Home Visiting: A Service Strategy to Reduce Poverty and Mitigate Its Consequences

Structural and relational factors for successful cross-sector collaboration in home visiting: a multiple case study

BACKGROUND

Aligning delivery and financing systems across sectors to create broader systems of care can improve the health and well-being of families experiencing adversities. We aimed to identify structural and relational factors for best practices to achieve successful cross-sector collaboration among home visiting programs in the United States.

MATERIALS AND METHODS

We used a multiple case study approach to identify best practices for successful cross-sector collaboration between home visitors and other community service providers. We selected five diverse exemplary cases with cross-sector collaboration with variation in implementing agency type and geographic location. Cases were selected using a positive deviance approach based on strong coordination and integration with different community service provider types identified from previous survey data. We conducted in-depth qualitative interviews with home visiting staff, community providers, and clients with a total of 76 interviews conducted from 2021 to 2022. We wrote memos to synthesize themes within each case through data triangulation using interview data, documents, and site visit observations. We compared themes across the five cases to create a cross-case synthesis of best practices for successful cross-sector collaboration.

RESULTS

Across the five cases, relational factors including leadership from all levels, champions across sectors, and shared goals between community providers were key factors for successful collaboration. Interpersonal relationships, coupled with the desire and capacity to engage, facilitated effective coordination to address families' needs. At the structural level, shared data systems, written agreements, and co-location enabled care coordination activities. Community Advisory Boards provided a venue for developing partnerships, relationship-building, resource-sharing, and increasing awareness of home visiting.

CONCLUSIONS

We identified key elements of successful cross-sector collaboration across five case studies where home visitors coordinate care frequently and/or are structurally integrated with a range of providers. These learnings will inform future interventions to improve home visiting collaboration with other community providers to create a system of care to enhance family well-being.

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.

Service Coordination in Early Childhood Home Visiting: a Multiple-Case Study

Early childhood home visiting is a preventive service delivery strategy that aims to promote child and parent health, positive parenting, child development and school readiness, and family economic self-sufficiency. To meet families' needs, programs provide a combination of direct services, and referrals and linkages to community-based services. Service coordination is therefore a critical component of home visiting's role within the early childhood system of care. This multiple-case study describes facilitators and barriers to service coordination, as identified by home visiting program staff and families. We interviewed program managers, supervisors, home visitors, and families from four local home visiting programs in the eastern USA with diverse contextual characteristics that showed evidence of having strong coordination. Using multiple-case study methodology, we analyzed the data to understand key facilitators and barriers to service coordination for each case and identify and describe common themes across cases. Facilitators included interagency relationships and collaboration; a culture of teamwork; dedicated, well-connected staff; supervision; trusting relationships with families; and warm handoffs. Barriers to service coordination were limited availability and accessibility of local resources, perceived stigma among other service providers, and families' ambivalence toward some services. Home visiting staff and families emphasized that relationships at multiple levels are fundamental to service coordination, barriers are complex, and coordination is time- and labor-intensive. Coalitions that bring together diverse stakeholder groups at the state and local levels can provide meaningful coordination support to the early childhood services.

Improving connections to early childhood systems of care via a universal home visiting program in Massachusetts

Welcome Family is a universal, short-term nurse home visiting program designed to promote optimal maternal and infant physical and mental well-being and provide an entry point into the early childhood system of care to all families with newborns up to 8 weeks old living in defined communities in Massachusetts. The present study examines whether: 1) Welcome Family meets its goal of successfully connecting families to two early childhood programs-evidence-based home visiting (EBHV) and early intervention (EI)-relative to families with similar background experiences who do not participate in Welcome Family, and 2) whether these impacts are conditional on families' race and ethnicity and their primary language-two characteristics that are related to structural racism and health inequities. The study used coarsened exact matching (CEM) based on birth certificate data to match Welcome Family participants who enrolled during 2013-2017 to mothers and their infants living in the home visiting catchment areas who did not receive home visiting during the study period. Primary study outcomes included enrollment in any EBHV program supported by the Massachusetts Maternal, Infant, and Early Childhood Home Visiting (MA MIECHV) program up to age 1 year, measured using MA MIECHV home visiting program data, and EI service receipt for children aged up to age 3 years, measured using EI program data. Impacts were assessed by fitting weighted regression models adjusted for preterm birth, maternal depression, and substance use. Mothers' race, ethnicity, and language were included in the model as moderators of Welcome Family impacts on enrollment in EBHV and EI. Welcome Family participants (n = 3,866) had more than double the odds of EBHV enrollments up to age 1 and had 1.39 greater odds of receiving EI individualized family service plans (IFSPs) up to age 3 relative to the comparison group (n = 46,561). Mothers' primary language moderated Welcome Family impacts on EBHV enrollments. Universal, short-term programs such as Welcome Family may be an effective method of ensuring families who could benefit from more intensive early childhood services are identified, engaged, and enrolled.

