Developing a multicomponent implementation strategy for mental health interventions within the Nurse-Family Partnership: An application of the EPIS framework

Social Support Is Protective Against the Effects of Discrimination on Parental Mental Health Outcomes

BACKGROUND

Discrimination, or unfair treatment based on individual characteristics such as gender, race, skin color, and or sexual orientation, is a pervasive social stressor that perpetuates health disparities by limiting social and economic opportunity and is associated with poor mental and physical health outcomes.

AIMS

The purpose of the present study is to (1) examine the association between maternal experiences of discrimination and paternal experiences of discrimination; (2) explore how discrimination relates to parental (maternal and paternal) stress and depressive symptoms; and (3) examine whether social support exerts protective effects.

METHODS

The sample was 2,510 mothers and 1,249 fathers from the Child Community Health Network study. Linear regression models were conducted to explore associations between maternal and paternal discrimination. In addition, mediation analyses were conducted to explore if social support functioned as a mediator between discrimination on parental stress and depressive symptoms.

RESULTS

Most mothers (40.3%) and fathers (50.7%) identified race as the predominant reason for discrimination. Experiencing discrimination was significantly related to stress and depressive symptoms for both parents, and all forms of social support mediated these relationships. Our findings suggest that social support can act as a protective factor against the negative association between discrimination and both stress and depressive symptoms.

CONCLUSIONS

These findings highlight the need to integrate social support into existing interventions and include fathers in mental health screenings in primary-care settings. Finally, we briefly describe the role of nurses and other allied health professionals in addressing discrimination in health care and health policy implications.

Evaluating the tailored implementation of a multisite care navigation service for mental health in rural and remote Australia (The Bridging Study): protocol for a community-engaged hybrid effectiveness-implementation study

BACKGROUND

A dramatic decline in mental health of people worldwide in the early COVID-19 pandemic years has not recovered. In rural and remote Australia, access to appropriate and timely mental health services has been identified as a major barrier to people seeking help for mental ill-health. From 2020 to 2021 a care navigation model, Navicare, was co-designed with rural and remote communities in the Greater Whitsunday Region of Central Queensland in Australia. The Exploration, Preparation, Implementation and Sustainment (EPIS) framework was used to design and guide multiple aspects of a multisite study, The Bridging Study, to evaluate the implementation of Navicare in Australia.

METHODS

A community-engaged hybrid effectiveness-implementation study design will focus on the tailored implementation of Navicare at three new sites as well as monitoring implementation at an existing site established since 2021. Study outcomes assessed will include sustained access as the co-primary outcome (measured using access to Navicare mental health referral services) and Proctor's Implementation Outcomes of feasibility, acceptability, appropriateness, adoption, fidelity, implementation cost, and sustainability. Data collection for the implementation evaluation will include service usage data, community consultations, interviews, and workshops; analysed using mixed methods and guided by EPIS and other implementation frameworks. Pre-post effectiveness and cost-consequence study components are embedded in the implementation and sustainment phases, with comparison to pre-implementation data and value assessed for each EPIS phase using hospital, service, and resource allocation data. A scaling up strategy will be co-developed using a national roundtable forum in the final year of the study. Qualitative exploration of other aspects of the study (e.g., mechanisms of action and stakeholder engagement) will be conducted.

DISCUSSION

Our study will use tailoring to local sites and a community-engaged approach to drive implementation of a mental health care navigation service in rural and remote Australia, with expected benefits to mental healthcare access. This approach is consistent with policy recommendations nationally and internationally as building blocks for rural health including the World Health Organization Framework for Action on Strengthening Health Systems to Improve Health Outcomes.

TRIAL REGISTRATION

Prospectively registered on April 2, 2024, on the Australian New Zealand Clinical Trials Registry, no. ACTRN12624000382572. https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=386665&isReview=true .

Comparison of Weighting Methods to Understand Improved Outcomes Attributable to Public Health Nursing Interventions

BACKGROUND

The complex work of public health nurses (PHNs) specifically related to mental health assessment, intervention, and outcomes makes it difficult to quantify and evaluate the improvement in client outcomes attributable to their interventions.

OBJECTIVES

We examined heterogeneity across parents of infants served by PHNs receiving different interventions, compared the ability of traditional propensity scoring methods versus energy-balancing weight (EBW) techniques to adjust for the complex and stark differences in baseline characteristics among those receiving different interventions, and evaluated the causal effects of the quantity and variety of PHN interventions on client health and social outcomes.

