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

A Social Network Analysis of a Multi-sector Service System for Intimate Partner Violence in a Large US City

About one in four women in the US report having experienced some form of intimate partner violence (IPV) during their lifetime and an estimated 15.5 million children live in families in which IPV occurred in the past year. Families of young children with IPV experiences often face complex needs and require well-coordinated efforts among service providers across social and health sectors. One promising partnership aims to support pregnant and parenting IPV survivors through coordination between IPV agencies and community-based maternal and early childhood home visiting programs. This study used social network analysis (SNA) to understand the interconnectedness of the system of IPV prevention and intervention for families with young children in a large US city. The SNA included 43 agencies serving this population across various service domains spanning IPV, legal, maternal and child health, and public benefit programs. An SNA survey collected data on four forms of collaboration between agencies, including formal administrative relationship, referral reciprocity, case consultation, and shared activities in community committees/organizing bodies. Density and centrality were the primary outcomes of interest. A community detection analysis was performed as a secondary analysis. The overall level of interconnectedness between the 43 responding agencies was low. Making referrals to each other was the most common form of collaboration, with a network density of 30%. IPV agencies had the highest average number of connections in the networks. There was a high level of variation in external collaborations among home visiting agencies, with several home visiting agencies having very few connections in the community but one home visiting program endorsing collaborative relationships with upwards of 38 partner agencies in the network. In serving families at risk for IPV, home visiting agencies were most likely to have referral relationships with mental health provider agencies and substance use disorder service agencies. A community detection analysis identified distinct communities within the network and demonstrated that certain agency types were more connected to one another while others were typically siloed within the network. Notably, the IPV and home visiting communities infrequently overlapped. Sensitivity analyses showed that survey participants' knowledge of their agencies' external collaborations varied by their work roles and agencies overall had low levels of consensus about their connectedness to one another. We identified a heterogeneous service system available to families of young children at-risk for or experiencing IPV. Overall inter-agency connectedness was low, with many siloed agencies and a lack of shared knowledge of community resources. Understanding current collaborations, silos, and centrality of agencies is an effective public health tool for allocating scarce resources across diverse service sectors to efficiently improve the system serving families experiencing IPV.

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.

Development and validation of a goal attainment scale for families affected by maternal substance use

The Team for Infants Exposed to Substance use (TIES) Program is a longstanding home-based family support program that provides a multidisciplinary, community-facing model to address the complex needs of families with young children affected by maternal substance use. The model required a comprehensive assessment tool to guide creation of individualized family goals with steps to achievement and measurement of progress on those goals. This article describes the development of a goal attainment scale and the analysis conducted to validate the scale for the service population. TIES model developers and community partners developed the goal attainment scale to assess outcomes in key domains: maternal substance use, parenting, child and maternal health, income, and housing. Data were collected from 2012 to 2019 from 220 participants and analyzed in 2020. Exploratory factor analysis (EFA) and confirmatory factor analysis were conducted. Twenty-five of the original 30 items were retained in a six-factor structure. The total percentage of variance explained was 64.44% with six factors, and Cronbach's alpha was .90. For the split-half method, the reliability of scale was .90 for unbiased conditions. Therefore, the scale reached acceptable reliability and validity. The scale provides a comprehensive approach to measure family outcomes across multiple domains addressing key risk and protective factors. This family-centered scale serves both therapeutic and evaluation purposes, acting as an intervention guide and a goal attainment measurement tool.

Identification of families in need of support: Correlates of adverse childhood experiences in the right@home sustained nurse home visiting program

Background

Little is known about the efficacy of pregnancy screening tools using non-sensitive sociodemographic questions to identify the possible presence of as yet undiagnosed disease in individuals and later adverse childhood events disclosure.

Objectives

The study aims were to: 1) record the prevalence of risk disclosed by families during receipt of a sustained nurse home visiting program; and 2) explore patterns of relationships between the disclosed risks for their child having adverse experiences and the antenatal screening tool, which used non-sensitive demographic questions.

Design

Retrospective, observational study.