Referrals to Home Visiting: Current Practice and Unrealized Opportunities

INTRODUCTION

Evidence supports ongoing investment in maternal and early childhood home visiting in the US. Yet, a small fraction of eligible families accesses these services, and little is known about how families are referred. This report describes priority populations for home visiting programs, the capacity of programs to enroll more families, common sources of referrals to home visiting, and sources from which programs want to receive more referrals.

METHODS

We conducted a secondary analysis of data from a national web-based survey of members of the Home Visiting Applied Research Collaborative (HARC), focusing on a small set of items that directly addressed study aims. Survey respondents (N = 87) represented local programs implementing varying home visiting models diverse in size and geographic context.

RESULTS

Programs prioritized enrollment of pregnant women; parents with mental health, substance abuse or intimate partner violence concerns; teen parents; and children with developmental delays or child welfare involvement. Most respondents reported capacity to enroll more families in their programs. Few reported receiving any referrals from pediatric providers, child welfare, early care and education, or TANF/other social services. Most desired more referrals, especially from healthcare providers, WIC, and TANF/other social services.

DISCUSSION

Given that most programs have the capacity to serve more families, this study provides insights regarding providers with whom home visiting programs might strengthen their referral systems.

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.

Barriers to and Systems Solutions for Increasing Early Childhood Home Visiting Referrals by Health Care Providers Serving Urban and Rural Communities

Early childhood home visiting (ECHV) is an evidence-based prevention strategy that directly impacts maternal and child health by mitigating the poor outcomes associated with socioeconomic disadvantage and adverse childhood experiences that disproportionately affect marginalized populations. Despite its promise, health care providers in many communities do not routinely refer patients to these services. This qualitative study examined barriers to health care providers' referrals to ECHV services and identified systems-level strategies to overcome those barriers through semistructured interviews with 37 health care providers in New Mexico. Most participants were pediatricians or family practice physicians working in hospitals or community-based primary care settings, and the majority served rural communities. Barriers included insufficient knowledge about ECHV programs; lack of trust of program providers; time constraints; concerns about available funding; lack of a standardized referral process; and concerns about stigma and messaging. Five systems-level recommendations were developed to improve practice: (1) educating health care providers; (2) developing messaging prompts for providers to use when talking with patients about ECHV; (3) increasing engagement among providers and ECHV programs; (4) standardizing referral systems within practices; and (5) promoting universal referrals. Additional research is ongoing to determine the degree to which these health promotion strategies increase referrals and participation in ECHV.

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.

Program, cultural and neighbourhood factors related to attrition from a community-based enriched medical home program in the United States

Attrition from clinical interventions targeting underserved populations is a substantive challenge to achieving optimal health outcomes. Our nationally recognised enriched medical home intervention (EMHI) utilised community health worker home visitation to improve health outcomes of children by engaging the entire family and removing barriers to care-seeking. Families were enrolled into the program between 2013 and 2016, and, as part of the evaluation of the program's success, we identified predictors of program completion by conducting a secondary analysis of 304 families participating in the EMHI evaluation research. Program completers finished participation in the EMHI with mutual agreement that the family can independently follow recommended care. Program non-completers were either lost to follow-up or dropped out before reaching this milestone. Data were collected using electronic medical records and validated self-report surveys to assess constructs such as social support, mental health difficulties and neighbourhood characteristics. The EMHI participants were primarily families with infants <24 months old, Medicaid-insured and Latino. In the multivariable logistic regression model, EMHI program factors as well as community factors independently predicted program continuation and retention. Specifically, families learning about newborn care or with preferred spoken language Spanish were more likely to complete the program. Participants reporting neighbourhood distrust had a greater likelihood of non-completion than others. Results underscore the importance of cultural competency and community involvement in program design and dissemination. Our findings are applicable to other home-based interventions with the goal of supporting underserved families in following recommended clinical care.

Evidence-Based Early Home Visiting for Mothers and Parents With Intellectual Disability: Home Visitor Perceptions and Practices

Evidence-based maternal, infant, and early home visiting (EBHV) is a potential strategy to support parent and child health and well-being among families headed by a parent with an intellectual disability (ID). Little is known about the capacity of EBHV programs to meet the needs of parents with ID effectively. This study examined home visitor practices and perceptions of services for parents with ID. Home visiting staff recruited from a national practice-based research network participated in web-based surveys. Practices and perceptions varied widely across sites and were associated with home visitor knowledge and self-efficacy and site implementation supports, such as policies, curricula, and community collaboration. More work is needed to understand and strengthen EBHV services for parents with ID.

