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

A Qualitative Inquiry into Nurse-Family Partnership Black Client Perspectives

Nurse-Family Partnership (NFP) is a home visiting program designed to improve pregnancy outcomes, child health and development, and life course outcomes for families facing socioeconomic inequalities through support and education provided by nurses to first-time mothers during pregnancy and up to 2 years postpartum. Studies show that home visiting programs like NFP have positive outcomes, but attrition remains a concern which may impact the desired health equity goals. Black mothers are more likely to withdraw from the NFP program, and research is lacking regarding their experiences in home visiting programs despite facing maternal health inequities rooted in racism. The present study aimed to understand factors that influenced program continuation and provide insights for program improvement. Semi-structured qualitative interviews were conducted with 21 Black NFP clients from multiple sites. Key findings include the importance of the nurse-client relationship, access to reliable health information, and racial concordance in the nurse-client pairing. Clients valued supportive, nonjudgmental nurses who provided dependable support and education. Racially concordant partnerships were perceived as more comfortable and understanding, fostering trust and open communication. Clients also suggested that invasion of privacy during home visits and a lack of connection with their nurse could contribute to program discontinuation. Efforts to increase program retention of Black clients should focus on fostering a strong nurse-client alliance. Recommendations include increasing racial diversity in the nurse workforce, implementing a nurse-client matching system, and allowing clients to request a new nurse if needed.

Maintaining Family Engagement During Home Visitor Turnover: a Mixed Methods Study of Best Practices

Evidence-based home visiting services (EBHV) are available in states and localities nationwide through the federally-funded Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. Nevertheless, the anticipated benefits of EBHV, such as improved child developmental outcomes and increased positive parenting practices, may be undermined by the fact that most families withdraw from services earlier than the model developers planned. Prior studies have linked family attrition with staff turnover. The current study used a mixed methods design to investigate the conditions under which families remained active in the home visiting program after their assigned home visitor resigned. Coincidence Analysis revealed that giving families advance notice (at least 1 month) prior to the home visitors' upcoming resignation or developing a strong positive working alliance with the inheriting home visitor appears to independently make a difference for ongoing family engagement at 3 and 6 months following a staff transition. These findings suggest that emphasizing how staff turnover is managed may mitigate the risk of family withdrawal during these transitions.

What contributes to the long-term implementation of an evidence-based early childhood intervention: a qualitative study from Germany

Background

Rigorous research trials have demonstrated that early childhood interventions can reach socially disadvantaged families and can have a lasting impact on the healthy development of their children. However, little is known about the internal and contextual factors that contribute to the long-term implementation of such interventions. In this study, we investigated the development of the home visiting program Pro Kind. The program was adapted from the evidence-based US-American Nurse-Family Partnership program and was implemented in Germany in 2006. Using an exploratory approach, we examined factors contributing to the long-term implementation of this program.

Methods

Qualitative interviews with program implementers (midwives, social workers, program managers) of the Pro Kind program and key stakeholders in two cities in Germany were conducted. Interview guides were developed to assess participants' perceptions and experiences on how the program had developed over time internally and in the interaction with its environment. Data were collected between March and September 2021. Drawing on the Consolidated Framework for Implementation Research (CFIR), data was coded according to the principles of thematic analysis.

Results

A total of 25 individuals (11 program implementers, 14 key stakeholders) were interviewed. The identified factors related to three out of five domains of the CFIR model in our analysis. First, regarding the intervention characteristics, the evidence of effectiveness and the relative advantage of the implementation of the program compared to similar interventions were viewed as contributors to long-term implementation. However, the program's adaptability was discussed as a constraining factor for reaching the target group. Second, concerning the inner setting, stakeholders and program implementers perceived the implementation climate, the leadership engagement and the program's size as relevant factors for networking strategies and program visibility. Third, as part of the outer setting, the degree of networking with external stakeholders was highlighted of great importance for the program.

Conclusions

We identified several factors of particular importance for the long-term implementation and sustainability of an early childhood intervention at the practice level, particularly in the local context in Germany. These findings should inform the design of impactful, scalable, and sustainable early childhood interventions targeting disadvantaged families.

"This has changed me to be a better mum": A qualitative study exploring how the Australian Nurse-Family Partnership Program contributes to the development of First Nations women's self-efficacy

BACKGROUND

The Australian Nurse-Family Partnership Program is based on the Nurse-Family Partnership program from the United States, which was designed to support first-time mothers experiencing social and economic disadvantage from early in pregnancy until their child's second birthday. International trials have demonstrated this program measurably improves family environment, maternal competencies, and child development. The Australian program has been tailored for mothers having a First Nations baby.

AIM

This study aimed to understand how the program impacts self-efficacy using a qualitative interpretive approach.

METHODS

The study took place in two sites within one Aboriginal Community Controlled Health Service in Meanjin (Brisbane), Australia. Twenty-nine participants were interviewed: first-time mothers having a First Nations baby who had accessed the program (n = 26), their family members (n = 1), and First Nations Elders (n = 2). Interviews were conducted either face-to-face or by telephone, using a yarning tool and method, to explore women's experiences and perceptions. Yarns were analysed using reflexive thematic analysis.

FINDINGS

Three main themes were generated: 1) sustaining connections and relationships; 2) developing self-belief and personal skills; and 3) achieving transformation and growth. We interpret that when the program facilitates the development of culturally safe relationships with staff and peers, it enables behaviour change, skill development, personal goal setting and achievement, leading to self-efficacy.

DISCUSSION

Located within a community-controlled health service, the program can foster cultural connection, peer support and access to health and social services; all contributing to self-efficacy.

CONCLUSION

We recommend the program indicators are strengthened to reflect these findings and enable monitoring and reporting of activities that facilitate self-efficacy, growth, and empowerment.

Equitable reach: Patient and professional recommendations for interventions to prevent perinatal depression and anxiety

OBJECTIVE

Perinatal depression and anxiety are the most common complications in the perinatal period and disproportionately affect those experiencing economic marginalization. Fewer than 15% of individuals at risk for perinatal depression are referred for preventative counseling. The goal of this study was to elicit patient and perinatal care professionals' perspectives on how to increase the reach of interventions to prevent perinatal depression and anxiety among economically marginalized individuals.

METHODS

We conducted qualitative interviews with perinatal individuals with lived experience of perinatal depression and/or anxiety who were experiencing economic marginalization (n = 12) and perinatal care professionals and paraprofessionals (e.g., obstetrician/gynecologists, midwives, doulas; n = 12) serving this population. Three study team members engaged a "a coding consensus, co-occurrence, and comparison," approach to code interviews.

RESULTS

Perinatal individuals and professionals identified prevention intervention delivery approaches and content to facilitate equitable reach for individuals who are economically marginalized. Factors influential included availability of mental health counselors, facilitation of prevention interventions by a trusted professional, digital health options, and options for mental health intervention delivery approaches. Content that was perceived as increasing equitable intervention reach included emphasizing stigma reduction, using cultural humility and inclusive materials, and content personalization.

CONCLUSIONS

Leveraging varied options for mental health intervention delivery approaches and content could reach perinatal individuals experiencing economic marginalization and address resource considerations associated with preventative interventions.

Cross-sector Collaboration Between Public Health, Healthcare and Social Services Improves Retention: Findings from a Nurse Home Visiting Program

The study aimed to examine the association between cross-sector collaboration in Nurse-Family Partnership (NFP), a model home visiting program, and participant retention. We used the 2018 NFP Collaboration Survey that measured agency-level collaboration, operationalized as relational coordination and structural integration, among nine community provider types (including obstetrics care, substance use treatment, child welfare). This dataset was linked to 2014-2018 NFP program implementation data (n = 36,900). We used random-intercept models with nurse-level random effects to examine the associations between provider-specific collaborations and participant retention adjusting for client, nurse, and agency characteristics. The adjusted models suggest that stronger relational coordination between nurses and substance use treatment providers (OR:1.177, 95% CI: 1.09-1.26) and greater structural integration with child welfare (OR: 1.062, CI: 1.04-1.09) were positively associated with participant retention at birth. Stronger structural integration between other home visiting programs and supplemental nutrition for women, infants, and children was negatively associated with participant retention at birth (OR: 0.985, CI: 0.97-0.99). Structural integration with child welfare remained significantly associated with participant retention at 12-month postpartum (OR: 1.032, CI: 1.01-1.05). In terms of client-level characteristics, clients who were unmarried, African-American, or visited by nurses who ceased NFP employment prior to their infant's birth were more likely to drop out of the NFP program. Older clients and high school graduates were more likely to remain in NFP. Visits by a nurse with a master's degree, agency rurality, and healthcare systems that implement the program were associated with participant retention. Cross-sector collaboration in a home visiting setting that bridges healthcare and addresses social determinants of health has potential to improve participant retention. This study sets the groundwork for future research to explore the implications of collaborative activities between preventive services and community providers.