Participants and methods

Data about the participants in the intervention arm of the Australian right@home trial, which is scaffolded on the Maternal Early Childhood Sustained Home-visiting model, collected between 2013 and 2017 were used. Screening data from the 10-item antenatal survey of non-sensitive demographic risk factors and disclosed risks recorded by the nurse in audited case files during the subsequent 2 year intervention were examined (n = 348). Prevalence of disclosed risks for their child having adverse experiences were analysed in 2019 using multiple response frequencies. Phi correlations were conducted to test associations between screening factors and disclosed risks.

Results

Among the 348 intervention participants whose files were audited, 300 were noted by nurses to have disclosed risks during the intervention, with an average of four disclosures. The most prevalent maternal disclosures were depression or anxiety (57.8%). Mental health issues were the most prevalent partner and family disclosures. Screening tool questions on maternal smoking in pregnancy, not living with another adult, poverty and self-reporting anxious mood were significantly associated with a number of disclosed risks for their child having adverse experiences.

Conclusions

These findings suggest that a non-sensitive sociodemographic screening tool may help to identify families at higher risk for adverse childhood experiences for whom support from a sustained nurse home visiting program may be beneficial.

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.

Screening for intimate partner violence in healthcare settings: An implementation-oriented systematic review

Background

Intimate partner violence (IPV) is a population health problem affecting millions of women worldwide. Screening for IPV within healthcare settings can identify women who experience IPV and inform counseling, referrals, and interventions to improve their health outcomes. Unfortunately, many screening programs used to detect IPV have only been tested in research contexts featuring externally funded study staff and resources. This systematic review therefore investigated the utility of IPV screening administered by frontline clinical personnel.

Methods

We conducted a systematic literature review focusing on studies of IPV screening programs for women delivered by frontline healthcare staff. We based our data synthesis on two widely used implementation models (Reach, Effectiveness, Adoption, Implementation and Maintenance [RE-AIM] and Proctor's dimensions of implementation effectiveness).

Results

We extracted data from 59 qualifying studies. Based on data extraction guided by the RE-AIM framework, the median reach of the IPV screening programs was high (80%), but Emergency Department (ED) settings were found to have a much lower reach (47%). The median screen positive rate was 11%, which is comparable to the screen-positive rate found in studies using externally funded research staff. Among those screening positive, a median of 32% received a referral to follow-up services. Based on data extraction guided by Proctor's dimension of appropriateness, a lack of available referral services frustrated some efforts to implement IPV screening. Among studies reporting data on maintenance or sustainability of IPV screening programs, only half concluded that IPV screening rates held steady during the maintenance phase. Other domains of the RE-AIM and Proctor frameworks (e.g., implementation fidelity and costs) were reported less frequently.

Conclusions

IPV is a population health issue, and successfully implementing IPV screening programs may be part of the solution. Our review emphasizes the importance of ongoing provider trainings, readily available referral sources, and consistent institutional support in maintaining appropriate IPV screening programs.

Plain language abstract

Intimate partner violence (IPV) is a population health problem affecting millions of women worldwide. IPV screening and response can identify women who experience IPV and can inform interventions to improve their health outcomes. Unfortunately, many of the screening programs used to detect IPV have only been tested in research contexts featuring administration by externally funded study staff. This systematic review of IPV screening programs for women is particularly novel, as previous reviews have not focused on clinical implementation. It provides a better understanding of successful ways of implementing IPV screening and response practices with frontline clinical personnel in the context of routine care. Successfully implementing IPV screening programs may help mitigate the harms resulting from IPV against women. Findings from this review can inform future efforts to improve implementation of IPV screening programs in clinical settings to ensure that the victims of IPV have access to appropriate counseling, resources, and referrals.

What is the role of firearms in nonfatal intimate partner violence? Findings from civil protective order case data

BACKGROUND

Perpetrators of intimate partner violence (IPV) use firearms to injure, scare, and manipulate their partners. Abusers who have a firearm in their homes are more likely to threaten and/or kill their partner. To date, however, limited research documents the nature of IPV perpetrator firearm access or the prevalence of nonfatal firearm abuse behaviors.

