Mixed methods analysis of participant attrition in the nurse-family partnership

Technology to Augment Early Home Visitation for Child Maltreatment Prevention: A Pragmatic Randomized Trial

Early home visitation (EHV) for child maltreatment prevention is widely adopted but has received inconsistent empirical support. Supplementation with interactive software may facilitate attention to major risk factors and use of evidence-based approaches. We developed eight 20-min computer-delivered modules for use by mothers during the course of EHV. These modules were tested in a randomized trial in which 413 mothers were assigned to software-supplemented e-Parenting Program ( ePP), services as usual (SAU), or community referral conditions, with evaluation at 6 and 12 months. Outcomes included satisfaction, working alliance, EHV retention, child maltreatment, and child maltreatment risk factors. The software was well-received overall. At the 6-month follow-up, working alliance ratings were higher in the ePP condition relative to the SAU condition (Cohen's d = .36, p < .01), with no differences at 12 months. There were no between-group differences in maltreatment or major risk factors at either time point. Despite good acceptability and feasibility, these findings provide limited support for use of this software within EHV. These findings contribute to the mixed results seen across different models of EHV for child maltreatment prevention.

Is the Families First Home Visiting Program Effective in Reducing Child Maltreatment and Improving Child Development?

While home visiting programs are among the most widespread interventions to support at-risk families, there is a paucity of research investigating these programs under real-world conditions. The effectiveness of Families First home visiting (FFHV) was examined for decreasing rates of being in care of child welfare, decreasing hospitalizations for maltreatment-related injuries, and improving child development at school entry. Data for 4,562 children from home visiting and 5,184 comparison children were linked to deidentified administrative health, social services, and education data. FFHV was associated with lower rates of being in care by child's first, second, and third birthday (adjusted risk ratio [aRR] = 0.75, 0.79, and 0.81, respectively) and lower rates of hospitalization for maltreatment-related injuries by third birthday (aRR = 0.59). No differences were found in child development at kindergarten. FFHV should be offered to at-risk families to decrease child maltreatment. Program enhancements are required to improve child development at school entry.

Derivation and Evaluation of a Risk-Scoring Tool to Predict Participant Attrition in a Lifestyle Intervention Project

Participant attrition in clinical trials and community-based interventions is a serious, common, and costly problem. In order to develop a simple predictive scoring system that can quantify the risk of participant attrition in a lifestyle intervention project, we analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), an evidence-based lifestyle intervention to prevent diabetes in 36 American Indian and Alaska Native communities. SDPI-DP participants were randomly divided into a derivation cohort (n = 1600) and a validation cohort (n = 801). Logistic regressions were used to develop a scoring system from the derivation cohort. The discriminatory power and calibration properties of the system were assessed using the validation cohort. Seven independent factors predicted program attrition: gender, age, household income, comorbidity, chronic pain, site's user population size, and average age of site staff. Six factors predicted long-term attrition: gender, age, marital status, chronic pain, site's user population size, and average age of site staff. Each model exhibited moderate to fair discriminatory power (C statistic in the validation set: 0.70 for program attrition, and 0.66 for long-term attrition) and excellent calibration. The resulting scoring system offers a low-technology approach to identify participants at elevated risk for attrition in future similar behavioral modification intervention projects, which may inform appropriate allocation of retention resources. This approach also serves as a model for other efforts to prevent participant attrition.

Understanding change among multi-problem families: Learnings from a formative program assessment

This paper describes the implementation of a long-term voluntary intervention to prevent chronic maltreatment among multi-problem families with histories of child welfare involvement. A small formative evaluation included a limited number of interviews with program participants during the first year of program implementation (n=10), a retrospective case file review (n=17) of closed cases following the first three years of implementation, and notes from ongoing meetings and discussion with program staff. Findings regarding client engagement, long-term interaction between risk and services, and program refinement are discussed. Despite the program's voluntary nature, positive comments from families, and extensive engagement strategies, only about 22% of families remained engaged for the full two-year program. Material hardship was one of the most persistent risk factors from baseline to termination. In many cases, unforeseen negative events occurred that, at least partly, derailed progress. In all cases, progress made was not reflective of a consistent linear process used in the design of most child welfare programs. Implications for program theory and design are discussed.

