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The Video to Recovery: The Effectiveness of Video Interactive Guidance (VIG) Interventions in Improving Parental Mental Health Outcomes
Authors
Emma Louise Bohan and Dr. Aoife McLoughlin
Department of Educational Psychology, Inclusive and Special Education, Mary Immaculate College, South Circular Road, Limerick, Ireland, V94 VN26
All Appendices can be found in the pdf - link at the bottom of the page
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Abstract
A systematic review is presented to answer the review question: how effective are VIG interventions in improving parental mental health outcomes? Five studies (N = 189 participants) published between 2004 and 2017 were examined. The studies included parents who completed a VIG intervention and whose mental health outcomes were measured. Due to the limited research available, both qualitative and quantitative studies were evaluated. Gough’s (2007) Weight of Evidence framework was used to critically appraise the studies on their relevance and quality, in answering the review question. In summary, the studies add to the novel evidence-base, for the effectiveness of VIG interventions in improving parental mental health outcomes. However, these results ought to be interpreted with caution, as only two study designs (randomised controlled trials), were deemed to be the most appropriate in answering the review question. Overall, these findings have worthy implications for future practice and research, particularly the area of educational and child psychology. Educational and child psychologists (ECPs) are expected to understand, recommend and deliver evidence-based psychological interventions. Thus, VIG training may be helpful for ECPs working with vulnerable parents. Future research should review the evidence based on studies of one methodology, so true comparative judgements can be made.
Keywords: systematic review, VIG, parents, mental health
Introduction
Video Interactive Guidance
Video interactive guidance (VIG) is a novel relational intervention, which is typically used with parents or caregivers and young children, as an early intervention approach (Maxwell et al., 2016). According to the Association for Video Interactive Guidance UK (AVIGuk, n.d.), VIG is employed in clinical practice by practitioners from various professional backgrounds, including educational and child psychologists (ECPs), social workers, nurses and support workers, to refer to but a few. The aim of the VIG practitioner is to use video feedback of natural interactions between the child and their parent to enhance communication within their relationship. The intervention of VIG is, in essence, based on a process of change, which commences with the parent seeking support to alter an unfavourable behaviour or attitude. As such, the parent is encouraged to drive this change, through hope for an improved future relationship with their child (AVIGuk, n.d.). The aim is to use video feedback to support the parent and their child to diverge from incongruent interactions to those of a more harmonious and therefore, attuned nature (Doria et al., 2014). In clinical practice, the VIG intervention entails the practitioner recording a minimum of one video of interaction between the child and their parent. Subsequently, an evaluation session is facilitated by the practitioner with the parent, which focuses on a shared review of the video (AVIGuk, n.d.). This evaluation session centres around reflections on the “micro moments of carefully selected elements of successful interaction” (Maxwell et al., 2016, p.7) recorded between the parent and their child (AVIGuk, n.d.).
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Psychological Theory and Empirical Evidence
In terms of theoretical underpinnings, VIG is rooted in the psychological theories of attachment theory (Bowlby, 1969) and social learning theory (Bandura, 1986). Attachment theory (Bowlby, 1969) is defined as the “nature of the infant’s security within their relationship with their parent” (Kennedy et al., 2010, p.60). As such, it is recognised that the relationship lies at the heart of VIG. The aim of VIG is to improve the relationship by increasing parental sensitivity towards the child and promoting attuned relations (Kennedy et al., 2010). There is a developing body of evidence, which argues that VIG is an effective intervention for cultivating a secure attachment between parents and children (Kennedy et al., 2010). For instance, a meta-analysis of 29 studies by Fukkink (2008) has shown significant improvements in parental sensitivity, following a VIG intervention (effect size: 0.49). Moreover, a meta-analysis of 51 studies has suggested that VIG interventions were more effective in fostering attachment (effect size: 0.44), as opposed to other attachment related interventions (Bakermans-Kranenberg et al., 2003). As a result, VIG is recommended as an evidence-based intervention by the National Institute for Health and Care Excellence (NICE) for parents of children experiencing attachment related difficulties (NICE, 2015).
