Evidence-based Home Visitation Research Articles

Firearm screening and secure storage counseling among home visiting providers: a cross-sectional study of SafeCare® providers in the U.S.

Firearms used in pediatric firearm deaths are most often obtained from the child's home, making secure firearm storage initiatives imperative in prevention efforts. Evidence-based home visiting (EBHV) programs are implemented with over 277,000 families annually, providing an opportunity for secure firearm storage counseling. The purpose of this study was to assess EBHV providers' experiences with firearm screening ("assessment"), secure storage counseling, and their perceptions for related training needs. Providers in the U.S. from SafeCare®, an EBHV program often implemented with families experiencing increased risk of child neglect and physical or emotional abuse, were invited to participate in a survey to examine firearm assessment and attitudes toward and experiences with firearm safety counseling. Survey items were primarily Likert scale ratings to indicate level of agreement, with some open-ended follow-up questions. Descriptive statistics (i.e., frequencies and percentages) were used to report item-level agreement. A post hoc analysis was conducted using Spearman correlation to examine the association between assessment and counseling and provider-level factors. Sixty-three SafeCare providers consented to and completed the survey items. Almost three-quarters (74.6%) agreed/strongly agreed that they assess in-home firearm availability. However, 66.7% agreed/strongly agreed that they have not been adequately trained to discuss firearm safety topics. A substantial proportion (80.6%) indicated they would counsel more if materials and training on this topic were available. Response variability emerged by level of urbanicity. A post hoc analysis found that providers' self-reported frequency of assessment and counseling were associated with their comfort level discussing firearm safety and whether or not they had worked with families impacted by firearm injury. SafeCare providers report a need for materials and training on secure firearm storage, and a willingness to provide more counseling with proper training to the families they serve. Findings illuminate the need for secure storage initiatives for EBHV programs, which have broad service reach to a substantial number of at-risk U.S. families annually.

Engaging Community in Prioritizing Outcomes to Improve Family Health in Evidence-Based Nurse Home Visiting: Using a Modified e-Delphi Method.

Evidence-based home visiting programs are designed to improve maternal child health. Nurse-Family Partnership (NFP) is a model evidence-based home visiting program, shown to improve pregnancy outcomes, child development, and economic self-sufficiency for first-time mothers and their families experiencing social and economic adversities, enrolling them early in pregnancy. Recently, NFP has expanded its services to multiparous women (previous live births) and enrolling women past 28 weeks gestation (late registrants) in selected agencies in Florida since 2021. To study the process and impacts of expanding NFP to expanded populations (multiparous and/or late registrants), we convened a diverse Advisory Committee to guide the NFP expansion evaluation in Florida. This study employed a modified e-Delphi method with three rounds of data collection, to engage diverse partners to identify process and impact outcomes for the NFP expansion evaluation. Child maltreatment was identified as the highest priority outcome. Process outcomes included program reach, client enrollment, and client engagement, while impact outcomes included maternal physical health, maternal mental health and substance use, birth outcomes, and breastfeeding practices. The Advisory Committee further identified potential data sources to measure these outcomes. Identifying and selecting key process and impact outcomes using a community-engaged process is necessary to ensure equal buy-in from all partners and to inform rigorous program evaluation. This study showed that using methods such as e-Delphi is feasible and effective for achieving thoughtful and rigorous decision-making, even in times of uncertainty like the COVID-19 pandemic.

Improving connections to early childhood systems of care via a universal home visiting program in Massachusetts