Evaluation of a Community-Based Approach to Strengthen Retention in Early Childhood Home Visiting

Home visiting (HV) is a strategy for delivering services designed to promote positive parenting and prevent exposure to toxic stress during a critical period of child development. Home visiting programs are voluntary and family engagement and retention in service can influence outcomes. Most participants receive less home visits and for a shorter time than prescribed by evidence-based models. The purpose of this study was to evaluate community-based enrichment of HV (CBE-HV), an approach that was developed and implemented to increase engagement and retention in HV. CBE-HV strategies included (1) community engagement, (2) ancillary supports for families in HV, and (3) enhancements to a HV program. A retrospective, quasi-experimental study was conducted to estimate the effect of CBE-HV on the retention of families in a HV program. Comparisons of study participants were made post-implementation of CBE-HV (n = 2191) and over time (n = 3786)-pre- versus post-CBE-HV implementation in the study communities. The CBE-HV effect was statistically significant and protective (hazards ratio [HR] 0.77, 95 % confidence interval [CI]: 0.67, 0.88), indicating that attrition from HV was 23 % less in the CBE-HV group relative to the post-implementation comparison group. In the temporal comparison of study communities, CBE-HV was also associated with a significantly lower risk of HV attrition (HR: 0.71, 95 % CI: 0.56, 0.89). The study demonstrated that CBE-HV is a promising approach to achieve stronger retention and engagement in HV. Further research is needed to identify the components of CBE-HV approaches that are most effective.

Motivational interviewing competencies among UK family nurse partnership nurses: a process evaluation component of the building blocks trial

Background

Motivational Interviewing (MI) is a person-centred counselling approach to behaviour change which is increasingly being used in public health settings, either as a stand-alone approach or in combination with other structured programmes of health promotion. One example of this is the Family Nurse Partnership (FNP) a licensed, preventative programme for first time mothers under the age of 20, delivered by specialist family nurses who are additionally trained in MI. The Building Blocks trial was an individually randomised controlled trial comparing effectiveness of Family Nurse Partnership when added to usual care compared to usual care alone within 18 sites in England. The aim of this process evaluation component of the trial is to determine the extent to which Motivational Interviewing skills taught to Family Nurse Partnership nurses were used in their home visits with clients.

Methods

Between July 2010 and November 2011, 92 audio-recordings of nurse-client consultations were collected during the ‘pregnancy’ and ‘infancy’ phases of the FNP programme. They were analysed using The Motivational Interviewing Treatment Integrity (MITI) coding system.

Results

A competent level of overall MI adherent practice according to the MITI criteria for ‘global clinician ratings’ was apparent in over 70 % of the consultations. However, on specific behaviours and the MITI-derived practitioner competency variables, there was a large variation in the percentage of recordings in which “beginner proficiency” levels in MI (as defined by the MITI criteria) was achieved, ranging from 73.9 % for the ‘MI adherent behaviour’ variable in the pregnancy phase to 6.7 % for ‘percentage of questions coded as open’ in the infancy phase.

Conclusions

The results suggest that it is possible to deliver a structured programme in an MI-consistent way. However, some of the behaviours regarded as key to MI practice such as the percentage of questions coded as open can be more difficult to achieve in such a context. This is an important consideration for those involved in designing effective structured interventions with an MI-informed approach and wanting to maintain fidelity to both MI and the structured programme.

Trial registration

Current Controlled Trials ISRCTN23019866 Registered 20/4/2009.