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VIG is also underpinned by social learning theory (Bandura, 1986), which postulates that observing oneself executing a behaviour well, fosters internal attitudes and beliefs of self-efficacy. As such, the aim of VIG is to enhance parental self-efficacy beliefs through the self-modelling aspect of the intervention, as well as, through reflections on the successful moments of interaction. An emerging evidence-base has linked VIG interventions to clinically meaningful improvements in parental behaviours and attitudes (Fukkink, 2008). Moreover, results from a study by Doria et al. (2014) has proposed that VIG has been successful in enhancing parental self-efficacy as well as, parental attitude and behavioural modifications. Within the literature, it is regarded that self-efficacy beliefs are central to mental health and well-being (Dupéré, 2012), which lends us to the next area of discussion; parental mental health.
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Video Interactive Guidance and Parental Mental Health
A variety of parental mental health difficulties, including depression (Murray & Cooper, 1997), borderline personality disorder (Laulik et al., 2013) and schizophrenia (Wan et al., 2008) have been linked to low levels of sensitivity (Kennedy et al., 2017). Therefore, it can be hypothesised that attachment-based interventions, such as VIG, which aim to enhance parental sensitivity, may play a role in the alleviation of mental health difficulties (Kennedy et al., 2017). As such, a limited number of research studies have included measures to explore the effectiveness of VIG in improving parental mental health outcomes, with conflicting results emerging. For instance, results have suggested that VIG is an effective intervention for promoting parental happiness (Doria at al., 2014). Moreover, a randomised controlled trial (RCT) conducted by Hoffenkamp et al. (2014) indicated a significant reduction in withdrawn behaviours for mothers who had experienced a traumatic childbirth, post a VIG intervention. However, this study did not indicate significant improvements in parental stress or postnatal depression. Similarly, a RCT conducted by Barlow et al. (2016) suggested that the delivery of a VIG intervention did not result in improving anxiety, depression, parental stress or post-traumatic stress disorder for preterm parents (parents of an infant born at 32 weeks or less gestation). It can be contended that these contradictory results allude to the need for further research in this area, specifically, to weigh up the mental health outcomes resulting from a VIG intervention.
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Rationale and Relevance to the area of Educational and Child Psychology
A core professional competency of the ECP, as a scientist-practitioner, is to understand, share and apply a critical knowledge of theory and research regarding the effectiveness of psychological interventions, to support mental well-being at a child and familial level (The British Psychological Society, 2019; Jones & Mehr, 2007). While an evidence-base pre-exists for VIG as an effective psychological intervention for attachment related difficulties, there are conflicting outcomes emerging for its effectiveness in improving parental mental health outcomes. As such, this systematic review seeks to evaluate the evidence to determine if VIG interventions may also lend themselves to be helpful interventions in improving mental health outcomes in parents. If so, VIG may be considered, recommended and employed as an evidence-based intervention by ECPs working with parents experiencing mental health and/or attachment related difficulties. Thus, the following review question has been developed.
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Review Question
How effective are VIG interventions in improving parental mental health outcomes?
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Search Strategy
A thorough search of the peer-reviewed literature base was conducted from September 30th, 2020 to December 8th, 2020. The following databases were searched: Academic Search Complete, PsycArticles and SAGE Journals. Keywords pertaining to the review question (see Appendix A, Table 1) were searched and included “parent*” (participants), “VIG” (intervention) and “mental health” (outcomes). The search also included the variety of terms used to refer to the intervention within the literature i.e. “video interaction guidance”, “video interactive guidance” and “VIG”.
The initial search identified 122 articles. The titles of these articles underwent a screening process against the inclusion and exclusion criteria, detailed in Table 2 (Appendix B). Five articles were deemed appropriate for inclusion in this systematic review (see Table 3.1, Appendix C). An overview of the studies is mapped in Table 3.2 (Appendix C). As advised by Liberati et al. (2009), a PRISMA flow diagram is detailed in Figure 1 (Appendix D) to summarise the search process. Appendix E (Table 4.1 and Table 4.2) presents the list of excluded articles as well as the rationale for exclusion.