Tiered Universal and Targeted Early Childhood Interventions: Enhancing Attendance Across Families with Varying Needs

This study examined whether a two-tiered parenting program, which provides universal primary prevention along with targeted secondary prevention only for families with increased needs, would have mutually beneficial impacts on attendance across two program components. A secondary analysis of the Smart Beginnings (SB) randomized controlled trial was conducted. SB takes place from birth to age 3 and combines universal delivery of the Video Interaction Project (VIP) with targeted delivery of the Family Check-Up (FCU) for families identified as having increased risks following yearly screening. The current study analyzed whether attendance in VIP in the first six months was associated with FCU attendance for eligible families at six months, and whether FCU attendance at six and 18 months was associated with subsequent VIP attendance. Analyses included logistic and mixed-effects Poisson regression, as well as group-based trajectory analysis. VIP attendance predicted later FCU attendance (AOR = 5.43, p < .01), and FCU attendance predicted later VIP attendance (IRR = 1.35, p < .01) and a high-stable VIP attendance trajectory (AOR=14.98, p < .01). Findings provide strong support for the ability of tiered models to engage parents, to promote effective and efficient service delivery to reduce disparities in school readiness, and their potential to overcome common barriers to attendance and scaling by addressing the heterogeneity of risk among low-income families.

Pilot test of a measure to assess clients' perceptions of their home visitors

Home visiting services for caregivers of infants and young children have been found to be an effective method for promoting child development. Unfortunately, such services suffer from high rates of attrition, suggesting the need to identify factors related to client retention in services. Research has indicated that the client-provider relationship is an important predictor of client retention in home visiting services; however, measures to assess this relationship are limited. This study reports on a pilot test of the Client Perceptions of Home Visitors Questionnaire, developed to assess home visiting clients' perceptions of their relationship with their home visitor. The measure was completed by 39 diverse home visiting clients during pregnancy in a midwestern town in the United States. The scale was found to have good internal consistency. Validity analyses found that the scale was positively associated with client satisfaction with services and perceived provider cultural sensitivity. The scale was also positively associated with retention in services at an 8-month follow-up. Additional research should examine the measure's psychometrics with larger samples.

Tailoring Perinatal Health Communication: Centering the Voices of Mothers at Risk for Maternal Mortality and Morbidity

The United States has the highest maternal mortality rate of any industrialized country. According to the Centers for Disease Control, Black women die at 2-3 times the rate of white women, and the infant mortality rate in the U.S. is 2.5 times higher than their White counterparts. Maternal and child health programs, such as Healthy Start, are an important gateway to increasing awareness, education, and referral to perinatal care and mental health services. This paper explored mothers' perceptions of the importance of health and healthcare during pregnancy and postpartum and their preferences for communication from a community-based service program, such as Healthy Start. Data were collected from four focus groups with 29 expectant or current mothers. Most participants (57.7%) identify as Black or African American. They age from 24 to 43 with a mean of 31.7. We analyzed the data using the thematic analysis approach. Themes that emerged supported an overall desire for inclusive, strength-based educational materials. Use of advocacy-based health educational materials, materials that show diverse and realistic images of mothers, peer-based education through testimonials, and health education materials that are easy to understand and apply to one's own experience emerged as the broad theme from the focus groups.

Does customised care improve satisfaction and positively enable parents in sustained home visiting for mothers and children experiencing adversity?

Background

The Maternal Early Childhood Sustained Home-visiting program (MECSH) is a structured nurse-delivered program designed to address health inequities experienced by families experiencing significant adversity. There is strong evidence for the effectiveness of this program, but limited research exploring the practice and process elements that are core to positive parent outcomes. This study aimed to examine the relationship between customised care related to the mother’s risk factors and parent satisfaction and enablement in the delivery of a MECSH-based program.

Methods

A cross-sectional study design was used. Program delivery data collected as part of a large randomised controlled trial of a MECSH-based sustained nurse home visiting program in Australia (right@home) were analysed. This study used the data collected from the intervention arm in the trial (n = 352 women). Parent satisfaction was measured at child age 24 months using the modified short-form Patient Satisfaction Questionnaire. Parent enablement was measured at child age 24 months by a modified Parent Enablement Index. Customised care was defined as appropriate provision of care content in response to four maternal risks: smoking, mental health, domestic violence and alcohol and drugs. Logistic analysis was performed to assess the impact of customised care on parent satisfaction and enablement while adjusting for covariates such as sociodemographic factors. A significance level of 95% was applied for analysis.

Results

Our results indicated high levels of satisfaction with the care provided and positive enablement. There were several sociodemographic factors associated with satisfaction and enablement, such as language spoken at home and employment experience. The mothers who received customised care in response to mental health risk and domestic violence had significantly greater satisfaction with the care provided and experienced an increase in enablement compared to those who did not receive such care.

Conclusion

This study contributes to the existing body of empirical research that examines the relationship between care processes and client outcomes in the delivery of home visiting services. It is essential for the sustained nurse home visiting service model to be flexible enough to cater for variations according to family circumstances and needs while maintaining a core of evidence-based practice.

Using mixed-methods in evidence-based nursing: a scoping review guided by a socio-ecological perspective

Background

Increased pressure for evidence-based practice in nursing necessitates that researchers use effective approaches. Mixed-methods research (MMR) has potential to improve the knowledge and implementation of evidence-based nursing (EBN) by generating outcome-based and contextually-focused evidence.

Aims

To identify methodological trends in how MMR is used in EBN research.

Methods

Searches were completed in PubMed, CINAHL, and Google Scholar using the terms "nursing", "mixed-methods", and "evidence-based". Seventy-two articles using MMR to address EBN and published 2000-2021 were reviewed across content themes and methodological domains of the Socio-Ecological Framework for MMR.

Results

Mixed-methods research has been used to study how EBN strategies are perceived, developed and assessed, and implemented or evaluated. A few studies provided an MMR definition reflecting the methods perspective, and the dominant MMR rationale was gaining a comprehensive understanding of the issue. The leading design was concurrent, and half of studies intersected MMR with evaluation, action/participatory, and/or case-study approaches. Research quality was primarily assessed using criteria specific to quantitative and qualitative approaches.

Conclusions

Mixed-methods research has great potential to enhance EBN research by generating more clinically useful findings and helping nurses understand how to identify and implement the best available research evidence in practice.

Expert-generated standard practice elements for evidence-based home visiting programs using a Delphi process

BACKGROUND

States, territories, non-profits, and tribes are eligible to obtain federal funding to implement federally endorsed evidence-based home visiting programs. This represents a massive success in translational science, with $400 million a year allocated to these implementation efforts. This legislation also requires that 3% of this annual funding be allocated to tribal entities implementing home visiting in their communities. However, implementing stakeholders face challenges with selecting which program is best for their desired outcomes and context. Moreover, recent reviews have indicated that when implemented in practice and delivered at scale, many evidence-based home visiting programs fail to replicate the retention rates and effects achieved during clinical trials. To inform program implementers and better identify the active ingredients in home visiting programs that drive significant impacts, we aimed to develop an expert derived consensus taxonomy on the elements used in home visiting practice that are essential to priority outcome domains.

METHODS

We convened a panel of 16 experts representing researchers, model representatives, and program implementers using a Delphi approach. We first elicited standard practice elements (SPEs) using open-ended inquiry, then compared these elements to behavior change techniques (BCTs) given their general importance in the field of home visiting; and finally rated their importance to 10 outcome domains.

