CONTEXTUAL ISSUES FOR IMPLEMENTATION AND EVALUATION OF HOME-VISITATION PROGRAMS FOR AMERICAN INDIAN AND ALASKA NATIVE COMMUNITIES: AN INTRODUCTION TO THE TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING PROGRAM

Engaging Indigenous communities in research to inform practice: The multisite implementation evaluation of Tribal home visiting

Community engagement (CE) is widely acknowledged as a way to enhance the ethics, rigor, and impact of research. Additionally, CE is a demonstrated way to integrate Indigenous and colonial (western) research systems. For these reasons and others, designers of the Multi-site Implementation Evaluation of Tribal Home Visiting (MUSE) used a community-engaged approach to study the implementation of federally funded home-visiting programs across 17 Indigenous communities throughout the United States. This paper describes MUSE's community-engaged approach and its practical applications from the perspective of the MUSE study team. The paper highlights key outcomes attributable to CE, addresses barriers to CE, and details responses to these barriers and their impacts. Adding to the rich evidence base demonstrating the value of community-engaged approaches, MUSE demonstrates that in-depth CE is feasible and valuable in multisite studies done in partnership with Indigenous communities.

Implementation fidelity of the Promoting First Relationships intervention program in a Native community

Promoting First Relationship (PFR) is an evidence-based intervention designed to promote positive, supportive relationships between primary caregivers and their young children. Implementing and testing the efficacy of PFR in a remote Native community is especially challenging and requires methods and tools for ensuring implementation fidelity. Tribal members of a Native community were successfully trained and certified to deliver PFR by university-based personnel. During PFR delivery, they achieved very high scores on adherence to intervention content (M = 0.99, SD = 0.02), and their quality of delivery uniformly exceeded established criteria. High attrition occurred before PFR was delivered. However, participants who remained in the study completed all 10 sessions of PFR content. Participants' satisfaction with the program was very high (M = 3.90 [of 4 points], SD = 0.19). High implementation fidelity was attained in the face of many inherent challenges. The suite of methods and tools used for training, monitoring, and evaluating implementation fidelity in this study provides an example that may be useful in the evaluation of evidence-based programs more generally.

Mobilizing the fourth trimester to improve population health: interventions for postpartum transitions of care

Birthing people in the United States, particularly those from marginalized communities, experience an unexpectedly high rate of morbidity and mortality. Optimal postpartum care is an opportunity to address immediate maternal health concerns while providing a connection to further high-value primary care. However, postpartum care in the United States is fragmented and incomplete. In response to this failure, the American College of Obstetricians and Gynecologists has called for obstetricians to develop individualized care plans that facilitate transitions from obstetrical to primary care after delivery. In this clinical opinion, we review previous interventions that have aimed to increase postpartum care engagement and bridge gaps in care. Although numerous interventions have been trialed, few have been both successful and scalable. We provide recommendations on ways to reimagine equitable and effective postpartum care interventions with multidisciplinary collaboration.

Development of an Electronic Screening and Brief Intervention to Address Perinatal Substance Use in Home Visiting: Qualitative User-Centered Approach

BACKGROUND

Perinatal substance use (SU) is prevalent during pregnancy and the postpartum period and may increase the risks to maternal and child health. Many pregnant and postpartum women do not seek treatment for SU because of fear of child removal. Home visiting (HV), a voluntary supportive program for high-risk families during the perinatal period, is a promising avenue for addressing unmet SU needs. Confidential delivery of screening and brief intervention (BI) for SU via computers has demonstrated high user satisfaction among pregnant and postpartum women as well as efficacy in reducing perinatal SU. This study describes the development of the electronic screening and BI for HV (e-SBI-HV), a digital screening and BI program that is adapted from an existing electronic screening and BI (e-SBI) for perinatal SU and tailored to the HV context.

OBJECTIVE

This study aimed to describe the user-centered intervention development process that informed the adaptation of the original e-SBI into the e-SBI-HV, present specific themes extracted from the user-centered design process that directly informed the e-SBI-HV prototype and describe the e-SBI-HV prototype.

METHODS

Adaptation of the original e-SBI into the e-SBI-HV followed a user-centered design process that included 2 phases of interviews with home visitors and clients. The first phase focused on adaptation and the second phase focused on refinement. Themes were extracted from the interviews using inductive coding methods and systematically used to inform e-SBI-HV adaptations. Participants included 17 home visitors and 7 clients across 3 Healthy Families America programs in New Jersey.

RESULTS

The e-SBI-HV is based on an existing e-SBI for perinatal SU that includes screening participants for SU followed by a brief motivational intervention. On the basis of the themes extracted from the user-centered design process, the original e-SBI was adapted to address population-specific motivating factors, address co-occurring problems, address concerns about confidentiality, acknowledge fear of child protective services, capitalize on the home visitor-client relationship, and provide information about SU treatment while acknowledging that many clients prefer not to access the formal treatment system. The full e-SBI-HV prototype included 2 digital intervention sessions and home visitor facilitation protocols.