Maternal Warning Signs Education During Home Visiting: Results from a Formative Evaluation in Maryland

Background:

Maternal mortality rate reviews have identified the need for improved patient education regarding the warning signs of maternal complications to reduce preventable deaths. Maternal and child home visiting programs have the potential to deliver this education in communities.

Aims:

This study sought to evaluate the baseline provision of warning signs education among home visiting programs in Maryland and to assess the acceptability of and preferences for warning signs education materials among program staff.

Materials and Methods:

This sequential exploratory, mixed-methods study included qualitative interviews and focus group discussions followed by a web-based survey of all home visiting programs providing early postpartum visits in Maryland.

Results:

Twenty-five home visiting program staff took part in qualitative data collection, and survey responses were submitted by a manager from 40 of 58 eligible home visiting programs (69% response rate). All survey respondents agreed that home visiting programs should provide warning signs education and more than 80% of programs provided some warning signs education during pregnancy and the postpartum period. Printed pamphlets were provided by 68% of programs for pregnancy complications and 43% for postpartum complications. Only 33% of respondents were satisfied with their existing warnings signs education materials; 98% were interested in new illustrated pamphlets and 88% were interested in education videos. Qualitative participants considered pamphlets with simple designs, limited text, and visuals, as the most accessible for home visiting clients.

Conclusions:

There are opportunities to strengthen and expand warning signs education in Maryland through home visiting programs using new printed and video education materials.

Adapting a South African social innovation for maternal peer support to migrant communities in Sweden: a qualitative study

Introduction and aim

Social and health disparities persist in Sweden despite a high quality and universally accessible welfare system. One way of bridging social gaps is through social innovations targeting the most vulnerable groups. The South African Philani model, a social innovation for peer support aimed at pregnant women and mothers of young children, was adapted to the local context in southern Sweden. This study aimed to document and analyze the process of adapting the Philani model to the Swedish context.

Methods

Eight semi-structured interviews and three workshops were held with eleven stakeholders and peer supporters in the implementing organization and its steering committee. The data were analyzed using thematic analysis.

Results

The analysis resulted in five main themes and fifteen sub-themes representing different aspects of how the peer support model was contextualized. The main themes described rationalizations for focusing on social determinants rather than health behaviors, using indirect mechanisms and social ripple effects to achieve change, focusing on referring clients to established public and civil society services, responding to a heterogeneous sociocultural context by recruiting peer supporters with diverse competencies, and having a high degree of flexibility in how contact was made with clients and how their needs were met.

Conclusion

The South African Philani model was contextualized to support socially disadvantaged mothers and expectant mothers among migrant communities in Sweden. In the process, adaptations of the intervention’s overall focus, working methods, and recruitment and outreach strategies were motivated by the existing range of services, the composition of the target group and the conditions of the delivering organization. This study highlights various considerations that arise when a social innovation developed in a low- or middle-income context is implemented in a high-income context.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01687-4.

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.

Lifecourse factors associated with flourishing among US children aged 1-5 years

AIM

This study aimed to examine the association between lifecourse factors and flourishing among children ages 1-5 years.

STUDY DESIGN

Using data from the combined 2016 and 2017 National Survey of Children's Health (N = 18 007 children aged 1-5 years), flourishing was defined as parent-reported child's affection, resilience, curiosity about learning, and affect. Multivariable logistic regression modelled the associations between lifecourse factors and flourishing. These factors were identified according to the lifecourse health development model.

RESULTS

Approximately 63% of children aged 1-5 years were flourishing. Children who were female (vs. male, adjusted prevalence ratio [APR]: 1.06, 95% confidence interval [CI]: 1.00-1.11), White, non-Hispanic (vs. Black, non-Hispanic, APR: 1.13, 95% CI: 1.01-1.26), not having a special health care need (vs. special health care need, APR: 1.15, 95% CI: 1.03-1.26), not having an emotional, developmental or behavioural disorder (EBD) (vs.

EBD, APR

1.66, 95% CI:1.23-2.10), spoke English at home (vs. other language, APR: 1.30, 95% CI: 1.06-1.54), parents received emotional social support (vs. no emotional social support, APR: 1.11, 95% CI: 1.01-1.21) and who lived in a supportive neighbourhood (vs. not in supportive neighbourhood, APR: 1.12, 95% CI:1.05-1.18) were more likely to flourish. Children from households within 0%-99% of the federal poverty level (APR: 0.89, 95% CI: 0.79-0.98) were less likely to be flourishing compared with their counterparts from households within 400% of the federal poverty level.

CONCLUSIONS

Findings indicate that several lifecourse factors are associated with young children's flourishing, including being female, White, non-Hispanic, not having a special health care need or EBD, English as a primary language, parents receiving emotional social support, having neighbourhood support and a lower household income. Our findings promote the continuation of programmes supporting diverse and low-income children's families and communities such as home visiting and Head Start, which provide avenues for bolstering children's health and development across the lifespan.

