Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial

Introducing the revised framework for developing and evaluating complex interventions: A challenge and a resource for nursing research

This invited discussion paper highlights key updates in the MRC/NIHR's revised framework for the development and evaluation of complex nursing interventions and reflects on the implications for nursing research.

Getting our ducks in a row: The need for data utility comparisons of healthcare systems data for clinical trials

BACKGROUND

Better use of healthcare systems data, collected as part of interactions between patients and the healthcare system, could transform planning and conduct of randomised controlled trials. Multiple challenges to widespread use include whether healthcare systems data captures sufficiently well the data traditionally captured on case report forms. "Data Utility Comparison Studies" (DUCkS) assess the utility of healthcare systems data for RCTs by comparison to data collected by the trial. Despite their importance, there are few published UK examples of DUCkS.

METHODS-AND-RESULTS

Building from ongoing and selected recent examples of UK-led DUCkS in the literature, we set out experience-based considerations for the conduct of future DUCkS. Developed through informal iterative discussions in many forums, considerations are offered for planning, protocol development, data, analysis and reporting, with comparisons at "patient-level" or "trial-level", depending on the item of interest and trial status.

DISCUSSION

DUCkS could be a valuable tool in assessing where healthcare systems data can be used for trials and in which trial teams can play a leading role. There is a pressing need for trials to be more efficient in their delivery and research waste must be reduced. Trials have been making inconsistent use of healthcare systems data, not least because of an absence of evidence of utility. DUCkS can also help to identify challenges in using healthcare systems data, such as linkage (access and timing) and data quality. We encourage trial teams to incorporate and report DUCkS in trials and funders and data providers to support them.

Effectiveness of nurse-home visiting in improving child and maternal outcomes prenatally to age two years: a randomised controlled trial (British Columbia Healthy Connections Project)

BACKGROUND

We investigated the effectiveness of Nurse-Family Partnership (NFP), a prenatal-to-age-two-years home-visiting programme, in British Columbia (BC), Canada.

METHODS

For this randomised controlled trial, we recruited participants from 26 public health settings who were: <25 years, nulliparous, <28 weeks gestation and experiencing socioeconomic disadvantage. We randomly allocated participants (one-to-one; computer-generated) to intervention (NFP plus existing services) or comparison (existing services) groups. Prespecified outcomes were prenatal substance exposure (reported previously); child injuries (primary), language, cognition and mental health (problem behaviour) by age two years; and subsequent pregnancies by 24 months postpartum. Research interviewers were masked. We used intention-to-treat analyses. (ClinicalTrials.gov, NCT01672060.) RESULTS: From 2013 to 2016 we enrolled 739 participants (368 NFP, 371 comparison) who had 737 children. Counts for child injury healthcare encounters [rate per 1,000 person-years or RPY] were similar for NFP (223 [RPY 316.17]) and comparison (223 [RPY 305.43]; rate difference 10.74, 95% CI -46.96, 68.44; rate ratio 1.03, 95% CI 0.78, 1.38). Maternal-reported language scores (mean, M [SD]) were statistically significantly higher for NFP (313.46 [195.96]) than comparison (282.77 [188.15]; mean difference [MD] 31.33, 95% CI 0.96, 61.71). Maternal-reported problem-behaviour scores (M [SD]) were statistically significantly lower for NFP (52.18 [9.19]) than comparison (54.42 [9.02]; MD -2.19, 95% CI -3.62, -0.75). Subsequent pregnancy counts were similar (NFP 115 [RPY 230.69] and comparison 117 [RPY 227.29]; rate difference 3.40, 95% CI -55.54, 62.34; hazard ratio 1.01, 95% CI 0.79, 1.29). We observed no unanticipated adverse events.

CONCLUSIONS

NFP did not reduce child injuries or subsequent maternal pregnancies but did improve maternal-reported child language and mental health (problem behaviour) at age two years. Follow-up of long-term outcomes is warranted given that further benefits may emerge across childhood and adolescence.

Evaluating the real-world implementation of the Family Nurse Partnership in England: a data linkage study

Background/objectives

The Family Nurse Partnership is an intensive home visiting programme for adolescent mothers. We aimed to evaluate the effectiveness of the Family Nurse Partnership on outcomes up to age 7 using national administrative data.

Design

We created a linked cohort of all mothers aged 13-19 using data from health, educational and children's social care and defined mothers enrolled in the Family Nurse Partnership or not using Family Nurse Partnership system data. Propensity scores were used to create matched groups for analysis.

Setting

One hundred and thirty-six local authorities in England with active Family Nurse Partnership sites between 2010 and 2017.

Participants

Mothers aged 13-19 at last menstrual period with live births between April 2010 and March 2019, living in a Family Nurse Partnership catchment area and their firstborn child(ren).

Interventions

The Family Nurse Partnership includes up to 64 home visits by a family nurse from early pregnancy until the child's second birthday and is combined with usual health and social care. Controls received usual health and social care.

Main outcome measures

Indicators of child maltreatment (hospital admissions for injury/maltreatment, referral to social care services); child health and development (hospital utilisation and education) outcomes and maternal hospital utilisation and educational outcomes up to 7 years following birth.

Data sources

Family Nurse Partnership Information System, Hospital Episode Statistics, National Pupil Database.

Results

Of 110,520 eligible mothers, 25,680 (23.2%) were enrolled in the Family Nurse Partnership. Enrolment rates varied across 122 sites (range: 11-68%). Areas with more eligible mothers had lower enrolment rates. Enrolment was higher among mothers aged 13-15 (52%), than 18-19 year-olds (21%). Indicators of child maltreatment: we found no evidence of an association between the Family Nurse Partnership and indicators of child maltreatment, except for an increased rate of unplanned admissions for maltreatment/injury-related diagnoses up to age 2 for children born to Family Nurse Partnership mothers (6.6% vs. 5.7%, relative risk 1.15; 95% confidence interval 1.07 to 1.24). Child health and developmental outcomes: there was weak evidence that children born to Family Nurse Partnership mothers were more likely to achieve a Good Level of Development at age 5 (57.5% vs. 55.4%, relative risk 1.05; 95% confidence interval 1.00 to 1.09). Maternal outcomes: There was some evidence that Family Nurse Partnership mothers were less likely to have a subsequent delivery within 18 months of the index birth (8.4% vs. 9.3%, relative risk 0.92; 95% confidence interval 0.88 to 0.97). Younger and more vulnerable mothers received higher numbers of visits and were more likely to achieve fidelity targets. Meeting the fidelity targets was associated with some outcomes.

Limitations

Bias by indication and variation in the intervention and usual care over time and between areas may have limited our ability to detect effects. Multiple testing may have led to spurious, significant results.

Conclusions

This study supports findings from evaluations of the Family Nurse Partnership showing no evidence of benefit for maltreatment outcomes measured in administrative data. Amongst all the outcomes measured, we found weak evidence that the Family Nurse Partnership was associated with improvements in child development at school entry, a reduction in rapid repeat pregnancies and evidence of increased healthcare-seeking in the mother and child.

Future work

Future evaluations should capture better measures of Family Nurse Partnership interventions and usual care, more information on maternal risk factors and additional outcomes relating to maternal well-being.

Study registration

The study is registered as NIHR CRN Portfolio (42900).

Funding

This award was funded by the National Institute of Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/99/19) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 11. See the NIHR Funding and Awards website for further award information.

Primary Care Interventions to Prevent Child Maltreatment: US Preventive Services Task Force Recommendation Statement

Importance

Child maltreatment, which includes child abuse and neglect, can have profound effects on health, development, survival, and well-being throughout childhood and adulthood. The prevalence of child maltreatment in the US is uncertain and likely underestimated. In 2021, an estimated 600 000 children were identified by Child Protective Services as experiencing abuse or neglect and an estimated 1820 children died of abuse and neglect.

Objective

The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate benefits and harms of primary care-feasible or referable behavioral counseling interventions to prevent child maltreatment in children and adolescents younger than 18 years without signs or symptoms of maltreatment.

Population

Children and adolescents younger than 18 years who do not have signs or symptoms of or known exposure to maltreatment.

Evidence Assessment

The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of primary care interventions to prevent child maltreatment in children and adolescents younger than 18 years without signs or symptoms of or known exposure to maltreatment.

Recommendation

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. (I statement).

Primary Care Interventions to Prevent Child Maltreatment: Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Child maltreatment is associated with serious negative physical, psychological, and behavioral consequences.

Objective

To review the evidence on primary care-feasible or referable interventions to prevent child maltreatment to inform the US Preventive Services Task Force.

Data Sources

PubMed, Cochrane Library, and trial registries through February 2, 2023; references, experts, and surveillance through December 6, 2023.

Study Selection

English-language, randomized clinical trials of youth through age 18 years (or their caregivers) with no known exposure or signs or symptoms of current or past maltreatment.

Data Extraction and Synthesis

Two reviewers assessed titles/abstracts, full-text articles, and study quality, and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.

Main Outcomes and Measures

Directly measured reports of child abuse or neglect (reports to Child Protective Services or removal of the child from the home); proxy measures of abuse or neglect (injury, visits to the emergency department, hospitalization); behavioral, developmental, emotional, mental, or physical health and well-being; mortality; harms.

Results

Twenty-five trials (N = 14 355 participants) were included; 23 included home visits. Evidence from 11 studies (5311 participants) indicated no differences in likelihood of reports to Child Protective Services within 1 year of intervention completion (pooled odds ratio, 1.03 [95% CI, 0.84-1.27]). Five studies (3336 participants) found no differences in removal of the child from the home within 1 to 3 years of follow-up (pooled risk ratio, 1.06 [95% CI, 0.37-2.99]). The evidence suggested no benefit for emergency department visits in the short term (<2 years) and hospitalizations. The evidence was inconclusive for all other outcomes because of the limited number of trials on each outcome and imprecise results. Among 2 trials reporting harms, neither reported statistically significant differences. Contextual evidence indicated (1) widely varying practices when screening, identifying, and reporting child maltreatment to Child Protective Services, including variations by race or ethnicity; (2) widely varying accuracy of screening instruments; and (3) evidence that child maltreatment interventions may be associated with improvements in some social determinants of health.

