Nurse Home Visiting for Families Experiencing Adversity: A Randomized Trial

Identifying Service, Research and Policy priorities for preventing the impacts of family adversity on children's mental health: An Australian national resource allocation study with professional and lived experience experts

OBJECTIVES

The objective of this study was to develop Service, Research and Policy priorities to prevent the impact of family adversity on child mental health and determine comparative priorities of diverse stakeholders to those with lived experience of adversity.

METHODS

Value-weighting approach conducted in a staged process: (i) professionals and experts with lived experience from health, education, justice and social care sectors attended a national symposium to identify priorities for family adversity and mental health and (ii) a subsequent resource allocation survey gathered views from participants and external experts on symposium priorities.

RESULTS

Consensus was reached on priorities. Service priorities included establishing intersectoral hubs for children and families and early childhood nurse home-visiting programs. Research priorities included scaling up evidence-based interventions and evaluating cross-sector, flexible funding models for services addressing childhood adversity. Policy priorities included developing evidence-based policies with evaluation and implementation plans and flexible funding models to support integrated care.

CONCLUSIONS

Our results provide detailed and actionable clarity on next steps to address family adversities.

IMPLICATIONS FOR PUBLIC HEALTH

The priorities call for a focus on cross-sectoral approaches to preventing or mitigating the effects of family adversity. The current Australian policy environment provides a timely opportunity to action the proposed interventions.

Impact of the Korea Early Childhood Home-visiting Intervention (KECHI) on child health and development and maternal health: a randomised controlled trial protocol

INTRODUCTION

Randomised controlled trials (RCTs) of early childhood home-visiting interventions led by nurses have been conducted mainly in Western countries, whereas such trials have been limited in non-Western cultures, including Asia. In South Korea, a national nurse home visit programme (Korea Early Childhood Home-visiting Intervention (KECHI)) was developed in 2020 and launched throughout the country. We designed a pragmatic RCT to evaluate the effectiveness of KECHI on child health and development and maternal health.

METHODS AND ANALYSIS

Eligible participants will be pregnant women at <37 weeks of gestation with risk factor scores of 2 or over, who are sufficiently fluent in Korean to read and answer the questionnaire written in Korean and live in districts where the KECHI services are available. Eight hundred participants will be recruited from the general community and through the District Public Health Centres. The participants will be randomised 1:1 to KECHI plus usual care or usual care. KECHI encompasses 25-29 home visits, group activities and community service linkage. Participants will complete assessments at baseline (<37 weeks gestation), 6 weeks, 6 months, 12 months, 18 months and 24 months post partum. The six primary outcomes will be (1) home environment (assessed by Infant/Toddler Home Observation for Measurement of the Environment), (2) emergency department visits due to injuries, (3) child development (assessed using Korean Bayley Scales of Infant and Toddler Development-III), (4) breastfeeding duration, (5) maternal self-rated health and (6) community service linkage.

ETHICS AND DISSEMINATION

This trial has received full ethical approval from the Institutional Review Board of the Seoul National University Hospital. Written consent will be obtained from the participants. The results will be reported at conferences, disseminated through peer-reviewed publications and used by the Korean government to expand the KECHI services.

TRIAL REGISTRATION NUMBER

NCT04749888.

Analysis of the current situation and trend of home-based individualized nursing for residents in a certain area in China

OBJECTIVE

The aim of this study is to examine the perception, willingness to engage, and demand of community residents regarding the 'internet + nursing service' in a designated pilot area, aiming to offer insights for the widespread adoption of the 'internet + nursing service' throughout China.

METHODS

A survey pertaining to the 'internet + nursing service' was conducted from March to April 2022. The study specifically targeted residents within two sub-districts of a city in the Jiangsu province. The sampling technique employed in this study was stratified random sampling.

RESULTS

Out of a total of 400 community residents selected from two sub-districts in this region, 378 provided valid responses, resulting in an effective rate of 94.5%. Within the study cohort, 80 participants (21.16%) demonstrated familiarity with the concept of 'internet + nursing service.' Additionally, 231 participants (61.11%) conveyed their willingness to adopt such services. Regarding service preferences, the primary demands were for health guidance, vital sign monitoring, and basic care. Challenges in implementing the service were attributed to concerns related to medical risks, personal safety for both nurses and patients, and potential breaches of privacy.

CONCLUSIONS

Residents in the pilot area exhibited a moderate awareness of the 'internet + nursing service,' with a relatively high willingness to embrace the program. There is a need for further refinement of pertinent laws, widespread dissemination of policies, and enhancements in the quality of nursing services. These measures aim to ensure that a greater number of community residents can avail themselves of improved home-based nursing services.

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

Background

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

Methods

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

Results

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

Conclusions

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

'Everything's adaptable': A qualitative study of how nurses make decisions in sustained home-visiting care with mothers and children experiencing adversity

AIMS

To explore nurse decision-making processes in the delivery of sustained home-visiting care for mothers of young children who are experiencing adversity.

DESIGN

Qualitative descriptive research design using focus group interviews.

METHODS

Thirty-two home-visiting nurses participated in four focus group interviews exploring their decision-making in the care they provide to families. The data were analysed using a reflexive thematic analysis approach.

RESULTS

Four steps of a recurring stepwise decision-making process were identified: (1) information gathering; (2) exploring; (3) implementing; (4) checking. The facilitators and barriers to effective decision-making processes were also identified and included elements relating to good relationship skills, a good attitude, high quality training and mentoring and resources.

CONCLUSION

The findings indicate that a recurring stepwise process of decision-making requires both analytical and intuitive approaches. The intuition required by home-visiting nurses is to sense unvoiced client needs and identify the right time and way to intervene. The nurses were engaged in adapting the care in response to the client's unique needs while ensuring the fidelity of the programme scope and standards. We recommend creating an enabling working environment with cross-disciplinary team members and having well-developed structures, particularly the feedback systems such as clinical supervision and case reviews. Enhanced skills to establish trusting relationships with clients can help home-visiting nurses make effective decisions with mothers and families, particularly in the face of significant risk.

IMPACT

This study explored nurse decision-making processes in the context of sustained home-visiting care, which has been largely unexplored in the research literature. Understanding the effective decision-making processes, particularly when nurses customize or individualize the care in response to the client's unique needs, assists with the development of strategies for precision home-visiting care. The identification of facilitators and barriers informs approaches designed to support nurses in effective decision-making.