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Literature Review and Synthesis of Findings
Weight of Evidence Framework
Gough’s (2007) Weight of Evidence (WoE) framework was used to critically appraise the five research studies included in this systematic review, based on their relevance and quality. The WoE framework consists of judgements based on four areas. These relate to the methodological quality of each study (WoE A), the appropriateness of the methodology in relation to the review question (WoE B) and the relevance of the study in relation to the review question (WoE C). Finally, the resulting scores from judgements based on WoE A, B and C are calculated to provide a mean score, which informs the overall WoE (WoE D). WoE D details the degree to which each study provides relevant and quality research evidence, to answer the review question.
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To make judgements based on WoE A, the Gersten et al. (2005) coding protocol (Appendix F) was applied, as two of the studies included in this review were experimental in nature (RCTs). This coding protocol is appropriate as it allows for an appraisal of the methodological quality of quantitative studies. To appraise the RCTs, questions related to essential and desirable quality indicators were employed. Resulting scores from these indicators were summated and rated to inform the overall WoE A rating. Subsequently, the Brantlinger et al. (2005) coding criteria (Appendix G) was applied to evaluate the WoE A for the remaining three qualitative studies. This coding protocol is appropriate as it assesses the methodological quality of qualitative studies, through questions related to credibility measures and quality indicator measures. The credibility and quality indicator measure scores were taken together and calculated to provide a mean score, which informed the overall WoE A score and rating, for all qualitative studies in the review.
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Next, to inform WoE B (Appendix H), all studies were appraised based on the appropriateness of the methodology in relation to the review question. Judgements regarding WoE B were based on Petticrew & Roberts (2003) typology of evidence. This typology of evidence is suitable as it highlights the importance of coordinating research questions to specific types of research designs. As such, the qualitative designs and quantitative designs included in this review were weighted differently. Different weightings were also given depending on measures employed (standardised tests, self-report measures, observations or interviews). Following this, judgements based on WoE C (Appendix I) were applied to each study. These judgements allowed for an evaluation of the studies, based on the relevance of each study in relation to the review question. In doing so, a mean score was calculated based on relevant details provided in each study relating to the participants, intervention and outcome measures. The mean score was used to inform the rating, final score and WoE C descriptor. Finally, WoE A, B & C scores were taken together and calculated to provide a mean score, which informed the overall WoE (WoE D, Table 1).
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Table 1: Overall WoE Rating
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Participants
The review consists of five studies, which were executed from 2004 to 2017. While four of the studies were carried out in the United Kingdom (Barlow et al., 2016; Doria et al., 2014; Kennedy et al., 2017; Tilley & Chambers, 2004), one study was carried out in the Netherlands (Hoffenkamp et al., 2014). All studies adhered to the inclusion criteria (Table 2, Appendix B), which specified that participants must be parents, who have undergone a VIG intervention with their child. In total, the studies included 189 participants, with a sample size range from N = 1 (Kennedy et al., 2017) to N = 150 (Hoffenkamp et al., 2014). Three studies reported a gender imbalance, comprising of participants that were 100% female (mothers) (Doria et al., 2014; Kennedy et al., 2017; Tilley & Chambers, 2004). Barlow et al. (2016) and Hoffenkamp et al. (2014) both examined the effect of the intervention on parents of preterm babies, meaning that comparison across groups may be possible for these two studies. However, as Barlow et al. (2016) study was conducted in the United Kingdom, while Hoffenkamp et al. (2014) study was conducted in the Netherlands, the different cultural norms in both countries may have impacted the results. Thus, it is important to be cognisant of this limitation, when evaluating and comparing the findings from both studies.