Conclusion and Relevance

The evidence base on interventions feasible in or referable from primary care settings to prevent child maltreatment suggested no benefit or insufficient evidence for direct or proxy measures of child maltreatment. Little information was available about possible harms. Contextual evidence pointed to the potential for bias or inaccuracy in screening, identification, and reporting of child maltreatment but also highlighted the importance of addressing social determinants when intervening to prevent child maltreatment.

The effect of home nurse visits on infant weight and breastfeeding: Systematic review and meta-analysis

AIMS

The primary aim of this systematic review and meta-analysis is to evaluate the effects of home nurse visiting on infant weight and breastfeeding; the secondary aim is to determine the duration, frequency and content of home visits.

METHODS

A systematic search of the PubMed, CINAHL, Embase (Ovid), Web of Science, Google Scholar and DergiPark databases for publications between September 2000 and January 2019 was conducted using established methods in compliance with the PRISMA-P declaration guideline. Two authors independently evaluated the studies for inclusion and bias, extracted the data and checked their accuracy.

RESULTS

This meta-analysis includes a total of 34 studies, 28 on breastfeeding and nine on infant weight. The average effect size of the 28 studies investigating the effect on breastfeeding was found to be OR: 2.24; 95% CI: 1.73-2.90; p < 0.001. The average effect size of the nine studies investigating the effect on infant weight was found to be ES: 0.197; 95% CI: 0.027-0.368; p < 0.05.

CONCLUSION

There is an association between nurse home visits and breastfeeding and infant weight. Home visits by nurses should continue to remain within the nursing role and be analysed appropriately for mother and baby health.

Toward a nuanced assessment of the role of intensive home visiting in improving outcomes for families: commentary on Catherine et al. (2023)

Families' experiences during the transition to parenthood and early childhood profoundly shape the lifetime trajectory of both parents and children, laying the foundation for societal inequities. Intensive home visiting programs, which aim to provide in-home support to socio-economically vulnerable parents during the transition to parenthood, are a prominent policy across the globe to provide support to less-resourced families. In this issue of the Journal of Clinical Psychology and Psychiatry, in their article titled 'Effectiveness of nurse-home visiting in improving child and maternal outcomes prenatally to age two years: A randomised controlled trial (British Columbia Healthy Connections Project)', Catherine et al. provide evidence from a randomized controlled trial of the impact of the Nurse-Family Partnership in Canada on child injury, language and behavior and birth spacing outcomes. This commentary discusses the paper's contribution and reflects on opportunities and challenges in building a nuanced understanding of the evidence-base supporting intensive home visiting programs.

Scoping review protocol: exploration of the barriers and facilitators to the uptake of early postnatal contraception

INTRODUCTION

It is well documented that many women do not desire a short interpregnancy interval. Medical societies, government agencies and leaders in the field recommend that contraception should be part of maternity care. Short spaced and unplanned pregnancies increase the chances of mortality and morbidity in the mother and child. The WHO recommends a 24-month interpregnancy interval; however, short pregnancy intervals remain common. The goal of this scoping review will be to explore barriers and facilitators to the uptake of early postnatal contraception. A review of globally published literature relating to the implementation of a postnatal contraception service provision globally will be carried out which will highlight evidence gaps, strengths and weaknesses of studies associated with uptake and known barriers and facilitators to the uptake of early postnatal contraception.

METHODS AND ANALYSIS

This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. The search strategy aims to locate both published and unpublished studies. An initial limited search of PubMed and CINAHL was undertaken to identify articles on the provision of postnatal contraception. The search strategy will be adapted for each included database CINAHL, SCOPUS, MEDLINE, PROSPERO and COCHRANE from 1 January 1993 to 1 January 2023 and reviewed by two reviewers. The data will be analysed and presented in tables, diagrams and text.

ETHICS AND DISSEMINATION

Ethical approval is not required. This review is a retrospective review of widely and publicly available evidence. The review findings will be disseminated via publication in peer-reviewed journals, as part of a PhD thesis and conference presentation.

SCOPING REVIEW QUESTION

What are the barriers and facilitators to early postnatal contraception provision and uptake?

Home Visits With A Registered Nurse Did Not Affect Prenatal Care In A Low-Income Pregnant Population

There is an urgent need to improve maternal and neonatal health outcomes and decrease their racial disparities in the US. Prenatal nurse home visiting programs could help achieve this by increasing the use and quality of prenatal care and facilitating healthy behaviors during pregnancy. We conducted a randomized controlled trial of 5,670 Medicaid-eligible pregnant people in South Carolina to evaluate how a nurse home visiting program affected prenatal health care and health outcomes. We compared outcomes between the treatment and control groups and found little evidence of statistically significant differences in the intensity of prenatal care use, receipt of guideline-based prenatal care services, other health care use, or gestational weight gain. Nor did we find treatment effects in subgroup analyses of socially vulnerable participants (46.9 percent of the sample) or non-Hispanic Black participants (52.0 percent of the sample). Compared with the broader Medicaid population, our trial participants had more health and social risk factors, more engagement with prenatal care, and similar pregnancy outcomes. Delivering intensive nurse home visiting programs to the general Medicaid population might not be an efficient method to improve prenatal care for those who need the most support during pregnancy.

Targeted health and social care interventions for women and infants who are disproportionately impacted by health inequalities in high-income countries: a systematic review

BACKGROUND

Disadvantaged populations (such as women from minority ethnic groups and those with social complexity) are at an increased risk of poor outcomes and experiences. Inequalities in health outcomes include preterm birth, maternal and perinatal morbidity and mortality, and poor-quality care. The impact of interventions is unclear for this population, in high-income countries (HIC). The review aimed to identify and evaluate the current evidence related to targeted health and social care service interventions in HICs which can improve health inequalities experienced by childbearing women and infants at disproportionate risk of poor outcomes and experiences.

METHODS

Twelve databases searched for studies across all HICs, from any methodological design. The search concluded on 8/11/22. The inclusion criteria included interventions that targeted disadvantaged populations which provided a component of clinical care that differed from standard maternity care.

RESULTS

Forty six index studies were included. Countries included Australia, Canada, Chile, Hong Kong, UK and USA. A narrative synthesis was undertaken, and results showed three intervention types: midwifery models of care, interdisciplinary care, and community-centred services. These intervention types have been delivered singularly but also in combination of each other demonstrating overlapping features. Overall, results show interventions had positive associations with primary (maternal, perinatal, and infant mortality) and secondary outcomes (experiences and satisfaction, antenatal care coverage, access to care, quality of care, mode of delivery, analgesia use in labour, preterm birth, low birth weight, breastfeeding, family planning, immunisations) however significance and impact vary. Midwifery models of care took an interpersonal and holistic approach as they focused on continuity of carer, home visiting, culturally and linguistically appropriate care and accessibility. Interdisciplinary care took a structural approach, to coordinate care for women requiring multi-agency health and social services. Community-centred services took a place-based approach with interventions that suited the need of its community and their norms.

CONCLUSION

Targeted interventions exist in HICs, but these vary according to the context and infrastructure of standard maternity care. Multi-interventional approaches could enhance a targeted approach for at risk populations, in particular combining midwifery models of care with community-centred approaches, to enhance accessibility, earlier engagement, and increased attendance.

TRIAL REGISTRATION

PROSPERO Registration number: CRD42020218357.

Lessons learned from using linked administrative data to evaluate the Family Nurse Partnership in England and Scotland

Introduction

"Big data" - including linked administrative data - can be exploited to evaluate interventions for maternal and child health, providing time- and cost-effective alternatives to randomised controlled trials. However, using these data to evaluate population-level interventions can be challenging.

Objectives

We aimed to inform future evaluations of complex interventions by describing sources of bias, lessons learned, and suggestions for improvements, based on two observational studies using linked administrative data from health, education and social care sectors to evaluate the Family Nurse Partnership (FNP) in England and Scotland.

Methods

We first considered how different sources of potential bias within the administrative data could affect results of the evaluations. We explored how each study design addressed these sources of bias using maternal confounders captured in the data. We then determined what additional information could be captured at each step of the complex intervention to enable analysts to minimise bias and maximise comparability between intervention and usual care groups, so that any observed differences can be attributed to the intervention.

Results

Lessons learned include the need for i) detailed data on intervention activity (dates/geography) and usual care; ii) improved information on data linkage quality to accurately characterise control groups; iii) more efficient provision of linked data to ensure timeliness of results; iv) better measurement of confounding characteristics affecting who is eligible, approached and enrolled.

Conclusions

Linked administrative data are a valuable resource for evaluations of the FNP national programme and other complex population-level interventions. However, information on local programme delivery and usual care are required to account for biases that characterise those who receive the intervention, and to inform understanding of mechanisms of effect. National, ongoing, robust evaluations of complex public health evaluations would be more achievable if programme implementation was integrated with improved national and local data collection, and robust quasi-experimental designs.

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.

Effect of digital health, biomarker feedback and nurse or midwife-led counselling interventions to assist pregnant smokers quit: a systematic review and meta-analysis

OBJECTIVE

To assess the effect of digital health (DH), biomarker feedback (BF) and nurse or midwife-led counselling (NoMC) interventions on abstinence in pregnant smokers during pregnancy and postpartum.

