Engagement in paraprofessional home visitation: families' reasons for enrollment and program response to identified reasons

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.

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.

Parent satisfaction with sustained home visiting care for mothers and children: an integrative review

AIM

To synthesise and analyse the existing literature regarding parent satisfaction with sustained home visiting care for mothers and children.

BACKGROUND

Sustained home visiting is a service delivery mechanism of both prevention and intervention, in which people receive structured support services within their home environment over an extended period of months or years. For the purposes of this paper, sustained home visiting refers to in-home nursing support to address health inequities for mothers and young children. Sustained home visiting programs have been found to support improved health, wellbeing, and developmental outcomes for children and families. However, there is limited knowledge with regards to the level of parent satisfaction with care provided at home, and the factors and elements of care parents perceive to be critical to their satisfaction. It is important for healthcare practitioners to understand what practices and process parents consider to be a priority in securing their ongoing engagement.

DESIGN

Integrative review.

DATA SOURCES

PubMed/Medline, CINAHL, Embase, and PsycINFO.

METHODS

A multi-step approach was used to search and retrieve peer-reviewed studies from the databases. Study selection, data extraction, data synthesis and critical appraisal were undertaken by two independent researchers.

RESULTS

A total of 13 studies met the inclusion criteria, including nine quantitative and four qualitative studies. The review found that parents provided with home visiting interventions had higher levels of satisfaction with care than those who received routine or facility-based care. Service dose was a factor associated with parent satisfaction, however, the direction of impact on parent satisfaction was mixed. Other elements of care parents perceived as important to service satisfaction included the nurse-client relationship, being treated with respect, empowerment, and emotional support.

CONCLUSION

While it is critically important that home visiting practitioners provide evidence-based care and interventions, it is equally important that services are delivered in the context of positive and empowering relationships. Further research is recommended to understand the care process and mechanisms that enhance parent satisfaction and positive experiences, providing optimal quality of care.

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

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

Following through: Interventions to improve long-term outcomes of preterm infants

The inequalities in income, wealth, and opportunity so deeply ingrained in our society's history of enslavement, genocide, racism, and discrimination are root causes of health disparities. Follow through is a comprehensive approach that begins before birth and continues into childhood, where health professionals, families, and communities partner to meet the social as well as medical needs of infants and families to achieve health equity. This article discusses potentially better practices for follow through, offering neonatal care providers tangible ways to address social determinants of health, the conditions in which people are born, grow, work, live, and age and the systems that creates these conditions.

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

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

Diversity of adverse childhood experiences among adolescent mothers and the intergenerational transmission of risk to children's behavior problems

RATIONALE

It is important to investigate the diversity and variability among adverse childhood experiences (ACEs) in young mothers because they are likely to experience considerable adverse exposures during childhood as well as challenging environments following childbirth.

OBJECTIVE

The current study used latent class analysis with a diverse sample of young mothers to identify subgroups of mothers based on their adverse childhood experiences (ACEs). Subsequent analyses were conducted to examine class specific differences in maternal mental health postpartum and their children's socio-emotional functioning at eight years of age.

RESULTS

Four classes of participants were identified based on mothers' ACEs, including a high, multiple-risk class, a low-risk class, a high-risk for abuse class, and a high-risk for household dysfunction class. These classes were associated with differences in maternal and child functioning. The low-risk class showed significantly better maternal and child health and well-being than the high-risk class. However, nuanced differences were seen for mothers and their children across all classes; for example, children of mothers in the high-risk for abuse class scored significantly better on internalizing behaviors than children from the high, multiple-risk class, but not better on externalizing behaviors. Further, children of mothers in the high-risk for household dysfunction class scored better than the high, multiple-risk class on externalizing behaviors but not better on scores of internalizing behaviors.

CONCLUSION

Understanding the differences in how certain types of childhood adversity are associated with mothers' and their children's later health and well-being will bolster the use of only a sum score of ACEs for both how we research risk and in supporting clinicians to provide targeted care.

Video-Delivered Family Therapy for Home Visited Young Mothers With Perinatal Depressive Symptoms: Quasi-Experimental Implementation-Effectiveness Hybrid Trial

BACKGROUND

The Federal Maternal, Infant, and Early Childhood Home Visiting Program is a national child abuse prevention strategy that serves families at risk for child maltreatment throughout the United States. Significant portions of the clients are young mothers who screen positive for clinically significant perinatal depressive symptoms and experience relational discord that worsens their symptoms. Although home visitors refer those who screen positive for depression to community-based treatment, they infrequently obtain treatment because of multiple barriers. These barriers are compounded for home visited families in rural areas.

OBJECTIVE

This pilot study aimed to explore the feasibility, acceptability, and effectiveness of a video-delivered family therapy intervention on reducing maternal depressive symptoms and improving family functioning and emotion regulation.