Nurse Family Partnership: Comparing Costs per Family in Randomized Trials Versus Scale-Up

The literature that addresses cost differences between randomized trials and full-scale replications is quite sparse. This paper examines how costs differed among three randomized trials and six statewide scale-ups of nurse family partnership (NFP) intensive home visitation to low income first-time mothers. A literature review provided data on pertinent trials. At our request, six well-established programs reported their total expenditures. We adjusted the costs to national prices based on mean hourly wages for registered nurses and then inflated them to 2010 dollars. A centralized data system provided utilization. Replications had fewer home visits per family than trials (25 vs. 31, p = .05), lower costs per client ($8860 vs. $12,398, p = .01), and lower costs per visit ($354 vs. $400, p = .30). Sample size limited the significance of these differences. In this type of labor intensive program, costs probably were lower in scale-up than in randomized trials. Key cost drivers were attrition and the stable caseload size possible in an ongoing program. Our estimates reveal a wide variation in cost per visit across six state programs, which suggests that those planning replications should not expect a simple rule to guide cost estimations for scale-ups. Nevertheless, NFP replications probably achieved some economies of scale.

Cluster Randomized Controlled Trial of Intervention to Increase Participant Retention and Completed Home Visits in the Nurse-Family Partnership

We conducted a cluster-based randomized controlled trial of an intervention designed to improve participant retention in community replication sites of the Nurse-Family Partnership (NFP). We registered 26 sites and randomized them into three groups: retention intervention (RI, N = 9), delayed RI (DRI, N = 6), or control (C, NFP as usual, N = 11). The RI consisted of training nurses to give more explicit control over the frequency of visits and content of the program to the parent participants. Two of the sites assigned to the RI, two assigned to the DRI, and two out of four nurses in one other site assigned to the DRI chose not to participate in the intervention. Primary analyses (intention to treat) contrasted changes in participant retention and completed visits (the primary outcomes) in the two intervention groups (RI and DRI) compared to control sites, focusing on differences in performance among baseline cohorts compared to cohorts enrolled during the first year during which the retention intervention was implemented. Compared to baseline, retention declined in the control sites over time but stayed the same in the RI and DRI sites (p value for interaction = 0.099). Compared to baseline, the number of completed home visits declined over time in the control sites but did not in the RI and DRI sites, producing a significant treatment difference in change in mean completed home visits over time (2.71 visits, SE = 1.164, p = 0.020). The intervention offset a decline over time in retention and completed home visits found in the control group during the time covered by this trial. Quantitative and qualitative evaluation of the intervention indicated that improvements are needed to promote its uptake.

Participant and site characteristics related to participant retention in a diabetes prevention translational project

Using multilevel analysis, this study investigated participant and site characteristics associated with participant retention in a multisite diabetes prevention translational project among American Indian and Alaska Native (AI/AN) people. We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), a lifestyle intervention to prevent diabetes implemented in 36 AI/AN grantee sites. A total of 2,553 participants were recruited and started the intervention between January 1, 2006 and July 31, 2008. They were offered the 16-session Lifestyle Balance Curriculum from the Diabetes Prevention Program (DPP) in the first 16-24 weeks of intervention. Generalized estimating equation models and proportional hazards models with robust standard error estimates were used to evaluate the relationships of participant and site characteristics with retention. As of July 31, 2009, about 50 % of SDPI-DP participants were lost to follow-up. Those who were younger, male, with lower household income, no family support person, and more baseline chronic pain were at higher risk for both short-term and long-term retention failure (i.e., not completing all 16 DPP sessions and loss to follow-up, respectively). Sites with large user populations and younger staff had lower likelihood of retaining participants successfully. Other site characteristics related to higher risk for retention failure included staff rating of participant disinterest in SDPI-DP and barriers to participant transportation and child/elder care. Future translational initiatives need to pay attention to both participant- and site-level factors in order to maximize participant retention.

