Understanding maternal intentions to engage in home visiting programs

Engagement Measures in Maltreatment Prevention Studies: A Scoping Review

Prevention services can promote public health by building protective factors and reducing maltreatment risk. Yet, engaging caregivers in prevention services presents a unique set of challenges. Measurement studies are important first steps to increase the knowledge of caregiver engagement in prevention services. The purpose of this scoping review was to investigate how family engagement has been measured and operationalized in the studies of maltreatment prevention/positive parenting programs. The review examined quantitative and mixed methods studies conducted in the U.S., which measured multiple dimensions of client engagement, including behavioral, attitudinal, and relational domains. A total of 88 studies selected from PubMed, CINAHL, ERIC, PsycINFO, Social Work Abstracts, Academic Search Premier, and Web of Science were included in this review. Results indicated that studies examine engagement constructs in all three domains of engagement with a primary focus on behavioral engagement. The attitudinal and relational engagement was mostly assessed through general satisfaction surveys, and a limited number of studies utilized validated measures to assess those constructs. While most studies reported acceptable internal reliabilities, only two studies reported other dimensions of psychometric qualities. Only one validated measure was found, which assessed client perceptions of provider cultural competence. More measurement studies are needed to further incorporate multiple dimensions of engagement into the studies of maltreatment prevention programs, which can inform the effort to develop tailored implementation strategies to fully engage various groups of parents in maltreatment prevention programs.

Cross-sector Collaboration Between Public Health, Healthcare and Social Services Improves Retention: Findings from a Nurse Home Visiting Program

The study aimed to examine the association between cross-sector collaboration in Nurse-Family Partnership (NFP), a model home visiting program, and participant retention. We used the 2018 NFP Collaboration Survey that measured agency-level collaboration, operationalized as relational coordination and structural integration, among nine community provider types (including obstetrics care, substance use treatment, child welfare). This dataset was linked to 2014-2018 NFP program implementation data (n = 36,900). We used random-intercept models with nurse-level random effects to examine the associations between provider-specific collaborations and participant retention adjusting for client, nurse, and agency characteristics. The adjusted models suggest that stronger relational coordination between nurses and substance use treatment providers (OR:1.177, 95% CI: 1.09-1.26) and greater structural integration with child welfare (OR: 1.062, CI: 1.04-1.09) were positively associated with participant retention at birth. Stronger structural integration between other home visiting programs and supplemental nutrition for women, infants, and children was negatively associated with participant retention at birth (OR: 0.985, CI: 0.97-0.99). Structural integration with child welfare remained significantly associated with participant retention at 12-month postpartum (OR: 1.032, CI: 1.01-1.05). In terms of client-level characteristics, clients who were unmarried, African-American, or visited by nurses who ceased NFP employment prior to their infant's birth were more likely to drop out of the NFP program. Older clients and high school graduates were more likely to remain in NFP. Visits by a nurse with a master's degree, agency rurality, and healthcare systems that implement the program were associated with participant retention. Cross-sector collaboration in a home visiting setting that bridges healthcare and addresses social determinants of health has potential to improve participant retention. This study sets the groundwork for future research to explore the implications of collaborative activities between preventive services and community providers.

Engagement and Retention of Families in Universal Australian Nurse-Home-Visiting Services: A Mixed-Methods Study

Family support is offered to Australian parents of young children using a mix of targeted and universal child and family health services including nurse-home-visiting programmes. These rely on the voluntary engagement of families. In this study, the capacity to engage and retain families, including those at risk of becoming involved with child protection services, was examined. The broad objective was to identify nursing practices used at the interface of health and child protection services and to articulate those practices. Child and Family Health Nurses (CFHN) (n = 129) participated in a pragmatic, multilevel mixed-methods study. A questionnaire was used to identify nursing practices in the first phase of this study followed by focus groups in the second phase to describe these practices in more detail. Three practice themes were identified and described: enrolment, retention and conclusion of the nurse-family relationship. Universal child and family health services feature flexible, advanced, and multidimensional family support services including child protection practices. This paper focuses on practices employed by nurses to engage and retain families where child protection concerns are identified.

