Nurse Home Visit Program to Promote Parenting In Brazil: Premises And Planning

This paper aims to analyze the delity of the regarding the planning and the operative framework of the young Mothers Cargivers’


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Background Home Visitation programs, with a focus in the improvement of parenting skills, positively in uence childhood development and family functioning by enabling relationships that are more responsive and sensitive between parents and children. (1,2) Many different home visitation programs around the world which fortify parenting competencies have been proven to be effective, for some relevant outcomes in early childhood, including: maternal health; child health; positive parenting practices, child development and school performance; reduction of child abuse; economic self-su ciency of the family; recognise and use the social services present in the neighborhood; reduction in juvenile delinquency, family violence and crime (3) . There is still a remaining question about the speci c contribution of those programs to the families living in low-and -middleincome countries. (4) The implementation of Home visitation programs with a focus on parenting in developing countries, like Brazil, is recent. Thus, besides the di culties related to the availability of resources to implement these programs, socioeconomic vulnerability of the population creates a complex web of factors that impact child development. (5) Although programs that aim to promote parenting competencies are structured in different forms (concerning frequency of intervention, content of visits, professional training), the home visit (HV) approach is one of the most common forms of offering this kind of intervention (6) . HV is a good choice for programs with a focus on parenting, considering that the effects of parental competencies are seen within families and households (7) . Once the professional is inside the residence, is better to observe up close the socioeconomic reality, see the stimuli offered to the children in the environment, and note the comprehension of health needs (9) . Facing the objectives to building parenting competencies, home visitation programs consider registered nurses as competent professionals for deliver the intervention.
Such professionals forge lasting relationships with the participants and create a foundation of trust (9) , beyond promoting emotional well-being and self-su ciency of the family. (10) The dynamic and contextual nature of HV requires that they be organized based on the balance between the content that needs to be delivered and the exibility that the demands of the home bring. Therefore, knowing the topics discussed during HV and assessing their delity to the objectives of the intervention program are essential to ensure the achievement of results. (11,12) .
When certain themes, that were not initially part of the Home Visitation program's intention, emerge The focus frequently comes like the range of the themes which are not "planned and predicted" by the program's protocol. (13) Given this, adopting strategies to monitor HVs allows to identify the RN's capacity of effectively work with different themes regarding both the individual and the families receiving the intervention. (14) The objective of this study is to describe the content and priorities of prenatal HVs conducted by 3 nurses as part of the analysis of delity of Young Mothers Caregivers Program (YMCP).