'It Was Easier Because I Had Help': Mothers' Reflections on the Long-Term Impact of Sustained Nurse Home Visiting

OBJECTIVES

This qualitative descriptive study sought women's views of the Maternal Early Childhood Sustained Home-visiting (MECSH) program they received from prior to birth to child-age 2-years. MECSH is a structured nurse home visiting program for a broad range of women of all ages (both primiparous and multiparous) who experienced stressors in pregnancy that could negatively impact on maternal and child outcomes. Women were asked for their perceptions of how and why the intervention worked for them, and the impact of the intervention on their subsequent parenting to child-age 5-years.

METHODS

Thirty-six women participated in a semi-structured interview when their child commenced formal schooling at age 5-years. Recorded and transcribed data were analysed using qualitative content analysis.

RESULTS

Women described the importance of a positive relationship with the nurse, and nurses' availability and responsiveness as critical to positive impacts. The interventions they recalled receiving were consistent with the comprehensive MECSH program model. The intervention impacted on women's emotional well-being, confidence and help-seeking behaviour, and positively impacted on their parenting of their MECSH program child and their older and subsequent children. A small number of women reported feeling stressed and disconnected from services following program completion, however, most women continued to apply the learnings from the program.

CONCLUSIONS

Overall women reported positive impacts not just for themselves and their parenting abilities during the 2-year intervention program, but also described ongoing benefit to their subsequent parenting in the preschool period.

The role of session zero in successful completion of chronic disease self-management program workshops

BACKGROUND

The Chronic Disease Self-Management Program (CDSMP) has been widely disseminated among various racial and ethnic populations. In addition to the six required CDSMP workshop sessions, the delivery sites have the option to offer a Session Zero (or zero class), an information session offered prior to Session One as a marketing tool. Despite assumptions that a zero class is helpful, little is known about the prevalence of these additional sessions or their impact on retaining participants in CDSMP workshops. This study aims to describe the proportion of CDSMP workshops that offered Session Zero and examine the association between Session Zero and workshop completion rates.

METHODS

Data were analyzed from 80,987 middle-aged and older adults collected during a two-year national dissemination of CDSMP. Generalized estimating equation regression analyses were conducted to assess the association between Session Zero and successful workshop completion (attending four or more of the six workshop sessions).

RESULTS

On average, 21.04% of the participants attended workshops that offered Session Zero, and 75.33% successfully completed the CDSMP workshop. The participants of the workshops that offered Session Zero had significantly higher odds of completing CDSMP workshops than those who were not offered Session Zero (OR = 1.099, P = <0.001) after controlling for participants' demographic characteristics, race, ethnicity, living status, household income, number of chronic conditions, and workshop delivery type.

CONCLUSION

As one of the first studies reporting the importance of an orientation session for participant retention in chronic disease management intervention projects, our findings suggest offering an orientation session may increase participant retention in similar translational efforts.

Patterns of visit attendance in the nurse-family partnership program

OBJECTIVES

We examined visit attendance patterns in the Memphis trial of the Nurse-Family Partnership and associations between these patterns and family characteristics, outcomes, and treatment-control differences in outcomes.

METHODS

We employed repeated measures latent class analysis to identify attendance patterns among the 228 mothers assigned to receive home nurse visits during pregnancy and until the child was aged 2 years, associated background characteristics, outcomes, and treatment-control differences by visit class. Home visits were conducted from June 1990 to March 1994. We collected outcome data from May 1992 to April 1994 and July 2003 to December 2006.

RESULTS

We identified 3 visit attendance patterns. High attenders (48%) had the most visits and good outcomes. Low attenders (33%) had the most education and the best outcomes. Increasing attenders (18%) had the fewest completed visits during pregnancy, the poorest intake characteristics, and the poorest outcomes. Treatment-control group differences varied by class, with high and low attenders having better outcomes on some measures than did their control group counterparts.

CONCLUSIONS

Three patterns were associated with distinct groups of mothers with different long-term outcomes. Further examination and use of patterns to classify mothers and prioritize resources may improve efficiency in the Nurse-Family Partnership.