RESULTS

Our process identified 48 SPEs derived from the panel, with 83 additional BCTs added based on the literature. Six SPEs, mostly related to home visitor characteristics and skills, were rated essential across all outcome domains. Fifty-three of the 83 BCTs were rated unnecessary across all outcome domains.

CONCLUSIONS

This work represents the first step in a consensus-grounded taxonomy of techniques and strategies necessary for home visiting programs and provides a framework for future hypothesis testing and replication studies.

Towards precision home visiting: results at six months postpartum from a randomized pilot implementation trial to assess the feasibility of a precision approach to Family Spirit

Background

Shared implementation challenges at scale in early childhood home visiting have led researchers to explore precision home visiting as a promising service delivery mechanism to better address families’ unique needs and build greater program efficiencies. This randomized controlled pilot study aimed to assess the acceptability of a precision approach to one home visiting model, Family Spirit® and explore potential differences between Precision Family Spirit (PFS) and Standard Family Spirit (Standard FS) on participant-home visitor relationship and maternal outcomes.

Methods

Participants (N = 60) were at least 14 years old, pregnant or within 2 months postpartum, and enrolled in Family Spirit. Four sites in Michigan were randomized 1:1 to deliver PFS (up to 17 core lessons plus up to 13 additional lessons as needed) or Standard FS (home visiting services as usual). Primary (program acceptability, participant satisfaction, home visitor-participant relationship quality, retention, adherence) and secondary (knowledge, quality of life, difficulty with parenting problems, substance use, depression, stress) outcomes at 6 months postpartum are presented. PFS participants also self-reported on quality of life, difficulty with parenting problems, stress, substance use, and concerns with sexual and reproductive health and self and child’s nutrition status at each home visit. This informed which lessons they should receive.

Results

Mothers in both groups reported positive program acceptability, satisfaction, and home visitor-participant relationships at 6 months postpartum. However, open-ended feedback from Standard FS participants indicates that some lesson content may not be applicable to all participants. At 6 months, retention was 82.3% for PFS and 66.7% for Standard FS, and adherence was 30.1% for PFS and 20.6% for Standard FS.

Conclusions

Preliminary findings indicate that precision home visiting may be acceptable and feasible. A definitive trial is needed to build on this pilot data, assess outcomes for mothers and children participating in a precision approach to home visiting as compared to standard home visiting, and ready this approach for scale.

Trial registration

ClinicalTrials.govNCT03975530 (first posted on 05/06/2019).

Home visitor perspectives on implementing a precision approach to home visiting in communities serving Native American families

Family Spirit (FS) is a federally endorsed evidence-based home visiting programs serving as a key prevention strategy for expectant families and families with young children. Like other home-visiting programs, it shares client challenges in retention and engagement during implementation. We assessed (1) the feasibility and acceptability of implementing a precision approach to FS; and (2) differences in approaches to FS delivery. Home visitors, serving primarily Native American families, that delivered a standard (N = 6) or a precision approach (N = 6) to FS across four study sites each participated in up to four virtual focus group discussions (FGDs) (N = 16). Facilitators and barriers to implementation were identified across the curriculum approach, relational and contextual levels. Facilitators: Relevant and culturally sensitive lessons, lesson structure, client-home visitor relationship, client buy-in, home visitor autonomy, leadership support, flexible funding, and training. Barriers: Irrelevant lessons, substance use content, missing topics, families experiencing crises, client and home visitor availability, client feedback, nonsupportive leadership, inadequate funding, and organizational policies and practices. The precision approach offers (1) tailoring of lessons that supports relevance of content to clients; and (2) a target timeframe that supports flexibility in lesson delivery. This model structure may improve client participation and retention.

Relationship-Based Home Visiting Services for Families Affected by Substance Use Disorders: A Qualitative Study

Home visiting programs face many challenges when providing evidence-based services to families affected by substance use disorders (SUDs). We conducted interviews and focus groups with community stakeholders and parents to elucidate important considerations when intentionally attempting to meet the needs of families affected by SUDs through home visiting programs. We identified one primary theme "Who is the client?" that describes how to ensure caregivers perceive themselves as an important focus of the program. Collectively, participants revealed that understanding caregivers' emotional experiences was critical for effectively transforming their subjective experiences of the program. These emotional experiences were related to the quality of their relationships with their children, other family members, and service providers. Three sub-themes illustrate specific examples: 1) responding to the unique emotional needs of mothers in recovery, 2) considering emotional states to inform inclusion in programs, and 3) addressing complex family dynamics related to SUDs in the home. Implications of these findings are discussed.

Electronic Screening and Brief Intervention to Address Perinatal Substance Use in Home Visiting: A Qualitative Description of Intervention Development (Preprint)

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.

Public health nurses' perceptions of their interactions with child protection services when supporting socioeconomically disadvantaged young mothers in British Columbia, Canada

BACKGROUND

Children of girls and young women experiencing socioeconomic disadvantage are at risk of maltreatment and associated health and developmental problems. Nurse-Family Partnership (NFP) is an early intervention program designed to improve child and maternal health outcomes. The effectiveness of NFP is being evaluated in British Columbia (BC) through a randomized controlled trial, augmented by a process evaluation to identify influences on how NFP was implemented.

OBJECTIVE

To describe how public health nurses providing NFP perceived their interactions with child protection professionals.

PARTICIPANTS AND SETTING

Forty-seven public health nurses across BC.

METHODS

The principles of interpretive description informed the qualitative component of the process evaluation. Data from interviews and focus groups were analyzed using the framework analysis approach. A thematic framework was generated through processes of coding, charting and mapping, with a focus on organizational and systems influences.

RESULTS

Nurses' practice in supporting families often involved engagement with child protection services. Four themes about the nature of this work were identified: 1) developing a deeper understanding of the disciplinary perspectives of child protection, 2) striving for strengthened collaboration, 3) navigating change and uncertainty, and 4) responding to family and community complexity.

CONCLUSIONS

Participants valued the contribution of child protection professionals and expressed willingness to collaborate to support families. However, collaboration was constrained by multiple structural barriers. Collaborative models offer possibilities for integrated practice, although can be difficult to implement within current health and child protection systems and child protection regulatory contexts.

Characteristics Associated with Participant Attrition and Retention in a Perinatal Home Visiting Program

Using data from the Florida Maternal, Infant, and Early Childhood Home Visiting (MIECHV) funded programs, we examined program- and participant-level characteristics associated with participant retention by time of enrollment. Analyses of data for 1,807 women enrolled in 11 sites across three years included descriptive statistics; Kaplan-Meier survival curve estimation and multilevel survival analyses using shared frailty model to assess participant- and program-level characteristics overall and by time of enrollment (during pregnancy or post-delivery). Median retention time for MIECHV participants was 462 days. The primary reason for attrition was loss-to-follow-up (59.4%) due to change of address/telephone. We found participant age > 25 years (compared to < 20 years), enrollment during pregnancy, and an average of 1.5-2.0 home visit/month to be protective, while current/history of substance abuse was a risk factor for attrition. To improve participant retention, the Florida MIECHV program may need to bolster efforts to support housing stability, increase outreach and engagement to younger women, address barriers to achieving two home visits per month throughout the program, and target differential predictors of participant attrition depending on time of enrollment.

Improving interagency service integration of the Australian Nurse Family Partnership Program for First Nations women and babies: a qualitative study

Background

The Australian Nurse Family Partnership Program (ANFPP) is an evidence-based, home visiting program that offers health education, guidance, social and emotional support to first-time mothers having Aboriginal and/or Torres Strait Islander (First Nations) babies. The community-controlled sector identified the need for specialised support for first time mothers due to the inequalities in birthing and early childhood outcomes between First Nations’ and other babies in Australia. The program is based on the United States’ Nurse Family Partnership program which has improved long-term health outcomes and life trajectories for mothers and children. International implementation of the Nurse Family Partnership program has identified interagency service integration as key to program recruitment, retention, and efficacy. How the ANFPP integrates with other services in an Australian urban setting and how to improve this is not yet known. Our research explores the barriers and enablers to interagency service integration for the Australian Nurse Family Partnership Program ANFPP in an urban setting.