SETTINGS

Any healthcare setting servicing pregnant women, including any country globally.

PARTICIPANTS

Pregnant women of any social, ethnic or geographical background who smoke.

METHODS

We searched Embase, Medline, Web Of Science, Google Scholar, PsychINFO, CINAHL and PubMed between 2007 and November 2021. We included published original intervention studies in English with comparators (usual care or placebo). Two independent assessors screened and abstracted data. We performed a random-effects meta-analysis, assessed risk of bias with the Cochrane Tool and used Grading of Recommendations Assessment, Development and Evaluation to assess the quality of evidence.

RESULTS

We identified 57 studies and included 54 in the meta-analysis. Sixteen studies assessed DH (n=3961), 6 BF (n=1643), 32 NoMC (n=60 251), 1 assessed NoMC with BF (n=1120) and 2 NoMC with DH interventions (n=2107). DH interventions had moderate certainty evidence to achieve continuous abstinence (CA) at late pregnancy (4 studies; 2049 women; RR=1.98, 95% CI 1.08 to 3.64, p=0.03) and low certainty evidence to achieve point prevalence abstinence (PPA) postpartum (5 studies; 2238 women; RR=1.46, 95% CI 1.05 to 2.02, p=0.02). NoMC interventions had moderate certainty evidence to achieve PPA in late pregnancy (15 studies; 16 234 women; RR=1.54, 95% CI 1.16 to 2.06, p<0.01) and low certainty evidence to achieve PPA postpartum (13 studies; 5466 women; RR=1.79, 95% CI 1.14 to 2.83, p=0.01). Both DH and BF interventions did not achieve PPA at late pregnancy, nor NoMC interventions achieve CA postpartum. The certainty was reduced due to risk of bias, heterogeneity, inconsistency and/or imprecision.

CONCLUSION

NoMC interventions can assist pregnant smokers achieve PPA and DH interventions achieve CA in late pregnancy. These interventions may achieve other outcomes.

The COSI trial: a study protocol for a multi-centre, randomised controlled trial to explore the clinical and cost-effectiveness of the Circle of Security-Parenting Intervention in community perinatal mental health services in England

BACKGROUND

Perinatal mental health difficulties affect up to 27% of birthing parents during pregnancy and the first postnatal year, and if untreated are associated with difficulties in bonding and long-term adverse outcomes to children. There are large evidence gaps related to psychological treatment, particularly in group therapy approaches and parent-infant interventions. One intervention showing preliminary efficacious findings and user acceptability is Circle of Security-Parenting (COS-P), which is a brief, weekly, group programme. However, these studies were underpowered and predominantly non-randomised, and there has never been a research trial in England or with birthing parents experiencing severe and complex perinatal mental health difficulties. The aim of the research is to conduct a randomised control trial to test whether COS-P will reduce perinatal mental health symptoms in birthing parents accessing NHS perinatal mental health services, compared to treatment as usual (TAU). Secondary objectives include exploring whether the intervention improves parenting sensitivity, emotion regulation skills, attachment security and infant development. Additionally, the project aims to examine whether the intervention is acceptable to parents and NHS staff, and whether it is cost-effective.

METHODS

COSI is an individually randomised, single-blind parallel arm controlled trial with an embedded internal pilot aiming to recruit 369 participants in a 2:1 ratio (intervention: TAU). Participants will be recruited from ten NHS community perinatal mental health services in England and screened based on clinical levels of both mental health symptoms (average CORE-OM score ≥ 1.1) and postnatal bonding difficulties (total PBQ score ≥ 12). This trial has 90% power to detect a MCID of 5 points on the CORE-OM. Primary and secondary outcomes will be measured at baseline, 3, 7 and 12 months after baseline. Service use and quality of life measures will also be collected alongside a process evaluation of parents' and interveners' views and experiences.

DISCUSSION

This will be the first large pragmatic trial to test whether COS-P is effective for birthing parents with severe and complex perinatal mental health difficulties in improving their mental health symptoms. If shown to be effective, the intervention could be delivered widely across the NHS and other similar services globally.

TRIAL REGISTRATION

ISRCTN, ISRCTN18308962. Registered 18 February 2022.

Usage of digital, social and goal-setting functionalities to support health behavior change: A mixed methods study among disadvantaged women during or after pregnancy and their healthcare professionals

OBJECTIVE

We aimed to gain insight into how and to what extent social (i.e. private/group chat) and goal-setting (e.g. rewards) functionalities in digital interventions for health behavior change were used by clients and nurses in a preventive care program for disadvantaged women during or after pregnancy, and which factors influenced usage.

METHODS

We collected quantitative and qualitative data on usage of these functionalities in 'Kindle', a mHealth intervention to prepare for health behavior change.

RESULTS

We found that nurses (n = 5) and clients (n = 20) scarcely used both functionalities. They sent 862 messages in the social functionality whose security they appreciated, but habitually used WhatsApp likewise. Moreover, nurses were hesitant to let their clients interact in the group chat. Clients formulated 59 personal goals, which they found difficult to do. Nurses rewarded 846 points for clients' progress on goal attainment, but found it hard to determine how many points to reward. Clients and nurses indicated that the functionality made it more fun and easy to discuss clients' personal goals.

CONCLUSIONS

To conclude, digital, social and goal-setting functionalities were used to a limited extent by nurses and clients, and need optimization before implementation to support disadvantaged groups to change their health behavior.

Mental health prevention and treatment programs for infants experiencing homelessness: A systematic review

Experiencing homelessness in infancy has been linked to negative physical and mental health outcomes. Parental well-being and the parent-infant relationship can also be negatively impacted by experiencing homelessness. While numerous parent-based infant mental health programs have been identified by a recent review, the goal of this study was to further determine the extent to which these existing programs were developed and/or examined with at-risk populations such as families experiencing homelessness. Out of 60 programs identified by Hare et al., in press, only three had been implemented specifically in shelter settings with infants 0-12 months (Parent-Infant Psychotherapy, New Beginnings, and My Baby's First Teacher). Additionally, when examining programs that began in later infancy (after 12 months), only 2 programs were implemented in shelter settings (Incredible Years and Parent-Child Interaction Therapy). Implications for research, policy, and clinicians regarding implementation of evidence-based prevention/treatment programs for parents and their infants experiencing homelessness are discussed.

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.

Maternal mental health and social support from online communities during pregnancy

Social determinants of public health have gained increasing attention. This paper studied whether social support from online communities related to maternal mental health. We focused on online maternity communities that group users with a similar prenatal status to facilitate their exchange of personal experiences and knowledge about maternal caring during pregnancy. Such online maternity communities are getting increasingly popular and can be found across countries and societies. We invited users-currently pregnant and gave birth within 1 year at the time of the study-from one such community in China to participate in a survey. The survey measured their perceived social support (PSS) exclusively from the peer group in the online community, their mental health and newborns' birth outcomes (N = 500). Users reported high score in PSS from the online peer group which was comparable to the ones from family, significant other and friends in other studies. We used linear regression models to examine the effects of PSS on mental health and birth outcomes. We found that a one-point increase in the PSS score was associated with a 0.19-point (p < 0.1) decrease in the prenatal depression and a 0.26-point (p < 0.01) decrease in the postnatal depression, which was equivalent to 3% and 4.5% of the average respectively. Moreover, a one-point increase in the PSS score was associated with a 14.49-gram increase in a newborn's weight (p < 0.01).

Characteristics of enrolment in an intensive home-visiting programme among eligible first-time adolescent mothers in England: a linked administrative data cohort study

BACKGROUND

Intensive home visiting for adolescent mothers may help reduce health disparities. Given limited resources, such interventions need to be effectively targeted. We evaluated which mothers were enrolled in the Family Nurse Partnership (FNP), an intensive home-visiting service for first-time young mothers commissioned in >130 local authorities in England since 2007.

METHODS

We created a population-based cohort of first-time mothers aged 13-19 years giving birth in English National Health Service hospitals between 1 April 2010 and 31 March 2017, using administrative hospital data linked with FNP programme, educational and social care data. Mothers living in a local authority with an active FNP site were eligible. We described variation in enrolment rates across sites, and identified maternal and FNP site characteristics associated with enrolment.

RESULTS

Of 110 520 eligible mothers, 25 680 (23.2% (95% CI: 23.0% to 23.5%)) were enrolled. Enrolment rates varied substantially across 122 sites (range: 11%-68%), and areas with greater numbers of first-time adolescent mothers achieved lower enrolment rates. Mothers aged 13-15 years were most likely to be enrolled (52%). However, only 26% of adolescent mothers with markers of vulnerability (including living in the most deprived areas and ever having been looked after as a child) were enrolled.

CONCLUSION

A substantial proportion of first-time adolescent mothers with vulnerability markers were not enrolled in FNP. Variation in enrolment across sites indicates insufficient commissioning of places that is not proportional to level of need, with mothers in areas with large numbers of other adolescent mothers least likely to receive support.

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.

The impact of a specialist home-visiting intervention on the language outcomes of young mothers and their children: a pragmatic randomised controlled trial

BACKGROUND

Young mothers are more likely to provide a suboptimal early language environment for their children who in turn show impairments in their language development, yet few studies have used observational methods to assess the effectiveness of home-visiting programmes in improving the language outcomes of young mothers and their children. The Family Nurse Partnership (FNP) is a licensed home-visiting intervention developed in the USA and introduced into practice in England. The intervention involves up to 64 structured home visits from early pregnancy until the child's second birthday by specially recruited and trained Family Nurses. We assessed the effectiveness of FNP in improving the language outcomes of first-time teenage mothers and their infants.