Quasi-experimental pilot study of intervention to increase participant retention and completed home visits in the nurse-family partnership

We evaluated an intervention to increase participant retention and engagement in community practice settings of the Nurse-Family Partnership (NFP), an evidence-based program of nurse home visiting for low-income, first-time parents. Using a quasi-experimental design (6 intervention and 11 control sites that delivered the NFP), we compared intervention and control sites on retention and number of completed home visits during a 10-month period after the intervention was initiated. Nurses at the five intervention sites were guided in tailoring the frequency, duration, and content of the visits to participants' needs. NFP nurses at the control sites delivered the program as usual. At the intervention sites, participant retention and completed home visits increased from the pre-intervention to intervention periods, while at the control sites, these outcomes decreased from the pre-intervention to intervention periods, leading to a significant intervention-control difference in change in participant retention (hazard ratio, 0.42; p = 0.015) and a 1.4 visit difference in change in completed home visits (p < 0.001, ES = 0.36). We conclude that training nurse home visitors to promote adaptation of program dosage and content to meet families' needs shows promise as a way to improve participant retention and completed home visits.

An examination of prenatal and postpartum depressive symptoms among women served by urban community health centers

We characterized depressive symptoms in the prenatal and/or postpartum periods and examined associated risk factors among 594 women who received care at community health care centers. Women were screened with comprehensive risk assessments, which included the Patient Health Questionnaire-9 depression screen, during pregnancy and at least 4 weeks after delivery. Fifteen percent had depressive symptoms in the prenatal period only; 6 % in the postpartum period only, and 8 % had depressive symptoms in both periods. Risk markers varied for women who reported depressive symptoms at one period only compared with those who reported persistent depressive symptoms. Age (25 years versus younger), having experienced abuse, not living with the infant's father, and cigarette smoking were associated with depressive symptoms at both periods; being US-born, lacking social support, and experiencing food insecurity were associated with reporting symptoms only in the prenatal period, and lack of phone access was associated with risk only in the postpartum period. Our findings confirm the importance of repeated screenings for depressive symptoms during the perinatal period. The variability in risk markers associated with periods of reported depressive symptoms may reflect their varying associations with persistence, new onset, or recovery from depressive symptoms.

Women's reasons for attrition from a nurse home visiting program

OBJECTIVE

To describe mothers' reasons for leaving a home visiting program early.

DESIGN

Qualitative descriptive study using semistructured interviews of mothers who dropped out of the Nurse-Family Partnership (NFP) and two focus groups with nurses and nurse supervisors at an NFP site.

SETTING

A New York State site of a NFP home visitation program for low-income new mothers designed to improve the physical and emotional care of children.

PARTICIPANTS

Participants included 21 mothers, 8 nurses, and 3 nurse-supervisors.

METHODS

Semistructured interviews and focus groups were used to collect data, which were analyzed using content analysis.

RESULTS

The program was not perceived to fit a mother's needs when she was overwhelmed with other responsibilities, the nurse did not meet her expectations, the content was not of interest, or the mother did not desire visits after the infant was born. Nurses and mothers described the need for mothers to have organizational and communication skills, such as keeping track of appointments, calling to reschedule, articulating needs, and asking for assistance. Disruptive external influences included nurse turnover and unstable living situations, including frequent moves and crowded housing. Each of these types of barriers had potential to interact with the others, creating complex combinations of challenges to retention.

CONCLUSION

NFP retention might be improved by reframing program relevance to individual mothers and increasing maternal organizational and communication skill development.

Improving the nurse-family partnership in community practice

BACKGROUND

Evidence-based preventive interventions are rarely final products. They have reached a stage of development that warrant public investment but require additional research and development to strengthen their effects. The Nurse-Family Partnership (NFP), a program of nurse home visiting, is grounded in findings from replicated randomized controlled trials.

OBJECTIVE

Evidence-based programs require replication in accordance with the models tested in the original randomized controlled trials in order to achieve impacts comparable to those found in those trials, and yet they must be changed in order to improve their impacts, given that interventions require continuous improvement. This article provides a framework and illustrations of work our team members have developed to address this tension.