Methods

A qualitative study using individual and group interviews. Purposive and snowball sampling was used to recruit clients, staff (internal and external to the program), Elders and family members. Interviews were conducted using a culturally appropriate ‘yarning’ method with clients, families and Elders and semi-structured interview guide for staff. Interviews were audio-recorded and transcribed prior to reflexive thematic analysis.

Results

Seventy-six participants were interviewed: 26 clients, 47 staff and 3 Elders/family members. Three themes were identified as barriers and three as enablers. Barriers: 1) confusion around program scope, 2) duplication of care, and 3) tensions over ‘ownership’ of clients. Enablers (existing and potential): 1) knowledge and promotion of the program; 2) cultural safety; and 3) case coordination, co-location and partnership forums.

Conclusion

Effective service integration is essential to maximise access and acceptability of the ANFPP; we provide practical recommendations to improve service integration in this context.

Prenatal and Infancy Home Visiting in Germany: 7-Year Outcomes of a Randomized Trial

OBJECTIVES

Given the lasting positive effects of prenatal and infancy home visiting in the United States on disadvantaged mothers and children at school age, we analyzed the follow-up effects of a German home visiting program (ProKind). We hypothesized improvements in 3 domains at child age 7 years: (1) child development and life satisfaction, (2) maternal mental health and life satisfaction, and (3) adverse parenting, abusive parenting, and neglectful parenting.

METHODS

We conducted a randomized controlled trial of home visiting, enrolling 755 pregnant, low-income women with no previous live births. The intervention comprised 32.7 home visits by family midwives and/or social pedagogues until child age 2 years. Assessments were completed on 533 7-year-old firstborn offspring to evaluate 8 primary hypotheses.

RESULTS

We found significant positive effects for 4 of the 8 primary hypotheses. Mothers in the intervention group reported fewer behavioral problems among their children in the Child Behavior Checklist (effect size [ES] = 0.21; 95% confidence interval [CI]: 0.03 to 0.38), less child abusive parenting (ES = 0.19; 95% CI: 0.00 to 0.37), fewer maternal mental health problems (ES = 0.25; 95% CI: 0.07 to 0.43), and higher maternal life satisfaction (ES = 0.25; 95% CI: 0.07 to 0.43). Additional preregistered subgroup analyses regarding child sex revealed larger effects for boys and mothers of boys.

CONCLUSIONS

The results suggest that in a western European welfare state, home visiting targeting disadvantaged mothers has lasting effects in important outcome domains. Therefore, home visits also appear to be an effective and efficient public health intervention in European settings.

A Qualitative Study of Mothers' Perspectives on Enrolling and Engaging in an Evidence-Based Nurse Home Visiting Program

Prevention programs like Nurse-Family Partnership® (NFP) must enroll and retain clients of the intended population to maximize program impact. NFP is an evidence-based nurse home visitation program shown in randomized trials to improve maternal and child health and life course outcomes for first-time parents experiencing economic adversity, particularly for mothers with limited psychological resources. The purpose of this study was to understand enrollment and engagement experiences of mothers with previous live births referred to NFP in a formative study of the program for this population, but did not enroll or dropped out before program graduation. We used a grounded theory approach and purposively selected three NFP sites with variation in enrollment rates. We conducted telephone interviews with 23 mothers who were either referred to NFP and declined enrollment or former clients who dropped out before graduation. All interviews were conducted in English, recorded, transcribed, and validated. We developed an iterative codebook with multiple coders to analyze our data in NVivo11 and wrote thematic memos to synthesize data across study sites. Mothers described experiencing overlapping risk factors including physical and behavioral health conditions, child welfare involvement, and housing insecurity. Mothers from all sites discussed how they were referred to the NFP program, their experience of the enrollment process, reasons for enrolling or not enrolling, and reasons for dropping out after initial enrollment. Key themes that influenced mothers' decision-making were: perceptions of program value, not needing the program, their living situation or being too busy as a deterrence, and past experiences including a distrust of health care. Reasons for attrition were related to no longer needing the service, being assigned a new nurse, being too tired postpartum, and moving out of the service area. One way to support home visiting nurses in family enrollment and engagement is to build their professional capacity to implement trauma-informed strategies given mothers' life experiences.

Instructive roles and supportive relationships: client perspectives of their engagement with community health workers in a rural south African home visiting program

Background

Community health worker (CHW) programs have been positioned as a way to meet the needs of those who experience marginalization and inequitable access to health care, and current global health narratives also emphasize their adaptable nature to meet growing health burdens in low-income settings. However, as CHW programs adopt more technical roles, the value of CHWs in building relationships with clients tends to be overlooked. More importantly, these programs are often reframed and redeployed without attending to the interests and needs of program clients themselves. We set out to gather perspectives of program and CHW engagement from clients of a maternal and child health program in rural South Africa.

Methods

We conducted 26 interviews with pregnant or recently-delivered clients of the Enable Mentor Mother program between February–March 2018. After obtaining informed consent, a trained research assistant conducted all interviews in the clients’ home language, isiXhosa. Interviews, translated and transcribed into English, were organized and coded using ATLAS.ti software and thematically analyzed.

Results

We found that clients’ home-based interactions with Mentor Mothers were generally positive, and that these engagements were characterized by two core themes, instructive roles and supportive relationships.. Instructive roles facilitated the transfer of knowledge and uptake of new information for behavior change. Relationships were developed within the home visit setting, but also extended beyond routine visits, especially when clients required further instrumental support. Clients further discussed a sense of agency gained through these interactions, even in cases where they chose not to, or were unable to, heed their Mentor Mother’s advice.

Conclusions

These findings highlight the important roles that CHWs can assume in providing both instructive and supportive care to clients; as deepening relationships may be key for encouraging behavior change, these findings pinpoint the need to bolster training and support for CHWs in similar programs. They also emphasize the importance of integrating more channels for client feedback into existing programs, to ensure that clients’ voices are heard and accounted for in shaping ongoing engagement within the communities in which these programs operate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-020-01377-z.

Precision Family Spirit: a pilot randomized implementation trial of a precision home visiting approach with families in Michigan-trial rationale and study protocol

Background

Home visiting is a well-supported strategy for addressing maternal and child health disparities. However, evidence-based models generally share implementation challenges at scale, including engagement and retention of families. Precision home visiting may address this issue. This paper describes the first known pilot randomized implementation trial of a precision home visiting approach vs. standard implementation. Primary aims are to: 1) explore the acceptability and feasibility of a precision approach to home visiting and 2) examine the difference between Standard Family Spirit and Precision Family Spirit on participants’ program satisfaction, client-home visitor relationship, goal alliance, and the impact of these factors on participant engagement and retention. Secondary aims are to explore potential differences on maternal behavioral and mental health outcomes and child development outcomes to inform sample size estimations for a fully powered study.

Methods

This is a pilot Hybrid Type 3 implementation trial. Four Michigan communities primarily serving the Native American families and already using Family Spirit were randomized by site to receive Standard Family Spirit or Precision Family Spirit. Participants include N = 60 mothers at least 14 years of age (pregnant or with a newborn < 2 months of age) currently enrolled in Family Spirit. Precision Family Spirit participants receive core lessons plus additional lessons based on needs identified at baseline and that emerge during the trial. Control mothers receive the standard sequence of Family Spirit lessons. Data is collected at baseline (< 2 months postpartum), and 2, 6, and 12 months postpartum. All Precision Family Spirit participants are invited to complete qualitative interviews at study midpoint and endpoint. All home visitors are invited to participate in focus groups between study midpoint and endpoint. Exploratory data analysis will assess feasibility, acceptability, client-home visitor relationship, retention, adherence, and potential differences in intervention outcomes.

Discussion

This trial will provide new information about the acceptability and feasibility of precision home visiting and pilot data on program satisfaction, client-home visitor relationship, goal alliance, retention, and targeted maternal-child intervention outcomes. Findings will inform the design of a fully powered randomized implementation trial of precision vs. standard home visiting.

Trial registration

ClinicalTrials.gov #NCT03975530; Registered on June 5, 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-020-00753-4.