METHODS

Federal law restricts firearm access for IPV perpetrators in qualifying domestic violence protective order (DVPO) cases and information about firearms should be disclosed during the DVPO process. We used secondary data from civil DVPO cases (n = 406) in North Carolina that were collected using a representative sampling strategy. Data were from DVPO case files and structured DVPO hearing observations. We conducted a content analysis to record IPV perpetrator access to guns and reported firearm abuse behaviors. We used a linear regression analysis to determine whether IPV perpetrator gun access was associated with higher levels of reported abuse. We also examined factors associated with perpetration of nonfatal firearm abuse.

RESULTS

We found evidence of perpetrator firearm access in nearly half of all cases (46%, n = 108). Controlling for covariates, gun access was significantly associated with higher levels of reported IPV (b = 0.5, p < .001). Firearm abuse was reported in nearly one out of four cases (23.1%, n = 101), and often entailed spoken threats, displaying a gun, or holding a partner at gun point. The only factors associated with firearm abuse in the multivariate models were related to English language speaking/fluency.

CONCLUSIONS

Gun access should be considered an indicator for severe IPV. We must ensure that existing legal mechanisms to identify and restrict abuser access to firearms are fully implemented and enforced. Firearm abuse often manifests as non-physical coercive control which is traumatic and has the potential to escalate to homicide, even in the absence of past physical violence.

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.

The Intersection Between Adverse Childhood Experiences and Environmental Tobacco Smoke in U.S. Households With Children

INTRODUCTION

Environmental tobacco smoke (ETS) is a potent risk factor for secondhand smoke (SHS) exposure. Research reveals, moreover, that children who are exposed to SHS are at an increased risk of disease and premature mortality. Limited research, however, has examined whether households with children experiencing accumulating adverse childhood experiences (ACEs) are also more likely to be characterized by ETS-particularly in the form of family members smoking inside the housing unit.

AIMS AND METHODS

The current study employs a nationally representative sample of 102 341 households with children from the three most recent cohorts of National Survey of Children's Health. Both multinomial logistic regression and a strategic comparison approach are used to examine the association between ACEs and ETS categories.

RESULTS

A large majority of households characterized by ETS report one or more ACEs, while households without ETS are largely void of ACEs. Findings indicate that this association is not merely a function of general family member smoking, as ACEs are strongly and uniquely associated with family smoking inside the housing unit-above and beyond family members smoking more generally.

CONCLUSIONS

Households exhibiting an accumulation of ACEs may benefit from interventions providing resources and education supporting smoke-free home environments. Such families may also be screened and referred through existing family and parenting programs administered in the home environment (eg, home visiting).

IMPLICATIONS

Public health initiatives designed to mitigate child adversities from early life stages may help reduce ETS in housing units-thereby diminishing the risk of secondhand smoke (SHS) exposure among children.

A Promising Approach in Home Visiting to Support Families Affected by Maternal Substance Use

Introduction

Many factors influence women’s use of alcohol and other drugs while pregnant and postpartum. Substance use impacts the maternal-child relationship during the critical neonatal period. The first days and months of human development lay the foundation for health and well-being across the lifespan, making this period an important window of opportunity to interrupt the transmission of trauma and stress to the next generation. Pregnant and postpartum women with a history of substance use require specialized support services.

Methods

The Team for Infants Exposed to Substance abuse (TIES) Program provides a holistic, multi-disciplinary, community-based model to address the complex needs of families with young children affected by maternal substance use.

Results

A multi-year implementation study of the model yielded results that indicate the effectiveness of this home-based family support intervention. The model focuses on reducing maternal alcohol and other drug use, increasing positive parenting, promoting child and maternal health, and improving family income and family housing. A key component of the model is establishing a mutual, trusting relationship between the home visiting specialists and the family. Foundational to the TIES model is a family-centered, culturally competent, trauma-informed approach that includes formal interagency community partnerships

Discussion

This article describes elements of the model that lead to high retention and completion rates and family goal attainment for this unique population.