Mothers' experiences of emotional abuse from an intimate partner and its associations with children's developmental outcomes at 5 years

BACKGROUND

Intimate partner violence (IPV) is associated with an increased risk of poorer child development. Existing research has focused on physical abuse with less known about the associations with emotional IPV.

OBJECTIVE

To describe the period prevalence of mother's experiences of emotional IPV during children's preschool years and associations with child mental, physical, social, and cognitive development.

METHODS

Secondary analysis of control group data (n = 194) from an Australian randomised trial (right@home), which recruited pregnant women experiencing social adversity from antenatal clinics in 2013-14. Women reported emotional abuse (Composite Abuse Scale) at child ages 3-5 years. Measures of child development at 5 years included: Strengths and Difficulties Questionnaire, Social Skills Improvement System, Pediatric Quality of Life Inventory, Clinical Evaluation of Language Fundamentals, School Entry Alphabetic and Phonological Awareness Readiness Test, NIH executive function subtests, sleep and health. The prevalence of emotional IPV from 3 to 5 years was estimated. Regression models compared developmental outcomes according to emotional IPV exposure, adjusted for child age, child gender, and maternal education. Missing data were accounted for using multiple imputation.

RESULTS

From 3-5 years, emotional IPV was experienced by 57% of women. Emotional IPV exposure was consistently associated with poorer child developmental outcomes. Differences were most apparent for SDQ internalising (mean difference 1.2, 95% CI 0.2 to 2.1) and externalising difficulties (1.2, 95% CI -0.1 to 2.4).

CONCLUSIONS

Emotional IPV was highly prevalent amongst families experiencing social adversity. Developing acceptable and effective identification processes and interventions that prioritise families experiencing co-occurring social adversities should be a public health priority.

Embedding nurse home visiting in universal healthcare: 6-year follow-up of a randomised trial

OBJECTIVE

Nurse home visiting (NHV) is designed to redress child and maternal health inequities. Of the previous trials to investigate NHV benefits beyond preschool, none were designed for populations with universal healthcare. To address this evidence gap, we investigated whether the Australian 'right@home' NHV programme improved child and maternal outcomes when children turned 6 and started school.

METHODS

A screening survey identified pregnant women experiencing adversity from antenatal clinics across two states (Victoria, Tasmania). 722 were randomised: 363 to the right@home programme (25 visits promoting parenting and home learning environment) and 359 to usual care. Child measures at 6 years (first school year): Strengths and Difficulties Questionnaire (SDQ), Social Skills Improvement System (SSIS), Childhood Executive Functioning Inventory (CHEXI) (maternal/teacher-reported); general health and paediatric quality of life (maternal-reported) and reading/school adaptation items (teacher-reported). Maternal measures: Personal Well-being Index (PWI), Depression Anxiety Stress Scales, warm/hostile parenting, Child-Parent Relationship Scale (CPRS), emotional abuse and health/efficacy items. Following best-practice methods for managing missing data, outcomes were compared between groups (intention-to-treat) using regression models adjusted for stratification factors, baseline variables and clustering (nurse/site level).

RESULTS

Mothers reported on 338 (47%) children, and teachers on 327 (45%). Patterns of group differences favoured the programme arm, with small benefits (effect sizes ranging 0.15-0.26) evident for SDQ, SSIS, CHEXI, PWI, warm parenting and CPRS.

CONCLUSIONS

Four years after completing the right@home programme, benefits were evident across home and school contexts. Embedding NHV in universal healthcare systems from pregnancy can offer long-term benefits for families experiencing adversity.

TRIAL REGISTRATION NUMBER

ISRCTN89962120.

Having to manage: culturally and linguistically diverse mothers' lived experiences with sustained nurse home visiting programs

BACKGROUND

Culturally and linguistically diverse (CALD) mothers with young children with limited English proficiency (LEP) encounter multiple barriers in accessing and engaging with primary healthcare services. The aim of this study was to explore the lived experiences and perceptions of CALD mothers with LEP in receiving child and family health nursing (CFHN) services and sustained nurse home visiting (SNHV) programs.

METHODS

Fourteen mothers were interviewed from two large Local Health Districts in Sydney. All interviews were audio-recorded for transcription purposes. Interpretative Phenomenology Analysis (IPA) was used for analysis and the socioecological approach was applied to interpret the data.

RESULTS

CALD mothers with LEP experienced both challenges and facilitators in their access and engagement with CFHN services and SNHV programs that were identified in four themes: managing culture; managing the service system; managing the relationship; and strengths and weaknesses of CFHN services.

CONCLUSION

The integration of strategies such as building trusting relationships, using female professional interpreters and better understanding of CALD mothers' cultural practices may address CALD mothers' needs and facilitate communication. Design and development of model of support involving CALD mothers with LEP in ways that voice their ideas could meet their needs and contribute to better engagement of this vulnerable population with CFHN services and SNHV programs.

Effect of early childhood development interventions delivered by healthcare providers to improve cognitive outcomes in children at 0-36 months: a systematic review and meta-analysis

OBJECTIVE

To determine the effect of early childhood development interventions delivered by healthcare providers (HCP-ECD) on child cognition and maternal mental health.

DESIGN

Systematic review, meta-analysis.

SETTING

Healthcare setting or home.

PARTICIPANTS

Infants under 1 month of age.

INTERVENTIONS

HCP-ECD interventions that supported responsive caregiving, early learning and motor stimulation. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, Database of Abstracts of Reviews of Effects and Cochrane Database of Systematic Reviews were searched until 15 November 2021. Studies reporting prespecified outcomes were pooled using standard meta-analytical methods.

MAIN OUTCOME MEASURES

Cognitive development in children at 0-36 months.

RESULTS

Forty-two randomised controlled trials with 15 557 infants were included in the narrative synthesis. Twenty-seven trials were included in the meta-analyses. Pooled data from 13 trials suggest that HCP-ECD interventions may improve cognitive outcomes in children between 0 and 36 months (Bayley Scales of Infant Development version IIII (BSID-III) mean difference (MD) 2.65; 95% CI 0.61 to 4.70; 2482 participants; low certainty of evidence). Pooled data from nine trials suggest improvements in motor development (BSID-III MD 4.01; 95% CI 1.54 to 6.48; 1437 participants; low certainty of evidence). There was no evidence of improvement in maternal mental health (standardised MD -0.13; 95% CI -0.28 to 0.03; 2806 participants; 11 trials; low certainty of evidence).