The concept, importance and values of support during childbearing and breastfeeding - A discourse paper

BACKGROUND

Professional support in childbearing has beneficial effects on childbirth experience, interactions within the family, breastfeeding and medical outcomes. However, more knowledge is needed about prerequisites for professional support to be valuable and satisfactory during childbearing.

AIM

The aim of this discourse paper is to describe and explore prerequisites for professional support that are of value for women and their families during childbearing as well as how healthcare organizations can be formed to facilitate these prerequisites.

DESIGN

Discourse paper.

METHODS

This discourse paper is based on our own experiences and is supported by literature and theory.

RESULTS

Well-functioning structures and processes facilitate professional support that leads to safe, secure, calm and prepared parents with the ability to handle the challenges of childbearing and parenting. When organizing care in childbearing, prerequisites for support needs must also be considered.

Transitioning to telehealth due to COVID-19: Maintaining model fidelity in a home visiting program for parents of vulnerable infants

Maintaining treatment fidelity when implementing evidence‐based interventions is a significant challenge. The inability to deliver in‐person services due to the COVID‐19 pandemic critically challenged the foundation of implementation fidelity for home visiting programs across the globe. The Attachment and Biobehavioral Catch‐Up (ABC) program is an evidence‐based home visiting intervention designed to increase sensitivity in parents of infants who have experienced early adversity. ABC's community effectiveness is due to rigorous fidelity monitoring and supervision. Fidelity is measured by microanalytic coding of parenting opportunities and “in‐the‐moment” commenting, the active ingredient of ABC. In this study, we examined intervention fidelity among parent coaches implementing ABC through telehealth. Random 5‐min clips from 510 telehealth ABC session videos conducted by 91 parent coaches at 48 agencies were coded for their frequency and quality of in‐the‐moment comments. On average, parent coaches were able to exceed in‐person commenting fidelity standards when implementing ABC through the telehealth format. The active fidelity monitoring and supervision inherent to ABC's dissemination afforded a smooth transition to implementing ABC through telehealth while adhering to fidelity standards. Procedural and clinical challenges to telehealth implementation are discussed, along with future directions for telehealth program effectiveness.

Examining Adolescent Family Experiences as Risks for Young Adulthood Intimate Partner Violence in Two Longitudinal Samples

Little research has examined multiple family risks that may act as precursors to the cycle of violence, or the link between child maltreatment and subsequent intimate partner violence perpetration. Scholarly work that addresses this gap has important implications for early prevention and intervention efforts aimed at reducing family violence in adolescence and young adulthood. Based upon the family stress model and the cycle of violence hypothesis, it was hypothesized that adolescent experiences of economic pressure, caregiver depressed mood, and caregiver conflict would increase risk for abusive parenting and that abusive parenting in adolescence would link these family experiences to partner violence perpetration in young adulthood. The model was tested using longitudinal data spanning 12 years from two studies: The Iowa Youth and Families Project (N = 306, 56.2% women), a sample of White, married-parent families, and the Family and Community Health Study (N = 213, 53.3% women), a sample of Black families diverse in terms of family structure. Path model analyses provided support for the proposed model in each sample, highlighting the importance of considering several adolescent family experiences in work on the etiology of partner violence. Policy and practice interventions are offered, such as the need for economic supports for families, accessible mental health care, and relationship education programming for youth.

National Home Visiting Collaborative Improves Developmental Risk Detection and Service Linkage

OBJECTIVE

Fewer than 50% of children with developmental delay are identified before they start school, and only 10% of those identified receive services. Between May 2014 and August 2016, the Home Visiting Collaborative Improvement and Innovation Network (HV-CoIIN) aimed to improve early detection and linkage to services so that 80% of children with an identified developmental concern would receive timely, targeted developmental support.

METHODS

HV-CoIIN enrolled 13 home visiting programs in 8 states and 1 tribe in a Breakthrough Series Collaborative (BTS). These programs tested interventions aligned with 5 key drivers: early detection, referral and follow-up, home visitor capacity, families engaged in developmental promotion, and data systems. Run charts were used to study measures. The main outcome was the percent of children with an identified concern who were linked to developmental support. Process measures included the percent of visits where parents were asked if they had any concerns about their child's development and the percent of children screened every 6 months.

RESULTS

The percent of children with an identified developmental concern who received support increased from 70% to 82%. Parents were asked about developmental concerns at 95% of visits (baseline = 75%), and 90% of children were screened every 6 months (baseline = 51%).

CONCLUSIONS

Home visiting programs can reliably execute early detection and linkage to services for at-risk populations they serve. BTS holds promise for improving implementation of federal public health programs to improve population health outcomes.