Sociodemographic and Psychosocial Predictors of VIP Attendance in Smart Beginnings Through 6 Months: Effectively Targeting At-Risk Mothers in Early Visits

Past research on predictors of participation in early childhood parenting programs suggest that families experiencing higher levels of sociodemographic adversity (e.g., younger maternal age, single parenthood, lower income or education) are less likely to participate in parenting programs. This is significant, as it may indicate that those most in need of additional support are the least likely to receive it. Data from a randomized control trial (RCT) of Smart Beginnings, an integrated, tiered model for school readiness, were used to explore predictors of attendance in Video Interaction Project (VIP) through 6 months. VIP is a primary preventive intervention delivered in tandem with pediatric well-child visits, aimed at reducing income-based disparities in early child development through promotion of responsive parent-child interactions. Using Poisson distribution models (N = 403; treatment arm, n = 201), we find that demographic, socioeconomic status (SES), and psychosocial variables are associated with program attendance but not always in the expected direction. While analyses show that first-time mothers have higher levels of program attendance as expected, we find that less-educated mothers and those with lower parenting self-efficacy have higher levels of attendance as well. The latter findings may imply that the VIP intervention is, by some indicators, effectively targeting families who are more challenging to engage and retain. Implications for pediatric-based interventions with population-level accessibility are discussed.

Best Practices for Engaging Pregnant and Postpartum Women at Risk of Substance Use in Longitudinal Research Studies: a Qualitative Examination of Participant Preferences

There are significant barriers in engaging pregnant and postpartum women that are considered high-risk (e.g., those experiencing substance use and/or substance use disorders (SUD)) into longitudinal research studies. To improve recruitment and retention of this population in studies spanning from the prenatal period to middle childhood, it is imperative to determine ways to improve key research engagement factors. The current manuscript uses a qualitative approach to determine important factors related to recruiting, enrolling, and retaining high-risk pregnant and postpartum women. The current sample included 41 high-risk women who participated in focus groups or individual interviews. All interviews were analyzed to identify broad themes related to engaging high-risk pregnant and parenting women in a 10-year longitudinal research project. Themes were organized into key engagement factors related to the following: (1) recruitment strategies, (2) enrollment, and (3) retention of high-risk pregnant and parenting women in longitudinal research studies. Results indicated recruitment strategies related to ideal recruitment locations, material, and who should share research study information with high-risk participants. Related to enrollment, key areas disclosed focused on enrollment decision-making, factors that create interest in joining a research project, and barriers to joining a longitudinal research study. With regard to retention, themes focused on supports needed to stay in research, barriers to staying in research, and best ways to stay in contact with high-risk participants. Overall, the current qualitative data provide preliminary data that enhance the understanding of a continuum of factors that impact engagement of high-risk pregnant and postpartum women in longitudinal research with current results indicating the need to prioritize recruitment, enrollment, and retention strategies in order to effectively engage vulnerable populations in research.

"The hardest job you will ever love": Nurse recruitment, retention, and turnover in the Nurse-Family Partnership program in British Columbia, Canada

Background

Nurse turnover is a significant issue and complex challenge for all healthcare sectors and is exacerbated by a global nursing shortage. Nurse-Family Partnership is a community health program for first-time pregnant and parenting girls and young women living in situations of social and economic disadvantage. In Canada, this program is delivered exclusively by public health nurses and only within a research context. The aim of this article is to explore and describe factors that contribute to recruitment, retention, and turnover of public health nurses delivering Nurse-Family Partnership in British Columbia, Canada between 2013 and 2018.

Methods

Interpretive description was used to guide sampling, data collection and analytic decisions in this qualitative component drawn from the British Columbia Healthy Connections Project mixed methods process evaluation. Semi-structured, individual interviews were conducted with 28 public health nurses who practiced in and then exited Nurse-Family Partnership.

Results

Nurses were motivated to join this program because they wanted to deliver an evidence-based program for vulnerable young mothers that fit with their personal and professional philosophies and offered nurse autonomy. Access to program resources attracted nursing staff, while delivering a program that prioritizes maintaining relationships and emphasizes client successes was a positive work experience. Opportunities for ongoing professional development/ education, strong team connections, and working at full-scope of nursing practice were significant reasons for nurses to remain in Nurse-Family Partnership. Personal circumstances (retirement, family/health needs, relocation, career advancement) were the most frequently cited reasons leading to turnover. Other factors included: involuntary reasons, organizational and program factors, and geographical factors.

Conclusions

Public health organizations that deliver Nurse-Family Partnership may find aspects of job embeddedness theory useful for developing strategies for supporting recruitment and retention and reducing nurse turnover. Hiring nurses who are the right fit for this type of program may be a useful approach to increasing nurse retention. Fostering a culture of connectivity through team development along with supportive and communicative supervision are important factors associated with retention and may decrease turnover. Many involuntary/external factors were specific to being in a study environment. Program, organizational, and geographical factors affecting nurse turnover are modifiable.

Strengthening the Power of Evidence-Based Prevention in Cooperative Extension: A Capacity-Building Framework for Translation Science-Driven Behavioral Health

Background

Translation science entails application of information gained through scientific research to practices intended to improve prevention and public health. The outreach arm of Land-Grant Universities—the Cooperative Extension System—is uniquely poised to facilitate this translation process and contribute to resolution of current substance misuse and other behavioral health issues.

Objective

This paper summarizes selected literatures that guided the conceptualization of a framework for building Extension’s capacity to enhance the translation process, in order to better address substance misuse and other behavioral health issues.

Method

Peer-reviewed literature was obtained from journals representing varied disciplines including medicine, public health, education, and psychology. Journals for Extension professionals were a prominent source of relevant literature. The literature review informed the identification of relevant practice gaps, barriers in addressing those gaps, and the development of a capacity-building framework.

Results

The framework described highlights opportunities for building Cooperative Extension’s capacity to address goals in four key domains. These goals include (1) catalyzing Extension’s organizational development to support science-driven practices, (2) bolstering prevention and behavioral health-oriented professional development for Extension faculty and staff, (3) creating a stronger culture of behavioral health in Extension, and (4) strengthening Extension’s financing of prevention-oriented behavioral health efforts.

Conclusion

Addressing the capacity-related goals identified in this paper could be a major catalyst for enhancing the power of proven, prevention-oriented behavioral health and, thereby, the well-being of our families, communities and nation.

Parent Involvement in Maternal, Infant, and Early Childhood Home Visiting Programs: an Integrative Review

Despite the evidence and investment in evidence-based federally funded maternal, infant, and early childhood home visiting, substantial challenges persist with parent involvement: enrolling, engaging, and retaining participants. We present an integrative review and synthesis of recent evidence regarding the influence of multi-level factors on parent involvement in evidence-based home visiting programs. We conducted a search for original research studies published from January 2007 to March 2018 using PubMed, Embase, Cochrane, and CINAHL databases. Twenty-two studies met criteria for inclusion. Parent and family characteristics were the most commonly studied influencing factor; however, consistent evidence for its role in involvement was scarce. Attributes of the home visitor and quality of the relationship between home visitor and participant were found to promote parent involvement. Staff turnover was found to be a barrier to parent involvement. A limited number of influencing factors have been adequately investigated, and those that have reveal inconsistent findings regarding factors that promote parent involvement in home visiting. Future research should move beyond the study of parent- and family-level characteristics and focus on program- and home visitor-level characteristics which, although still limited, have demonstrated some consistent association with parent involvement. Neighborhood characteristics have not been well studied and warrant future research.

Utilizing broad-based partnerships to design a precision approach to implementing evidence-based home visiting

The aim of this paper is to describe a participatory process for adapting an implementation strategy, using a precision approach, for an evidence-based home visiting program, Family Spirit. Family Spirit serves Native American and low-income communities nationwide. To redesign Family Spirit's implementation strategy, we used workshops (n = 5) with key stakeholders and conducted an online survey with implementers (n = 81) to identify hypothesized active ingredients and "pivot points" to guide when to tailor the program and for whom. Active ingredients identified included the relationship between the home visitor and clients, lessons ensuring child safety and healthy development, parent-child communication, and goal setting. Pivot points included whether the client is a first-time mother who has substance abuse history, has a baby at risk for childhood obesity, and/or has sexual or reproductive health concerns. These results are informing the adaptation of Family Spirit' implementation strategy making it more responsive to diverse families while balancing fidelity to the previously proven standard model.