CONCLUSIONS

We report promising evidence, particularly for cognitive and motor outcomes, of the effect of HCP-ECD interventions. However, effect sizes were small, and the certainty of evidence ranged from very low to moderate. Additional high-quality research is required.

PROSPERO REGISTRATION NUMBER

CRD42019122021.

Emulating a target trial of intensive nurse home visiting in the policy-relevant population using linked administrative data

BACKGROUND

Populations willing to participate in randomized trials may not correspond well to policy-relevant target populations. Evidence of effectiveness that is complementary to randomized trials may be obtained by combining the 'target trial' causal inference framework with whole-of-population linked administrative data.

METHODS

We demonstrate this approach in an evaluation of the South Australian Family Home Visiting Program, a nurse home visiting programme targeting socially disadvantaged families. Using de-identified data from 2004-10 in the ethics-approved Better Evidence Better Outcomes Linked Data (BEBOLD) platform, we characterized the policy-relevant population and emulated a trial evaluating effects on child developmental vulnerability at 5 years (n = 4160) and academic achievement at 9 years (n = 6370). Linkage to seven health, welfare and education data sources allowed adjustment for 29 confounders using Targeted Maximum Likelihood Estimation (TMLE) with SuperLearner. Sensitivity analyses assessed robustness to analytical choices.

RESULTS

We demonstrated how the target trial framework may be used with linked administrative data to generate evidence for an intervention as it is delivered in practice in the community in the policy-relevant target population, and considering effects on outcomes years down the track. The target trial lens also aided in understanding and limiting the increased measurement, confounding and selection bias risks arising with such data. Substantively, we did not find robust evidence of a meaningful beneficial intervention effect.

CONCLUSIONS

This approach could be a valuable avenue for generating high-quality, policy-relevant evidence that is complementary to trials, particularly when the target populations are multiply disadvantaged and less likely to participate in trials.

Nurse home visiting to improve child and maternal outcomes: 5-year follow-up of an Australian randomised controlled trial

OBJECTIVES

Nurse home visiting (NHV) is widely implemented to address inequities in child and maternal health. However, few studies have examined longer-term effectiveness or delivery within universal healthcare systems. We evaluated the benefits of an Australian NHV program ("right@home") in promoting children's language and learning, general and mental health, maternal mental health and wellbeing, parenting and family relationships, at child ages 4 and 5 years.

SETTING AND PARTICIPANTS

Randomised controlled trial of NHV delivered via universal, child and family health services (the comparator). Pregnant women experiencing adversity (≥2 of 10 risk factors) were recruited from 10 antenatal clinics across 2 states (Victoria, Tasmania) in Australia.

INTERVENTION

Mothers in the intervention arm were offered 25 nurse home visits (mean 23·2 home visits [SD 7·4, range 1-43] received) of 60-90 minutes, commencing antenatally and continuing until children's second birthdays.

PRIMARY AND SECONDARY OUTCOMES MEASURED

At 4 and 5 years, outcomes were assessed via parent interview and direct assessment of children's language and learning (receptive and expressive language, phonological awareness, attention, and executive function). Outcomes were compared between intervention and usual care arms (intention to treat) using adjusted regression with robust estimation to account for nurse/site. Missing data were addressed using multiple imputation and inverse probability weighting.

RESULTS

Of 722 women enrolled in the trial, 225 of 363 (62%) intervention and 201 of 359 (56%) usual care women provided data at 5 years. Estimated group differences showed an overall pattern favouring the intervention. Statistical evidence of benefits was found across child and maternal mental health and wellbeing, parenting and family relationships with effect sizes ranging 0·01-0·27.

CONCLUSION

An Australian NHV program promoted longer-term family functioning and wellbeing for women experiencing adversity. NHV can offer an important component of a proportionate universal system that delivers support and intervention relative to need.

TRIAL REGISTRATION

2013-2016, registration ISRCTN89962120.

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.

Evaluating the implementation of Cradle to Kinder: An intensive home-visitation support program for families experiencing disadvantage

BACKGROUND

The Australian evidence supporting the effectiveness of home visitation programs for families experiencing disdavantage is mixed. These inconsistent findings could be attributed to the varied ways in which home visitation programs are implemented, and a lack of evaluation.

OBJECTIVE

This qualitative paper explores the barriers and facilitators to the implementation of Cradle to Kinder - a long-term, intensive, home visitation family support program for vulnerable young caregivers at risk of child removal across Victoria, Australia.

METHOD

Semi-structured interviews and focus groups were conducted with 37 stakeholders from all levels of intervention delivery (i.e., clients, internal staff, external stakeholders). Data collection and thematic analysis were informed by the Consolidated Framework for Implementation Research (CFIR).

RESULTS

According to stakeholders, four key CFIR constructs facilitated the implementation of Cradle to Kinder: Effective Engagement, Relative Advantage, Organisational Culture, and Learning Climate. Implementation was challenged by factors within the Peer Pressure construct, which involved managing expectations and push-back from external organisations and services.

CONCLUSION

The current findings highlight the importance of organisational commitment to successful implementation. The next phase of this research is to establish the effectiveness of Cradle to Kinder. Indeed, greater implementation-effectiveness evaluations of family support programs are required to ensure that such programs effectively meet the needs of families and improve their outcomes.

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.

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.

Inequities in vulnerable children's access to health services in Australia

INTRODUCTION

Children born into families at risk of becoming or remaining poor are at significant risk of experiencing childhood poverty, which can impair their start to life, and perpetuate intergenerational cycles of poverty. This study sought to quantify health service utilisation, costs and funding distribution amongst children born into vulnerable compared to non-vulnerable families.

METHODS

This study used a large linked administrative dataset for all women giving birth in Queensland, Australia between July 2012 and July 2018. Health service use included inpatient, emergency department (ED), general practice, specialist, pathology and diagnostic imaging services. Costs included those paid by public hospital funders, private health insurers, Medicare and out-of-pocket costs.

RESULTS

Vulnerable children comprised 34.1% of the study cohort. Compared with non-vulnerable children, they used significantly higher average numbers of ED services during the first 5 years of life (2.52±3.63 vs 1.97±2.77), and significantly lower average numbers of specialist, pathology and diagnostic imaging services. Vulnerable children incurred significantly greater costs to public hospital funders compared with non-vulnerable children over the first 5 years of life ($16 053 vs $10 247), and significantly lower private health insurer, Medicare and out-of-pocket costs.