METHODS

A total of 13 home visited families received the video-delivered family therapy intervention. This study included a historical comparison group of mothers (N=13) who were previously enrolled in home visiting and screened positive for clinically significant perinatal depressive symptoms but refused treatment. A licensed marriage and family therapist delivered the family therapy intervention using Health Insurance Portability and Accountability Act-compliant videoconferencing technology on a computer from an office. Families participated in sessions in their homes using cell phones, tablets, and computers equipped with microphones and video cameras. Outcomes were measured following the final therapy session (post intervention) and 2 months later (follow-up). Depressive symptom scores of mothers who received the video-delivered family therapy intervention were compared with those of mothers in the historical comparison group over a 6-month period. Univariate statistics and correlations were calculated to assess measures of feasibility. Percentages and qualitative thematic analysis were used to assess acceptability. Wilcoxon signed-rank tests were used to assess changes in maternal and family outcomes.

RESULTS

No families dropped out of the study. All families reported that the technology was convenient and easy to use. All families reported high satisfaction with the video-delivered intervention. Nearly all families reported that they preferred video-delivered family therapy instead of clinic-based therapy. Therapeutic alliance was strong. Mothers demonstrated a statistically significant reduction in depressive symptoms (P=.001). When compared with mothers in the historical comparison group, those in the family therapy intervention showed a significant reduction in depressive symptoms (P=.001). Families demonstrated statistically significant improvements in family functioning (P=.02) and cognitive reappraisal (P=.004).

CONCLUSIONS

This pilot study yielded preliminary findings that support the feasibility, acceptability, and effectiveness of the video-delivered family therapy intervention for underserved home visited families in rural areas. Our findings are very promising, but more research is needed to ultimately influence mental health practices and policies that pertain to video-delivered mental health interventions in unsupervised settings (eg, homes).

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

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

Impact of a Child Abuse Primary Prevention Strategy for New Mothers

First Steps (FS) is a brief obstetrics-based primary prevention strategy that aims to strengthen protective factors to prevent child maltreatment. This randomized controlled trial assessed how well FS services aligned with family interests and needs, how FS providers used communication strategies to build partnership with mothers, and the impact of FS on mothers' parenting knowledge in core content areas and access to services. Mothers completed a baseline survey and were randomly assigned to FS and control conditions (n = 374 and 375, respectively). The parenting education services provided to mothers were assessed by independent participant report immediately postintervention for the full FS group and by analysis of audio-recordings of the FS encounter for a subsample (n = 150). Outcomes were measured at 4 months via maternal survey. Compared to controls at follow-up, FS mothers had significantly higher knowledge scores in some areas but similar access to needed services. Few mothers lacked access to most services at baseline, and FS content was similar to that provided by other hospital personnel. FS providers' communication style promoted rapport, but providers did not tailor content to mothers' educational and service access needs. Implications of the findings for similar services are discussed.

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

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

Measuring dosage: a key factor when assessing the relationship between prenatal case management and birth outcomes

To assess whether a measure of prenatal case management (PCM) dosage is more sensitive than a dichotomous PCM exposure measure when evaluating the effect of PCM on low birthweight (LBW) and preterm birth (PTB). We constructed a retrospective cohort study (N = 16,657) of Iowa Medicaid-insured women who had a singleton live birth from October 2005 to December 2006; 28 % of women received PCM. A PCM dosage measure was created to capture duration of enrollment, total time with a case manager, and intervention breadth. Propensity score (PS)-adjusted odds ratios (ORs), and 95 % confidence intervals (95 % CIs) were calculated to assess the risk of each outcome by PCM dosage and the dichotomous PCM exposure measure. PS-adjusted ORs of PTB were 0.88 (95 % CI 0.70-1.11), 0.58 (95 % CI 0.47-0.72), and 1.43 (95 % CI 1.23-1.67) for high, medium, and low PCM dosage, respectively. For LBW, the PS-adjusted ORs were 0.76 (95 % CI 0.57-1.00), 0.64 (95 % CI 0.50-0.82), and 1.36 (95 % CI 1.14-1.63), for high, medium, and low PCM dosage, respectively. The PCM dichotomous participation measure was not significantly associated with LBW (OR = 0.95, 95 % CI 0.82-1.09) or PTB (0.97, 95 % CI 0.87-1.10). The reference group in each analysis is No PCM. PCM was associated with a reduced risk of adverse pregnancy outcomes for Medicaid-insured women in Iowa. PCM dosage appeared to be a more sensitive measure than the dichotomous measure of PCM participation.

Association of maternal and community factors with enrollment in home visiting among at-risk, first-time mothers

OBJECTIVES

We identified individual and contextual factors associated with referral and enrollment in home visiting among at-risk, first-time mothers.

METHODS

We retrospectively studied referral and enrollment in a regional home visiting program from 2007 to 2009 in Hamilton County, Ohio. Using linked vital statistics and census tract data, we obtained individual and community measures on first-time mothers meeting eligibility criteria for home visiting (low income, unmarried, or age < 18 years). Generalized linear modeling was performed to determine factors associated with relative risk (RR) of (1) referral to home visiting among eligible mothers and (2) enrollment after referral.