METHOD

We conducted a pragmatic, non-blinded, randomised controlled trial to test whether the FNP programme improved mothers' and children's language production at 24 months postpartum. Eligible participants were nulliparous, aged 19 years or younger, and were recruited at less than 25 weeks' gestation from community midwifery settings (Country). Pregnant young mothers were randomly assigned to FNP plus usual care (n = 243) or usual care alone (n = 233). At 24 months postpartum, mother-child dyads were observed during a standardised free-play task with their first-born child and features of their language production was coded. Data was analysed using multi-level modelling; linear or poisson/negative binomial regression models were used as appropriate.

RESULTS

A small effect of FNP on mothers' productive language was detected, where mothers in the FNP group demonstrated higher mean length of utterances than mothers who received usual care alone, mean difference (adjusted by minimisation variables and by site, linear regression) = 0.10, p < .05, 95% CI (0.004-0.20), d = .18. No differences were detected between groups regarding other characteristics of maternal language or children's language outcomes.

CONCLUSION

This observational study conducted within the context of a randomised-controlled trial suggests that the FNP home-visiting programme may have a small, but potentially important impact on young mothers' speech to their toddlers. Exploratory analyses identified family environment, maternal, and child related predictors of the language outcomes of young mothers and their offspring. Trial registration This trial is registered with ISRCTN, number ISRCTN23019866, 20/04/2009.

Early Stimulation and Nutrition: The Impacts of a Scalable Intervention

Early childhood development is becoming the focus of policy worldwide. However, the evidence on the effectiveness of scalable models is scant, particularly when it comes to infants in developing countries. In this paper, we describe and evaluate with a cluster-Randomized Controlled Trial an intervention designed to improve the quality of child stimulation within the context of an existing parenting program in Colombia, known as FAMI. The intervention improved children's development by 0.16 of a standard deviation (SD) and children's nutritional status, as reflected in a reduction of 5.8 percentage points of children whose height-for-age is below -1 SD.

Effect of an Intensive Nurse Home Visiting Program on Adverse Birth Outcomes in a Medicaid-Eligible Population: A Randomized Clinical Trial

IMPORTANCE

Improving birth outcomes for low-income mothers is a public health priority. Intensive nurse home visiting has been proposed as an intervention to improve these outcomes.

OBJECTIVE

To determine the effect of an intensive nurse home visiting program on a composite outcome of preterm birth, low birth weight, small for gestational age, or perinatal mortality.

DESIGN, SETTING, AND PARTICIPANTS

This was a randomized clinical trial that included 5670 Medicaid-eligible, nulliparous pregnant individuals at less than 28 weeks' gestation, enrolled between April 1, 2016, and March 17, 2020, with follow-up through February 2021.

INTERVENTIONS

Participants were randomized 2:1 to Nurse Family Partnership program (n = 3806) or control (n = 1864). The program is an established model of nurse home visiting; regular visits begin prenatally and continue through 2 postnatal years. Nurses provide education, assessments, and goal-setting related to prenatal health, child health and development, and maternal life course. The control group received usual care services and a list of community resources. Neither staff nor participants were blinded to intervention group.

MAIN OUTCOMES AND MEASURES

There were 3 primary outcomes. This article reports on a composite of adverse birth outcomes: preterm birth, low birth weight, small for gestational age, or perinatal mortality based on vital records, Medicaid claims, and hospital discharge records through February 2021. The other primary outcomes of interbirth intervals of less than 21 months and major injury or concern for abuse or neglect in the child's first 24 months have not yet completed measurement. There were 54 secondary outcomes; those related to maternal and newborn health that have completed measurement included all elements of the composite plus birth weight, gestational length, large for gestational age, extremely preterm, very low birth weight, overnight neonatal intensive care unit admission, severe maternal morbidity, and cesarean delivery.

RESULTS

Among 5670 participants enrolled, 4966 (3319 intervention; 1647 control) were analyzed for the primary maternal and neonatal health outcome (median age, 21 years [1.2% non-Hispanic Asian, Indigenous, or Native Hawaiian and Pacific Islander; 5.7% Hispanic; 55.2% non-Hispanic Black; 34.8% non-Hispanic White; and 3.0% more than 1 race reported [non-Hispanic]). The incidence of the composite adverse birth outcome was 26.9% in the intervention group and 26.1% in the control group (adjusted between-group difference, 0.5% [95% CI, -2.1% to 3.1%]). Outcomes for the intervention group were not significantly better for any of the maternal and newborn health primary or secondary outcomes in the overall sample or in either of the prespecified subgroups.

CONCLUSIONS AND RELEVANCE

In this South Carolina-based trial of Medicaid-eligible pregnant individuals, assignment to participate in an intensive nurse home visiting program did not significantly reduce the incidence of a composite of adverse birth outcomes. Evaluation of the overall effectiveness of this program is incomplete, pending assessment of early childhood and birth spacing outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03360539.

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.

A randomized controlled trial of a proportionate universal parenting program delivery model (E-SEE Steps) to enhance child social-emotional wellbeing

Background

Evidence for parenting programs to improve wellbeing in children under three is inconclusive. We investigated the fidelity, impact, and cost-effectiveness of two parenting programs delivered within a longitudinal proportionate delivery model (‘E-SEE Steps’).

Methods

Eligible parents with a child ≤ 8 weeks were recruited into a parallel two-arm, assessor blinded, randomized controlled, community-based, trial with embedded economic and process evaluations. Post-baseline randomization applied a 5:1 (intervention-to-control) ratio, stratified by primary (child social-emotional wellbeing (ASQ:SE-2)) and key secondary (maternal depression (PHQ-9)) outcome scores, sex, and site. All intervention parents received the Incredible Years^® Baby Book (IY-B), and were offered the targeted Infant (IY-I)/Toddler (IY-T) program if eligible, based on ASQ:SE-2/PHQ-9 scores. Control families received usual services. Fidelity data were analysed descriptively. Primary analysis applied intention to treat. Effectiveness analysis fitted a marginal model to outcome scores. Cost-effectiveness analysis involved Incremental Cost-Effectiveness Ratios (ICERs).

Results

The target sample (N = 606) was not achieved; 341 mothers were randomized (285:56), 322 (94%) were retained to study end. Of those eligible for the IY-I (n = 101), and IY-T (n = 101) programs, 51 and 21 respectively, attended. Eight (of 14) groups met the 80% self-reported fidelity criteria. No significant differences between arms were found for adjusted mean difference scores; ASQ:SE-2 (3.02, 95% CI: -0.03, 6.08, p = 0.052), PHQ-9 (-0.61; 95% CI: -1.34, 0.12, p = 0.1). E-SEE Steps had higher costs, but improved mothers’ Health-related Quality of Life (0.031 Quality Adjusted Life Year (QALY) gain), ICER of £20,062 per QALY compared to control. Serious adverse events (n = 86) were unrelated to the intervention.

Conclusions

E-SEE Steps was not effective, but was borderline cost-effective. The model was delivered with varying fidelity, with lower-than-expected IY-T uptake. Changes to delivery systems and the individual programs may be needed prior to future evaluation.

Trial registration

International Standard Randomized Controlled Trial Number: ISRCTN11079129.

A systematic review and qualitative meta-synthesis of the roles of home-visiting nurses working with women experiencing family violence

AIMS

To systematically review and synthesize qualitative research exploring home-visiting nurses' roles and identify the challenges for nurses working with women experiencing family violence.

DESIGN

We undertook a thematic synthesis of qualitative studies, focusing on the family violence work of nurse home visitors.

DATA SOURCES

A systematic search of four scientific databases (ProQuest Central, CINAHL, MEDLINE, EMBASE) was undertaken in August 2021. Grey literature was searched, including government and non-government research documents, theses, clinical guidelines, policy documents and practice frameworks.

REVIEW METHODS

Inclusion criteria included research from high-income countries, peer-reviewed qualitative studies in English published from 1985 to 2021, and included research on home-visiting nurse family violence practice. The first author conducted the data search and the initial screening. The first and second authors independently reviewed the full text of 115 papers, identifying 26 for inclusion in the thematic synthesis (Figure 1-PRISMA flowchart).

RESULTS

The thematic synthesis identified two themes: (1) relationship building-with the client, with services and with colleagues/self; and (2) family violence practice-ask/screen, validate/name, assess risk/safety plan and safeguard children.

CONCLUSION

The thematic synthesis confirmed the multiple roles fulfilled by home-visiting nurses and enabled insight into the challenges they face as they undertake complex and demanding work. The roles of the home-visiting nurse have evolved, with the initial focus on safeguarding children leading to broader family violence nursing practice roles, including the identification of family violence and safety planning discussions with women.

IMPACT

Our meta-synthesis has confirmed the high-level communication and rapport-building skills required by nurses undertaking complex and conflicting roles. Nurses need support and supervision to undertake emotionally demanding work. Integrated health systems, clinical practice guidelines and tools, and training programmes need to encompass the breadth and complexity of the roles of these specialist practitioners.

Implementation of postpartum care for women in primary care in the South of Brazil

Abstract Objectives: to determine the implementation level and analyze favorable and unfavorable aspects of operationalization women’s care in postpartum period in primary care. Methods: evaluation study of the normative type, performed through a multiple case study in three cities in the South States in Brazil, with a collection of primary and secondary data. The implementation level (classification: satisfactory, partial, incipient, and critical) was determined by the Matriz de Análise e Julgamento (Analysis and Judgment Matrix), consisted of the dimensions of management and execution, and the respective sub-dimensions. Thematic and imbricated analysis of the cases were performed. Results: postpartum care was incipient in the management dimension for all the cases, with a higher implementation level for the “care coordination and intersectorality mechanisms” (partial) sub-dimension. In the execution dimension in case 3 was partially implemented, and the others were incipient. The breastfeeding sub-dimension had a higher implementation level for all the cases, and the longitudinality, mental health and reproductive planning sub-dimensions had a lower implementation level. Care in relation to domestic violence and mental health occurred unsystematically, and reproductive planning focused on hormonal contraceptive methods. Conclusion: management does not provide ideal conditions for healthcare professionals’ performance; and, in the execution dimension are not incorporated as the main necessity in the health care practice in women’s health.