Intention to Engage in Maternal and Child Health Home Visiting

Home visiting (HV) programs have the potential to improve maternal and child health. As federal and state initiatives expand the reach of these programs, understanding what factors enhance uptake and retention of the services becomes increasingly important. This qualitative study used a Reasoned Action Model (RAM) and a cultural lens to explore factors influencing the engagement of women with low-income in HV programs. We conducted 21 semi-structured interviews in both English and Spanish in a prenatal clinic in an urban public health department. The constructs most salient for participants were emotions and affect, behavioral beliefs, and self-efficacy. In the context of an urban public health prenatal clinic, HV marketing and outreach should highlight convenience and social support, as well as clearly communicate program content and intent. In practice, HV programs must be flexible to work around work and home schedules; marketing and outreach should emphasize that flexibility.

Nurse-Family Partnership and Geography: An Intersectional Perspective

Nurse-Family Partnership is a targeted public health intervention program designed to improve child and maternal health through nurse home visiting. In the context of a process evaluation, we posed the question: "In what ways do Canadian public health nurses explain their experiences with delivering this program across different geographical environments?" The qualitative methodology of interpretive description guided study decisions and data were collected through 10 focus groups with 50 nurses conducted over 2 years. We applied an intersectionality lens to explore the influence of all types of geography on the delivery of Nurse-Family Partnership. The findings from our analysis suggest that the nature of clients' place and their associated social and physical geography emphasizes inadequacies of organizational and support structures that create health inequities for clients. Geography had a significant impact on program delivery for clients who were living with multiple forms of oppression and it worked to reinforce disadvantage.

Engagement in home visiting: An overview of the problem and how a coalition of researchers worked to address this cross-model concern

Home visiting is a widely supported intervention strategy for parents of young children who are in need of parenting skill improvement. However, parental engagement limits the potential public health impact of home visiting, as these programs often have low enrollment rates, as well as high attrition and low completion rates for those who enroll in these programs. The Coalition for Research on Engagement and Well-being (CREW) provided support for three pilot projects representing different home visiting models and aspects of engagement. The results of these pilot projects are presented in this special section. The purpose of this commentary is to introduce CREW and highlight the importance of a cross-model project to improve engagement among home visiting programs.

Informing Precision Home Visiting: Identifying Meaningful Subgroups of Families Who Benefit Most from Family Spirit

The Maternal, Infant, and Early Childhood Home Visiting Program was reauthorized February 8, 2018, and invests $2 billion over 5 years to improve mothers' and children's outcomes across the life course. Along with this investment, the home-visiting field is striving for implementation innovations to deliver the greatest impact to the most families at the most efficient cost through a focus on precision home visiting. Consistent with the precision home-visiting approach to identify meaningful subgroups to guide content tailoring, the purpose of this paper is to answer (1) how and to what degree an evidence-based home-visiting model benefits mothers and children with substance use or depression and (2) what baseline characteristics indicate who can benefit most. We completed a secondary data analysis of the most recently completed randomized controlled trial (RCT) of Family Spirit (N = 322), a federally endorsed home-visiting intervention designed for young Native American mothers and their children. We examined how baseline differences in mothers' substance use, depression, and demographic characteristics (household mobility, education, parity, and premature birth) moderated mothers' and children's intervention-related outcomes. Children born to mothers with past substance use histories benefited more from the intervention than children born to abstinent mothers (p < 0.01). Unstable housing, parity, and low educational attainment emerged as moderators of intervention effectiveness. Results from this investigation will serve as a basis for designing and evaluating a precision approach to Family Spirit and may provide lessons for other models to explore tailoring variables for optimal impact and efficiency. Trial Registry: NCT00373750.

Principles of Precision Prevention Science for Improving Recruitment and Retention of Participants

Precision medicine and precision public health focus on identifying and providing the right intervention to the right population at the right time. Expanding on the concept, precision prevention science could allow the field to examine prevention programs to identify ways to make them more efficient and effective at scale, including addressing issues related to engagement and retention of participants. Research to date on engagement and retention has often focused on demographics and risk factors. The current paper proposes using McCurdy and Daro (Family Relations, 50, 113-121, 2001) model that posits a complex mixture of individual, provider, program, and community-level factors synergistically affect enrollment, engagement, and retention. The paper concludes recommending the use of research-practice partnerships and innovative, rapid cycle methods to design and improve prevention programs related to participant engagement and retention at scale.

Client attrition in the Nurse-Family Partnership® : Revisiting metrics of impact in a home visitation program in the United States

The Nurse-Family Partnership^® (NFP) is an evidence-based home-visiting program for low-income, first-time mothers. NFP^® has demonstrated benefits for reducing child maltreatment and improving parenting, child development and families' economic self-sufficiency. It is now implemented widely in the US where, despite the use of home visits, which generally reduce barriers to program participation, only 35% of clients nationwide complete the 2.5-year program. This concurrent mixed-methods study was conducted in 2013 in an urban northeastern US NFP site and included administrative program data, surveys (n = 56), in-depth interviews (n = 14) with nurse home visitors, and focus groups with nurse supervisors (n = 13). We explored associations between nurses' attrition rates and their perspectives on client attrition and retention strategies. We further conducted an inductive thematic analysis of the qualitative data. Findings indicate that nurses' attrition rates were not significantly associated with their views and strategies to retain clients. Nurses and supervisors noted that clients' competing priorities and 'chaotic lives' primarily explained attrition. They thought that clients often left the program upon receiving enough information and skills or achieving key milestones, which may reflect reaching a saturation point, albeit prior to the full completion of the program. We offer recommendations to assess performance based on client accomplishments rather than whether they participated until the prescribed endpoint.

Association between participation in the Families First Home Visiting programme and First Nations families' public health outcomes in Manitoba, Canada: a retrospective cohort study using linked administrative data

OBJECTIVE

To determine whether the Families First Home Visiting (FFHV) programme, which provides home visiting services to families across Manitoba, is associated with improved public health outcomes among First Nations families facing multiple parenting challenges.

DESIGN

Retrospective cohort study using population-based administrative data.

SETTING

Manitoba, Canada.

PARTICIPANTS

First Nations children born in Manitoba in 2003-2009 (n=4010) and their parents enrolled in FFHV compared with non-enrolled families with a similar risk profile.

INTERVENTION

FFHV supports public health in Manitoba by providing home visiting services to First Nations and non-First Nations families with preschool children and connecting them with resources in their communities.

OUTCOMES

Predicted probability (PP) and relative risk (RR) of childhood vaccination, parental involvement in community support programmes and children's development at school entry.

RESULTS

FFHV participation was associated with higher rates of complete childhood vaccination at age 1 (PP: FFHV 0.715, no FFHV 0.661, RR 1.08, 95% CI 1.03 to 1.14) and age 2 (PP: FFHV 0.465, no FFHV 0.401, RR 1.16, 95% CI 1.08 to 1.25), and with parental involvement in community support groups (PP: FFHV 0.149, no FFHV 0.097, RR 1.54, 95% CI 1.27 to 1.86). However, there was no difference between FFHV participants and non-participants in rates of children being vulnerable in at least one developmental domain at age 5 (PP: FFHV 0.551, no FFHV 0.557, RR 1.00, 95% CI 0.91 to 1.11).

CONCLUSIONS

FFHV supports First Nations families in Manitoba by promoting childhood vaccination and connecting families to parenting resources in their communities, thus playing an important role in fulfilling the mandate of public health practice.