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To ensure the relevance of the study in relation to the review question (WoE B, Appendix H), most of the studies included participants with diagnosed mental health difficulties or vulnerabilities, which included anxiety, depression, post-traumatic stress disorder, postnatal depression, borderline personality traits, problems of substance misuse, history of suicide attempts, history of self-harm and history of severe sexual abuse (Barlow et al., 2016; Hoffenkamp et al., 2014; Kennedy et al., 2017; Tilley & Chambers, 2004). One study was included, which did not sufficiently describe the participants’ pre-existing mental health difficulties or vulnerabilities (Doria et al., 2014). This study was included due to the limited scope of studies within this research area and consequently, it was weighted with a low WoE C rating (Appendix I), within the participant domain. Conversely, the highest WoE C ratings were given to studies which included parents with pre-existing mental health difficulties within the clinical range, as evidenced through standardised tests. For example, half of the participants in Barlow et al. (2016) study met the criteria for anxiety and depression at baseline, while one fifth met the criteria for post-traumatic stress disorder. Moreover, in Hoffenkamp et al. (2014) study, 20.7% (N = 31) of mothers presented with having experienced a traumatic childbirth. Medium WoE C ratings were given to studies which included parents with pre-existing mental health difficulties (or vulnerabilities), which were not evidenced through standardised tests, but were described in sufficient detail (Barlow et al., 2016; Kennedy et al., 2017; Tilley & Chambers, 2004).
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Study Design
Two of the studies included in the review conducted RCTs (Barlow et al., 2016; Hoffenkamp et al., 2014), to evaluate the effectiveness of the VIG intervention on parental mental health. Barlow et al.’s (2016) RCT assessed the potential of VIG in increasing parental sensitivity in parents (N = 31 parents) of preterm infants (born at 32 weeks or less gestation) using the CARE-Index as a primary outcome measure of parental sensitivity. Secondary outcomes comprised of parenting stress, depression, anxiety and post-traumatic stress and were measured using validated self-report scales. The data was collected from the intervention and control group at baseline and post-intervention and analysed on an intent-to-treat basis, using analyses of covariance. The results indicated large, however, non-significant differences, favouring the intervention group for parental sensitivity and infant cooperativeness. In addition, there were medium to large non-significant differences favouring the intervention group for depression, anxiety and parenting stress. There was no difference between groups in the cohort of parents with post-traumatic stress. Thus, the researchers concluded that VIG appears to be a promising intervention in improving parental sensitivity in parents of preterm infants, but that extra elements explicitly targeting parental trauma may also be required. Similarly, Hoffenkamp et al.’s (2014) RCT, investigated the efficacy of VIG, adjunct to standard hospital care, for parents (N = 150 families) of preterm infants (25-37 weeks of gestation). The primary outcome was parental interactive behaviour (sensitivity, intrusiveness and withdrawal), as witnessed in video recorded dyadic parent-infant interaction. Secondary outcomes included parental bonding, stress responses and psychological well-being based on self-report. Intervention effects were analysed on an intention-to-treat basis, using multilevel modelling and analyses of covariance. Results indicated that VIG was shown to be effective in improving sensitive behaviour and reducing withdrawn behaviour in mothers and fathers. In contrast to Barlow et al.’s (2016) RCT, the positive effects of VIG were particularly found in mothers who experienced the preterm birth as very traumatic. Overall, the researchers concluded that VIG is a helpful addition to standard hospital care, lessening the potential negative impact of preterm birth on the parent-infant relationship.