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.

Nurse-led home-visitation programme for first-time mothers in reducing maltreatment and improving child health and development (BB:2-6): longer-term outcomes from a randomised cohort using data linkage

OBJECTIVES

Measure effectiveness of family nurse partnership (FNP) home-visiting programme in reducing maltreatment and improving maternal health and child health, developmental and educational outcomes; explore effect moderators, mediators; describe costs.

DESIGN

Follow-up of BB:0-2 trial cohort (ISRCTN:23019866) up to age 7 years in England using record linkage.

PARTICIPANTS

1618 mothers aged 19 years or younger and their firstborn child(ren) recruited to BB:0-2 trial at less than 25 weeks gestation and not mandatorily withdrawn from trial or opted out. Intervention families were offered up to a maximum of 64 home visits by specially trained nurses from pregnancy until firstborn child was 2 years old, plus usually provided health and social care support. Comparator was usual care alone.

OUTCOME MEASURES

Primary outcome: state-verified child-in-need status recorded at any time during follow-up.

SECONDARY OUTCOMES

referral to social services, child protection registration (plan), child-in-need categorisation, looked-after status, recorded injuries and ingestions any time during follow-up, early childcare and educational attendance, school readiness and attainment at key stage 1 (KS1), healthcare costs.

RESULTS

Match rates for 1547 eligible children (1517 singletons, 15 sets of twins) were 98.3% (NHS Digital) and 97.4% (National Pupil Database). There was no difference between study arms in the proportion of children being registered as in need (adjusted OR 0.98, 95% CI 0.74 to 1.31), or for any other measure of maltreatment. Children in the FNP arm were more likely to achieve a good level of development at reception age (school readiness) (adjusted OR 1.24, 95% CI 1.01 to 1.52). After adjusting for birth month, children in FNP arm were more likely to reach the expected standard in reading at KS1 (adjusted OR 1.26, 95% CI 1.02 to 1.57). We found no trial arm differences for resource use and costs.

CONCLUSIONS

FNP did not improve maltreatment or maternal outcomes. There was evidence of small advantages in school readiness and attainment at KS1.

TRIAL REGISTRATION NUMBER

ISRCTN23019866.

Public health nurses' perceptions of their interactions with child protection services when supporting socioeconomically disadvantaged young mothers in British Columbia, Canada

BACKGROUND

Children of girls and young women experiencing socioeconomic disadvantage are at risk of maltreatment and associated health and developmental problems. Nurse-Family Partnership (NFP) is an early intervention program designed to improve child and maternal health outcomes. The effectiveness of NFP is being evaluated in British Columbia (BC) through a randomized controlled trial, augmented by a process evaluation to identify influences on how NFP was implemented.

OBJECTIVE

To describe how public health nurses providing NFP perceived their interactions with child protection professionals.

PARTICIPANTS AND SETTING

Forty-seven public health nurses across BC.

METHODS

The principles of interpretive description informed the qualitative component of the process evaluation. Data from interviews and focus groups were analyzed using the framework analysis approach. A thematic framework was generated through processes of coding, charting and mapping, with a focus on organizational and systems influences.

RESULTS

Nurses' practice in supporting families often involved engagement with child protection services. Four themes about the nature of this work were identified: 1) developing a deeper understanding of the disciplinary perspectives of child protection, 2) striving for strengthened collaboration, 3) navigating change and uncertainty, and 4) responding to family and community complexity.

CONCLUSIONS

Participants valued the contribution of child protection professionals and expressed willingness to collaborate to support families. However, collaboration was constrained by multiple structural barriers. Collaborative models offer possibilities for integrated practice, although can be difficult to implement within current health and child protection systems and child protection regulatory contexts.

Attitudes towards the collection and linkage of maltreatment data for research: A qualitative study

INTRODUCTION

Factors that affect public and professionals' attitudes towards the collection and linkage of health and other data have been explored in the literature. Thus far there has been no study exploring attitudes towards the collection of child maltreatment data.

OBJECTIVES

Our aim is to explore attitudes regarding the collection and linkage of maltreatment data for research.

METHODS

Participants included younger mothers, older mothers, care-experienced young people, and professionals who were responsible for recording child maltreatment data. Four face-to-face focus groups were conducted, one with younger mothers (n = 6), one with older mothers (n = 10), and two with care-experienced young people (n = 6 and n = 5). An online focus group was conducted with professionals (n = 10), two of whom additionally participated in telephone interviews. Transcribed audio-recorded data were inductively coded, a portion were double-coded by a second researcher, and thematically analysed.

RESULTS

Three major themes were identified. The first concerned issues of consent, specifically the conditions for providing consent and factors influencing this. The second concerned trust in data security and validity, the organisations and individuals providing and using the data, and how the information provided shapes attitudes. The third theme explored the benefits of research and the researchers' role in child protection. Participants wanted the choice of providing consent for data collection, especially when consenting on behalf of another, but there were concerns that maltreated children were unidentifiable in anonymised datasets. Care-experienced young people were concerned about data collection from Social Services records due to their sensitivity. There was a general lack of understanding about how research data is viewed and the accuracy of records.

CONCLUSIONS

Novel findings in the study were strongly related to the sensitive nature of the topic. The findings may be particularly useful when designing research studies and participant materials and a co-productive approach to this should be taken.

Birth-Related Outcomes for Second Children Following Home Visiting Program Enrollment for New Parents of First Children

Introduction

Home visiting (HV) programs aim to promote child and family health through perinatal intervention. HV may benefit second children through improving subsequent pregnancy and birth outcomes. However, HV impacts on birth outcomes of second children have not been examined in a naturalistic setting.

Methods

Using data from Connecticut Nurturing Families Network (NFN) home visiting program of families enrolled from 2005 to 2015, we compared birth-related outcomes (birthweight, preterm birth, Cesarean section delivery, prenatal care utilization) of second children (n = 1758) to demographically similar propensity-score-matched families that were not enrolled in NFN (n = 5200). We examined whether the effects of NFN differed by maternal age, race and ethnicity, or visit attendance pattern.

Results

There was no program effect for the full sample. The effect of NFN did not differ by maternal age or visit attendance pattern but did differ by maternal race and ethnicity. Black women in NFN were more likely to receive adequate prenatal care during their second pregnancy (OR 1.05; 95% CI 1.01, 1.09) and Hispanic women in NFN were less likely to deliver by Cesarean section for their second birth (OR 0.97; 95% CI 0.94, 0.99), compared to Black and Hispanic women in the comparison group respectively. There was a protective program effect on prematurity of the second child (OR 0.92; 95% CI 0.85, 0.996) for women with a preterm first birth.

Discussion

These findings suggest that benefits of HV extend to subsequent birth-related outcomes for women from marginalized racial/ethnic groups. HV may help buffer some harmful social determinants of health.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10995-021-03365-3.

Early positive approaches to support for families of young children with intellectual disability: the E-PAtS feasibility RCT

Background

Parents of children with intellectual disability are 1.5–2 times more likely than other parents to report mental health difficulties. There is a lack of clinically effective and cost-effective group well-being interventions designed for family carers of young children with intellectual disability.

Aim

To examine the feasibility of a randomised controlled trial of the clinical effectiveness and cost-effectiveness of the Early Positive Approaches to Support (E-PAtS) intervention.

Design

A feasibility study (including randomisation of families into a two-arm trial), questionnaires to assess the feasibility of proposed outcome measures (including resource use and health-related quality of life) and practitioner/family carer interviews. An additional question was included in an online UK survey of families, conducted by the research team to assess usual practice, and a survey of provider organisations.

Setting

Families recruited from community contexts (i.e. third sector, local authority services, special schools) and self-referral. The E-PAtS intervention was delivered by trained community-based providers.

Participants

Families with at least one child aged 1.5–5 years with an intellectual disability. At least one parent had to have English-language ability (spoken) for E-PAtS programme participation and participants had to provide informed consent.

Interventions

E-PAtS intervention – two caregivers from each family invited to eight 2.5-hour group sessions with usual practice. Usual practice – other support provided to the family, including other parenting support.

Objectives

To assess randomisation willingness/feasibility, recruitment of providers/parents, retention, usual practice, adherence, fidelity and feasibility of proposed outcome measures (including the Warwick–Edinburgh Mental Well-Being Scale as the proposed primary outcome measure, and parent anxiety/depression, parenting, family functioning/relationships, child behavioural/emotional problems and adaptive skills, child and parent quality of life, and family services receipt as the proposed secondary outcome measures).

Results

Seventy-four families (95 carers) were recruited from three sites (with 37 families allocated to the intervention). From referrals, the recruitment rate was 65% (95% confidence interval 56% to 74%). Seventy-two per cent of families were retained at the 12-month follow-up (95% confidence interval 60% to 81%). Exploratory regression analysis showed that the mean Warwick–Edinburgh Mental Well-Being Scale well-being score was 3.96 points higher in the intervention group (95% confidence interval –1.39 to 9.32 points) at 12 months post randomisation. High levels of data completeness were achieved on returned questionnaires. Interviews (n = 25) confirmed that (1) recruitment, randomisation processes and the intervention were acceptable to family carers, E-PAtS facilitators and community staff; (2) E-PAtS delivery were consistent with the logic model; and (3) researchers requesting consent in future for routine data would be acceptable. Recorded E-PAtS sessions demonstrated good fidelity (96% of components present). Adherence (i.e. at least one carer from the family attending five out of eight E-PAtS sessions) was 76%. Health-related quality-of-life and services receipt data were gathered successfully. An online UK survey to assess usual practice (n = 673) showed that 10% of families of young children with intellectual disability received any intervention over 12 months. A provider survey (n = 15) indicated willingness to take part in future research.