A mixed-methods feasibility study of the Home Parenting Education and Support Program for families at risk of child maltreatment and recurrence in Australia

BACKGROUND

Efforts to prevent child maltreatment and its recurrence in infancy and early childhood are critical to disrupting pathways to poor physical and mental health and interpersonal relationships across the life course. The Home Parenting Education and Support (HoPES) program is an intensive 8-week home-visiting intervention for families of infants and young children (0-4 years) receiving child protection services or welfare services.

OBJECTIVE

The aims of this feasibility study were to: (a) explore parents' and clinicians' perceptions of the outcomes related to participation in HoPES, and (b) obtain preliminary data about potential intervention outcomes related to parent-child interactions, parent mental health, and parenting self-efficacy.

PARTICIPANTS AND SETTING

HoPES was delivered to 30 families by a child and family health service. Seven mothers and eight HoPES clinicians also participated in qualitative interviews.

METHODS

A mixed-methods evaluation was conducted incorporating qualitative interviews and self-report pre-post intervention data was conducted.

RESULTS

Interviews with mothers identified perceived benefits for parent mental health and wellbeing, parenting, and relationships with children. This was further supported by clinician interviews and by the analysis of pre-post assessment data which revealed moderate to large decreases in maternal stress (d = 0.35) and increases in parental self-efficacy (0.76).

CONCLUSIONS

The findings of this study have important implications for further development of HoPES, and the design of a rigorous evaluation in next stage of evaluation research.

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.

Components associated with the effect of home visiting programs on child maltreatment: A meta-analytic review

BACKGROUND

Home visiting programs are widely endorsed for preventing child maltreatment. Yet, knowledge is lacking on what and how individual program components are related to the effectiveness of these programs.

OBJECTIVE

The aim of this meta-analysis was to increase this knowledge by summarizing findings on effects of home visiting programs on child maltreatment and by examining potential moderators of this effect, including a range of program components and delivery techniques.

METHODS

A literature search yielded 77 studies (N=48,761) examining the effectiveness of home visiting programs, producing 174 effect sizes. In total, 35 different program components and delivery techniques were coded.

RESULTS

A small but significant overall effect was found (d=0.135, 95 % CI (0.084, 0.187), p<0.001). Programs that focused on improving parental expectations of the child or parenthood in general (d = 0.308 for programs with this component versus d = 0.112 for programs without this component), programs targeting parental responsiveness or sensitivity to a child's needs (d = 0.238 versus d = 0.064), and programs using video-based feedback (d = 0.397 versus d = 0.124) yielded relatively larger effects. Providing practical and instrumental assistance was negatively associated with program effectiveness (d=0.044 versus d = 0.168). Further, program effects were larger when percentages of non-Caucasians/non-Whites in samples and follow-up durations increased.

CONCLUSIONS

In general, home visiting programs can prevent child maltreatment only to a small extent. However, implementing specific components and techniques can improve program effectiveness.

Knowledge of and Attitudes Toward Perinatal Home Visiting in Women with High-Risk Pregnancies

INTRODUCTION

Published research indicates that some perinatal home visiting programs are highly effective. However, there is a dearth of information regarding how these services apply to women experiencing a high-risk pregnancy. The aim of this study was to determine the potential acceptability of home visiting services within this vulnerable population and identify what services women want.

METHODS

Four focus groups (N = 32) were conducted with a population of low-income, pregnant individuals in medically underserved central Georgia (United States). Participants were evaluated based on their current exposure to home visiting, receptiveness to home visiting, and reasons for apprehension regarding home visiting.

RESULTS

The results of this study were mixed, with women expressing both interest in and reluctance about home visiting programs. Themes of distrust and fear of judgment or persecution existed. Women also varied with regard to what home visiting services they would like offered. Those discussed included assistance with maternal or infant medical needs, maternal function tasks, household tasks, and child care.