CONCLUSION

There are clear inequities in vulnerable children's health service utilisation in Australia. Greater examination of the uptake and cost-effectiveness of maternal and child services is needed, as these services support children's development in the critical first 1000 days of life.

The Impact of Nurse Home Visiting on the Use, Dose and Quality of Formal Childcare: 3-Year Follow-Up of a Randomized Trial

OBJECTIVE

We investigated whether nurse home visiting (NHV) affects the uptake and quality of formal early childhood education and care (ECEC) at child ages 2 and 3 years, and reasons for using ECEC at 3 years.

METHODS

Design: Secondary analysis of the "right@home" randomized trial of NHV.

PARTICIPANTS

722 pregnant Australian, English-speaking women experiencing adversity recruited from antenatal clinics across 2 states.

INTERVENTION

25 nurse home visits to 2 years; Control: universal well-child nursing service.

MEASURES

Parents reported formal ECEC use (government approved and subsidized), comprising long or family day care (LDC), and reasons for use. ECEC quality was classified using the Australian government's national ratings. Eighty-three percent of parents provided data at 2 years (306 intervention/290 control); and 69% at 3 years (255 intervention/240 control).

ANALYSIS

Intention-to-treat analyses were conducted using adjusted regression models, addressing missing data using multiple imputation and inverse probability weighting.

RESULTS

There was no evidence of group differences in ECEC uptake or quality, although control families may have used more LDC at 3 years (mean difference 2.8 hours, 95% confidence interval, -0.2 to 5.8 hours). Intervention parents reported using ECEC to support their children's social development more frequently than controls (48% vs 33%) but less for work/study (39% vs 46%).

CONCLUSIONS

The right@home NHV program did not impact ECEC uptake or quality, although it may influence parents' reasons for using ECEC. If supported by policy and provision, there is an opportunity for NHV programs to promote the transition to high-quality ECEC and evaluate the synergistic benefit on children's development.

Telesimulation about home visits and child care: facilitators, barriers and perception of Nursing students

OBJECTIVE

to evaluate the facilitators, barriers and perceptions of Nursing students in learning about home visiting and child care through Telesimulation during the COVID-19 pandemic.

METHOD

a qualitative study to evaluate Telesimulation via computers, grounded on Kolb's theoretical model. A semi-structured questionnaire and the Student Satisfaction and Self-Confidence in Learning Scale were applied, with descriptive analysis and qualitative thematic analysis on the perceptions of 41 Nursing students.

RESULTS

the contextualized Telesimulation provided learning opportunities in dimensions of the pedagogical strategy, telesimulated scenario, communication and specificities of child care in home visits. It was considered a safe and dynamic activity that helped knowledge consolidation and reflective attitudes, proximity to reality, and develop interaction, observation and types of approaches. There were restrictions due to Internet connection failures. A large percentage of the students indicated good satisfaction and self-confidence level with learning in the scale applied.

CONCLUSION

the real clinical situation with remote immersion allowed observation, decision-making, reflection and elaboration of conclusions, inherent to the experiential learning cycle. The set of elements of this Telesimulation created an environment that stimulated the interest of Nursing students for other learning stages, suggesting a space that strengthens knowledge and maintains dialogue with face-to-face practices.

Telessimulação sobre visita domiciliar e cuidado infantil: facilidades, barreiras e percepções de estudantes de enfermagem

Resumo Objetivo: avaliar as facilidades, barreiras e percepções de estudantes de enfermagem na aprendizagem sobre visita domiciliar e cuidado infantil por telessimulação na pandemia da COVID-19. Método: estudo qualitativo avaliativo de telessimulação por computador, fundamentado no modelo teórico de Kolb. Foram aplicados um questionário semiestruturado e a Escala de Satisfação de Estudantes e Autoconfiança na Aprendizagem, com análise descritiva e análise qualitativa temática sobre percepções de 41 graduandos de enfermagem. Resultados: a telessimulação contextualizada proporcionou oportunidades de aprendizagem em dimensões da estratégia pedagógica, cenário telessimulado, comunicação e especificidades do cuidado infantil em visita domiciliar. Atividade segura e dinâmica, auxiliou a solidificar conhecimentos e atitudes reflexivas, aproximação à realidade, desenvolvimento da interação, observação e tipos de abordagens. Houve restrições por falhas de conexão. Grande parte dos estudantes indicou níveis bons de satisfação e autoconfiança com a aprendizagem na escala aplicada. Conclusão: a situação clínica real com imersão remota permitiu observação, tomada de decisão, reflexão e elaboração de conclusões inerentes ao ciclo de aprendizagem experiencial. O conjunto de elementos desta telessimulação criou um ambiente que estimulou o interesse dos estudantes de enfermagem para outras etapas de aprendizagem, sugerindo um espaço que fortalece conhecimentos e que guarda interlocução com as práticas presenciais.

Telesimulación en visitas domiciliarias y cuidado infantil: facilidades, barreras y percepciones de estudiantes de enfermería

Resumen Objetivo: evaluar las facilidades, barreras y percepciones de estudiantes de enfermería en el aprendizaje sobre visita domiciliaria y cuidado infantil por telesimulación en la pandemia de COVID-19. Método: estudio cualitativo que evalúa la telesimulación por computadora, basado en el modelo teórico de Kolb. Se aplicó un cuestionario semiestructurado y la Escala de Satisfacción de los Estudiantes y Autoconfianza en el Aprendizaje, con análisis descriptivo y análisis temático cualitativo sobre las percepciones de 41 estudiantes de enfermería. Resultados: la telesimulación contextualizada brindó oportunidades de aprendizaje en los aspectos estrategia pedagógica, escenario telesimulado, comunicación y especificidades del cuidado infantil en visitas domiciliarias. Es una actividad segura y dinámica, que contribuyó a consolidar conocimientos y actitudes reflexivas, permitió un acercamiento a la realidad, el desarrollo de la interacción, observación y tipos de acercamientos. Hubo restricciones por fallas en la conexión. La mayoría de los estudiantes indicaron buenos niveles de satisfacción y confianza en sí mismos con el aprendizaje en la escala aplicada. Conclusión: la situación clínica real con participación a distancia permitió la observación, toma de decisiones, reflexión y elaboración de conclusiones inherentes al ciclo de aprendizaje experiencial. El conjunto de elementos de esta telesimulación creó un ambiente que estimuló el interés de los estudiantes de enfermería por otras etapas de aprendizaje, por lo que se considera un espacio que fortalece el conocimiento y dialoga con las prácticas presenciales.