Limitations

Obtaining session recordings for fidelity was difficult. Recruitment processes need to be reviewed to improve diversity and strategies are needed to improve primary outcome completion.

Conclusions

Study processes were feasible. The E-PAtS intervention was well received and outcomes for families were positive. A barrier to future organisation participation is funding for intervention costs. A definitive trial to test the clinical effectiveness and cost-effectiveness of E-PAtS would be feasible.

Trial registration

Current Controlled Trials ISRCTN70419473.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 2. See the NIHR Journals Library website for further project information.

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.

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.

A mixed-methods feasibility study of an intervention to improve men's mental health and wellbeing during their transition to fatherhood

BACKGROUND

Many health visiting services in England use the Promotional Guide system with mothers and fathers, an intervention to support their transition to parenthood, but there is little known about its use and effectiveness, especially with fathers. The aim of this study was to test the feasibility and acceptability of the Promotional Guide system with first-time fathers and pilot potential outcome measures to assess their mental health and wellbeing.

METHODS

A mixed methods prospective observational cohort study. Expectant first-time fathers were recruited from four London (UK) local authority boroughs. Data were collected through online pre and post intervention questionnaires, and semi-structured telephone interviews. Quantitative data were analysed using descriptive statistics and qualitative data were analysed using framework analysis.

RESULTS

Eighty-six fathers were interested in participating; 7 did not meet inclusion criteria and 79 were invited to complete the baseline questionnaire. Questionnaires completed by 45 men at both timepoints were included in the final analysis. Mean and standard deviations were calculated for all outcomes, showing a slight deterioration in the scores across all measures in the postnatal period compared to the antenatal. Ten of these men were also interviewed. Six major categories were identified: 1) Experience of health visitor contact, 2) Experience of Promotional Guides, 3) Experience of perinatal health services, 4) Experience of fatherhood, 5) Fathers' mental health and wellbeing, and 6) Experience of the research process. While antenatal and postnatal outcomes were collected from 45 first-time fathers, none had received the intervention in its entirety. This study identified major gaps in the implementation of the Promotional Guide system with fathers.

CONCLUSION

This study assessed recruitment of first-time fathers, time to complete recruitment, and retention rates and identified outcome measures that could be used in a future definitive study. While it wasn't possible to examine the potential changes following the use of the Promotional Guide system, the study reported on the changes in the fathers' 'states' in the antenatal and postnatal period. It provided a narrative on whether first-time fathers found it acceptable to be asked about their mental health and wellbeing, highlighted their specific needs during their transition to fatherhood, and how they wanted to be supported. It also identified barriers to implementation of the Promotional Guide system by health visitors, which need to be addressed prior to any future research into this intervention. These findings have a number of implications for researchers, health professionals, health service managers, commissioners, policy makers and parents.

Improving interagency service integration of the Australian Nurse Family Partnership Program for First Nations women and babies: a qualitative study

Background

The Australian Nurse Family Partnership Program (ANFPP) is an evidence-based, home visiting program that offers health education, guidance, social and emotional support to first-time mothers having Aboriginal and/or Torres Strait Islander (First Nations) babies. The community-controlled sector identified the need for specialised support for first time mothers due to the inequalities in birthing and early childhood outcomes between First Nations’ and other babies in Australia. The program is based on the United States’ Nurse Family Partnership program which has improved long-term health outcomes and life trajectories for mothers and children. International implementation of the Nurse Family Partnership program has identified interagency service integration as key to program recruitment, retention, and efficacy. How the ANFPP integrates with other services in an Australian urban setting and how to improve this is not yet known. Our research explores the barriers and enablers to interagency service integration for the Australian Nurse Family Partnership Program ANFPP in an urban setting.

Methods

A qualitative study using individual and group interviews. Purposive and snowball sampling was used to recruit clients, staff (internal and external to the program), Elders and family members. Interviews were conducted using a culturally appropriate ‘yarning’ method with clients, families and Elders and semi-structured interview guide for staff. Interviews were audio-recorded and transcribed prior to reflexive thematic analysis.

Results

Seventy-six participants were interviewed: 26 clients, 47 staff and 3 Elders/family members. Three themes were identified as barriers and three as enablers. Barriers: 1) confusion around program scope, 2) duplication of care, and 3) tensions over ‘ownership’ of clients. Enablers (existing and potential): 1) knowledge and promotion of the program; 2) cultural safety; and 3) case coordination, co-location and partnership forums.

Conclusion

Effective service integration is essential to maximise access and acceptability of the ANFPP; we provide practical recommendations to improve service integration in this context.

Child maltreatment data: A summary of progress, prospects and challenges

BACKGROUND

In 1996, the ISPCAN Working Group on Child Maltreatment Data (ISPCAN-WGCMD) was established to provide an international forum in which individuals, who deal with child maltreatment data in their respective professional roles, can share concerns and solutions.

OBJECTIVE

This commentary describes some of the key features and the status of child maltreatment related data collection addressed by the ISPCAN-WGCMD.

METHODS

Different types of data collection methods including self-report, sentinel, and administrative data designs are described as well as how they address different needs for information to help understand child maltreatment and systems of prevention and intervention.

RESULTS

While still lacking in many parts of the world, access to child maltreatment data has become much more widespread, and in many places a very sophisticated undertaking.

CONCLUSION

The ISPCAN-WGCMD has been an important forum for supporting the continued development and improvement in the global effort to understand and combat child maltreatment thus contributing to the long term goals of the UN Convention on the Rights of the Child. Nevertheless, based on what has been learned, even greater efforts are required to improve data in order to effectively combat child maltreatment.

Framework for the development and evaluation of complex interventions: gap analysis, workshop and consultation-informed update

BACKGROUND

The Medical Research Council published the second edition of its framework in 2006 on developing and evaluating complex interventions. Since then, there have been considerable developments in the field of complex intervention research. The objective of this project was to update the framework in the light of these developments. The framework aims to help research teams prioritise research questions and design, and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods.

METHODS

There were four stages to the update: (1) gap analysis to identify developments in the methods and practice since the previous framework was published; (2) an expert workshop of 36 participants to discuss the topics identified in the gap analysis; (3) an open consultation process to seek comments on a first draft of the new framework; and (4) findings from the previous stages were used to redraft the framework, and final expert review was obtained. The process was overseen by a Scientific Advisory Group representing the range of relevant National Institute for Health Research and Medical Research Council research investments.

RESULTS

Key changes to the previous framework include (1) an updated definition of complex interventions, highlighting the dynamic relationship between the intervention and its context; (2) an emphasis on the use of diverse research perspectives: efficacy, effectiveness, theory-based and systems perspectives; (3) a focus on the usefulness of evidence as the basis for determining research perspective and questions; (4) an increased focus on interventions developed outside research teams, for example changes in policy or health services delivery; and (5) the identification of six 'core elements' that should guide all phases of complex intervention research: consider context; develop, refine and test programme theory; engage stakeholders; identify key uncertainties; refine the intervention; and economic considerations. We divide the research process into four phases: development, feasibility, evaluation and implementation. For each phase we provide a concise summary of recent developments, key points to address and signposts to further reading. We also present case studies to illustrate the points being made throughout.

LIMITATIONS

The framework aims to help research teams prioritise research questions and design and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods. In many of the areas of innovation that we highlight, such as the use of systems approaches, there are still only a few practical examples. We refer to more specific and detailed guidance where available and note where promising approaches require further development.

CONCLUSIONS

This new framework incorporates developments in complex intervention research published since the previous edition was written in 2006. As well as taking account of established practice and recent refinements, we draw attention to new approaches and place greater emphasis on economic considerations in complex intervention research. We have introduced a new emphasis on the importance of context and the value of understanding interventions as 'events in systems' that produce effects through interactions with features of the contexts in which they are implemented. The framework adopts a pluralist approach, encouraging researchers and research funders to adopt diverse research perspectives and to select research questions and methods pragmatically, with the aim of providing evidence that is useful to decision-makers.

FUTURE WORK

We call for further work to develop relevant methods and provide examples in practice. The use of this framework should be monitored and the move should be made to a more fluid resource in the future, for example a web-based format that can be frequently updated to incorporate new material and links to emerging resources.

FUNDING

This project was jointly funded by the Medical Research Council (MRC) and the National Institute for Health Research (Department of Health and Social Care 73514).

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.

Mobile Health for Smoking Cessation Among Disadvantaged Young Women During and After Pregnancy: User-Centered Design and Usability Study

Background

Smoking prevalence during and after pregnancy remains high among socioeconomically disadvantaged women. Mobile health (mHealth) apps with game and social support elements seem promising to support smoking cessation.

Objective

This study aims to describe the user-centered design and usability evaluation of Kindle, an mHealth app with game and social support elements, to support disadvantaged young women during and after pregnancy through the first stages of smoking cessation.

Methods

Disadvantaged women (n=9), members of their social networks (n=4), and nurses supporting these women (n=51) were informants throughout the iterative prototype development of Kindle according to the International Organization for Standardization 9241-11:2018. Specific phases included understanding the context of use through secondary analysis of qualitative interview data (phase 1), establishing the user and organizational requirements (phase 2), production of design solutions (phase 3), and usability inspection of the prototype through a heuristic evaluation (3 experts) along with user testing by a think aloud method (5 disadvantaged women and 5 nurses; phase 4). Usability problems were categorized according to the principles of the Healthcare Information and Management Systems Society.