Motivational Interviewing in Child Welfare Services: A Systematic Review

Families in the child welfare (CW) system who cannot be engaged in services are at high risk of negative outcomes. As motivational interviewing (MI) has been shown to improve engagement in similar contexts. This study aimed to systematically review MI with CW families as well as MI training with CW workers and social work students training to become CW workers. The review used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched multiple databases in June 2018. In September 2019, the initial search was repeated with additional searches to identify gray literature. Eight studies described the acquisition of MI among CW workers or student trainees, and 11 studies evaluated the impact of MI on families in CW. MI's impact on some family outcomes, such as engagement in services, was mixed, though MI paired with other evidence-based treatments showed positive effects. With regard to training CW workers and students in MI, differences in training duration, intensity, and modality make conclusions difficult, though trainees generally described MI favorably and some studies showed training increased worker empathy and self-efficacy. Importantly, few published studies have evaluated whether MI-trained CW workers impact out-of-home-care placement, and no studies have evaluated their impact on maltreatment.

Seeing the Forest in Family Violence Research: Moving to a Family-Centered Approach

Victims of family violence are sorted into fragmented systems that fail to address the family as an integrated unit. Each system provides specialized care to each type of victim (child, older adult, adult, animal) and centers on the expertise of the medical and service providers involved. Similarly, researchers commonly study abuse from the frame of the victim, rather than looking at a broader frame-the family. We propose the following 5 steps to create a research paradigm to holistically address the response, recognition, and prevention of family violence.By developing an integrated research model to address family violence, and by using that model to support integrated systems of care, we propose a fundamental paradigm shift to improve the lives of families living with and suffering from violence.

Pilot of a screening, brief intervention and referral to treatment process for symptoms of trauma among primary care patients

BACKGROUND

For populations with high rates of trauma exposure yet low behavioural health service use, identifying and addressing trauma in the primary care setting could improve health outcomes, reduce disability and increase the efficiency of health system resources.

OBJECTIVE

To assess the acceptability and feasibility of a screening, brief intervention and referral to treatment (SBIRT) process for trauma and symptoms of posttraumatic stress disorder (PTSD) among American Indian and Alaska Native people. We also examine the short-term effects on service utilization and the screening accuracy of the Primary Care Posttraumatic Stress Disorder Screen.

METHODS

Cross-sectional pilot in two tribal primary care settings. Surveys and interviews measured acceptability among patients and providers. Health service utilization was used to examine impact. Structured clinical interview and a functional disability measure were used to assess screening accuracy.

RESULTS

Over 90% of patient participants (N = 99) reported the screening time was acceptable, the questions were easily understood, the right staff were involved and the process satisfactory. Ninety-nine percent would recommend the process. Participants screening positive had higher behavioural health utilization in the 3 months after the process than those screening negative. The Primary Care Posttraumatic Stress Disorder Screen was 100% sensitive to detect current PTSD with 51% specificity. Providers and administrators reported satisfaction with the process.

CONCLUSIONS

The SBIRT process shows promise for identifying and addressing trauma in primary care settings. Future research should explore site specific factors, cost analyses and utility compared to other behavioural health screenings.

Addressing maternal depression in home visiting: Findings from the home visiting collaborative improvement and innovation network

Background

Maternal depression is common among low-income women enrolled in home visiting programs, yet there is considerable variability in the extent to which it is identified and addressed. This study examines outcomes related to postpartum depression screening, receipt of evidence-based services, and reductions in depressive symptoms among clients of home visiting programs in the Health Resources and Services Administration’s Maternal, Infant, and Early Childhood Home Visiting Program Home Visiting Collaborative Improvement and Innovation Network (HV CoIIN), the first U.S. national application of the Institute for Healthcare Improvement’s Breakthrough Series (BTS) Model in home visiting programs.

Methods and findings

Fourteen home visiting programs in eight states, serving a geographically and racially diverse caseload of pregnant women and new mothers, took part in the HV CoIIN. Women in participating home visiting programs received the intervention strategies implemented by their program during participation in the collaborative. HV CoIIN strategies included specific policies and protocols for depression screening and home visitor response to screening results; home visitor training and supervision; delivery of prevention and treatment interventions; and tracking systems for screening, referral, and follow-up. HV CoIIN’s proposed primary outcome was that 85% of women who accessed evidence-based services would experience a 25% reduction in depressive symptoms three months after accessing services. Secondary outcomes included an increased percentage of women who were screened for depression within three months of enrollment or birth, who verbally accepted a referral to evidence-based services, and who received one or more evidence-based service contacts. HV CoIIN resulted in improved symptoms among women who accessed services, from 51.1% to 59.9%. HV CoIIN also improved the percent of women screened for depression, from 83.6% to 96.3%, and those with positive depression screens who accessed evidence-based services, from 41.6% to 65.5%. Home visiting programs in this study were early adopters of quality improvement activities, which may limit the generalizability of these results to other home visiting programs.