Methods
This study on the implementation of a pilot of a home visit program focused on adolescent mothers, analyzed the notes contained in the visit protocol lled out by visiting nurses hired to work in the Young Mothers Caregivers Program. (YMCP). This qualitative and longitudinal study was conducted by the coordinator team of the YMCP as well as pos graduated students, all female researchers from the university and trained in qualitative analysis before. The research team was informed by the YMCP participating in research meetings promoted by the coordinators. The analysis focused documents collected from the Home Visits registers lled by the nurses during (month, years, from 35 participants) and content analysis techniques to examine the frequency and prevalence of words and themes throughout the nurse's notes of prenatal visits of the program.
The protocols, which address the adolescents assisted by YMCP, used as the source for data collection in this study. These protocols contained the records of 390 HVs, representing the total number of visits performed during the prenatal period of 35 participants who remained in the program.
The protocols' records were organized and entered into spreadsheets using the software Excel 2013.
From these worksheets, speci cally the study examined the records referring to the actions that took place during each visit and the actions planned for future visits. These records of actions were analyzed based on the frequency with which they appeared.
The study used content analysis, looking speci cally at recurring themes and using word clouds as a technique, as an analytical strategy to describe and interpret the content of the documents and text analyzed. This assisted with the interpretation of messages and brought a new level of understanding to the data's meaning that goes beyond the literature. The literature describes the process of analyzing content in ve steps: 1) Preparing the information; 2) "Unitization" or transforming content into units; 3) Categorizing or classifying the units into categories; 4) Description; 5) Interpretation (15) .
In this study, the HV records were organized in Excel spreadsheets. Followed by material exploration and categorization into themes, and then processing and interpretation of results. The analysis of the contents of the reports were followed by: rst reading of each report and then were elaborated themes according to the main subject addressed in that action. Each single home visit can generate more than one theme if the nurse describes more than one action to be developed. The themes were extracted during sequential readings of the material, not previously established. The study analyzed the actions that were both planned and executed during the three trimesters of pregnancy, which classi ed as the following: 1st − 6th HV as the rst trimester; 7th to 11th HV as the second trimester; and 12th − 17th HV as the third trimester.
The creation of word clouds utilized as a complement to the thematic analysis. This approach allowed for the visualization of words extracted from the text in a graphic form. In these diagrams, the words with a higher frequency of appearances in the text appear in larger fonts than the other words, thus creating an image of words of various sizes. Word clouds are a useful tool for quantitatively analyzing spoken, written and / or transcribed texts. (16) In this study, wordart.com, one of the free tools for word cloud creation, used with the following con gurations: organization by common English terms and use of a layout with a color scheme.
The utilization of these visualization techniques for qualitative data requires attention to ensure that the qualitative information is not simply reduced and simpli ed to counts of frequency. Thus, it is recommended to include excerpts from the analyzed content to not lose the essence and depth which characterize qualitative research. (16) Description YMCP was part of the pilot stage of the research project, "The Effect of a Home-visitation Program for Young Mothers Regarding Childhood Development", a randomized control clinical trial, which began in August of 2015 and ended in May of 2018, as part of an inter-institutional partnership and nanced in part by development agencies (http://inpd.org.br/?page_id=4062). The study was registered on clinicaltrial.gov with the code NCT02807818 and depended on up to three nurses for its implementation.
YMCP was a pilot initiative using HVs for adolescents between the ages of 14 and 19 who live in a socioeconomically vulnerable situation in the West Zone of the municipality of São Paulo, Brazil. The program's structured axes to promote better development in early childhood are: improving health outcomes; promoting sensitive and responsive relationships (positive parenting); improve domestic environment; strengthen familiar and social net; and improving the individual capabilities to achieve a better integration of the labor market into life. YMCP offered to 40 adolescent rst-time mothers of a low socioeconomic level, from the rst trimester of pregnancy up until the child's second birthday.
The RN received initial training, weekly supervision, and special training in lling out the protocol for the systematization of actions, which especially constructed for the program (17) .
YMCP treated the following axes as guidelines for its approach to young mothers and their family (18) : 1. Health and care: support and stimulate maternal actions aimed at maintaining and improving maternal and child health; 2. Environmental health: help the teenage mother to identify, organize, and use the physical and relational resources that could help her in the care of the child, taking into consideration the different necessities of the development process; 3. Parenting and bond: to help the teenage mother and father of the baby develop knowledge and capabilities to support with con dence the comprehensive health and development of the child; 4. Family and social support: help the teenage mother to understand and manage her relationships with people who are bene cial to the mother and the needs of the child 5. Life course: to help the teenage mother identify relevant goals for her life to increase the opportunities for social and economic independence.
The total frequency of visits planned during pregnancy was up to 17, depending on the date of entry of the mother into the program and/ or her availability to accommodate the visitor.

Results
Reports from 390 HVs delivered for 35 adolescents were analyzed. There were 180 HVs in the rst trimester of pregnancy (1st − 6th HV), 133 HVs in the second trimester of pregnancy (7th to 11th HV); and 77 HVs in the third trimester of pregnancy (12th − 17th HV). There is a clear reduction in the number of visits, which is due to factors such as abandoning the study or lack of availability of the mother. Table 1 presents extracts from the nurses' reports, the number of apparitions and their corresponding categorization. In this table, the sixteen most relevant themes in terms of frequency discussed. Praise 64 "Praise health care." "Praise decrease in cigarette use and recommend cessation." "Praise attachment and behavior change." "Strengthen and praise the ability to communicate." Feelings 46 "Stimulating expression of feelings towards his mother and the care that was offered to him in childhood." "Use dramatization so she can work out better ideas and feelings." "Feeling of solitude to be worked on." "Encourage the pregnant woman to express her feelings regarding the separation of the parents and the absence of the mother in childhood." Attachment 45 "Encourage attachment through communication and caring in the belly." "Improving attachment between pregnant and fetus." "Work attachment using the last performed imaging exam." "Stimulate the current attachment pattern." "Strengthen attachment signs by praising and speaking of importance." Health Care 44 "Investigate prenatal progress and linkage at the health center." "Encourage going to health check for appointment scheduling." "Strengthen selfcare skills with health care guidelines." "Guide folic acid use strategy." Family 17 "Talk to her mother about communication during the visit." "Not feeling comfortable with her mother close at the time of the visit, but she does not have to ask to leave. Try the next one another place to talk. " Empowerment 14 "Strengthen her ability to position herself before her husband, clarifying that her body has its own rhythm and that it concerns her." "Stimulate the expression of your intentions and expectations of being more independent." Doubt 14 "Be available by phone and messages." "Make room for the pregnant woman to bring her doubts." "Be available to clarify doubts." Paternity 8 "Encourage dialogue with the baby's father." "Hold conversations regarding your relationship with the baby's father." "Guidance on the importance of the father of the child in the follow-up of pregnancy." "Investigate and encourage partner participation in prenatal routines." Table 1 For the formation of the word clouds, themes grouped by the gestational trimester corresponding to each participant at the time of the HV in question.