Early Impacts of Room to Grow: A Multifaceted Intervention Supporting Parents and Children Age Zero to Three

Children experiencing poverty or low incomes fare worse than their more advantaged peers on a host of developmental and educational outcomes. Interventions have focused on strengthening parenting in families with young children, when supports appear to be most critical. But most parenting programs for low-income families fail to address parents' economic needs, which almost always take precedence relative to broader educational or developmental goals. In this article, we describe the early results of a multifaceted intervention aimed at supporting parents, infants, and toddlers in the first three years of life. The Room to Grow program provides parents, primarily mothers, with support from a clinical social worker, connections to community referrals, and up to $10,000 in material support for the baby in the form of in-kind assistance such as clothes, books, toys, strollers, and other necessities. The current study examines proximal outcomes of the intervention after one year using a randomized controlled trial evaluation design. The study finds that early impacts on proximal outcomes are uniformly positive, especially with regards to the presence of books and developmental goods in the home, developmentally-oriented parenting outcomes, and reduced stress and aggravation in the domain of parenting.

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.

Pediatric Primary Care and Partnerships Across Sectors to Promote Early Child Development

Poverty remains a critical predictor of children's school readiness, health and longer term outcomes. Early relational health (ERH) (ie, parenting practices and relationship quality) mediates the impact of poverty on child development, and thus has been the focus of many parenting interventions. Despite the documented efficacy of parenting interventions at reducing poverty-related disparities in child health and development, several key barriers prevent achieving population-level reach to families with young children. In the current paper we highlight several of these barriers including gaining population-level access to young children and families, reaching families only through single points of access, addressing the significant heterogeneity of risk that exists among families living in poverty, as well as addressing each of these barriers in combination. We suggest that understanding and confronting these barriers will allow family-centered interventions to more effectively address issues related to ERH at a population level, which in turn will reduce poverty-related disparities in child development.

Parents' Experiences of Receiving Professional Support Through Extended Home Visits During Pregnancy and Early Childhood-A Phenomenographic Study

Background: While becoming a parent can be challenging for all, it can particularly be challenging for those parents and children who are in a vulnerable situation—e.g., in families whose members have problems related to health, relationships, or socioeconomic status. It is essential for health care professionals to identify the more vulnerable families at an early stage. Home visits are one cost-effective way of identifying and supporting such families. This study describes the parental experiences of an intervention that involves professional support in the form of extended home visits. The aim of the study is to describe the parents' understanding of their experiences of receiving professional support through extended home visits both during pregnancy and the first 15 months of their child's life.

Methods/Design: A phenomenographic approach was used. Semi-structured interviews were conducted with 12 parents who had received the intervention. The interviews were analyzed using the seven-step phenomenography model described by Sjöström and Dahlgren.

Results: The following three descriptive categories emerged from the analysis: (1) conceptions concerning the meaning of the physical environment, (2) conceptions concerning extended home visits promoting feelings of self-confidence in the parental role, and (3) conceptions concerning extended home visits promoting parental participation and relations.

Conclusion and Clinical Implications: Extended home visits as a form of professional support appear to promote parental self-confidence in parenting ability, giving parents a feeling of security that facilitates conversation with professionals. Children and their entire families had natural roles during home visits, which allowed the children to behave more characteristically. Furthermore, the home visits were understood to facilitate social support through social activities at the child health center as well as integration into Swedish society for migrant parents. Professional support should be adjusted to the unique individual needs of parents, which demands a variety of supportive interventions—for example, reorganizing one or two of the regular clinical visits currently being scheduled as home visits instead.

The Role of State Context in Promoting Service Coordination in Maternal, Infant, and Early Childhood Home Visiting Programs

CONTEXT

The federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program provides funding to states to promote health and development of at-risk expectant families and families with young children. MIECHV programs are required to coordinate services within a larger system of care; yet, little is known about state-level factors that support coordination.

OBJECTIVE

This study examined state-level supports and barriers for coordination of home visiting with other entities within the early childhood system of care.

METHODS

A Web-based survey was distributed in 2016 via e-mail to MIECHV administrators in all 50 states, 5 US territories, and the District of Columbia. The survey elicited information on 5 domains shown by theory and prior research to support coordination: MIECHV leadership, state leadership, shared goals across sectors, data systems, and finance. Respondents also rated their perceptions of state-level coordination.

RESULTS

Forty-two (75%) of the MIECHV administrators participated in the survey. States and territories varied widely within and across the 5 domains of support for coordination. MIECHV leadership was an area of relative strength, whereas data systems and finance showed the most room for improvement. State leadership and shared goals were associated with stronger perceptions of state-level coordination.