Economic evaluation of an Australian nurse home visiting programme: a randomised trial at 3 years

OBJECTIVES

To investigate the additional programme cost and cost-effectiveness of 'right@home' Nurse Home Visiting (NHV) programme in relation to improving maternal and child outcomes at child age 3 years compared with usual care.

DESIGN

A cost-utility analysis from a government-as-payer perspective alongside a randomised trial of NHV over 3-year period. Costs and quality-adjusted life-years (QALYs) were discounted at 5%. Analysis used an intention-to-treat approach with multiple imputation.

SETTING

The right@home was implemented from 2013 in Victoria and Tasmania states of Australia, as a primary care service for pregnant women, delivered until child age 2 years.

PARTICIPANTS

722 pregnant Australian women experiencing adversity received NHV (n=363) or usual care (clinic visits) (n=359).

PRIMARY AND SECONDARY OUTCOME MEASURES

First, a cost-consequences analysis to compare the additional costs of NHV over usual care, accounting for any reduced costs of service use, and impacts on all maternal and child outcomes assessed at 3 years. Second, cost-utility analysis from a government-as-payer perspective compared additional costs to maternal QALYs to express cost-effectiveness in terms of additional cost per additional QALY gained.

RESULTS

When compared with usual care at child age 3 years, the right@home intervention cost $A7685 extra per woman (95% CI $A7006 to $A8364) and generated 0.01 more QALYs (95% CI -0.01 to 0.02). The probability of right@home being cost-effective by child age 3 years is less than 20%, at a willingness-to-pay threshold of $A50 000 per QALY.

CONCLUSIONS

Benefits of NHV to parenting at 2 years and maternal health and well-being at 3 years translate into marginal maternal QALY gains. Like previous cost-effectiveness results for NHV programmes, right@home is not cost-effective at 3 years. Given the relatively high up-front costs of NHV, long-term follow-up is needed to assess the accrual of health and economic benefits over time.

TRIAL REGISTRATION NUMBER

ISRCTN89962120.

Variations in sustained home visiting care for mothers and children experiencing adversity

Objective

This study aimed to examine the variations in care received by mothers and families within a sustained home visiting program. We sought to identify the extent to which there were variations in home visiting care in response to the program schedule and families’ risk factors.

Design and sample

Data collected within the right@home program, a randomized controlled trial (RCT) for a sustained nurse home visiting intervention in Australia, were analyzed. A total of 352 women comprised the intervention arm of the trial.

Measurements

Visit content in the home visiting program, sociodemographic data, and families’ risk factors were used for analysis.

Results

Our results confirmed that the majority of women received scheduled content on time or within an acceptable timeframe, except for the sleeping program. Women with identified risks were significantly more likely to receive content related to those risks than women without those risks (smoking: Odds Ratio [OR] = 15.39 [95%CI 3.7–64.7], mental health: OR = 15.04 [1.8–124.0], domestic violence: OR = 4.07 [2.0–8.3], and drugs and alcohol: OR = 1.81 [1.1–3.0]).

Conclusions

The right@home program had high compliance with the scheduled content. Capacity development in responding to mothers with the risk of domestic violence and drugs and alcohol is recommended. Further research is required to explore the relationship between variations in care and critical outcomes.

Birth order and socioeconomic disadvantage predict behavioural and emotional problems at age 3 years

AIM

The aim of this study was to describe sociodemographic and family predictors for behavioural and emotional problems in pre-schoolers.

METHODS

This was a cross-sectional study including 30,795 children in the Stockholm region whose parents had completed the Strength and Difficulties Questionnaire (SDQ) prior to a routine visit to a well-baby clinic at age 3 years. Multivariate logistic regression was used to analyse predictors for having a high total SDQ difficulties score.

RESULTS

Young parental age and a low level of parental education predicted high total SDQ score in a stepwise pattern. Being a first-born child was associated with a high SDQ score with an adjusted odds ratio of 2.10 (95% C.I. 1.84-2.41), compared with having older siblings. A sole physical custody arrangement predicted a high total SDQ score after parental separation. The percentage of children with a high total SDQ score increased with the Care Need Index (CNI) of the well-baby clinic.

CONCLUSIONS

This study identified socioeconomic disadvantage and being the first-born child as the main predictors of poor mental health at age 3 years. Well-baby clinics with socioeconomically disadvantaged catchment areas should be provided with adequate resources and methods for equitable prevention.

Mothers' Experiences with Child Protection Services: Using Qualitative Feminist Poststructuralism

BACKGROUND

The postpartum period is often portrayed as a blissful, calm and loving time when mothers, partners and family members bond with their newborn babies. However, this time may be experienced quite differently when mothers are monitored by Child Protection Services. Having a baby under these circumstances can be very difficult and traumatizing. While all new parents require support and information to help them through the transition to parenthood and address physical and psycho-social changes, mothers who are involved with Child Protection Services require more specialized support as they encounter higher incidences of postpartum stressors and higher rates of poverty, mental illness and substance abuse. The impact of support for mothers involved with Child Protection Services is not well-understood from the perspective of mothers.

AIM

The aim of the study was to understand how new mothers in Nova Scotia prioritized their postpartum needs and where they went to obtain information and support.

METHODS

Feminist poststructuralism was the methodology used to understand how the experiences of five mothers who accessed a family resource center and had been involved with Child Protection Services in Nova Scotia Canada had been personally, socially and institutionally constructed.

RESULTS

Themes include: (1) We are Mothers, (2) Being Red Flagged, (3) Lack of Trust, (4) Us Against Them and (5) Searching for Supportive Relationships.

CONCLUSION

Personal stories from all participants demonstrated how they experienced stigma and stereotypes from healthcare workers and were often not recognized as mothers. They also struggled to find information, supports and services to help them keep or regain their babies.

Sustained nurse home-visiting with culturally and linguistically diverse families: Australian nurses' perspectives

BACKGROUND

In Australia, sustained nurse home-visiting (SNHV) programs are designed and implemented to promote positive outcomes for mothers with young children experiencing complex life challenges. Despite the crucial role of trained public health nurses, there is a dearth of research about their experiences delivering these programs to culturally and linguistically diverse (CALD) families with limited English proficiency (LEP).