First Trimester
This phase includes the 1st − 6th HV, over the rst three months of the adolescent's participation in the program. At this point, one can see the efforts on the part of the nurse to plan and carry out actions related to the premises of the program. We highlight here a focus on nutrition, life course, and social network. Some actions also relate to the expression of feelings of acceptance of the pregnancy and the development of attachment. At the end of this phase, attitudes of positive reinforcement were observed, with praise directed at behavioral changes -primarily related to reductions in smoking, interpersonal relationships, and self-care.

FIGURE 1
Second Trimester During this phase, which covers the 7th − 11th HV, the nurse elaborates upon themes that introduced earlier on. Nutrition again highlighted as the largest theme concerning the planning of actions, followed by childbirth, and praise. Themes related to feelings (including stress, affection, attachment, family, and relationship with signi cant others) were all approached in detail, primarily because there is by this point a more developed bond with the nurse. Thus, the participant feels more willing to express her feelings.

FIGURE 2
Third Trimester The themes that emerged from the visits preceding the due date focused on preparation for birth. The visitor made themselves available to address concerns and doubts, and breastfeeding was a frequent topic, along with other practical activities. This period also was an opportunity to strengthen the bond between the mother and the baby, through encouraging attachment and the expression of feelings.

Discussion
The ndings show that the themes most prevalent in the planning for future visits related with the program's premises, highlighting the bond among the nurse and the adolescent mother in the program.
The axis "Health care" re ected in actions related to nutrition, expression of feelings, consumption of tobacco, and care with physical health. An emphasis can be seen on actions related to nutrition, primarily regarding weight control and the importance of a healthy diet. This can be understood related to the social vulnerability of the sample that was at risk for malnutrition even previously of the pregnancy. The YMP was based on the assumption that health data could be assessed by the Pregnant Health Booklet lled by health professionals in the public services, proposed at national level. Nevertheless, despite the vulnerability of our population, the proposed schedule was not followed for every pregnant youth. This circumstance created a problem for the nurse visitor to evaluate the physical dimension of pregnancy. However, this action lacks a proper instrument to ensure weight gain during pregnancy. The use of instruments for measuring would allow the possibility to follow the weight gain predicted during pregnancy with greater accuracy. One study, which compared the methods for monitoring weight gain of pregnant adolescents, found that the curve for evaluating the nutritional state of children and adolescents from the Body Mass Index, part of the World Health Organization, is an instrument that is both effective and easy to apply (19) .
The "Environment for health" axis has the objective of helping the mother to identify, comprehend, and use relational resources to adjust home environment to her needs as pregnant. In the program, the actions focused on the suitability of the home environment for the baby's arrival, in the search of residences that were safer, less overcrowded and with no exposure to tobacco, alcohol or psychological pressures. Additionally, frequently mentioned were the search for social assistance resources in situations of unemployment and the shortage of food. Notably, YMCP used the theory of bioecology as a theoretical reference in the construction of its care, which emphasizes the in uence of social, community, and family context on the mother and her decisions, behaviors, and forms of caring for her children (20) .
"Development of Parenting", another premise of YMCP, is also visible in a variety of actions since the beginning and over the pregnancy. Developing positive parenting is one of the most important objectives in home visit programs (3) . Young mothers for the rst time that are especially socioeconomically vulnerable are more prone to drop out of visitation programs before their end, however, involving other members of the family in the visit and addressing issues related to parenting both minimize the chances of dropping out (21) .
Despite the low quantity of actions related to engaging parents in the study, recent initiatives demonstrate the necessity of involving both parents in the home visit and in the course of pregnancy. A review of strategies adopted to improve the engagement father in visitation programs pointed out those mobilizing their needs or expectations a schedule that is more exible to conduct the visit and establish a relationship of trust between the visitor and the father. The study also highlighted a series of bene ts that occur when both parents are involved in the program's activities, such as: better knowledge of child development, personal growth in areas such as anger control and the role of a father, capabilities to manage their relationship with the mother, and connections with opportunities for employment as well as references to other programs that can provide assistance to the Family. (22) There is much evidence that is fundamental to include the father during pregnancy to create the bond for responsive care. (23) The mapping of the "Family and Social Network" was an action developed during pregnancy, which allowed for the reference and elaboration of social resources available to help the pregnant woman and her family. Through the construction of a family tree and an ecomap, one can visualize the family and social network of the pregnant woman that can be utilized when the adolescent nds it to be necessary (24) . Additionally, frequently mentioned were the search for social assistance resources in situations of unemployment and the shortage of food. Notably, YMP used the theory of bioecology as a theoretical reference in the construction of its care, which emphasizes the in uence of social, community, and family context on the mother and her decisions, behaviors, and forms of caring for her children (20) The premise of "Life Project" also approached during the HVs, in order to help the young pregnant to identify goals that would be relevant to her life, by encouraging the continuity of education, the job search, and family planning. Considering the importance of addressing this theme, and given that pregnancy in the teenage years, sometimes is a desire that is involved with many other lack of opportunities that could lead to serious bio-psychological complications for both the mother and child, which then makes them more prone to compromising their optimal development (25) .