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Both studies involved two-armed RCTs and as such, included an intervention group (VIG intervention) and a control group (standard hospital care for parents after preterm birth). Participants were randomly assigned to the treatment or intervention group, using telephone randomisation (Barlow et al., 2016) or computerised random numbers (Hoffenkamp et al., 2014), which is indicative of a truly randomised allocation process (BMJ Best Practice, n.d.-a). As RCTs are considered gold standard when evaluating the effectiveness of research (Petticrew and Roberts, 2003), these studies, therefore, both received a high WoE B rating (Appendix H). By contrast, all qualitative studies (Doria et al., 2014; Kennedy et al., 2017; Tilley & Chambers, 2004) were provided with a low WoE B rating, as qualitative designs are not deemed to be the most appropriate methodology in relation to answering the current review question. Nonetheless, on reflection, the qualitative studies did allow for an exploration into the participants real-lived experiences of VIG, as well as parental perspectives of the factors that contribute to the intervention’s success. The qualitative studies included a grounded theory methodology (Doria et al., 2014), a discourse analysis methodology (Tilley & Chambers, 2004) and a social constructionist approach (Kennedy et al., 2017). In terms of rigour, Tilley & Chambers (2004) provided evidence of triangulation, through use of varied data sources (interviews and video transcripts), in addition to investigator triangulation, through the involvement of several researchers. As such, in terms of WoE A (Appendix G), this aspect of the study was coded as providing medium evidence of triangulation, which was used to inform the overall credibility measures score. The other two studies, however, provided weak evidence of triangulation, inferring limited credibility, when compared to Tilley & Chambers (2004) study. For instance, Doria et al. (2014), solely provided evidence of data triangulation (data collected from therapeutic sessions, interviews and focus groups), while Kennedy et al. (2017), solely provided evidence of theory triangulation from multiple perspectives (therapist and supervisor). In terms of rigour, only one study (Kennedy et al., 2017), provided evidence of researcher reflexivity. This was demonstrated through the application of relational reflexivity, which is an approach employed to socially construct relationships between the therapist and the client (Burnham, 2005). As such, regarding WoE A, this study was coded as providing strong evidence of reflexivity and was summated and averaged with the other credibility measures, to provide an overall score and mean score. Largely, it can be deemed that all qualitative studies included, provided some evidence of methodological rigour (WoE A), through evidence of meeting several credibility and quality measures.
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Intervention
A strength of the current review is that all five studies employed a VIG intervention adhering to the recommended process of delivery, as indicated by the AVIGuk (n.d.). While this enabled a comparison across studies, based on the intervention, a limitation to be cognisant of is that there is no guaranteed consistency between the quality of the delivery. What is more, significant factors such as the role of the relationship have not been documented throughout any of these studies. The trained VIG practitioners detailed in the studies included community health staff (Barlow et al., 2016), hospital staff (Hoffenkamp et al., 2014) a therapist (Kennedy et al., 2017), two academics, one educational psychologist and two social workers (Doria et al., 2014). A critique of Tilley & Chambers (2004) study is that the practitioner demographic information is not detailed. Kennedy et al. (2017) delivered the VIG intervention over 8 sessions and Barlow et al. (2016) delivered the VIG intervention over 5 sessions. These studies, which delivered the greatest number of VIG sessions, received the highest WoE C ratings (Appendix I), as resulting changes in parental mental health outcomes may be indicative of true intervention effect. Tilley & Chambers (2004) did not report on the number of sessions that were provided. As a result, this study was provided with the lowest WoE C rating as it leaves one to question the rigor of the intervention in adhering to the recommended process of delivery (AVIGuk, n.d.). Moreover, in terms of limitations, the lack of information provided regarding the intervention process, means that this study cannot be truly compared with the others in this review. The nature of services provided in the control groups, for both quantitative studies were described (Barlow et al., 2016; Hoffenkamp et al., 2014). As such, both studies received a high WoE A (Appendix F) rating for this criterion within the essential quality indicators.
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Measures
It can be inferred that two quantitative studies, used the most robust measures through the administration of standardised mental health assessments, which demonstrate good psychometric properties (Barlow et al., 2016; Hoffenkamp et al., 2014). Barlow et al., (2016) used the Hospital Anxiety and Depression Scale (Zigmond & Smith, 1983), Parenting Stress Inventory (Terry, 1991) and Primary Care-Post-traumatic Stress Disorder (Prins et al., 2003). These standardised tests were administered at baseline and up to six weeks post-intervention. Moreover, Hoffenkamp et al. (2014) administered the Yale Inventory of Parental Thoughts and Actions (Feldman et al., 1999), Parental Stress Scale: Neonatal Intensive Care Unity (Miles et al., 1993), Edinburgh Postnatal Depression Scale (Cox et al., 1987) and Traumatic Event Scale (Wijma et al., 1997; Soet et al., 2003). These assessments were administered at a range of points including baseline, week one and month one. While not considered to be as robust as standardised tests, Hoffenkamp et al. (2014) also measured parental bonding, stress and psychological well-being through self-report measures (questionnaires), at four points ranging from week one to six months postpartum. Regarding WoE A and C (Appendix F, G & I), the highest weight was given to studies, which employed multiple (three or more) standardised measures of mental health, as it can be alluded that such measures would specifically answer the review question. Moreover, measuring at appropriate times i.e. baseline, in addition to, during or post intervention, can be considered to best capture the effectiveness of the intervention (Gersten et al., 2005). As such, the highest weight was given to studies which administered three or more standardised tests, at two or more measurement occasions. Thus, taken together, Barlow et al. (2016) and Hoffenkamp et al. (2014) both received a high rating within the outcome measures criteria for evaluating WoE A and C.
