 117-121. Timm, Margaret M. "Prenatal Education Evaluation." Nursing Research, 28 (November-December 1979): 338-342. Tocco, T. Salvatore, and Charles M. Bridges. "The Relationship Between the Self-Concepts of Mothers and Their Children." C h i l d Study Journal, 3 (1973): 161-179. Walker, Lorraine. "Providing More Relevant Maternity Services." JOGN, 3 (March/April 1974): 34-36. Williams, C i c e l y D. "Health Services i n the Home." P e d i a t r i c s , 52 (December 1973): 773-781. Williams, Janet K. "Learning Needs of New Parents." American Journal of  Nursing, 77 (July 1977): 1173. Williams, Tannis M., Sheena Davidson, Lesley Joy, and Susan L. Painter. "Parent-Infant Program: F i n a l Report." Vancouver: Department of Psychology, University of B r i t i s h Columbia, 1979. (Mimeographed.) Wilson, Ann L. "Parenting i n Perspective." Family ..and Community Health, I (November 1978): 65-77. Wuerger, Mardelle K. "The Young Adult Stepping Into Parenthood." American  Journal of Nursing, 76 (August 1976): 1283-1285. APPENDIX A NURSING INTERVIEW GUIDE NURSING INTERVIEW GUIDE F i r s t Interview How are things going? What areas do you f e e l good about i n the care of your infant? What other areas have gone well? (Acknowledge successes.) Is there any area of issue you would l i k e to improve on by the next appointment i n two months' time? Could we set a goal together for t h i s area for your next appointment? (Supply information to help achieve t h i s goal. Build on past successes. Write goal out for the mother and one for the chart.) My name i s . I would l i k e to meet with you i n two months' time to discuss t h i s area again. (Recorded on Goal Sheet. See Appendix C.) The baby appears to be doing w e l l . You are doing a good job i n caring for your i n f a n t . Second Interview How are you and the baby? How are you managing with reaching the goal of ? (Give c r e d i t i f goal met. Give c r e d i t f o r attempts to reach the goal.) What other areas do you f e e l good about? Is there any area you would l i k e some assistance with? What would you l i k e to accomplish i n the care of your infant by the next appointment i n two months' time? (Give help to accomplish t h i s goal.) You are doing w e l l i n caring for your in f a n t . APPENDIX B THE CONFIDENCE MEASURE M A T E R N A L - I N F A N T STUDY Name M o t h e r ' s A d d r e s s T e l e p h o n e N o . I n f a n t ' s B i r t h d a t e 65 QUESTIONNAIRE FOR MOTHERS OF INFANTS Instructions: When f i l l i n g out scales, c i r c l e the point which best describes how you f e e l . 1. Although your f e e l i n g s have probably been changing from day to day since you have had the baby at home, how would you say you f e e l now? Very energetic F a i r l y energetic About average fo r me F a i r l y t i r e d Very t i r e d Very anxious F a i r l y anxious About average for me F a i r l y relaxed Very relaxed Very happy F a i r l y happy About average fo r me Somewhat unhappy Very unhappy Very uncomfortable F a i r l y uncomfor table About average for me F a i r l y comfortable Very comfortable Very content F a i r l y content About average for me Somewhat impatient Very Impatient Very depressed Somewhat depressed About average for me Somewhat elated Very elated Very F a i r l y About average Somewhat Very s e l f - c o n f i d e n t s e l f - c o n f i d e n t f o r me unsure unsure 2. How confident do you f e e l about taking care of the baby? Very Moderately: S l i g h t l y S l i g h t l y -Moderately Very confident confident confident unsure unsure unsure 3. How does the baby's father f e e l about taking care of the baby? Very Moderately S l i g h t l y S l i g h t l y Moderately Very confident confident confident unsure unsure unsure 66 4. How would you say feeding has been progressing? Very Moderately S l i g h t Moderate Lots of smoothly smoothly problems problems problems 5. Some parents and babies f e e l close to each other r i g h t away, and some take a while getting acquainted. How close do you f e e l to your baby r i g h t now? Very Moderately S l i g h t l y Moderately S t i l l seems close close d i s t a n t d i s t a n t l i k e a stranger 6. How close does the baby's father f e e l to the baby r i g h t now? Very Moderately S l i g h t l y Moderately S t i l l seems close close d i s t a n t distant l i k e a stranger 7. How close would you say the baby f e e l s toward you r i g h t now? Very Moderately S l i g h t l y Moderately S t i l l treats me close close d i s t a n t d