Welcome Family is a universal, short-term nurse home visiting program designed to promote optimal maternal and infant physical and mental well-being and provide an entry point into the early childhood system of care to all families with newborns up to 8 weeks old living in defined communities in Massachusetts. The present study examines whether: 1) Welcome Family meets its goal of successfully connecting families to two early childhood programs—evidence-based home visiting (EBHV) and early intervention (EI)—relative to families with similar background experiences who do not participate in Welcome Family, and 2) whether these impacts are conditional on families’ race and ethnicity and their primary language—two characteristics that are related to structural racism and health inequities. The study used coarsened exact matching (CEM) based on birth certificate data to match Welcome Family participants who enrolled during 2013–2017 to mothers and their infants living in the home visiting catchment areas who did not receive home visiting during the study period. Primary study outcomes included enrollment in any EBHV program supported by the Massachusetts Maternal, Infant, and Early Childhood Home Visiting (MA MIECHV) program up to age 1 year, measured using MA MIECHV home visiting program data, and EI service receipt for children aged up to age 3 years, measured using EI program data. Impacts were assessed by fitting weighted regression models adjusted for preterm birth, maternal depression, and substance use. Mothers’ race, ethnicity, and language were included in the model as moderators of Welcome Family impacts on enrollment in EBHV and EI. Welcome Family participants (n = 3,866) had more than double the odds of EBHV enrollments up to age 1 and had 1.39 greater odds of receiving EI individualized family service plans (IFSPs) up to age 3 relative to the comparison group (n = 46,561). Mothers’ primary language moderated Welcome Family impacts on EBHV enrollments. Universal, short-term programs such as Welcome Family may be an effective method of ensuring families who could benefit from more intensive early childhood services are identified, engaged, and enrolled.

The Added Value of Targeting Specific Risk Factors for Child Maltreatment in an Evidence-Based Home Visitation Program: a Repeated Single-Case Time Series Study

The Added Value of Targeting Specific Risk Factors for Child Maltreatment in an Evidence-Based Home Visitation Program: a Repeated Single-Case Time Series Study

Barriers to Pediatric Mental Healthcare Access: Qualitative Insights from Caregivers

The Centers for Disease Control and Prevention approximates that 1 in 5 children experience a mental or behavioral health disorder. Pediatric mental healthcare service access cannot be improved without strong coordination between educational settings, social service providers for children, and adequate policy support. Addressing this critical child development issue is dependent on us understanding the barriers to mental healthcare access faced by pediatric populations. This qualitative study explored barriers to pediatric mental healthcare access based on in-depth interviews with 53 key informants representing childcare settings, K-12 schools, foster care settings, and evidence-based home visitation programs. Semi-structured interviews with participants identified barrier-related themes and subthemes. The themes reflect a series of hurdles related to pediatric mental healthcare access including, lack of preparedness/training for pediatric mental health screening and management, limited resources, lack of policy support, transportation, and family issues that have hindered mental health support for children. The findings highlight the compounding barriers to pediatric mental healthcare services and point to opportunities for improving pediatric mental health using a holistic approach. Future research should focus on designing and implementing community and organization-based strategies to break down these barriers for families to optimize their children’s mental health and wellness.

The Role of Open Science Practices in Scaling Evidence-Based Prevention Programs

The goal of creating evidence-based programs is to scale them at sufficient breadth to support population-level improvements in critical outcomes. However, this promise is challenging to fulfill. One of the biggest issues for the field is the reduction in effect sizes seen when a program is taken to scale. This paper discusses an economic perspective that identifies the underlying incentives in the research process that lead to scale up problems and to deliver potential solutions to strengthen outcomes at scale. The principles of open science are well aligned with this goal. One prevention program that has begun to scale across the USA is early childhood home visiting. While there is substantial impact research on home visiting, overall average effect size is .10 and a recent national randomized trial found attenuated effect sizes in programs implemented under real-world conditions. The paper concludes with a case study of the relevance of the economic model and open science in developing and scaling evidence-based home visiting. The case study considers how the traditional approach for testing interventions has influenced home visiting’s evolution to date and how open science practices could have supported efforts to maintain impacts while scaling home visiting. It concludes by considering how open science can accelerate the refinement and scaling of home visiting interventions going forward, through accelerated translation of research into policy and practice.

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

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

Prioritizing fidelity within public policies supporting evidence-based home visiting.

Prioritizing fidelity within public policies supporting evidence-based home visiting.

Strengthening family retention and relationships in home visiting programs through early screening and assessment practices

Evidence-based home visiting (EBHV) programs for pregnant women and families of young children prevent child maltreatment and improve maternal and child health outcomes. However, home visiting programs often struggle to retain families long enough to achieve positive outcomes. The current study (N = 1,032) sought to understand how home visitor relationship building skills and screening practices predict families’ duration in EBHV. Multilevel modeling revealed that screening practice helped retain families in EBHV programs longer. Interactions between screening practices and home visitors’ relationship building skills further showed screening practices were associated with longer duration in services when home visitor relationship building skills with families were weak. However, when home visitor relationship building skills were strong, screening practices were less influential on duration. Results suggest that screening practices may help build relationships with families which then enhances retention in services and increases the likelihood of achieving positive maternal and child outcomes.