AIM

This study aimed to explore the experiences of public health nurses in providing services to CALD families with LEP.

METHOD

Two focus groups were conducted with 13 public health nurses in two major local health districts in Sydney. The focus groups were audio recorded for transcription purposes, and thematically analyzed. A socioecological framework was applied during the analysis process.

RESULT

Five major themes were identified: (1) program issues; (2) service system issues in understanding and responding to diverse women; (3) issues working with interpreters; (4) trusting relationships; and (5) mother-related facilitators.

DISCUSSION

To achieve better access and engagement for CALD families, it is crucial that public health nurses increase their knowledge and awareness about potential challenges, such as female interpreter availability, and facilitators, such as engaging the broader family, in order to effectively deliver healthcare services to diverse populations.

Empowering Public Health Nurses and Community Home Visitors through Effective Communication Relationships

Home visiting programs for marginalized families have included both Public Health Nurses (PHNs) and Community Home Visitors (CHV). Support for families requires health care providers to implement effective communication and collaboration practices; however, few studies have examined how this is carried out. The purpose of this qualitative research study was to explore how an Enhanced Home Visiting (EHV) program in Nova Scotia Canada was organized, delivered through the experiences of PHNs and CHVs. Feminist post-structuralism informed by discourse analysis was used to understand how their experiences were socially and institutionally constructed. Individual semi-structured interviews were conducted with 6 PHNs and 8 CHVs and one focus group was held with 10 of the participants. A social discourse on mothering layered within a social discourse of working with a vulnerable population added a deeper understanding of how communication was constructed through the everyday practices of PHNs and CHVs. Findings may be used to inform reporting and communication practices between health care providers who work with marginalized families.

Schedules for home visits in the early postpartum period

BACKGROUND

Maternal complications, including psychological/mental health problems and neonatal morbidity, have commonly been observed in the postpartum period. Home visits by health professionals or lay supporters in the weeks following birth may prevent health problems from becoming chronic, with long-term effects. This is an update of a review last published in 2017.

OBJECTIVES

The primary objective of this review is to assess the effects of different home-visiting schedules on maternal and newborn mortality during the early postpartum period. The review focuses on the frequency of home visits (how many home visits in total), the timing (when visits started, e.g. within 48 hours of the birth), duration (when visits ended), intensity (how many visits per week), and different types of home-visiting interventions.

SEARCH METHODS

For this update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (19 May 2021), and checked reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) (including cluster-, quasi-RCTs and studies available only as abstracts) comparing different home-visiting interventions that enrolled participants in the early postpartum period (up to 42 days after birth) were eligible for inclusion. We excluded studies in which women were enrolled and received an intervention during the antenatal period (even if the intervention continued into the postnatal period), and studies recruiting only women from specific high-risk groups (e.g. women with alcohol or drug problems).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 16 randomised trials with data for 12,080 women. The trials were carried out in countries across the world, in both high- and low-resource settings. In low-resource settings, women receiving usual care may have received no additional postnatal care after early hospital discharge. The interventions and controls varied considerably across studies. Trials focused on three broad types of comparisons, as detailed below. In all but four of the included studies, postnatal care at home was delivered by healthcare professionals. The aim of all interventions was broadly to assess the well-being of mothers and babies, and to provide education and support. However, some interventions had more specific aims, such as to encourage breastfeeding, or to provide practical support. For most of our outcomes, only one or two studies provided data, and results were inconsistent overall. All studies had several domains with high or unclear risk of bias. More versus fewer home visits (five studies, 2102 women) The evidence is very uncertain about whether home visits have any effect on maternal and neonatal mortality (very low-certainty evidence). Mean postnatal depression scores as measured with the Edinburgh Postnatal Depression Scale (EPDS) may be slightly higher (worse) with more home visits, though the difference in scores was not clinically meaningful (mean difference (MD) 1.02, 95% confidence interval (CI) 0.25 to 1.79; two studies, 767 women; low-certainty evidence). Two separate analyses indicated conflicting results for maternal satisfaction (both low-certainty evidence); one indicated that there may be benefit with fewer visits, though the 95% CI just crossed the line of no effect (risk ratio (RR) 0.96, 95% CI 0.90 to 1.02; two studies, 862 women). However, in another study, the additional support provided by health visitors was associated with increased mean satisfaction scores (MD 14.70, 95% CI 8.43 to 20.97; one study, 280 women; low-certainty evidence). Infant healthcare utilisation may be decreased with more home visits (RR 0.48, 95% CI 0.36 to 0.64; four studies, 1365 infants) and exclusive breastfeeding at six weeks may be increased (RR 1.17, 95% CI 1.01 to 1.36; three studies, 960 women; low-certainty evidence). Serious neonatal morbidity up to six months was not reported in any trial. Different models of postnatal care (three studies, 4394 women) In a cluster-RCT comparing usual care with individualised care by midwives, extended up to three months after the birth, there may be little or no difference in neonatal mortality (RR 0.97, 95% CI 0.85 to 1.12; one study, 696 infants). The proportion of women with EPDS scores ≥ 13 at four months is probably reduced with individualised care (RR 0.68, 95% CI 0.53 to 0.86; one study, 1295 women). One study suggests there may be little to no difference between home visits and telephone screening in neonatal morbidity up to 28 days (RR 0.97, 95% CI 0.85 to 1.12; one study, 696 women). In a different study, there was no difference between breastfeeding promotion and routine visits in exclusive breastfeeding rates at six months (RR 1.47, 95% CI 0.81 to 2.69; one study, 656 women). Home versus facility-based postnatal care (eight studies, 5179 women) The evidence suggests there may be little to no difference in postnatal depression rates at 42 days postpartum and also as measured on an EPDS scale at 60 days. Maternal satisfaction with postnatal care may be better with home visits (RR 1.36, 95% CI 1.14 to 1.62; three studies, 2368 women). There may be little to no difference in infant emergency health care visits or infant hospital readmissions (RR 1.15, 95% CI 0.95 to 1.38; three studies, 3257 women) or in exclusive breastfeeding at two weeks (RR 1.05, 95% CI 0.93 to 1.18; 1 study, 513 women).