RESULTS

Of 8187 first-time mothers eligible for home visiting, 2775 were referred and 1543 were enrolled. Among referred women, high school completion (RR = 1.10) and any college (RR = 1.17) compared with no high school completion were associated with increased enrollment, and enrollment was less likely for those living in communities with higher socioeconomic deprivation (RR = 0.71; P < .05).

CONCLUSIONS

Barriers to enrollment in home visiting persisted at multiple ecological levels. Ongoing evaluation of enrollment in at-risk populations is critical as home visiting programs are implemented and expanded.

Enhancing home visiting with mental health consultation

Home visiting programs have been successful in engaging and enrolling families who are at high risk for stress, depression, and substance abuse. However, many of these mothers may not be receiving mental health services because home visitors lack the knowledge and skills to identify mental health or determine how to appropriately address these problems. In response, a growing number of home visiting programs are expanding their capacity by integrating a mental health provider into their ongoing operations. This approach, referred to as early childhood mental health consultation, involves a partnership between a professional consultant with early childhood mental health expertise and home visiting or family support programs, staff, and families. This integrated model holds the promise of promoting parent and child behavioral health by enhancing the capacity of home visitors to identify and appropriately address the unmet mental health needs of children and families. The article highlights efforts under way in several federally funded Linking Actions for Unmet Needs in Children's Health Project sites where local programs are testing the effectiveness of this model.

A clinical trial of in-home CBT for depressed mothers in home visitation

Despite negative outcomes for depressed mothers and their children, no treatment specifically designed to address maternal depression in the context of home visitation has emerged. In-Home Cognitive Behavioral Therapy (IH-CBT) is an adapted treatment that is delivered in the home, focuses on the needs of new mothers, and leverages ongoing home visiting to optimize engagement and outcomes. This study examined the efficacy of IH-CBT using a randomized clinical trial. Subjects were 93 new mothers in a home visiting program. Mothers with major depressive disorder identified at 3months postpartum were randomized into IH-CBT and ongoing home visitation (n=47) or standard home visitation (SHV; n=46) in which they received home visitation alone and could obtain treatment in the community. Depression was measured at pre- and posttreatment, and 3-month follow-up using interviews, clinician ratings, and self-report. Mothers receiving IH-CBT showed improvements in all indicators of depression relative to the SHV condition and these gains were maintained at follow-up. For example, 70.7% of mothers receiving IH-CBT were no longer depressed at posttreatment in terms of meeting criteria for major depressive disorder compared to 30.2% in the SHV group. These findings suggest that IH-CBT is an efficacious treatment for depressed mothers in home visitation programs.

Treatment of depressed mothers in home visiting: impact on psychological distress and social functioning

OBJECTIVES

Depression is prevalent in mothers receiving home visiting. Little is known about the impact of treatment on associated features of maternal depression in this population. The purpose of this study was to examine the impact of a novel, adapted treatment for depressed mothers in home visiting on psychological distress and social functioning.

METHODS

In-Home Cognitive Behavioral Therapy (IH-CBT) was developed to treat depressed mothers in home visiting. A randomized clinical trial design was used in which subjects were 93 new mothers in a home visiting program. Mothers with major depressive disorder identified at 3 months postpartum were randomized into IH-CBT and ongoing home visiting (n = 47) or standard home visiting (SHV; n = 46) in which they received home visitation alone and could obtain treatment in the community. Measures of psychological distress, social support, and social network were measured at pre-treatment, post-treatment, and three-month follow-up. Clinical features of depression and home visiting parameters were examined as potential moderators.

RESULTS

Subjects receiving IH-CBT reported decreased psychological distress at post-treatment (ES = 0.77) and follow-up (ES = 0.73). Examination of types of psychological distress indicated broad improvements at both time points. Those receiving IH-CBT reported increased social support over time relative to those in the SHV condition. Effect sizes were modest at post-treatment (ES = 0.38) but increased at follow-up (ES = 0.65). Improvements were seen in affiliative and belonginess aspects of social support, in contrast to tangible support which was statistically non-significant. Findings were not moderated by clinical features of depression or home visiting parameters. No group differences were found in size of and involvement with social networks.

CONCLUSIONS

IH-CBT is effective in reducing psychological distress and improving perceived social support in depressed mothers receiving home visiting. To the extent that mothers are better adjusted and feel socially supported, they are more available to their children and more amenable to home visiting services. IH-CBT is a feasible, readily adopted treatment that is compatible with multiple home visiting models. As a result it is a promising approach to help depressed mothers in home visiting. Additional interventions may be needed to support depressed mothers in building sizable and stable social networks.

Maternal perceptions of help from home visits by nurse-community health worker teams

We used data from a home visiting trial to examine low-income women's perceptions of services received from nurses (the community care [CC] group) and from a nurse-community health worker (CHW) team. More mothers in the nurse-CHW group than in the CC group reported receiving help in all of the categories assessed. For both groups, assistance with health education ranked highest among the types of assistance received. A higher percentage of women in the nurse-CHW group than the CC group reported that they received psychosocial help.