Locally Identified Priorities for Continuous Quality Improvement (CQI) During Early Implementation of an Evidence-Based Early Childhood Home Visiting Program.

The 2010 Affordable Care Act provided for evidence-based home visiting and an accompanying continuous quality improvement (CQI) process in all states and territories. This is an organizational-level study of one state's qualitative approach to CQI during early implementation, when data system infrastructure and local agency capacity were still developing. We examined the CQI topics created by local agencies and operationalized through a qualitative, strength-based CQI process. During the first 18 months, state and local site teams (n = 21) participated in 150 CQI teleconferences. We used qualitative content analysis of teleconference notes to identify issues important to sites and that could be addressed through a qualitative CQI process. Seven categories of CQI topics emerged: participant enrollment and retention; administrative infrastructure and capacity; programmatic resources and practices; community advisory boards; home visitor skill development; systems integration and strategic partnerships; and hiring home visiting staff. Sites added local nuances to frame and address CQI topics. When local sites identify their own CQI topics in early implementation, they addressed program need at multiple levels of influence. A few sites addressed individually focused topics traditional to CQI. Most often, sites engaged with institution- or community-focused topics atypical for CQI but nonetheless essential to launching a program: building skills and capacity for administrative and program implementation, and engaging with the local system of services. Oversight agencies should be prepared to address program, organization, partner or system level issues through CQI to foster program establishment. A site-centered, strength-based approach can support programs even when quantitative data are limited.

Education and employment outcomes in clients of the Nurse-Family Partnership.

Nurse-Family Partnership (NFP) is an evidence-based home visitation program designed for low-income, first-time mothers to support pregnancy, child development, and maternal self-sufficiency. This study examined educational and employment outcomes among NFP clients compared to a reference sample. Entropy balancing and a difference-in-difference design were used to compare the two samples of women from 2007 to 2016. There were 127,427 women in the NFP sample, and 787 women in the reference cohort. Educational outcomes included high school completion and employment outcomes consisted of employment status. Across a one-year interval, NFP mothers with less than a high school diploma or general education diploma (GED) at baseline showed a 9.5 percentage point increase in diploma or GED attainment compared to the reference mothers [95% CI: 0.015-0.180]. Similarly, mothers enrolled in NFP who were not employed at baseline showed a 7.8 percentage point increase in employment compared to the reference mothers [95% CI: 0.003-0.150]. The findings in this study show positive results for NFP mothers attaining high school completion and employment compared to mothers in the reference group. Such findings are of importance with regard to progression toward economic self-sufficiency and corresponding reduction of health disparities.

Multilevel Interaction Effects of Family and Community Factors on Mothers' Engagement in Evidence-Based Home Visiting.

Informed by ecological and family system frameworks, our study investigated the relationship between family- and community-level factors, and their cross-level interactions, with evidence-based home visiting program participation in a sample of 2409 mothers (mean age: 24.15 years). Using 2-level hierarchical linear modeling, we observed that mothers living in disadvantaged communities demonstrated less active engagement in evidence-based home visiting. Cross-level interaction effects revealed that mothers' unstable living conditions and psychiatric problems amplified the negative influence of disadvantaged communities on program engagement. Conversely, mothers who were first-time parents showed higher levels of participation in family support programs when they resided in disadvantaged communities.

Exploring the contributions and suitability of relational and community-centered fetal alcohol spectrum disorder (FASD) prevention work in First Nation communities.

This study provides initial evidence of the contributions and suitability of relational, trauma-informed, and community-based approaches for programs aimed at the prevention of future alcohol-and drug-exposed births. Specifically, this study extends understanding of the experiences of mentors providing evidence-based 3-year home visitation services through the Parent-Child Assistance Program (PCAP) in rural and isolated First Nation communities in Alberta, Canada. Using a participatory approach to this research project, we explored existing PCAP services to capture implementation across six rural and isolated Alberta fetal alcohol spectrum disorder (FASD) networks involving First Nation communities over an 8-month period. In total, we generated qualitative data with 35 participants to examine mentors' perceptions of the impacts and suitability of a relational, trauma-informed, and community-based approach to service delivery. Six major themes were revealed from the thematic analysis as key mechanisms of culturally responsive program delivery across the six FASD networks. Relational, trauma-informed, and community-centered FASD prevention programming was perceived to have positive impacts and be well suited for use within Indigenous communities, and allow for service delivery to be locally and culturally responsive.