i s t a n t l i k e a stranger 8. How close would the baby's father say the baby f e e l s toward him r i g h t now? Very Moderately S l i g h t l y Moderately S t i l l treats him close close distant d i s t a n t l i k e a stranger 9.. How much of the time are you able to t e l l what your baby needs or wants? Most of the More than Less than Seldom P r a c t i c a l l y time h a l f the time h a l f the time never 10. Do you f i n d i t d i f f i c u l t to quiet the baby down once she/he i s crying or fussing? Very Moderately S l i g h t l y Moderately Very easy easy d i f f i c u l t d i f f i c u l t d i f f i c u l t 67 Some babies seem pretty much the same as they did when they were born; others seem to change quite a b i t during the f i r s t few months. What would you say about your baby? Changed Moderately S l i g h t l y Almost the Seems the a l o t changed changed same^ same 12. For many parents, l i f e with an infant i s a serie s of ups and downs — there are good days and there are bad days. How would you say you are f e e l i n g about your a b i l i t y to cope with l i f e at home these days? (Check one) I usually f e e l that I can handle whatever may come up. I f e e l I can handle things most of the time. I t ' s mixed — some days thing go w e l l , but some days I don't f e e l l i k e coping very w e l l with things. I often f e e l that I am not handling things as well as I might. Most of the time I f e e l unsure of the way I am handling things. 13. Everything considered, how s a t i s f i e d would you say you are with your r e l a t i o n s h i p with your infant? Very s a t i s f i e d S a t i s f i e d Mixed f e e l i n g s D i s s a t i s f i e d Very d i s s a t i s f i e d 68 Please indicate whether you agree or disagree with the following statements by c i r c l i n g the point that best describes your reaction to each statement. 14. I can understand what my baby's needs are. 15. I make the r i g h t decisions about c h i l d rearing and things related to my baby. 16. I think other parents do a better job of bri n g -ing up t h e i r baby than I do with mine. 17. I f e e l confident that I can f u l f i l l my baby's needs. 18. I am content with how warm and af f e c t i o n a t e I am with my c h i l d . 19. I lose confidence when I am faced with a c h i l d -rearing s i t u a t i o n I am not sure how to handle. 20. I f e e l confident i n my a b i l i t y to be a parent. 21. I worry about how I w i l l handle things that might come up with my c h i l d i n the future. 22. I think I am coping w e l l with the demands of having a young baby. 23. I am not as patient with my baby as 1 ought to be. 24. I f e e l I am doing a good job of bringing up my baby. 25. I t bothers me when my opinions about c h i l d -rearing are d i f f e r e n t from those of other parents I know. CU CD S-i Q) OJ QJ 60 0) CJ u n) M CD u QJ 60 CO 60 CO 60 QJ ni •H cd U <CJ U CO P CO 60 60 •H •tH < <rj o a rH rH CU >> a; rH 4-1 rH rH 4-1 rH 60 cd 4-1 4-1 ni 60 a u rC X ! u a o CD 60 60 aj O u T J •H •H u •U o rH rH o 4 J s C/3 CO S C/J X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 69 26. I am not s a t i s f i e d with the goals I have for r a i s i n g my c h i l d . 27. I f e e l confident that I w i l l be able to provide what my c h i l d needs as he or she grows up. 28. I am not as confident and relaxed about handling my c h i l d as I should be 29. When I can't get my baby to do what I want, I lose confidence i n my a b i l i t y to be a good parent. 30. I f e e l I come close to my idea of" the i d e a l parent. (D CD CD fH CD CD (D 60 CD CD U cd u CD fH CD 60 CO 60 CD CD cd •H cd i-i < U CO p CO 60 60 •H >H < >> < p >. p rH rH >. CD CD >. rH •u rH r H 4-1 rH 60 cd •U 4-1 cd 60 S u Xi X ! fH a O CD 60 60 CD O u •H Ti fH 4-1 o rH rH o 4-1 CO CO C*> w X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Please make sure a l l questions are answered. APPENDIX C NURSE INSTRUCTIONS GOAL SHEET 71 EXPLANATION FOR NURSES PARTICIPATING IN THE STUDY I. C r i t e r i a for s e l e c t i o n of the sample i s as follows: a. Primiparous women attending the Child Health Conference f o r the f i r s t time when the infant i s two months old. b. They must speak and understand English. c. The infant must be normal and healthy ( i . e . no apparent abnormality or disease). d. The women must be from i n t a c t family s i t u a t i o n s (married). I I . Explain to the mother the purpose of the study i s to help us t r y to improve the c l i n i c s . The mother