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effect of home visits on maternal and neonatal mortality. Individualised care as part of a package of home visits probably improves depression scores at four months and increasing the frequency of home visits may improve exclusive breastfeeding rates and infant healthcare utilisation. Maternal satisfaction may also be better with home visits compared to hospital check-ups. Overall, the certainty of evidence was found to be low and findings were not consistent among studies and comparisons. Further well designed RCTs evaluating this complex intervention will be required to formulate the optimal package.

Hair cortisol in mother-child dyads: examining the roles of maternal parenting and stress in the context of early childhood adversity

Physiological stress is thought to be one way that early adversity may impact children's health. How this occurs may be related to parental factors such as mothers' own stress and parenting behaviour. Hair cortisol offers a novel method for examining long-term physiological stress in mother-child dyads. The current study used hair cortisol to examine the role that maternal physiological stress and parenting behaviours play in explaining any effects of adversity on young children's physiological stress. This cross-sectional study comprised 603 mother-child dyads at child age 2 years, recruited during pregnancy for their experience of adversity through an Australian nurse home visiting trial. Hair cortisol data were available for 438 participating mothers (73%) and 319 (53%) children. Confirmatory factor analysis was used to define composite exposures of economic (e.g. unemployment, financial hardship) and psychosocial (e.g. poor mental health, family violence) adversity, and positive maternal parenting behaviour (e.g. warm, responsive). Structural equation modelling examined maternal mediating pathways through which adversity was associated with children's physiological stress. Results of the structural model showed that higher maternal and child physiological stress (hair cortisol) were positively associated with one another. Parenting behaviour was not associated with children's physiological stress. There was no evidence of any mediating pathways by which economic or psychosocial adversity were associated with children's physiological stress. The independent association identified between maternal and child hair cortisol suggests that young children's physiological stress may not be determined by exogenous environmental exposures; endogenous genetic factors may play a greater role.

Systematic review: An exploration of core componentry characterizing effective sustained nurse home visiting programs

AIMS

To identify the core components or potential 'active ingredients' of sustained nurse home visiting (SNHV) programs that have demonstrated positive effects on maternal or child health, psychosocial development, or self-sufficiency outcomes among disadvantaged families in high-income countries.

DESIGN

Systematic review with narrative summary.

DATA SOURCES

Programs were identified from searches of several reputable evidence clearing houses and the following bibliographic databases: Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Cochrane Central Register of Controlled Trials. Year of publication was originally restricted from 2008 -2018, with additional searches conducted up to 2019.

REVIEW METHODS

This review of SNHV program componentry builds on a previous evaluation of program effectiveness. Programs were selected for inclusion if they had been tested in a randomized or cluster-randomized controlled trial (RCT/CRCT). Componentry characteristics related to program delivery, nurse provider, and outcome-specific intervention content were then extracted.

RESULTS

Comparison of the seven eligible programs showed seven common core components: antenatal commencement, support to child age 2 years, at least 19 scheduled visits and experienced or highly qualified nurses with program-specific training, caseloads of approximately 25 families, regular supervision, and multidisciplinary supports. Outcome-specific program content was generally not well reported.

CONCLUSION

The findings from this review have utility in guiding the development of minimum standard benchmarks and best-practice recommendations for SNHV programs and call for more detailed publication of core content componentry in the SNHV literature.

IMPACT

Identification of the core componentry underpinning program effectiveness should inform policy decisions on program selection, adaptation for specific populations, and quality control. Such evidence-based decision-making should in turn lead to better maternal and child outcomes among disadvantaged families in high-income countries, reducing societal and economic burdens of inequity.

Systematic review: Effects of sustained nurse home visiting programs for disadvantaged mothers and children

AIMS

To systematically evaluate published experimental studies of sustained nurse home visiting (SNHV) programs. This review summarizes the evidence and identifies gaps in the literature to inform practice, policy, and future research.

DESIGN

Restricted systematic review with narrative summary.

DATA SOURCES

Databases searched were Medline, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials. Year of publication was originally restricted from 2008 to the date of search (13 February 2018, with supplementary searches conducted to identify more recent publications (up to 2019). Several reputable evidence clearinghouses were also searched.

REVIEW METHODS

Studies were included if they used a randomized or cluster-randomized controlled trial to evaluate a home visiting program that: (a) targeted disadvantaged mothers; (b) commenced during pregnancy or prior to the child's first birthday; (c) had an intended duration of at least 12 months from the time of enrolment; and (d) was substantively delivered by nurses or midwives. Meta-analyses and reviews of studies meeting these criteria were also included. A quality appraisal was conducted for all studies.

RESULTS

Of 1,393 total articles, 30 met inclusion criteria. Seven specific SNHV programs were identified. Each demonstrated evidence of a positive statistical effect on at least one child or maternal outcome.

CONCLUSION

Sustained nurse home visiting programs benefit disadvantaged families, though effects vary across outcomes and subgroups. Further research is needed to discern the critical components of effective programs.

IMPACT

As SNHV programs have gained policy appeal, the need to evaluate the evidence-base supporting such interventions has become imperative. The findings of this review will assist policy-makers and practitioners in high-income countries to make evidence-informed decisions about which programs are best suited to addressing specific maternal and child outcomes for disadvantaged families. This should in turn ameliorate some of the inequalities in child development that have significant social and economic costs.

NURSING INTERVENTIONS TO PROMOTE CHILD DEVELOPMENT THROUGH BRONFENBRENNER'S BIOECOLOGICAL THEORY

ABSTRACT Objective: to analyze the benefits and limitations of nursing interventions for the promotion of child development, according to the Bioecological Theory of Human Development, by Bronfenbrenner. Method: an integrative review, from the databases PubMed, Lilacs, CINAHL, Web of Science and Scopus, using the descriptors: "child development" AND "nurses" OR "nursing". No time limit was set for publications. The search was perfomed in September 2019 and update in March 2020. Results: 24 studies were selected for the final sample. The predominant type of study design was the clinical trial (60%). The home visit was the most used strategy (60%). Seven main themes emerged from the outcomes of the interventions: the child, maternal health, parenting skills, relationship between nurse and mother/father, use of social benefits, professional practice, and family violence. The process component was present in all studies, portraying the relevance of proximal interactions in the home environment. Only two interventions had no impact on any outcome. Conclusion: nursing interventions showed benefits in all outcomes, especially in outcomes related to children and parental practices, and improved situations of interaction between caregivers and children, reducing punitive practices and violence against children. It is essential to consider the bioecological perspective, so that nursing interventions, in promoting child development, are more effective.