CONCLUSIONS

The findings indicate opportunities for shared learning among states to enhance coordination infrastructure. Such efforts should include multiple stakeholder perspectives and consideration of local and organizational contexts. This work could be facilitated using the service coordination toolkit developed as part of this project.

The Enhanced Maternal and Child Health nursing program in Victoria: a cross-sectional study of clinical practice

The Maternal and Child Health (MCH) service in Victoria comprises a universal service, an enhanced program providing additional support for vulnerable families (EMCH) and a 24-h MCH telephone line. There is anecdotal evidence of variation in EMCH programs between Local Government Areas, and this study aims to explore the variation in EMCH programs to inform future EMCH policy and practice. An online survey was sent to MCH coordinators in Victoria in December 2016 (n = 79), with a response rate of 70% (55/79). Quantitative data have been analysed using descriptive statistics, with open-ended questions examined using content analysis. The data confirms that EMCH programs vary significantly across the state. Differences include a variation in referral and intake criteria, different models of service and modes of delivery, differences in EMCH nurse working conditions, issues with data collection and a lack of systematic clinical tools. Variation in the EMCH program is greatest between urban and rural services and between advantaged and disadvantaged urban councils. Lack of consistent service delivery and data collection impairs program evaluation, including outcome measurement and evidence of program effectiveness.

Newborn Risk Factors for Subsequent Physical Abuse Hospitalizations

OBJECTIVES

To describe the prevalence of risk factors for abuse and newborns' risks for physical abuse hospitalizations during early infancy.

METHODS

We created a nationally representative US birth cohort using the 2013 and 2014 Nationwide Readmissions Databases. Newborns were characterized by demographics, prematurity or low birth weight (LBW), intrauterine drug exposure, and medical complexity (including birth defects). Newborns were tracked for 6 months from their birth hospitalization, and subsequent abuse hospitalizations were identified by using International Classification of Diseases, Ninth Revision codes. We calculated adjusted relative risks (aRRs) with multiple logistic regression, and we used classification and regression trees to identify newborns with the greatest risk for abuse on the basis of combinations of multiple risk factors.

RESULTS

There were 3 740 582 newborns in the cohort. Among them, 1247 (0.03%) were subsequently hospitalized for abuse within 6 months. Among infants who were abused, 20.4% were premature or LBW, and 4.1% were drug exposed. Premature or LBW newborns (aRR 2.16 [95% confidence interval (CI): 1.87-2.49]) and newborns who were drug exposed (aRR 2.86 [95% CI: 2.15-3.80]) were independently at an increased risk for an abuse hospitalization, but newborns with medical complexity or noncardiac birth defects were not. Publicly insured preterm or LBW newborns from rural counties had the greatest risk for abuse hospitalizations (aRR 9.54 [95% CI: 6.88-13.23]). Publicly insured newborns who were also preterm, LBW, or drug exposed constituted 5.2% of all newborns, yet they constituted 18.5% of all infants who were abused.

CONCLUSIONS

Preterm or LBW newborns and newborns who were drug exposed, particularly those with public insurance and residing in rural counties, were at the highest risk for abuse hospitalizations. Effective prevention directed at these highest-risk newborns may prevent a disproportionate amount of abuse.

Getting to the Warm Hand-Off: A Study of Home Visitor Referral Activities

Introduction

Conducted as part of the Massachusetts MIECHV evaluation, this study examined the role of home visitors (HVs) in facilitating families’ connections to early childhood systems of care. The aims of this study were to document the full range of HV behaviors related to service coordination.

Methods

The study sample was 65 participant cases from five program sites, comprising two home visiting models (HFM and PAT). We coded and analyzed 11,096 home visiting records, focusing on identifying referrals, connections, disconnections, and supportive behaviors across 20 service areas. Qualitative pattern analyses were conducted on a subsample of records to identify unique pathways from referral to connection.

Results

HVs discussed an average of 30 different programs with each participant, and overall, only 21% of referrals resulted in a service connection. This rate varied, with some (e.g., housing) requiring much more intensive HV support and yielding far fewer connections. HVs also worked to keep participants engaged once they were connected to a service, often discovering challenges in need of attention through monitoring activities.

Discussion

Home visiting is often thought of as a key entry point into a system of care. Findings from this study confirm this premise, highlighting both the centrality of home visiting in helping families navigate local systems of care, and the insufficiency of these systems to meet family needs.