has the r i g h t to refuse. Explain that she w i l l have to f i l l i n the questionnaire now and again i n two months'time when she returns f o r the infant's second immunization. Have her sign the consent and give her the Explanation for Mothers. Give the questionnaire to f i l l i n before you interview her. Return the consent and the questionnaire to me. I I I . Use the interview guide when interviewing her. Set a goal or goals with her and write i t on the Goal Sheet which should remain i n the Family Folder. Explain that you would l i k e to see her again at the next appointment. IV. Place a colored s t i c k e r on the outside of the Family Folder with your name on i t to ensure that you w i l l see her at her next appoint-ment. Put a questionnaire i n the Family Folder for use the next time she comes. V. Each nurse w i l l interview four mothers for the study. VI. When the mother returns i n two months' time, use the Goal Sheet to determine whether the goal has been reached. Use the interview guide for this interview. Have the mother f i l l i n the second questionnaire after you have talked to her. Return the question-naire to me with the goal sheet. Remove the sti c k e r from the Family Folder. 73 GOAL SHEET MATERNAL - INFANT STUDY Date Nurse Mother's Name — Infant's B.D. Areas i n Infant Care which are going well: Area where assistance needed: Mutual goal for 2 months hence: Suggested Methods for Reaching Goal: APPENDIX D INFORMED CONSENT EXPLANATION FOR MOTHERS 75 EXPLANATION FOR MOTHERS I am doing research f o r the Boundary Health Unit i n connection with my studies at the Univ e r s i t y of B r i t i s h Columbia on some experiences of new mothers i n the care of t h e i r i n f a n t s . P a r t i c i p a t i o n i n the research w i l l involve f i l l i n g i n a questionnaire today followed by attendance at the c h i l d health conference or Well Baby C l i n i c . I t w i l l also involve f i l l i n g i n the questionnaire again two months from today when you return for your next appointment at the c h i l d health conference. The findings from the study w i l l help us improve our interviews with mothers at the c h i l d health conference. Your name w i l l not be used and s t r i c t c o n f i d e n t i a l i t y w i l l be adhered to. You may refuse at any time to be i n the study without jeopardizing any services from the Boundary Health Unit. I f you are w i l l i n g to p a r t i c i p a t e i n the study please sign the consent form. Please f e e l free to c a l l me i f you have any questions. Home Number -O f f i c e Number -Peggy Pullen INFORMED CONSENT I understand t h i s study w i l l involve answering two questionnaires at the time of attendance at c h i l d health conferences, two months apart, and my i d e n t i t y w i l l remain anonymous. I understand the report of t h i s research w i l l be av a i l a b l e to students and professionals interested i n maternal-child care. I understand I can choose not to p a r t i c i p a t e , to withdraw from the study at any time and that I am free to ask questions at any time. Signature APPENDIX E TABLE OF DESCRIPTIVE STATISTICS 78 TOTALS OF THE MEANS OF QUESTION/SCORES IN THE PRETEST AND POSTTEST FOR THE CONTROL AND EXPERIMENTAL GROUPS Question Question Number Pretest Posttest Pretest Posttest Number Coded Control Control Experimental Experimental 1 2.75, . 2.25 2.5 2.0556 2 2.4375 2.5 2.222 1.9444 3 1.6875 1.375 1.111 1.27778 4 1.9375 2.3125 1.7778 1.4444 5 2,0625 1.875 1.6667 1.55556 6 2.9375 2.687 2.444 2.27778 7 2.5 1.75 2.0556 2.05556 2 8 1.8125 1.25 1.6111 1.3333 3 9 2.125 1.9375 2.2778 2.27778 4 10 1.75 1.75 1.8889 1.5 5 11 1.125 1.0 1.1111 1.0 6 12 1.5 1.25 1.444 1.2778 7 13 1.4375 1.125 1.333 1.1111 8 14 1.75 1.5625 1.889 1.5 9 15 1.4375 1.1875 1.444 1.333 10 16 2.0625 1.75 1.8333 1.6667 11 17 1.8125 1.625 1.944 1.7778 12 18 2.25 1.9375 1.7777 1.6111 13 19 1.4375 1.1875 1.0556 1.05556 14 20 1.9375 1.625 2.0 1.5 15 21 2.1875 1.5625 2.444 1.8333 16 22 1.625 1.625 1.7778 1.8333 17 23 1.5625 1.25 1.27778 1.3333 18 24 1.4375 1.1875 1.222 1.0 19 25 2.9375 2.5625 3.1111 2.66768 20 26 1.375 1.4375 1.2222 1.27778 21 27 3.625 2.875 4.2778 3.6667 22 28 1.625 1.4375 1.4444 1.16667 23 29 2.4375 2.1875 2.5 2.27778 24 30 1.875 1.375 1.16667 1.27778 25 31 2.25 2.6875 2.5 2.16667 26 32 2.0 1.5 1.8889 1.8889 27 33 1.4375 1.8125 1.5556 1.3333 28 34 1.875 1.6875 1.8333 1.38889 29 35 2.437 2.0 2.2222 1.8333 30 36 2.125 2.0 2.1111 1.9444 

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