Visit Attendance Patterns in Nurse-Family Partnership Community Sites

We examined visit attendance patterns of mothers enrolled in the Nurse-Family Partnership (NFP) home visitation program and associations between these patterns and characteristics of the families and sites, with the goal of increasing participant engagement. We utilized repeated measures latent class analysis to identify attendance patterns among 66,967 mothers in NFP sites across the USA. Mothers enrolled from 1996 to 2010. Data were collected by home visitors and aggregated by the NFP National Service Office. Five visit attendance patterns were identified. Consistent attenders (22%) remained engaged for the full program and attended 51.3 visits on average. Inconsistent attenders (9%) remained engaged but missed many visits, with an average of 36.4 visits. The remaining patterns were characterized by when participants left the program: early (28%; 6.7 visits), gradually (27%; 19.4 visits), or late (15%; 35.3 visits). Consistent and inconsistent attenders were less likely to use English as their primary language than other participants (R = 0.12; p < .001). Participants with more nurse changes per visit attended were more likely to drop out early (R = 0.11; p < .001). Sites with a higher percent of missing data had smaller portions of mothers who remained consistently engaged in the program over time (b = - 0.032; p < .01) and greater portions in the late (b = 0.007; p < .04) and gradual attrition classes (b = 0.018; p < .01). The large number of participants who dropped out early is concerning. Further exploration of this group may optimize use of resources by improving either retention or targeting of potential participants.

A Qualitative Evaluation of Engagement and Attrition in a Nurse Home Visiting Program: From the Participant and Provider Perspective

Beginning parenting programs in the prenatal and early postnatal periods have a large potential for impact on later child and maternal outcomes. Home-based parenting programs, such as the Nurse Family Partnership (NFP), have been established to help address this need. Program reach and impact is dependent on successful engagement of expecting mothers with significant risks; however, NFP attrition rates remain high. The current study qualitatively examined engagement and attrition from the perspectives of NFP nurses and mothers in order to identify mechanisms that enhance service engagement. Semi-structured interviews were conducted in focus groups composed of either engaged (27 total mothers) or unengaged (15 total mothers) mothers from the NFP program. NFP nurses (25 total nurses) were recruited for individual semi-structured interviews. Results suggest that understanding engagement in the NFP program requires addressing both initial and sustained engagement. Themes associated with enhanced initial engagement include nurse characteristics (e.g., flexible, supportive, caring) and establishment of a solid nurse-family relationship founded on these characteristics. Factors impacting sustained engagement include nurse characteristics, provision of educational materials on child development, individualized services for families, and available family support. Identified barriers to completing services include competing demands and lack of support. Findings of this study have direct relevance for workforce planning, including hiring and training through integrating results regarding effective nurse characteristics. Additional program supports to enhance parent engagement may be implemented across home-based parenting programs in light of the current study's findings.

Birth outcomes of second children after community-based home visiting: A research protocol

Birth-related outcomes, such as birth weight, have lifelong impacts on health. Home visiting (HV) is an established approach to improve the health of children and families, parenting practices, and connections to social and health services. Many HV programs target first-time mothers, in part because HV activities related to a first-birth may improve birth outcomes for subsequent children, but few researchers have examined these effects. We will link data from a statewide HV program (Nurturing Families Network [NFN]) to birth certificate data to create comparison groups and measure outcomes in this observational study. Specifically, we will compare birth outcomes for NFN second-children (n = 3000) to those for: (a) first-child older siblings whose birth/gestation led to NFN enrollment (n = 3000); (b) second children of families who were screened as eligible for NFN, but not offered the program due to home visitor availability and other logistical reasons (n = 650); and (c) non-NFN second children in a propensity-score-matched group created using the likelihood of enrollment in NFN based on maternal health, demographics, and neighborhood characteristics (n = 6000). The outcomes we will examine are birth spacing, prenatal care received, cesarean section rate, gestational age, and birth weight in second-children. We will also examine the associations between program attendance (i.e., missed visits, dropout) and birth outcomes, that will generate evidence that may be used in programmatic decisions regarding continued funding and/or modification of NFN, prioritization of specific retention efforts, and targeting of first-time mothers. Use of this evidence should improve outcomes for future NFN families and may inform similar programs.

Early-Literacy Intervention Conducted by Caregivers of Children with Language Impairment: Implementation Patterns Using Survival Analysis

This study examined implementation of an evidence-based home reading program by caregivers of children with language impairment. Caregivers received materials and supports to read with their children for 15 weeks, four times weekly; in total, 128 caregivers were enrolled. Survival analysis showed that 55% of caregivers completed the program, and the majority of dropouts did so early in the intervention. Mulitnominal logistic regression results showed that dropout was associated with household income, child literacy skills, and receipt of behavior-change techniques by caregivers, especially financial incentives (50 cents per book reading). Results may advance the science of implementation in the area of early childhood disability and could provide suggestions to improve caregivers' effectiveness in implementing interventions to their children.

Those Who Disappear and Those Who Say Goodbye: Patterns of Attrition in Long-Term Home Visiting

Most evidence-based home visiting models are designed to support families from pregnancy through a child's second birthday, though programs often struggle to retain families for this long. Previous research on client and program factors that predict attrition has produced mixed results, which may be partly because attrition is typically conceptualized as a homogeneous phenomenon. The current study sampled 991 women who received home visiting services from one of 26 agencies in a statewide network of evidence-based programs. Participants who remained in services were compared to three types of early leavers: those who communicated their intent to leave (active attrition), those whose cases closed due to non-participation (passive attrition), and those who moved from the service area. Within a year of enrollment, 42% of women exited services. Cox regression results suggested no differences in the timing of service exit among the three attrition types. Multinomial analyses revealed that, when compared to participants who remained in services, active leavers were more likely to be married or cohabitating, while passive leavers were more likely to be younger, African American, unemployed, and to have a home visitor with low job satisfaction. Participants who moved were less likely to be Latina and employed. An early pattern of inconsistent attendance was the strongest predictor of active and passive withdrawal. Rates of attrition varied by home visiting model, though inconsistent attendance was a robust predictor of passive attrition across models. This study underscores the need to scrutinize service duration as a metric of success in home visiting.

Integrating Retention Rates into Economic Analyses of Prevention Interventions

Evidence-based prevention interventions hold great promise for enhancing the well-being of individuals, families, and society. As these interventions are implemented in new contexts and at wider scales, policymakers and private sector organizations are increasingly interested in understanding the economic returns that programs produce through reductions of burden on public service systems, such as criminal justice and human services. Thus, it is important to ensure that economic models account for factors, such as retention, which are important when interventions are implemented in real-world contexts with selective populations and voluntary participation. Yet the field of prevention has provided little guidance to help researchers and policymakers analyze the economics of interventions so that estimates reflect the impact of implementation factors on intervention cost-effectiveness. This paper discusses the role retention plays in the economic efficiency of interventions when the prevention of child maltreatment is the primary motivation for funding these programs. We present a conceptual model to serve as a guide for explicit inclusion of retention rates when calculating cost estimates to be used in cost-effectiveness analysis. A case study is presented, demonstrating the variability in estimates dependent on the definition of retention and the estimated retention rate. The results underscore the importance of improving our understanding of factors underlying and related to retention, such as engagement, which may improve the precision of cost and cost-effectiveness analysis in applied settings.

Mother and Home Visitor Emotional Well-Being and Alignment on Goals for Home Visiting as Factors for Program Engagement

Objectives Family engagement in home visiting (HV), as indicated by length of enrollment, is a major challenge as most families do not stay enrolled for the intended duration prescribed by HV models. This study examined maternal and visitor emotional well-being as factors for maternal satisfaction with the program in addressing reasons for enrolling in HV and program engagement and the role of their working alliance with the visitor as a mediator of this. Methods Longitudinal data were collected from 148 mothers and 54 visitors in 21 HV programs. Mothers completed surveys shortly after enrolling and 6 months later to assess attributes of the working alliance with their visitor. Visitors completed a survey to assess work-related well-being. HV program data were used to measure engagement. Results Mothers enrolled for multiple, diverse reasons, most often to promote child development and parenting (96%). Mothers’ satisfaction with program efforts to address reasons for enrollment was highest for parenting (79%) and lowest for jobs and education (30%). Results of the mediational path model indicated that ratings of the visitor on goal alignment were positively associated with engagement. Maternal emotional availability and visitor work-related emotional exhaustion were negatively associated with engagement. Exploratory analyses suggested that ratings of the visitor on goal alignment were a stronger predictor of engagement for mothers with low emotional availability compared to other mothers. Conclusions for Practice Visitor alignment with mothers on goals and responsiveness to reasons for enrolling appear to be effective in promoting engagement. Individualizing services to reflect maternal goals and emotional capacity may be important strategies to address engagement challenges.