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Conversely, the qualitative studies (Doria et al., 2014; Kennedy et al., 2017; Tilley & Chambers, 2004) were weighted various ratings in terms of WoE A and C, specifically regarding the credibility of measures. In terms of credibility scores (WoE A), both Doria et al. (2014) and Tilley & Chambers (2004) were rated as providing medium evidence of prolonged field engagement, with both studies employing observations and in-depth interviews, in terms of measures. On the other hand, Kennedy et al. (2017) solely collected data from observations. While Doria et al. (2014) detailed the mean duration of both measures (mean observation time = 23 minutes, mean interview time = 22 minutes), Tilley & Chambers (2004) did not provide information regarding the length of observations or interviews. Thus, the limited credibility of measures employed in this study alluded to the low WoE A rating provided.
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Outcomes
Four studies suggested improvements in parental mental health outcomes following the implementation of the VIG intervention. Doria et al. (2014) suggested improved parental mental health outcomes, indicative through enhanced parental happiness, self-esteem and self-efficacy. Hoffenkamp et al. (2014) inferred a reduction in withdrawn behaviour for mothers who had experienced trauma. Kennedy et al. (2017) alluded to parental recovery in terms of mental well-being. Tilley & Chambers (2004) suggested that the VIG intervention was a helpful and optimistic tool in alleviating maternal postnatal depression. However, of worth to note, three of these studies were qualitative in nature. Accordingly, they were provided with a low WoE B rating (Appendix H), as they are not deemed to be the most appropriate methodology in relation to the review question. In contrast, Hoffenkamp et al. (2014) conducted a RCT, which is considered as gold standard when evaluating the effectiveness of research, as it offers the best evidence of causality (Petticrew & Roberts, 2003; BMJ Best Practice, n.d.-b). As such, this study and the Barlow et al. (2016) study were provided with high WoE B ratings. However, regarding outcomes, the Barlow et al. (2016) study did not suggest any improvements in parental mental health outcomes post VIG intervention. Each study, regarding WoE and outcomes, will be discussed next in more detail.
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While Doria et al. (2014), did not aim to assess the effectiveness of a VIG intervention on parental mental health outcomes, results suggested improvements in happiness, self-esteem and self-efficacy, post intervention. Thus, this study was included in the review, albeit, provided with a low WoE C rating (Appendix I) regarding outcome measures. Through a content analysis of interview transcripts, researchers identified happiness, self-esteem and self-efficacy as the strongest positive outcomes, thus inferring a positive intervention effect on parental mental health. In terms of implications, the findings from this study suggest that VIG has unique and positive contributions to make to the field of family psychotherapy, in terms of improving parental mental health outcomes. However, of worth to note, this study was provided with a low overall WoE D rating (Table 1), in terms of the degree to which it provides evidence in answering the review question.
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Hoffenkamp et al. (2014) evaluated the effectiveness of a VIG intervention in improving parental mental health outcomes, through standardised assessments of parental stress, postnatal depression and maternal trauma. These assessments were administered at a range of points including baseline, week one and month one. No significant intervention effects were revealed in the areas of parental stress and postnatal depression (p > 0.05). However, there was a significant reduction in withdrawn behaviour for a subgroup of mothers who had experienced a traumatic childbirth, post VIG intervention (p = 0.02). This was evidenced through a reduction in detachment and flatness of affect. In terms of implications for practice, this study can be considered to validate the necessity for baseline screenings for maternal trauma, following a preterm birth. Moreover, this study adds to the evidence-base for VIG as an effective intervention in improving parental mental health outcomes, particularly with the subgroup of mothers who have experienced a traumatic childbirth. This study was weighted with a high overall WoE D rating (Table 1). Despite this weighting, it is important to consider that other factors may have contributed to this improvement, such as interrelated biological and psychosocial factors (i.e. infants survival chances, developmental outcomes and future quality of life). Therefore, future research is recommended to further investigate this area and explore whether any improvements are directly attributed to the VIG interventions.