Stripping the Wallpaper of Practice: Empowering Social Workers to Tackle Poverty

The relationship between deprivation and health and educational inequalities has been well evidenced in the literature. Recent UK research has now established a similar social gradient in child welfare interventions (Bywaters et al. 2018) with children living in the most deprived areas in the UK facing a much higher chance of being placed on the child protection register or in out-of-home care. There is an emerging narrative that poverty has become the wallpaper of practice, “too big to tackle and too familiar to notice” (Morris et al. 2018) and invisible amid lack of public support and political will to increase welfare spending. This paper will examine poverty-related inequalities and how these affect families. It will discuss the importance of recognising that poverty is a social justice issue and a core task for social work and outline the range of supports that may be available for families to help lift them out of poverty. Finally, it will describe the development of a new practice framework for social work in Northern Ireland that challenges social workers to embed anti-poverty approaches in their practice. The framework emphasises that poverty is a social justice issue, seeks to provide practical support and guidance to re-focus attention, debate, and action on poverty in times of global economic uncertainty and give social workers the tools to make it central to their practice once again. It reinforces the need for social workers to understand and acknowledge the impact of poverty, and to advocate for and support those most in need. It aims to challenge and empower professionals to tackle poverty and inequality as an aspect of ethical and effective practice.

The implementation of a home visits program focused on parenting: an experience report

OBJECTIVE

To report the experience of implementing Home Visits as part of the Young Mothers Caregiver Program.

METHOD

The program focuses on the mother-child relationship as an object of care for developing parenting using the attachment theory, the self-efficacy theory and the bioecological theory as references. The construction of this program was centered on materials of international visitation programs, based on the translation of the material, elaboration and validation of the theoretical content.

RESULTS

The home visits performed by the nurses lasted an average of 1 hour, where issues related to health care, environmental health, life project, parenting, family and social network, in addition to the adolescents' demands were discussed. It was shown that nurses encountered difficulties in implementing the program.

CONCLUSION

By adopting Home Visits as a care tool with a focus on parenting, the experience of implementing the program proved to be an innovative technology, with great potential and relevance for promoting adolescent care and child development.

WIDENING THE SCOPE OF SOCIAL SUPPORT: THE FLORIDA MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING PROGRAM

The Florida Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program is designed to support pregnant women and families in developing skills and utilizing resources necessary to promote their children's physical, social, and emotional development. Little evaluation attention has focused on large-scale, public policy driven home-visiting programs. Social support provision is a critical component of a successful home-visiting program; therefore, there is a need to better understand participants' perceptions of social support provided to them in this context. Forty-five home-visiting participants from five Florida MIECHV programs completed semistructured telephone interviews. Participants discussed their experiences with the MIECHV program, including descriptions of their interactions with home visitors. Content analysis revealed that participants experienced multilayered social support from home-visiting staff. Families needed and received substantial emotional, instrumental, informational, and appraisal support at the individual level. This support was embedded within and strengthened by the strategies and activities of the home-visiting model of service provision. Results highlight the powerful opportunity home visiting offers as a method of service delivery within the larger system of care to increase social support in families experiencing high risk for negative maternal and child health outcomes. Implications for policy and practice are discussed.

DISCOVERING FRUGAL INNOVATIONS THROUGH DELIVERING EARLY CHILDHOOD HOME-VISITING INTERVENTIONS IN LOW-RESOURCE TRIBAL COMMUNITIES

Early childhood home-visiting has been shown to yield the greatest impact for the lowest income, highest disparity families. Yet, poor communities generally experience fractured systems of care, a paucity of providers, and limited resources to deliver intensive home-visiting models to families who stand to benefit most. This article explores lessons emerging from the recent Tribal Maternal and Infant Early Childhood Home Visiting (MIECHV) legislation supporting delivery of home-visiting interventions in low-income, hard-to-reach American Indian and Alaska Native communities. We draw experience from four diverse tribal communities that participated in the Tribal MIECHV Program and overcame socioeconomic, geographic, and structural challenges that called for both early childhood home-visiting services and increased the difficulty of delivery. Key innovations are described, including unique community engagement, recruitment and retention strategies, expanded case management roles of home visitors to overcome fragmented care systems, contextual demands for employing paraprofessional home visitors, and practical advances toward streamlined evaluation approaches. We draw on the concept of "frugal innovation" to explain how the experience of Tribal MIECHV participation has led to more efficient, effective, and culturally informed early childhood home-visiting service delivery, with lessons for future dissemination to underserved communities in the United States and abroad.