Keeping Our Eyes on the Prize: Focusing on Parenting Supports Depressed Parents' Involvement in Home Visiting Services

Objectives Improving family retention and engagement is crucial to the success of home visiting programs. Little is known about retaining and engaging depressed parents in services. The purpose of the study is to examine how home visit content moderates the association between depression and retention and engagement. Methods The sample (N = 1322) was served by Healthy Families America (n = 618) and Parents as Teachers (n = 704) between April 1, 2012 and June 30, 2016. Parents averaged 23 years (SD = 6). Nearly half of the parents were White (48%) and the majority was single (71%). Depression was screened with the Patient Health Questionnaire-2. Home visitors reported the percent of time focused on particular content and parent engagement at every home visit. Results Multilevel regression analyses showed the amount of time that home visitors spent supporting parent-child interaction moderated the association between depression and retention at 6 (B = .08, SE = .03, p = .003) and 12 (B = .1, SE = .03, p < .001) months, such that there was a stronger positive association for depressed parents. The main effects of child development focused content and retention at 6 (B = .07, SE = .01, p < .001) and 12 (B = .08, SE = .01, p < .001) months were positive, while effects of case management focused content at 6 (B = - .06, SE = .01, p < .001) and 12 (B = - .07, SE = .01, p < .001) months were negative. Conclusions Families were more likely to be retained when home visitors focused on child development and parent-child interaction, but less likely with more case management focus. Parents with positive depression screens were more likely to remain in services with more time spent focused on supporting parent-child interactions.

Feasibility of Implementing Infant Home Visiting in a Central Australian Aboriginal Community

The Australian Nurse-Family-Partnership Program, an adaption of the Olds’ Nurse-Family-Partnership (NFP), commenced in Alice Springs in 2009 (Central Australia FPP), aiming to improve the health and social outcomes of Aboriginal mothers and infants. This study explores the feasibility of NFP implementation in a remote Australian Aboriginal community. Feasibility was defined by programme uptake by eligible women, retention in the programme, actual vs. scheduled visits and extent of programme content delivery. Programme uptake was established from pregnancy data in the patient Clinical Information System and programme referrals to December 31, 2015. Rates of withdrawal, retention and content delivery were derived from FPP data and compared with published NFP data. Modified Poisson regression was used to identify client characteristics associated with retention beyond the child’s first birthday. There were 469 valid referrals (43% of eligible pregnancies) and 299 women with at least one completed home visit by December 31, 2015. Of these, 41% completed the programme to the child’s second birthday and 53% beyond the child’s first birthday. Dominant reasons for leaving were “moved out of service area” (35%) and “declined further participation” (35%). There was a statistically significant positive association for programme retention with later gestational age at referral (RR = 1.27, p value = 0.03). A high proportion (75%) of scheduled visits was achieved and high delivery of programme content (80%). Central Australia FPP is the first implementation of the NFP model in a remote Aboriginal community. This study found that it can be implemented successfully in this setting. Outcome evaluation is needed to test achievement of hypothesised benefits.

Service Engagement and Retention: Lessons from the Early Childhood Connections Program

The high attrition rates found in studies of early childhood home visitation create barriers to measuring the effectiveness of such programs. Most studies examine attrition at program completion. This practice may mask important differences in characteristics between families that end participation at various time points. This study helps address this gap by examining factors associated with percent attrition for early drop out (before three months) compared to the program midpoint (nine months or more) and program completion (18 months) using data from the treatment arm of a small feasibility study of enhanced referral to home visitation among child welfare-involved families (n = 64). Caregivers who identified as White tended to leave by the program midpoint and caregivers who had better social support were more likely to stay at the end of the program. This study is the only published study to date of participation in a community-based home visitation program by child welfare-involved families but several trends identified were consistent with prior studies with other populations. Given the very small sample size, both statistically significant and near significant trends are discussed in the context of existing literature. The practical variation found has implications for continuing to build knowledge of attrition in early childhood home visitation.

Exploring Multilevel Factors for Family Engagement in Home Visiting Across Two National Models

The associations of family, home visitor and site characteristics with family engagement within the first 6 months were examined. The variation in family engagement was also explored. Home visiting program participants were drawn from 21 Healthy Families America sites (1707 families) and 9 Nurse-Family Partnership sites (650 families) in New Jersey. Three-level nested generalized linear mixed models assessed the associations of family, home visitor and site characteristics with family receipt of a high dose of services in the first 6 months of enrollment. A family was considered to have received a high dose of service in the first 6 months of enrollment if they were active at 6 months and had received at least 50% of their expected visits in the first 6 months. In general, both home visiting programs engaged, at a relatively high level (Healthy Families America (HFA) 59%, Nurse-Family Partnership (NFP) 64%), with families demonstrating high-risk characteristics such as lower maternal education, maternal smoking, and maternal mental health need. Home visitor characteristics explained more of the variation (87%) in the receipt of services for HFA, while family characteristics explained more of the variation (75%) in the receipt of services for NFP. At the family level, NFP may improve the consistency with which they engage families by increasing retention efforts among mothers with lower education and smoking mothers. HFA sites seeking to improve engagement consistency should consider increasing the flexible in home visitor job responsibilities and examining the current expected-visit policies followed by home visitors on difficult-to-engage families.

A Home Visiting Parenting Program and Child Obesity: A Randomized Trial

BACKGROUND

Young children living in historically marginalized families are at risk for becoming adolescents with obesity and subsequently adults with increased obesity-related morbidities. These risks are particularly acute for Hispanic children. We hypothesized that the prevention-focused, socioecological approach of the "Minding the Baby" (MTB) home visiting program might decrease the rate of childhood overweight and obesity early in life.

METHODS

This study is a prospective longitudinal cohort study in which we include data collected during 2 phases of the MTB randomized controlled trial. First-time, young mothers who lived in medically underserved communities were invited to participate in the MTB program. Data were collected on demographics, maternal mental health, and anthropometrics of 158 children from birth to 2 years.

RESULTS

More children in the intervention group had a healthy BMI at 2 years. The rate of obesity was significantly higher (P < .01) in the control group (19.7%) compared with the intervention group (3.3%) at this age. Among Hispanic families, children in the MTB intervention were less likely to have overweight or obesity (odds ratio = 0.32; 95% confidence interval: 0.13-0.78).

CONCLUSIONS

Using the MTB program, we significantly lowered the rate of obesity among 2-year-old children living in low-socioeconomic-status communities. In addition, children of Hispanic mothers were less likely to have overweight or obesity at 2 years. Given the high and disproportionate national prevalence of Hispanic young children with overweight and obesity and the increased costs of obesity-related morbidities, these findings have important clinical, research, and policy implications.

Families First Home Visiting programme reduces population-level child health and social inequities

BACKGROUND

Home visiting has been shown to reduce child maltreatment and improve child health outcomes. In this observational study, we explored whether Families First, a home visiting programme in Manitoba, Canada, decreased population-level inequities in children being taken into care of child welfare and receiving complete childhood immunisations.

METHODS

De-identified administrative health and social services data for children born 2003-2009 in Manitoba were linked to home visiting programme data. Programme eligibility was determined by screening for family risk factors. We compared probabilities of being taken into care and receiving immunisations among programme children (n=4575), eligible children who did not receive the programme (n=5186) and the general child population (n=87 897) and tested inequities using differences of risk differences (DRDs) and ratios of risk ratios (RRRs).

RESULTS

Programme children were less likely to be taken into care (probability (95% CI) at age 1, programme 7.5 (7.0 to 8.0) vs non-programme 10.0 (10.0 to 10.1)) and more likely to receive complete immunisations (probability at age 1, programme 77.3 (76.5 to 78.0) vs non-programme 73.2 (72.1 to 74.3)). Inequities between programme children and the general population were reduced for both outcomes (being taken into care at age 1, DRD -2.5 (-3.7 to 1.2) and RRR 0.8 (0.7 to 0.9); complete immunisation at age 1, DRD 4.1 (2.2 to 6.0) and RRR 1.1 (1.0 to 1.1)); these inequities were also significantly reduced at age 2.

CONCLUSION

Home visiting programmes should be recognised as effective strategies for improving child outcomes and reducing population-level health and social inequities.