While the adolescents assisted by YMCP represent those who tend to have: high social vulnerability, a lack of nancial resources, a precarious family situation, insecure housing, and violence exposure, the themes proposed as premises of the program were successfully addressed during pregnancy. This is in contrast to what occurred in a home-visitation program in Australia, where the challenges of participants with a similar pro le in uenced the delity of the program. In the Australian case, the greater the number of adverse situations, the more compromised was the delity of the program to addressing the planned topics. (26) Another challenge of visitation program is the transformation of family needs into practical and effective actions. The nurse visitor identi es a necessity and plans a course of action; however, articulating this action with reference to the array of services available can be a challenge in terms of making concrete actions. These speci cs highlight a fragility at intersectoral level that is crucial to programs that aim to address the promotion of early childhood development. The evaluation of a visitation program in the United States revealed that the visitor is able to solve the family's immediate needs, such as a shortage of food or exposure to violence, even if this comes at the cost of not following the program's curriculum.
However, the study also describes di culties related to integrating the program with available services within the community, so that the families could be promptly attended. (27) Two themes equally relevant that emerged from the study were praise and availability to address concerns. These topics relate to the bond and relationship established between the visitor and the participant. When there is a relationship of trust between the young mother and the visitor, beyond just bringing about improved results in infantile development, there are also positive impacts on family functioning and parenthood quality (10) . A relationship that is well structured with the visitor, so that they are a trusted person in the woman's life, allows for the visitor to help resolve con icts and encourage the activation of the woman's social network when necessary. (26) It is clear from the reports prepared by the nurses, that the planning of actions was based on interaction and dialogue, in an attempt to apply pre-existing knowledge and re ect on previous experiences. Where there is a learning process, a Freirean perspective, involves motivational and emotional-relational aspects, as well as relationships established centered on an action. In this sense, learning is a re ective process, which involves many different actors and perspectives, in order to produce critical knowledge and meaning, a process that matches the perspective of family-centered care. (28) Conclusion Overall, the study highlights that the themes discussed in the HVs match those proposed by the YMCP. The study con rmed that the majority of actions planned by the visitors in fact realized in the following visit. This is the most important indicator of delity of the actions offered.
The interaction established between the adolescent mother and the visiting nurse is fundamental for care. In this study, the "praise" which appeared as a recurring action undertaken by the nurse could serve as a "facilitator" of the bond and interaction between the adolescent mother and the visiting nurse.
The focus on the premise related to caution with health was extremely evident during the period analyzed (prenatal), and this can be explained by the intense physical changes that the adolescent experiences at this stage, which seem to be "the most important" part of this period. When considering questions like, "how can I care for the baby; who is going to help me when I need to go back to study; should I go back to school or not" among others, these seem to be secondary issues during this phase.
The innovativeness of this study is presenting the potential and limits of structured interventions in a longitudinal context of home-based care. The central question was to verify how the uncertainties of daily domestic life, and its various demands, would interfere with the delivery of the actions planned as part of the YMCP and to what degree the visiting nurse would be able to stay faithful to the premises of the program.
The limitations of the study include that only the protocols during the pregnancy period investigated, even though the duration of the intervention is up to two years of the child's life.
The impact of nursing in this program stems from the theoretical and practical capabilities of the nurse to promote parenting. Thus, this prompts consideration of graduate and post-graduate courses in order to re ect the training they provide in terms of teaching and research.
For the next study, we suggest that the databases are structured and the systems for maintaining records allow for the possibility of evaluating and measuring actions over a longer period.

Conclusions For Practice
The protocols for the HVs should be exible when considering the needs of the families and individuals, especially those that are in a position of high social and economic vulnerability. Beyond this, the HVs should adopt strategies in terms of their approach and intervention that adapt to the reality of the necessities of the families living in certain realities, whether these are social, psychological, or healthrelative. This helps guarantee that the intervention has positive effects for the individual, family, and society. (13)

AVAILABILITY OF DATA AND MATERIAL
The datasets used and/or analyzed during the current study are available from the corresponding author on request.  Figure 1 Themes from home visits during the rst gestational trimester. Sao Paulo, 2020.

Figure 2
Themes from home visits during the second gestational trimester. Sao Paulo, 2020.

Figure 3
Themes from home visits in the third gestational trimester. Sao Paulo, 2020.