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Kennedy et al. (2017) evaluated the effectiveness of a VIG intervention in improving parental mental health outcomes, using a case study. Through a social constructionist approach, the findings from this study suggested that the shared process of attunement, with the VIG practitioner and parent, was central to parental recovery in terms of improving mental health outcomes. Regarding implications, the findings from this study allude to VIG as an effective intervention for improving parental mental health outcomes. Moreover, the study suggests that in terms of mental health, parents thrive when they form professional and comfortable working relationships with practitioners. This study was provided with a medium overall WoE D rating (Table 1).
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Tilley & Chambers (2004) evaluated the effectiveness of a VIG intervention in improving parental mental health outcomes, specifically, maternal postnatal depression. Results from this study suggested that the process of VIG indicated a minor but important shift in the participants narratives of the self (to create and re-create generative stories of the self). As such, findings give credence to VIG as being a helpful and optimistic intervention to employ with mothers with postnatal depression, inferring the positive implications for practice with this population. Nonetheless, it is imperative to note the overall WoE D rating (low) of this study, in Table 1.
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Barlow et al. (2016) evaluated the effectiveness of the VIG intervention in improving parental mental health, through standardised assessment of anxiety, depression, parental stress and post-traumatic stress disorder. Measurements were completed at baseline and six weeks post VIG intervention. A statistically significant difference was not reported (p > 0.05). However, despite this, the effect sizes ranged from 0.33 for depression (medium effect) to 0.87 for parental stress (large effect), inferring the need for better-powered studies in the future, with regards to sample size. While this study did not report significant improvements in parental mental health outcomes post intervention, it was weighted with a high overall WoE D score (Table 1).
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Reflections, Conclusions and Implications
Reflections on the Process
As first author (ELB), I wanted to offer some reflections on the process of using a systematic review to investigate the efficacy of VIG interventions in improving parental mental health outcomes. Firstly, my research experience to date has predominately centered upon qualitative research. As such, I initially perceived that a systematic review which included both qualitative and quantitative papers would prove challenging to appraise. However, on reflection, using Gough’s (2007) WoE framework provided me with a wholly structured method of making sense of a large body of both qualitative and quantitative information concerning VIG. Accordingly, I believe that the use of this framework quelled my anxieties about the inclusion of quantitative research, by guiding me through the steps of the review for both types of studies. Thus, in sum, Gough’s (2007) framework was helpful in supporting me to systematically use both qualitative and quantitative data to appraise whether or not VIG is an intervention which ‘works’ to improve parental mental health outcomes.
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Secondly, completing this systematic review within the realm of VIG has provided me with a strong theoretical insight into the intervention, as well as the current research and evidence base surrounding VIG. From this, I have been able to cognise the future research areas concerning VIG for my own doctoral research. For instance, having a particular interest in the area of disability, I deem it would be worthwhile to explore whether or not VIG would also lend itself to be a helpful intervention for improving the mental health outcomes of parents of children with disabilities, who are a cohort of parents particularly vulnerable to mental health difficulties (King et al., 1996).
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Conclusions
This review examined the effectiveness of the delivery of a VIG intervention in improving parental mental health outcomes. From the five studies reviewed, it was concluded that two were of high quality (WoE D, Table 1). These studies, which were both RCTs, were conducted by Barlow et al. (2016) and Hoffenkamp et al. (2014). Moreover, as the review has demonstrated, Kennedy et al. (2017) study was of a medium quality, while Doria et al. (2014) and Tilley & Chambers (2004) studies were of low quality, with regards to the review question.