DISCUSSION

Home visiting programs can be effective for improving maternal and child health outcomes. However, not all home visiting programs effectively reach their target population. More research is needed to determine what women who have high-risk conditions during pregnancy want help with and how to increase receptiveness. The results of this study could be informative to health care providers who treat persons with high-risk conditions in identifying adjunctive services for those in need of additional support.

Intention to Engage in Maternal and Child Health Home Visiting

Home visiting (HV) programs have the potential to improve maternal and child health. As federal and state initiatives expand the reach of these programs, understanding what factors enhance uptake and retention of the services becomes increasingly important. This qualitative study used a Reasoned Action Model (RAM) and a cultural lens to explore factors influencing the engagement of women with low-income in HV programs. We conducted 21 semi-structured interviews in both English and Spanish in a prenatal clinic in an urban public health department. The constructs most salient for participants were emotions and affect, behavioral beliefs, and self-efficacy. In the context of an urban public health prenatal clinic, HV marketing and outreach should highlight convenience and social support, as well as clearly communicate program content and intent. In practice, HV programs must be flexible to work around work and home schedules; marketing and outreach should emphasize that flexibility.

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

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

[One Size Fits All? Using Psychosocial Risk Assessments to Predict Service Use in Early Intervention and Prevention]

One Size Fits All? Using Psychosocial Risk Assessments to Predict Service Use in Early Intervention and Prevention Early intervention and prevention services offer a variety of programs. At the same time, program participants differ widely in their service use. This study aims at investigating the prognostic validity of psychosocial risk assessments in predicting the participants' service use. The psychosocial risk assessment "Heidelberg Stress Scale" is used to predict aspects of service use (dosage, attrition, intervention content, working relationship). Service use data of N = 1.514 participants of a home-visiting program will be analyzed via Machine-Learning-Algorithms. Dosage and intervention content can be predicted with psychosocial risk assessments. The classification strength is small. Global and continuous risk scales have a prognostic advantage over single categorical risk items. Financial burden has a significant influence on every aspect of service use. Psychosocial risk assessments provide additional information that can support intervention planning. Yet, these instruments should be supplemented by additional diagnostic information.

Service Engagement and Retention: Lessons from the Early Childhood Connections Program

The high attrition rates found in studies of early childhood home visitation create barriers to measuring the effectiveness of such programs. Most studies examine attrition at program completion. This practice may mask important differences in characteristics between families that end participation at various time points. This study helps address this gap by examining factors associated with percent attrition for early drop out (before three months) compared to the program midpoint (nine months or more) and program completion (18 months) using data from the treatment arm of a small feasibility study of enhanced referral to home visitation among child welfare-involved families (n = 64). Caregivers who identified as White tended to leave by the program midpoint and caregivers who had better social support were more likely to stay at the end of the program. This study is the only published study to date of participation in a community-based home visitation program by child welfare-involved families but several trends identified were consistent with prior studies with other populations. Given the very small sample size, both statistically significant and near significant trends are discussed in the context of existing literature. The practical variation found has implications for continuing to build knowledge of attrition in early childhood home visitation.

Exploring Multilevel Factors for Family Engagement in Home Visiting Across Two National Models

The associations of family, home visitor and site characteristics with family engagement within the first 6 months were examined. The variation in family engagement was also explored. Home visiting program participants were drawn from 21 Healthy Families America sites (1707 families) and 9 Nurse-Family Partnership sites (650 families) in New Jersey. Three-level nested generalized linear mixed models assessed the associations of family, home visitor and site characteristics with family receipt of a high dose of services in the first 6 months of enrollment. A family was considered to have received a high dose of service in the first 6 months of enrollment if they were active at 6 months and had received at least 50% of their expected visits in the first 6 months. In general, both home visiting programs engaged, at a relatively high level (Healthy Families America (HFA) 59%, Nurse-Family Partnership (NFP) 64%), with families demonstrating high-risk characteristics such as lower maternal education, maternal smoking, and maternal mental health need. Home visitor characteristics explained more of the variation (87%) in the receipt of services for HFA, while family characteristics explained more of the variation (75%) in the receipt of services for NFP. At the family level, NFP may improve the consistency with which they engage families by increasing retention efforts among mothers with lower education and smoking mothers. HFA sites seeking to improve engagement consistency should consider increasing the flexible in home visitor job responsibilities and examining the current expected-visit policies followed by home visitors on difficult-to-engage families.