METHODS

This retrospective study of 4,109 clients used existing Omaha System data generated during the routine documentation of PHN home visit data. We estimated the effects of intervention by computing and comparing weighted averages of the outcomes within the different treatment groups using two weighting methods: (a) inverse probability of treatment (propensity score) weighting and (b) EBWs.

RESULTS

Clients served by PHNs differed in baseline characteristics with clients with more signs/symptoms. Both weighting methods reduced heterogeneity in the sample. EBWs were more effective than inverse probability of treatment weighting in adjusting for multifaceted confounding and resulted in close balance of 105 baseline characteristics. Weighting the sample changed outcome patterns, especially when using EBWs. Clients who received more PHN interventions and a wider variety of them had improved knowledge, behavior, and status outcomes with no plateau over time, whereas the unweighted sample showed plateaus in outcomes over the course of home-visiting services.

DISCUSSION

Causal analysis of PHN-generated data demonstrated PHN intervention effectiveness for clients with mental health signs/symptoms. EBWs are a promising tool for evaluating the true causal effect of PHN home-visiting interventions.

A Mental Health Innovation for Nurse Home Visiting Program Shows Effectiveness in Reducing Depressive Symptoms and Anxiety

The objective of this paper is to report on the effectiveness of a mental health addition to a national nurse-delivered home visiting program. The methods are as follows: analysis of pre/post-launch of the standard Mental Health Intervention and comparison of 356 teams randomized to standard versus enhanced implementation. Stepwise regression controlled for significant client characteristics that were related to relevant outcomes. These characteristics were used in generalized mixed effect models comparing pre/post implementation and intervention and control groups. Pre/post analysis showed that only clients with no elevated mental health screening scores or mental health diagnoses at enrollment showed a significant decrease in depressive symptoms. Clients enrolled with and without mental health needs at enrollment significantly decreased on anxiety scores while referrals to mental health care increased. Teams receiving enhanced implementation enrolled more clients with mental health needs and clients completed more well-child visits and use of safe sleep practices. By integrating mental health care into maternal, infant, and early childhood home visiting programs, a new equitable model of primary mental health care can reach populations in need. This example provides a new paradigm of accessible and equitable mental health care for the future that can be implemented in a variety of home visiting programs.

Implementing mental health interventions within a national nurse home visiting program: A mixed-methods evaluation

BACKGROUND

Up to half of low-income mothers experience symptoms of depression and anxiety that affect their well-being and increase their children's risk for behavioral and emotional problems. To address this problem, an engaged research/practice planning team designed the Mental Health Innovation (MHI), a multicomponent implementation strategy that integrates evidence-based mental health interventions within the national Nurse-Family Partnership (NFP). The MHI includes four implementation strategies: online training modules, clinical resources, team meeting modules, and virtual consultation.

METHODS

A convergent, mixed methods observational design was applied to evaluate implementation outcomes, guided by the RE-AIM framework. We operationalized Reach as the number and demographics of women enrolled in NFP agencies exposed to MHI strategies. Adoption was operationalized as the number and proportion of nurses and supervisors who used MHI implementation strategies. For implementation, we assessed multilevel stakeholders' perceptions of strategy acceptability and feasibility. Data were pulled from NFP's national data management systems and collected through focus groups and surveys. Quantitative data were analyzed using counts and summary statistics. Qualitative themes were generated through content analysis.

RESULTS

The MHI reached agencies serving 51,534 low-income mothers (31.2% African American and 30.0% Latina). Adoption rates varied across implementation strategies. Between 60% and 76% of NFP nurses (N = 2,100) completed each online module. Between 27% and 51% of nurse supervisors (n = 125) reported using each team meeting module. Of 110 teams invited to participate in virtual consultation, 40.9% (n = 45) participated. Mothers served by agencies participating in virtual consultation differed significantly from those who did not, with lower percentages of African American and Latina. Qualitative themes suggest that MHI strategies were generally viewed as acceptable; perceptions of feasibility varied across strategies.

CONCLUSIONS

This study identified both strengths and opportunities for improvement. Further evaluation is needed to assess the MHI's effectiveness in improving mothers' mental health.