Conclusions

Home visiting programs can play an important role in closing gaps in maternal depression identification, referrals, service access, and symptom alleviation. Continuous quality improvement and BTS collaborative methods can be used to improve home visiting services in ways that advance national public health priorities and improve population health outcomes.

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.

Addressing Maternal Depression, Substance Use, and Intimate Partner Violence in Home Visiting: a Quasi-Experimental Pilot Test of a Screen-and-Refer Approach

This quasi-experimental pilot study describes preliminary impacts of the "Home Visitation Enhancing Linkages Project (HELP)," a pragmatic screen-and-refer approach for promoting identification of and linkage to treatment for maternal depression (MD), substance use (SU), and intimate partner violence (IPV) within early childhood home visiting. HELP includes screening for MD, SU, and IPV followed by a menu of motivational interviewing and case management interventions aimed at linking clients to treatment, designed for delivery within routine home visiting. HELP was piloted within four counties of a statewide home visiting system that were implementing Healthy Families America. HELP clients (N = 394) were compared to clients in five demographically matched counties that received usual Healthy Families services (N = 771) on whether their home visitors (1) identified MD, SU, and IPV risk; (2) discussed MD, SU, and IPV during home visits; and (3) made referrals for MD, SU, and IPV. All data were extracted from the program's management information system. A significant impact of HELP was found on discussion of risk in home visits for all three risk domains with large effect sizes (MD OR = 4.08; SU OR = 15.94; IPV OR = 9.35). HELP had no impact on risk identification and minimal impact on referral. Findings provide preliminary support for HELP as a way of improving discussion of client behavioral health risks during home visits, an important first step toward better meeting these needs within home visiting. However, more intensive intervention is likely needed to impact risk identification and referral outcomes.

The Development and Evaluation of a Statewide Training Center for Home Visitors and Supervisors

This paper informs practice in community-based home visiting workforce development by describing the development and evaluation of a university-based training certificate program for home visitors and supervisors. The Interactive Systems Framework for Dissemination and Implementation (ISF; Wandersman et al., 2008) guides our conceptualization and paper organization. The ISF describes the components involved in translating research findings into effective implementation of prevention programs. We describe implementation and lessons learned from seven development activities: (a) review of the literature, (b) survey of other training initiatives across the country, (c) focus groups with home visitors and supervisors, (d) consultation with individual home visitors, (e) creation of a state advisory board of home visiting providers and stakeholders, (f) evaluation of two pilot trainings, and (g) video development. We then present evaluation data from 49 home visitors and 23 supervisors who completed the training certificate program after the pilot trainings. Both home visitors and supervisors rated training satisfaction highly, reported significant increases in self-efficacy related to the training topics, and reported extensive use of motivational communication techniques, which are the foundational skills of the training content. These and other favorable results reflect the benefits of building on advances in theory and science-based practice and of involving providers and stakeholders repeatedly throughout the development process.

ADDRESSING SUBSTANCE-USE PROBLEMS IN TRIBAL HOME VISITING

Given the high rates for substance use among women and men of childbearing age, perinatal and early childhood home-visiting programs serving tribal communities must consider how they will address substance-use problems among the families they support. In this study, we explored the approaches to identifying and addressing family-based substance-use problems that were implemented by nine home-visiting programs serving American Indian/Alaska Native (AI/AN) communities that are funded through the federal Tribal Maternal, Infant, and Early Childhood Home Visiting Program (Tribal MIECHV). These programs demonstrated a high awareness of substance-use problems and took concrete action to address them above and beyond that included in the home-visiting model they used. All nine programs reported that they provided substance-use preventive services and screened for substance-use problems. While all programs referred to substance-use treatment programs when needed, in six programs the home visitor provided substance-use services. Through Tribal MIECHV, the intense need for substance-use education, assessment, service delivery, and referral in many AI/AN communities is pushing the home-visiting field forward to address this increasingly critical issue for low-income families across the United States and the world.