A community-based randomized controlled trial of Mom Power parenting intervention for mothers with interpersonal trauma histories and their young children

We conducted a study to evaluate the effectiveness of Mom Power, a multifamily parenting intervention to improve mental health and parenting among high-risk mothers with young children in a community-based randomized controlled trial (CB-RCT) design. Participants (N = 122) were high-risk mothers (e.g., interpersonal trauma histories, mental health problems, poverty) and their young children (age <6 years), randomized either to Mom Power, a parenting intervention (treatment condition), or weekly mailings of parenting information (control condition). In this study, the 13-session intervention was delivered by community clinicians trained to fidelity. Pre- and post-trial assessments included mothers' mental health symptoms, parenting stress and helplessness, and connection to care. Mom Power was delivered in the community with fidelity and had good uptake (>65%) despite the risk nature of the sample. Overall, we found improvements in mental health and parenting stress for Mom Power participants but not for controls; in contrast, control mothers increased in parent-child role reversal across the trial period. The benefits of Mom Power treatment (vs. control) were accentuated for mothers with interpersonal trauma histories. Results of this CB-RCT confirm the effectiveness of Mom Power for improving mental health and parenting outcomes for high-risk, trauma-exposed women with young children. ClinicalTrials.gov Identifier: NCT01554215.

Multilevel assessment of prenatal engagement in home visiting

BACKGROUND

Low engagement in prenatal home visiting may limit programme effectiveness to improve birth outcomes. Multiple factors may influence engagement.

METHODS

A retrospective cohort study of first-time mothers enrolled in home visiting prenatally in southwest Ohio from 2007 to 2010. The primary outcome was enrolment by 20weeks' gestation; a secondary outcome included home visit frequency. Two multilevel assessments were conducted using random intercept multilevel modelling; maternal covariates were nested first within the home visiting agency and then within the ZIP code. In the first model, variations attributable to individual agency and agency volume were assessed. In the second model nested within the ZIP code, violence rates by ZIP code and interaction terms between violence rates and maternal factors were evaluated.

RESULTS

Of 837 women, 25.3% enrolled ≤20 weeks and 7.4% enrolled early and received ≥75% of expected visits. The first model demonstrated a significant variation in early enrolment based on clustering by agency (p<0.001), however, agency volume was not a significant predictor. In the second model, violence rate was not associated with early enrolment (AOR 0.92, p=0.08), but an interaction term with maternal race was significant (p=0.02). The effect of increasing community violence disproportionately affected early enrolment among white women (AOR 0.80, p=0.005) compared with black women (AOR 0.95, p=0.30). In both the random intercept multilevel models, teenagers demonstrated a decreased likelihood of enrolling early (AOR 0.58, p=0.046 and AOR 0.49, p=0.004).

CONCLUSIONS

Prenatal home visiting engagement is related to maternal, agency and community factors, presenting multiple opportunities to optimise programme implementation.