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Results from four of the studies suggest that the delivery of a VIG intervention is effective in improving parental mental health outcomes. For instance, results demonstrated positive outcomes for parents such happiness, self-esteem and self-efficacy (Doria et al. (2014), significant reduction in the withdrawal behaviours of mothers who had experienced a traumatic childbirth (Hoffenkamp et al., 2014) a shared process of attunement with the VIG practitioner, which was deemed central to parental recovery, (Kennedy et al., 2017) and also a minor but important shift in the participant’s narratives of the self, which was alluded to alleviate maternal postnatal depression (Tilley & Chambers, 2004). However, a limitation which must be considered is that three of these studies were qualitative in nature and so, the methodology of these studies was not deemed to be the most appropriate in relation to the review question (WoE B, Appendix H). On the other hand, findings from Hoffenkamp et al. (2014) study can be considered to allude to the effectiveness of VIG in alleviating symptoms of post-traumatic stress disorder. Moreover, this study executed a RCT, which gives credence to the research for employing the most appropriate methodology in relation to the review question. Regarding the final study, no statistically significant difference was evident post intervention, in improving parental mental health outcomes (Barlow et al., 2016).
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To conclude, it can be argued that the studies in the current review add to the novel evidence base, for the effectiveness of VIG interventions in improving parental mental health outcomes. As such, this supports a movement away from the conflicting results, which were discussed earlier in the introduction of this review. However, it is important that these results are interpreted with caution, as it is recognised that only two study designs were deemed to be the most appropriate in answering the review question (Barlow et al., 2016; Hoffenkamp et al., 2014).
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Implications
In terms of future practice implications, the current review lends support to the delivery of VIG interventions to improve parental mental health, as well as attachment related difficulties. This conclusion has worthy practice implications for the area of educational and child psychology. A core professional competency of the ECP, in relation to psychological intervention and evaluation, is to possess a critical knowledge of the theory and research of the effectiveness of psychological interventions at a child and parental level. Moreover, ECPs are expected to deliver such interventions competently, to improve psychological well-being (BPS, 2019). Accordingly, resulting from this review, it may be helpful for ECPs to seek training as a VIG practitioner, so that they can understand, recommend and apply this intervention, with appropriate populations. Training may be particularly helpful for ECPs who are working in settings with parents, who may be at an increased risk of presenting with both mental health and attachment related difficulties i.e. perinatal and postnatal services (Hoffenkamp et al., 2014). What is more, to ensure that VIG interventions are delivered consistently in practice, it may be helpful for AVIGuk to consider the development of an adherence checklist, which includes information on the process of delivery and sections to record information about additional significant factors, such as the role of the relationship between the VIG practitioner and the participant.
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Regarding future research implications, two of the studies included in this review were quantitative in nature, while three were qualitative. As such, true comparison across the experimental and non-experimental groups could not be made (WoE A, Appendix F & G). This can be considered as a key limitation of this review. Therefore, it is recommended that future research seek to review the evidence, based on studies of one methodology, so true comparative judgements can be made. Specifically, in answering the current review question, a review of RCTs would prove most appropriate (Petticrew & Roberts, 2003). In conclusion, this review can be considered to add to the novel evidence-base, for the effectiveness of VIG interventions in improving parental mental health outcomes.
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Corresponding Authors and Details
1. Emma Louise Bohan
Trainee Educational and Child Psychologist (2020-2023)
Department of Educational Psychology, Inclusive and Special Education
Mary Immaculate College, South Circular Road, Limerick, Ireland, V94 VN26
Emmalouisebohan1@gmail.com | 15101711@micstudent.mic.ul.ie
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2. Dr. Aoife McLoughlin (Supervisor)
Teaching Fellow, and First Year Research Coordinator– DECPsy
Department of Educational Psychology, Inclusive and Special Education
Mary Immaculate College, South Circular Road, Limerick, Ireland, V94 VN26
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Declaration of Conflicting Interests
The authors declare that there is no known conflict of interest.
Funding
The authors declare that there is no known conflict of interest.
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