Inequalities in child development at school entry: A repeated cross-sectional analysis of the Australian Early Development Census 2009-2018

BACKGROUND

Australia is the only developed country to consistently undertake a developmental census of its children nationwide. The repeated collection of the Australian Early Development Census (AEDC) has provided an unprecedented opportunity to examine the prevalence of developmental vulnerability across Australia's states and territories, the socio-economic distribution of developmental vulnerability across jurisdictions, and how these distributions might have changed over time.

METHODS

This study employed multivariable logistic regressions to estimate the probability of developmental vulnerability within each jurisdiction and AEDC collection year (2009 to 2018), adjusting for jurisdictional differences in socio-demographic characteristics. To explore socio-economic inequalities in child development, adjusted slope index of inequality (SII) models were utilised.

FINDINGS

The results of this study found reductions in the adjusted prevalence of developmental vulnerability over time in Western Australia (26% to 20%) and Queensland (30% to 25%), with an increase observed in the Australian Capital Territory (27% to 30%). Analysis also indicated an increase in socio-economic inequalities over time in the Northern Territory (+12%), the Australian Capital Territory (+6%) and Tasmania (+4%). Sensitivity analysis found these effects to be robust with an alternative measure of socio-economic position.

INTERPRETATION

There is considerable variation in the prevalence and socio-economic inequalities in developmental vulnerability across Australia's jurisdictions. Future research should explore the policy drivers in early childhood education and health contributing to the findings of this study, with a particular focus on jurisdictions where there have been notable changes in developmental vulnerability and socio-economic inequality over time.

FUNDING

Analyses were funded under research contract by the Department of Education, Skills and Employment. Prof Brinkman is supported by a National Health and Medical Research Council fellowship, APP1160185.

Influential factor combinations leading to language outcomes following a home visiting intervention: A qualitative comparative analysis (QCA)

BACKGROUND

Children who experience adversity are more vulnerable to language difficulties. Early interventions beginning antenatally, such as home visiting, are provided to help prevent these problems. To improve the precision of early interventions, the impact of combinations of risk and protective factors over time must be explored and understood. There is, however, limited research investigating how such factors interact with intervention to change language outcomes over time.

AIM

To explore the different paths that lead to Good and Poor language in a cohort of children experiencing adversity whose mothers received an optimal dose of the Maternal Early Childhood Sustained Home visiting (MECSH) intervention over 2.5 years.

METHODS & PROCEDURES

A total of 24 low socioeconomic status (SES) mothers experiencing adversity and their children who received more than half the scheduled dose of the MECSH intervention were followed over time: from before birth to school entry. Data were extracted from surveys and direct measurement over the study course. Child language outcome at school entry and the influence of seven key child, maternal and environmental factors, which have been shown in previous research to result in Good and Poor language outcomes, were explored through qualitative comparative analysis (QCA). QCA is a qualitative analytical technique that provides a deeper understanding of factor combinations influencing language development.

OUTCOMES & RESULTS

Multiple paths to Good (six paths) and Poor language (seven paths) were found. Paths with mostly protective factors resulted in Good language, except when maternal antenatal distress was present. Paths with two or more influential risks usually resulted in Poor language outcomes. When children experiencing adversity received the MECSH home visiting intervention, there was no one risk or protective factor necessary for Good or Poor language outcomes; however, there were clear patterns of factor combinations.

CONCLUSIONS & IMPLICATIONS

Mothers' antenatal psychological resources were a flag for future language concerns which can be used to improve the precision of the MECSH intervention. They were highly influential to their children's Good and Poor language outcomes by 5 years, when over time they were combined with characteristics such as early childhood education, poor maternal responsivity and/or the number of children in the home. Knowledge of early conditions associated with later Poor language can help clinicians identify and respond in preventative and promoting ways to improve language skills. What this paper adds What is already known on the subject Children experiencing adversity are more vulnerable to language difficulties. Both risk for language difficulties and protection against them in this group are via a complex combination of factors. It is unknown how intervention works with these complex factors to result in Good and Poor language outcomes. What this paper adds to existing knowledge There are multiple paths to both Good and Poor language outcomes for children experiencing adversity. Mothers' psychological resources antenatally in combination with other key factors were particularly influential to Good and Poor language outcomes. What are the clinical implications of this work? In this study, maternal antenatal distress together with poor maternal responsivity were present in children's paths to Poor language outcomes at school entry. An extra focus on responsivity is required in antenatally distressed mothers of children experiencing adversity in early interventions. Children of mothers with good psychological resources antenatally who received home visiting intervention had Good language outcomes at 5 years when combined with 3 years or more of early childhood education and if there were one to two children in the home. Knowledge of these influences on language development can improve the precision of home visiting interventions and help clinicians tailor their visits to individual families' needs.

Quality of delivery of "right@home": Implementation evaluation of an Australian sustained nurse home visiting intervention to improve parenting and the home learning environment

Background

Home visiting programs are implemented in high income countries to improve outcomes for families with young children. Significant resources are invested in such programs and high quality evaluations are important. In the context of research trials, implementation quality is often poorly reported and, when reported, is variable. This paper presents the quality of implementation of the right@home program, a sustained nurse home visiting intervention trialled in Australia, and delivered in a ‘real world’ context through usual child and family health services. right@home is structured around the core Maternal Early Childhood Sustained Home-visiting (MECSH) program, which is a salutogenic, child focused prevention model.

Method

At each visit right@home practitioners completed a checklist detailing the client unique identifier, date of contact and activities undertaken. These checklists were collated to provide data on intervention dose, retention to program completion at child age 2 years, and visit content, which were compared with the program schedule. Quality of family-provider relationship was measured using the Session Rating Scale. Exploratory factor analysis was conducted to identify clusters of activities and allow qualitative assessment of concordance between program aims and program delivery.

Results

Of 363 intervention families offered the program, 352 (97·0%) commenced the program and 304 (87·3%) completed the program to child age 2 years. 253 of 352 (71·9%) families who commenced the program received more than 75 percent of scheduled visits including at least one antenatal visit. Families rated the participant-practitioner relationship highly (mean 39.4/40). The factor analysis identified six antenatal and six postnatal components which were concordant with the program aims.

Conclusions

The right@home program was delivered with higher adherence to program dose, schedule and content, and retention than usually reported in other home visiting research. Program compliance may have resulted from program design (visit schedule, dose, content and delivery flexibility) that was consistent with family aims.