Mixed-methods feasibility study on the cultural adaptation of a child abuse prevention model

The current study utilized mixed-methods analyses to examine the process of adapting a home-based parenting program for a local Latino community. The study examined the: (a) acceptability and cultural congruence of the adapted SafeCare® protocol, (b) adherence to the core components of SafeCare® while adapting to local community culture, and (c) social validity of the new model in addressing SafeCare® target areas (parenting, home safety, and child health). Participants were 28 Latino mothers and eight providers. After training in the adapted model, providers demonstrated improved knowledge and skills. All providers reached national certification standards for SafeCare®, demonstrating fidelity to the core components of the original model. Positive consumer-provider relationships were developed as reflected by the results on the Working Alliance (collaboration between caregivers and parents). Themes from the integrated results of the social validity measures and individual interviews with parents were perceived benefits of the program on targeted areas and cultural congruency of the approach. Recommendations are to consider using adaptation guidelines as outlined to promote local culturally congruent practices.

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.

Family risk as a predictor of initial engagement and follow-through in a universal nurse home visiting program to prevent child maltreatment

OBJECTIVE

As nurse home visiting to prevent child maltreatment grows in popularity with both program administrators and legislators, it is important to understand engagement in such programs in order to improve their community-wide effects. This report examines family demographic and infant health risk factors that predict engagement and follow-through in a universal home-based maltreatment prevention program for new mothers in Durham County, North Carolina.

METHODS

Trained staff members attempted to schedule home visits for all new mothers during the birthing hospital stay, and then nurses completed scheduled visits three to five weeks later. Medical record data was used to identify family demographic and infant health risk factors for maltreatment. These variables were used to predict program engagement (scheduling a visit) and follow-through (completing a scheduled visit).

RESULTS

Program staff members were successful in scheduling 78% of eligible families for a visit and completing 85% of scheduled visits. Overall, 66% of eligible families completed at least one visit. Structural equation modeling (SEM) analyses indicated that high demographic risk and low infant health risk were predictive of scheduling a visit. Both low demographic and infant health risk were predictive of visit completion.

CONCLUSIONS

Findings suggest that while higher demographic risk increases families' initial engagement, it might also inhibit their follow-through. Additionally, parents of medically at-risk infants may be particularly difficult to engage in universal home visiting interventions. Implications for recruitment strategies of home visiting programs are discussed.

Provider cultural competency, client satisfaction, and engagement in home-based programs to treat child abuse and neglect

Home-based programs to treat child abuse and neglect suffer from high rates of attrition, limiting their impact. Thus, research is needed to identify factors related to client engagement. Using data (N = 1,305) from a statewide family preservation program, this study investigated the role of program type (i.e., SafeCare(®) [SC] vs. Services as Usual [SAU]) and client perceived provider cultural competence on client satisfaction and engagement with services. Families in SC completed more treatment goals than those in SAU. In addition, provider cultural competence and client satisfaction were higher in SC than in SAU. Higher provider cultural competence was associated with higher goal attainment and satisfaction, and these effects partially mediated the service program differences. The effects of service type and cultural competence on goal attainment and satisfaction varied somewhat by client ethnicity. Findings suggest that clients receiving manualized programs for child maltreatment may be more likely to meet their goals and may perceive such programs to be culturally appropriate and satisfactory.

Predictors of client engagement and attrition in home-based child maltreatment prevention services

High rates of program attrition in home-based family support and child maltreatment prevention services are common. Researchexamining factors related to family engagement (i.e., enrollment and completion rates) may help program developers increase theimpact of child abuse prevention services by reducing attrition. The present study examined the relative influence of provider,program, and individual factors from the Integrated Theory of Parent Involvement (ITPI) as well as maternal and family demo-graphic and risk variables in predicting service enrollment and completion in a home-based child maltreatment prevention service(SafeCareþ) and a standard community care program (Services as Usual [SAU]). Participants were 398 female caregivers ofchildren ages 5 and below. Support was found for the primary role of program and provider factors in client enrollment andcompletion of services. Specifically, participants in SafeCareþ were 4 times more likely to enroll in services and 8.5 times morelikely to complete services than those in SAU. Family risk variables including intimate partner psychological aggression, substanceabuse, and depression were also significant predictors. Recommended next steps include integration of risk-related factors in theITPI framework and disentangling specific provider and program factors related to service engagement.