CONCLUSIONS

This study describes a user-centered approach for adapting an existing e-SBI for SU for use in the HV context. Despite the described challenges, home visitors and clients generally reacted favorably to the e-SBI-HV, noting that it has the potential to fill a significant gap in HV services. If proven effective, the e-SBI-HV could provide a way for clients to receive help with SU within HV, while maintaining their privacy and avoiding the overburdening of home visitors. The next step in this study would be to test the feasibility and preliminary efficacy of the e-SBI-HV.

Service Coordination to Address Maternal Mental Health, Partner Violence, and Substance Use: Findings from a National Survey of Home Visiting Programs

Maternal risks such as poor mental health, partner violence, and substance misuse can undermine child health and development. Maternal and early childhood home visiting programs address these risks primarily through referral and coordination with community-based services, yet effects on these outcomes have been small. This study assessed the strengths of local home visiting sites' systems to support coordination of mental health, partner violence, and substance use services. Investigators recruited home visiting sites (N = 88) representing diverse models from a national practice-based research network, the Home Visiting Applied Research Collaborative (HARC). Web-based surveys assessed five implementation system supports for coordination and nine coordination activities drawn from the Measurement Framework for Coordination developed earlier in the project. Surveys also assessed seven coordination barriers identified in previous research. Sites varied in their implementation supports and coordination activities; on average, sites had stronger systems in place to support screening and referring families than to support linkage and follow-up. Implementation supports and activity scores were higher for mental health and partner violence than for substance use. Across all service needs, scores were highest for offering a referral and documenting the caregiver's agreement for exchange of information between providers. Scores were lowest for offering a warm handoff. Lack of open slots and lack of transportation were major barriers to successful coordination for all three services. Results suggest that home visiting coordination could be strengthened by focusing on infrastructure for linkage and follow-up with services in the broader system of care.

Stress and Cardiometabolic Disease Risk for Indigenous Populations throughout the Lifespan

BACKGROUND

Indigenous people experience the greatest cardiometabolic disease disparity in the Unites States, yet high cardiometabolic disease risk factors do not fully explain the extent of the cardiometabolic disease disparity for Indigenous people. Stress, trauma, and racism occur at high rates within Indigenous communities and have not been well explored as significant contributors to cardiometabolic disease disparities despite emerging literature, and therefore will be described here.

METHODS

This descriptive study explores the relationship between cardiometabolic disease risks and Indigenous-specific stressors (e.g., early childhood stress and trauma, adulthood stress and trauma, and historical and intergenerational trauma) using current literature. Indigenous-specific protective factors against cardiometabolic disease are also reviewed.

RESULTS

Increasing research indicates that there is a relationship between Indigenous-specific stressful and traumatic life experiences and increased cardiometabolic disease risk. Mental health and psychophysiology play an important role in this relationship. Effective interventions to reduce cardiometabolic disease risk in Indigenous communities focus on ameliorating the negative effects of these stressors through the use of culturally specific health behaviors and activities.

CONCLUSIONS

There is increasing evidence that cultural connection and enculturation are protective factors for cardiometabolic disease, and may be galvanized through Indigenous-led training, research, and policy change.

Promoting First Relationships®: Implementing a Home Visiting Research Program in Two American Indian Communities

BACKGROUND

Few, if any, home visiting programs for children under the age of three have been culturally adapted for American Indian reservation settings. We recently adapted one such program: Promoting First Relationships®.

OBJECTIVES

To culturally adapt Promoting First Relationships® while maintaining program fidelity, we used a community-based participatory approach to elicit input from two American Indian partners.

METHODS

University-based researchers, reservation-based Native project staff, and Native tribal liaisons conducted collaborative meetings, conference calls, and focus groups to adapt Promoting First Relationships® to reflect local community needs and values.

LESSONS LEARNED

Working closely with onsite Native project staff, being flexible and open to suggestions, and attending to the logistical needs of the community are imperative to developing and implementing adaptations.

CONCLUSIONS

Several adaptations were made based on the collaboration between researchers and Native project staff. Collaboration is critical for adapting programs so they can be tested in ways that respect both American Indian culture and research needs.

CONTEXTUAL ISSUES FOR IMPLEMENTATION AND EVALUATION OF HOME-VISITATION PROGRAMS FOR AMERICAN INDIAN AND ALASKA NATIVE COMMUNITIES: AN INTRODUCTION TO THE TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING PROGRAM

Home-visiting programs have become a key component of evidence-based services for pregnant women, new mothers, their infants, and their families. When Congress authorized the Maternal Infant and Early Childhood Home Visiting Program (MIECHV) in 2010, it set aside 3% of the $1.5 billion in funding to support home-visiting programs operated by tribes, Tribal MIECHV programs have been funded in 14 states and have served over 3,100 families, providing nearly 55,000 home visits to families at risk for poor child, maternal, and family outcomes. In this Introduction to the Special Issue of the Infant Mental Health Journal on the Tribal MIECHV initiative, we provide some key contexts of the work of the Tribal MIECHV grantees as well as an overview of the issues covered in the other articles.