Results

Phase 1 resulted in an understanding of the VoorZorg program and the needs of VoorZorg nurses and clients (eg, focus on early stages of change and building new supportive networks to aid clients in smoking cessation). In phase 2, we established requirements (n=22; eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring at early stages of change in smoking cessation). Phase 3 resulted in a prototype of Kindle, combining the interface for nurses and clients, including the following functionalities: personal goal setting with earning points; secured chat function between nurses and other clients; and tips, diary, and profile creation. The heuristic evaluation and thinking aloud method in phase 4 revealed 78 usability problems in the interfaces. Most usability problems concerned simplicity (eg, unclear clickable button) and naturalness (eg, unclear icon).

Conclusions

The user-centered design and usability testing of the mHealth app Kindle yielded useful insights. The involvement of end users, specifically socioeconomically disadvantaged women during and after their pregnancy, resulted in a prototype that met their needs and requirements (eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring to the early stages of change in smoking cessation) to achieve readiness for smoking cessation. Moreover, the usability evaluation by end users and experts revealed unique usability problems for this population. These insights allow for further optimization of Kindle and encourage future studies to engage disadvantaged populations in all phases of mHealth intervention design and usability testing.

Prenatal and Infancy Home Visiting in Germany: 7-Year Outcomes of a Randomized Trial

OBJECTIVES

Given the lasting positive effects of prenatal and infancy home visiting in the United States on disadvantaged mothers and children at school age, we analyzed the follow-up effects of a German home visiting program (ProKind). We hypothesized improvements in 3 domains at child age 7 years: (1) child development and life satisfaction, (2) maternal mental health and life satisfaction, and (3) adverse parenting, abusive parenting, and neglectful parenting.

METHODS

We conducted a randomized controlled trial of home visiting, enrolling 755 pregnant, low-income women with no previous live births. The intervention comprised 32.7 home visits by family midwives and/or social pedagogues until child age 2 years. Assessments were completed on 533 7-year-old firstborn offspring to evaluate 8 primary hypotheses.

RESULTS

We found significant positive effects for 4 of the 8 primary hypotheses. Mothers in the intervention group reported fewer behavioral problems among their children in the Child Behavior Checklist (effect size [ES] = 0.21; 95% confidence interval [CI]: 0.03 to 0.38), less child abusive parenting (ES = 0.19; 95% CI: 0.00 to 0.37), fewer maternal mental health problems (ES = 0.25; 95% CI: 0.07 to 0.43), and higher maternal life satisfaction (ES = 0.25; 95% CI: 0.07 to 0.43). Additional preregistered subgroup analyses regarding child sex revealed larger effects for boys and mothers of boys.

CONCLUSIONS

The results suggest that in a western European welfare state, home visiting targeting disadvantaged mothers has lasting effects in important outcome domains. Therefore, home visits also appear to be an effective and efficient public health intervention in European settings.

Improving retention in antenatal and postnatal care: a systematic review of evidence to inform strategies for adolescents and young women living with HIV

INTRODUCTION

Young pregnant and postpartum women living with HIV (WLHIV) are at high risk of poor outcomes in prevention of mother-to-child transmission services. The aim of this systematic review was to collate evidence on strategies to improve retention in antenatal and/or postpartum care in this population. We also conducted a secondary review of strategies to increase attendance at antenatal care (ANC) and/or facility delivery among pregnant adolescents, regardless of HIV status, to identify approaches that could be adapted for adolescents and young WLHIV.

METHODS

Selected databases were searched on 1 December 2020, for studies published between January 2006 and November 2020, with screening and data abstraction by two independent reviewers. We identified papers that reported age-disaggregated results for adolescents and young WLHIV aged <25 years at the full-text review stage. For the secondary search, we included studies among female adolescents aged 10 to 19 years.

RESULTS AND DISCUSSION

Of 37 papers examining approaches to increase retention among pregnant and postpartum WLHIV, only two reported age-disaggregated results: one showed that integrated care during the postpartum period increased retention in HIV care among women aged 18 to 24 years; and another showed that a lay counsellor-led combination intervention did not reduce attrition among women aged 16 to 24 years; one further study noted that age did not modify the effectiveness of a combination intervention. Mobile health technologies, enhanced support, active follow-up and tracing and integrated services were commonly examined as standalone interventions or as part of combination approaches, with mixed evidence for each strategy. Of 10 papers identified in the secondary search, adolescent-focused services and continuity of care with the same provider appeared to be effective in improving attendance at ANC and/or facility delivery, while home visits and group ANC had mixed results.

CONCLUSIONS

This review highlights the lack of evidence regarding effective strategies to improve retention in antenatal and/or postpartum care among adolescents and young WLHIV specifically, as well as a distinct lack of age-disaggregated results in studies examining retention interventions for pregnant WLHIV of all ages. Identifying and prioritizing approaches to improve retention of adolescents and young WLHIV are critical for improving maternal and child health.

Nurse-Family Partnership nurses' attitudes and confidence in identifying and responding to intimate partner violence: An explanatory sequential mixed methods evaluation

AIMS

To evaluate the effect of an intimate partner violence intervention education component on nurses' attitudes in addressing intimate partner violence; complementary aims included understanding nurses' perceptions of the education and how it influenced their attitudes and confidence to address intimate partner violence in practice.

DESIGN

An explanatory sequential mixed methods design embedded within a 15-site cluster randomized clinical trial that evaluated an intimate partner violence intervention within the Nurse-Family Partnership programme.

METHODS

Data were collected between February 2011 and September 2016. Quantitative assessment of nurses' attitudes about addressing intimate partner violence was completed by nurses in the intervention (n = 77) and control groups (n = 101) at baseline, 12 months and at study closure using the Public Health Nurses' Responses to Women Who Are Abused Scale. Qualitative data were collected from nurses in the intervention group at two timepoints (n = 14 focus groups) and focused on their perceptions of the education component. Data were analysed using content analysis.

RESULTS

Nurses in the intervention group reported large improvements in their thoughts, feelings and perceived behaviours related to addressing intimate partner violence; a strong effect of the education was found from baseline to 12 months and baseline to study closure timepoints. Nurses reported that the education component was acceptable and increased their confidence to address intimate partner violence.

CONCLUSION

Nurses reported improved attitudes about and confidence in addressing intimate partner violence after receiving the education component. However, these findings need to be considered together with trial results showing no main effects for clients, and a low level of intervention fidelity.

IMPACT

These evaluation findings underscore that improvement in nurses' self-reported educational outcomes about addressing intimate partner violence cannot be assumed to result in adherence to intervention implementation or improvement in client outcomes. These are important considerations for developing nurse education on intimate partner violence.

A scoping review of 'think-family' approaches in healthcare settings

BACKGROUND

'Think-family' child health approaches treat child and parent/carer health as inter-related. They are promoted within health policy internationally (also called 'family paediatrics' or 'whole-family', 'family-centred' approaches or 'child-centred' approaches within adult services).

METHODS

We reviewed publications of think-family interventions. We developed a typology of these interventions using thematic analysis of data extracted from the included studies.

RESULTS

We included 62 studies (60% USA and 18% UK); 45/62 (73%) treated the parent as patient, helping the child by addressing parental mental health, substance and alcohol misuse and/or domestic violence. Our typology details three common mechanisms of change in relevant interventions: screening, health promotion and developing relationships (inter-professional and parent-professional).

CONCLUSIONS

Policy-makers, practitioners and researchers can use our typology to develop and evaluate think-family approaches within healthcare. Strong relationships between parents and professionals are key in think-family approaches and should be considered in service design. Although helping the child through the parent may be a good place to start for service development, care is needed to ensure parental need does not eclipse child need. Strategies that reach out to the parent behind the child (child as patient) and which work simultaneously with parent and child warrant attention.

A Brief Home-Based Parenting Intervention to Reduce Behavior Problems in Young Children: A Pragmatic Randomized Clinical Trial

IMPORTANCE

Behavior problems are one of the most common mental health disorders in childhood and can undermine children's health, education, and employment outcomes into adulthood. There are few effective interventions for early childhood.

OBJECTIVE

To test the clinical effectiveness of a brief parenting intervention, the Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD), in reducing behavior problems in children aged 12 to 36 months.

DESIGN, SETTING, AND PARTICIPANTS

The Healthy Start, Happy Start study was a 2-group, parallel-group, researcher-blind, multisite randomized clinical trial conducted via health visiting services in 6 National Health Service trusts in England. Baseline and 5-month follow-up data were collected between July 30, 2015, and April 27, 2018. Of 818 eligible families, 227 declined to participate, and 300 were randomized into the trial. Target participants were caregivers of children who scored in the top 20% for behavior problems on the Strengths and Difficulties Questionnaire. Participants were randomly allocated on a 1:1 basis to receive either VIPP-SD (n = 151) or usual care (n = 149), stratified by site and number of participating caregivers. Analysis was performed on an intention-to-treat basis. Statistical analysis was performed from September 5, 2019, to January 17, 2020.

INTERVENTIONS

All families continued to access usual care. Families allocated to VIPP-SD were offered 6 home-based video-feedback sessions of 1 to 2 hours' duration every 2 weeks.

MAIN OUTCOMES AND MEASURES

The primary outcome was the score on an early childhood version of the Preschool Parental Account of Children's Symptoms, a semistructured interview of behavior symptoms, at 5 months after randomization. Secondary outcomes included caregiver-reported behavior problems on the Child Behavior Checklist and the Strengths and Difficulties Questionnaire.