Development and implementation of a screen-and-refer approach to addressing maternal depression, substance use, and intimate partner violence in home visiting clients

Perinatal maternal depression (MD), substance use (SU), and intimate partner violence (IPV) are critical public health concerns with significant negative impacts on child development. Bolstering the capacity of home visiting (HV) programs to address these significant risk factors has potential to improve child and family outcomes. This study presents a description and mixed-methods feasibility evaluation of the "Home Visitation Enhancing Linkages Project (HELP)," a screen-and-refer approach to addressing MD, SU, and IPV within HV aimed at improving risk identification and linkage to treatment among HV clients. HELP was a three-phase intervention that included three evidence-based interventions: screening, motivational interviewing (MI), and case management (CM). This study presents quantitative fidelity data from 21 home visitors reporting on 116 clients in 4 HV programs, as well as qualitative data from structured interviews with 14 home visitors. Nearly all clients were screened and 22% screened positive on at least one risk domain. Rates of MI and CM implementation were lower than expected, however home visitors implemented general supportive interventions at high rates. Home visitor interviews revealed the following factors that may have impacted HELP implementation: client disclosure of risk, barriers to treatment access, systems integration, home visitor role perception, and integration of HELP into the broader HV curriculum. Implications of study findings for the design of future attempts to address maternal risk within HV are discussed.

Early Childhood Home Visiting

High-quality home-visiting services for infants and young children can improve family relationships, advance school readiness, reduce child maltreatment, improve maternal-infant health outcomes, and increase family economic self-sufficiency. The American Academy of Pediatrics supports unwavering federal funding of state home-visiting initiatives, the expansion of evidence-based programs, and a robust, coordinated national evaluation designed to confirm best practices and cost-efficiency. Community home visiting is most effective as a component of a comprehensive early childhood system that actively includes and enhances a family-centered medical home.

Generalizing about Public Health Interventions: A Mixed-Methods Approach to External Validity

Public health researchers and practitioners are calling for greater focus on external validity, the ability to generalize findings of evidence-based interventions (EBIs) beyond the limited number of studies testing effectiveness. For public health, the goal is applicability: to translate, disseminate, and implement EBIs for an impact on population health. This article is a review of methods and how they might be combined to better assess external validity. The methods include (a) better description of EBIs and their contexts; (b) combining of statistical tools and logic to draw inferences about study samples; (c) sharper definition of the theory behind the intervention and core intervention components; and (d) more systematic consultation of practitioners. For population impact, studies should focus on context features that are likely to be both important (based on program theory) and frequently encountered by practitioners. Mixed-method programs of research will allow public health to expand causal generalizations.

Perinatal Nurse Home Visiting Referral Patterns Among Women With Diabetes and Hypertension in Philadelphia

OBJECTIVE

To examine access to perinatal nurse home visiting services for high-risk pregnant women who have diabetes or hypertension.

DESIGN

Secondary data analysis.

SETTING

Philadelphia, PA.

PARTICIPANTS

Pregnant women who had a live birth during 2012 and those referred to a community-based agency for perinatal nurse home visiting because of their diagnosis of diabetes or hypertension.

METHODS

Access to services was measured by examining referral information (dosage, diagnosis, gestational age at time of referral, and insurance type) retrieved from administrative logs of the community-based organization that provides perinatal home visiting to high-risk pregnant women. The population-based prevalence rates of hypertension and diabetes were calculated from birth record data provided by the Philadelphia Department of Public Health.

RESULTS

During 2012, 595 pregnant women were referred for perinatal nurse home visiting services. The mean gestational age when referred for services was 24.9 weeks (standard deviation = 8.5) with a mean number of 8.8 authorized visits (standard deviation = 8). Associated with more authorized visits was having Medicaid as the insurance type and medical diagnoses that included hypertension (p < .01). Philadelphia prevalence rates for diabetes and hypertension varied by race and ethnicity (p < .001); Asian mothers had the greatest rates for diabetes and Black mothers the greatest rates for hypertension.

CONCLUSION

Various models of home visiting programs exist to improve maternal and child health outcomes. Because maternal morbidity and mortality rates are rising in the United States, further research about perinatal nurse home visiting programs for pregnant women with diabetes and hypertension is warranted.

Increasing the Delivery of Preventive Health Services in Public Education

The delivery of prevention services to children and adolescents through traditional healthcare settings is challenging for a variety of reasons. Parent- and community-focused services are typically not reimbursable in traditional medical settings, and personal healthcare services are often designed for acute and chronic medical treatment rather than prevention. To provide preventive services in a setting that reaches the widest population, those interested in public health and prevention often turn to school settings. This paper proposes that an equitable, efficient manner in which to promote health across the life course is to integrate efforts from public health, primary care, and public education through the delivery of preventive healthcare services, in particular, in the education system. Such an integration of systems will require a concerted effort on the part of various stakeholders, as well as a shared vision to promote child health via community and institutional stakeholder partnerships. This paper includes (1) examination of some key system features necessary for delivery of preventive services that improve child outcomes; (2) a review of the features of some common models of school health services for their relevance to prevention services; and (3) policy and implementation strategy recommendations to further the delivery of preventive services in schools. These recommendations include the development of common metrics for health outcomes reporting, facilitated data sharing of these metrics, shared organization incentives for integration, and improved reimbursement and funding opportunities.