METHODS

Because the NFP is delivered in communities outside of research contexts, we used quantitative and qualitative research to identify challenges with the NFP program model and its implementation, as well as promising approaches for addressing them.

RESULTS

We describe a framework used to address these issues and illustrate its use in improving nurses' skills in retaining participants, reducing closely spaced subsequent pregnancies, responding to intimate partner violence, observing and promoting caregivers' care of their children, addressing parents' mental health problems, classifying families' risks and strengths as a guide for program implementation, and collaborating with indigenous health organizations to adapt and evaluate the program for their populations. We identify common challenges encountered in conducting research in practice settings and translating findings from these studies into ongoing program implementation.

CONCLUSIONS

The conduct of research focused on quality improvement, model improvement, and implementation in NFP practice settings is challenging, but feasible, and holds promise for improving the impact of the NFP.

Building healthy children: evidence-based home visitation integrated with pediatric medical homes

BACKGROUND AND OBJECTIVES

The Building Healthy Children (BHC) collaborative has successfully integrated home visitation into medical care of infants born to young, low-income mothers. Patients receive parenting education, and therapy for parent-child trauma and maternal depression through home visitation. The goals are to avoid child maltreatment, improve parent and child health, and enhance family functioning.

METHODS

This randomized trial tests combining 3 evidence-based services versus screening and referral to community services only. Patients of 3 primary care practices are screened for eligibility (no previous Child Protective Services indication, maternal age <21 at first delivery, and ≤2 children younger than age 3). Treatment families receive Parents as Teachers, child-parent psychotherapy, and interpersonal psychotherapy as needed. Outreach workers assist with concrete needs, including transportation to medical visits. Participant evaluations and reviews of pediatric medical charts are performed at regular intervals. Electronic medical record communications and BHC social workers ensure full integration with the medical home.

RESULTS

Of all eligible families approached, 75% (n = 497) enrolled in BHC and 85% remained enrolled by age 3. At baseline, 37% of mothers were victims of child abuse/neglect, 22% showed significant depressive symptoms, and 59% of children were exposed to domestic violence. Preliminary analyses demonstrate avoidance of indicated Child Protective reports and foster placement and high rates of preventive care for enrolled children.

CONCLUSIONS

BHC offers a unique model of evidence-based home visiting services integrated into primary care. This promising program demonstrates high retention rates and addresses the multidimensional needs of young at-risk families.

Addressing core challenges for the next generation of type 2 translation research and systems: the translation science to population impact (TSci Impact) framework

Evidence-based preventive interventions developed over the past two decades represent great potential for enhancing public health and well-being. Research confirming the limited extent to which these interventions have been broadly and effectively implemented, however, indicates much progress is needed to achieve population-level impact. In part, progress requires Type 2 translation research that investigates the complex processes and systems through which evidence-based interventions are adopted, implemented, and sustained on a large scale, with a strong orientation toward devising empirically-driven strategies for increasing their population impact. In this article, we address two core challenges to the advancement of T2 translation research: (1) building infrastructure and capacity to support systems-oriented scaling up of evidence-based interventions, with well-integrated practice-oriented T2 research, and (2) developing an agenda and improving research methods for advancing T2 translation science. We also summarize a heuristic "Translation Science to Population Impact (TSci Impact) Framework." It articulates key considerations in addressing the core challenges, with three components that represent: (1) four phases of translation functions to be investigated (pre-adoption, adoption, implementation, and sustainability); (2) the multiple contexts in which translation occurs, ranging from community to national levels; and (3) necessary practice and research infrastructure supports. Discussion of the framework addresses the critical roles of practitioner-scientist partnerships and networks, governmental agencies and policies at all levels, plus financing partnerships and structures, all required for both infrastructure development and advances in the science. The article concludes with two sets of recommended action steps that could provide impetus for advancing the next generation of T2 translation science and, in turn, potentially enhance the health and well-being of subsequent generations of youth and families.