RESULTS

Among 300 participating children (163 boys [54%]; mean [SD] age, 23.0 [6.7] months), primary outcome data were available for 140 of 151 VIPP-SD participants (93%) and 146 of 149 usual care participants (98%). There was a mean difference in the total Preschool Parental Account of Children's Symptoms score of 2.03 (95% CI, 0.06-4.01; P = .04; Cohen d = 0.20 [95% CI, 0.01-0.40]) between trial groups, with fewer behavior problems in the VIPP-SD group, particularly conduct symptoms (mean difference, 1.61 [95% CI, 0.44-2.78]; P = .007; d = 0.30 [95% CI, 0.08-0.51]). Other child behavior outcomes showed similar evidence favoring VIPP-SD. No treatment or trial-related adverse events were reported.

CONCLUSIONS AND RELEVANCE

This study found that VIPP-SD was effective in reducing symptoms of early behavior problems in young children when delivered in a routine health service context.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN58327365.

Parenting interventions to promote early child development in the first three years of life: A global systematic review and meta-analysis

BACKGROUND

Parents are the primary caregivers of young children. Responsive parent-child relationships and parental support for learning during the earliest years of life are crucial for promoting early child development (ECD). We conducted a global systematic review and meta-analysis to evaluate the effectiveness of parenting interventions on ECD and parenting outcomes.

METHODS AND FINDINGS

We searched MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and Global Health Library for peer-reviewed, published articles from database inception until November 15, 2020. We included randomized controlled trials (RCTs) of parenting interventions delivered during the first 3 years of life that evaluated at least 1 ECD outcome. At least 2 reviewers independently screened, extracted data, and assessed study quality from eligible studies. ECD outcomes included cognitive, language, motor, and socioemotional development, behavior problems, and attachment. Parenting outcomes included parenting knowledge, parenting practices, parent-child interactions, and parental depressive symptoms. We calculated intervention effect sizes as the standardized mean difference (SMD) and estimated pooled effect sizes for each outcome separately using robust variance estimation meta-analytic approaches. We used random-effects meta-regression models to assess potential effect modification by country-income level, child age, intervention content, duration, delivery, setting, and study quality. This review was registered with PROSPERO (CRD42018092458 and CRD42018092461). Of the 11,920 articles identified, we included 111 articles representing 102 unique RCTs. Pooled effect sizes indicated positive benefits of parenting interventions on child cognitive development (SMD = 0.32, 95% CI [confidence interval]: 0.23, 0.40, P < 0.001), language development (SMD = 0.28, 95% CI: 0.18 to 0.37, P < 0.001), motor development (SMD = 0.24, 95% CI: 0.15 to 0.32, P < 0.001), socioemotional development (SMD = 0.19, 95% CI: 0.10 to 0.28, P < 0.001), and attachment (SMD = 0.29, 95% CI: 0.18 to 0.40, P < 0.001) and reductions in behavior problems (SMD = -0.13, 95% CI: -0.18 to -0.08, P < 0.001). Positive benefits were also found on parenting knowledge (SMD = 0.56, 95% CI: 0.33 to 0.79, P < 0.001), parenting practices (SMD = 0.33, 95% CI: 0.22 to 0.44, P < 0.001), and parent-child interactions (SMD = 0.39, 95% CI: 0.24 to 0.53, P < 0.001). However, there was no significant reduction in parental depressive symptoms (SMD = -0.07, 95% CI: -0.16 to 0.02, P = 0.08). Subgroup analyses revealed significantly greater effects on child cognitive, language, and motor development, and parenting practices in low- and middle-income countries compared to high-income countries; and significantly greater effects on child cognitive development, parenting knowledge, parenting practices, and parent-child interactions for programs that focused on responsive caregiving compared to those that did not. On the other hand, there was no clear evidence of effect modification by child age, intervention duration, delivery, setting, or study risk of bias. Study limitations include considerable unexplained heterogeneity, inadequate reporting of intervention content and implementation, and varying quality of evidence in terms of the conduct of trials and robustness of outcome measures used across studies.

CONCLUSIONS

Parenting interventions for children during the first 3 years of life are effective for improving ECD outcomes and enhancing parenting outcomes across low-, middle-, and high-income countries. Increasing implementation of effective and high-quality parenting interventions is needed globally and at scale in order to support parents and enable young children to achieve their full developmental potential.

A video-feedback parenting intervention to prevent enduring behaviour problems in at-risk children aged 12-36 months: the Healthy Start, Happy Start RCT

BACKGROUND

Behaviour problems emerge early in childhood and place children at risk for later psychopathology.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of a parenting intervention to prevent enduring behaviour problems in young children.

DESIGN

A pragmatic, assessor-blinded, multisite, two-arm, parallel-group randomised controlled trial.

SETTING

Health visiting services in six NHS trusts in England.

PARTICIPANTS

A total of 300 at-risk children aged 12-36 months and their parents/caregivers.

INTERVENTIONS

Families were allocated in a 1 : 1 ratio to six sessions of Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD) plus usual care or usual care alone.

MAIN OUTCOME MEASURES

The primary outcome was the Preschool Parental Account of Children's Symptoms, which is a structured interview of behaviour symptoms. Secondary outcomes included caregiver-reported total problems on the Child Behaviour Checklist and the Strengths and Difficulties Questionnaire. The intervention effect was estimated using linear regression. Health and social care service use was recorded using the Child and Adolescent Service Use Schedule and cost-effectiveness was explored using the Preschool Parental Account of Children's Symptoms.

RESULTS

In total, 300 families were randomised: 151 to VIPP-SD plus usual care and 149 to usual care alone. Follow-up data were available for 286 (VIPP-SD, n = 140; usual care, n = 146) participants and 282 (VIPP-SD, n = 140; usual care, n = 142) participants at 5 and 24 months, respectively. At the post-treatment (primary outcome) follow-up, a group difference of 2.03 on Preschool Parental Account of Children's Symptoms (95% confidence interval 0.06 to 4.01; p = 0.04) indicated a positive treatment effect on behaviour problems (Cohen's d = 0.20, 95% confidence interval 0.01 to 0.40). The effect was strongest for children's conduct [1.61, 95% confidence interval 0.44 to 2.78; p = 0.007 (d = 0.30, 95% confidence interval 0.08 to 0.51)] versus attention deficit hyperactivity disorder symptoms [0.29, 95% confidence interval -1.06 to 1.65; p = 0.67 (d = 0.05, 95% confidence interval -0.17 to 0.27)]. The Child Behaviour Checklist [3.24, 95% confidence interval -0.06 to 6.54; p = 0.05 (d = 0.15, 95% confidence interval 0.00 to 0.31)] and the Strengths and Difficulties Questionnaire [0.93, 95% confidence interval -0.03 to 1.9; p = 0.06 (d = 0.18, 95% confidence interval -0.01 to 0.36)] demonstrated similar positive treatment effects to those found for the Preschool Parental Account of Children's Symptoms. At 24 months, the group difference on the Preschool Parental Account of Children's Symptoms was 1.73 [95% confidence interval -0.24 to 3.71; p = 0.08 (d = 0.17, 95% confidence interval -0.02 to 0.37)]; the effect remained strongest for conduct [1.07, 95% confidence interval -0.06 to 2.20; p = 0.06 (d = 0.20, 95% confidence interval -0.01 to 0.42)] versus attention deficit hyperactivity disorder symptoms [0.62, 95% confidence interval -0.60 to 1.84; p = 0.32 (d = 0.10, 95% confidence interval -0.10 to 0.30)], with little evidence of an effect on the Child Behaviour Checklist and the Strengths and Difficulties Questionnaire. The primary economic analysis showed better outcomes in the VIPP-SD group at 24 months, but also higher costs than the usual-care group (adjusted mean difference £1450, 95% confidence interval £619 to £2281). No treatment- or trial-related adverse events were reported. The probability of VIPP-SD being cost-effective compared with usual care at the 24-month follow-up increased as willingness to pay for improvements on the Preschool Parental Account of Children's Symptoms increased, with VIPP-SD having the higher probability of being cost-effective at willingness-to-pay values above £800 per 1-point improvement on the Preschool Parental Account of Children's Symptoms.

LIMITATIONS

The proportion of participants with graduate-level qualifications was higher than among the general public.

CONCLUSIONS

VIPP-SD is effective in reducing behaviour problems in young children when delivered by health visiting teams. Most of the effect of VIPP-SD appears to be retained over 24 months. However, we can be less certain about its value for money.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN58327365.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 29. See the NIHR Journals Library website for further project information.

Smoking cessation among disadvantaged young women during and after pregnancy: Exploring the role of social networks

OBJECTIVE

Smoking prevalence during and after pregnancy remains high among socioeconomically disadvantaged, European women. This research aims to gain insight into the role of social networks on smoking cessation among disadvantaged young women during and after pregnancy.

DESIGN

Qualitative interview study.

SETTING

Dutch preventive care program (VoorZorg).

PARTICIPANTS

Disadvantaged young women during and after pregnancy (n = 17) who participated in a Dutch preventive care program, and members in their social networks (n = 4).

METHODS

All qualitative interviews were recorded, transcribed, and analyzed by iterative coding processes.

FINDINGS

Many women were not intrinsically motivated to quit smoking due to, amongst other factors, difficulties in their lives (e.g. domestic violence, psychosocial problems), limited supportive social networks, and a strong dependence on relatives who smoked. Women seemed to be prompted to smoke by smoking cues in their social networks, while distancing from smokers would lead to feelings of social exclusion. When attempting to stop smoking, women experienced little encouragement from their social networks, which instead often undermined their smoking cessation efforts.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The social networks of disadvantaged young women mostly had a negative role on their smoking cessation efforts. Our results emphasize the need to look at interventions that involve women's social networks, and explore novel opportunities, such as eHealth and mHealth applications so that these women can build supportive new social networks.