APPROACHES TO THE EVALUATION OF CULTURAL ADAPTATIONS OF HOME VISITING IN TRIBAL COMMUNITIES.

The research that underlies evidence-based practices is often based on relatively homogenous study samples, thus limiting our ability to understand how the study findings apply in new situations as well as our understanding of what might need to be adapted. In a preliminary effort to address those gaps, the requirements for the Tribal Maternal Infant and Early Childhood Home Visiting Program (MIECHV) included the expectation that grantees design and implement rigorous evaluations to address local priorities and to help build the knowledge base regarding the use of evidence-based home-visiting programs in tribal communities. A priority that emerged across many Tribal MIECHV grantees was to determine the added benefit of the cultural adaptations that they were making to their home-visiting programs. While there is literature to describe recommended processes for making cultural adaptations to evidence-based programs themselves, there are very few guidelines for evaluating these adaptations. In this article, we review the varied evaluation approaches utilized by Tribal MIECHV grantees and provide three case examples of how evaluators and tribal communities worked together to articulate evaluation questions and choose appropriate and feasible evaluation designs. The lessons derived from these Tribal MIECHV evaluation experiences have implications for the role of the evaluator in diverse communities across the country evaluating home visiting and other evidence-based practices in settings characterized by unique cultural contexts.

Using Evidence Based Home Visiting for Preventing Intergenerational Adverse Childhood Experiences

A body of literature has amassed in recent years examining risk factors and outcomes for children who have experienced various forms of trauma. Childhood maltreatment in various forms has commonly been termed adverse childhood experiences (ACEs), which are severe enough to negatively impact mental and physical health in both childhood and adulthood, as well as lead to a variety of undesirable life outcomes for affected adults. Less has been studied regarding the cyclical nature of child maltreatment and the effects that parents’ own history of childhood trauma may have on their children’s experience of trauma. Recent research has evaluated intervention strategies such as evidence-based home visiting (EBHV) programs for mothers and infants/toddlers that address this phenomenon and aims to interrupt the cycle of maltreatment. The benefits of home visiting will be reviewed and policy and cost implications related to preventive intervention are discussed.

Promoting father involvement in early home visiting services for vulnerable families: Findings from a pilot study of “Dads matter”

Despite mounting evidence on the importance of fathers in children’s development, evidence-based perinatal home visitation programs have largely overlooked fathers in the design and delivery of services. This paper describes the design, development, and pilot testing of the “Dads Matter” enhancement to standard home visiting services. Dads Matter is a manualized intervention package designed to fully incorporate fathers into perinatal home visiting services. Twenty-four families were enrolled in a pilot study to assess the feasibility, acceptability, and preliminary outcomes of the intervention. Using a quasi-experimental time-lagged design, 12 families received standard home visiting services and completed baseline and four-month post-tests. Home visitor staff were then trained and supervised to implement the Dads Matter enhancement in addition to standard services. Twelve additional families were then enrolled and completed baseline and four-month post-tests. Implementation data indicated that Dads Matter was implemented as planned. Cohen’s d scores on outcome measures indicate positive trends associated with Dads Matter in the quality of the mother-father relationship, perceived stress reported by both parents, fathers’ involvement with the child, maltreatment indicators, and fathers’ verbalizations toward the infant. Effect sizes generally ranged from moderate to large in magnitude and were larger than overall effect sizes of home visitation services alone reported in prior meta-analyses. Dads Matter appears to be a feasible, acceptable, and promising approach to improving fathers’ engagement in home visiting services and promoting family and child well-being.

An illustration of how program implementers can use population-specific analyses to facilitate the selection of evidence-based home visiting programs

Given that effective home visiting (HV) programs targeting at-risk families impact different outcomes and associations between risk factors and outcomes may vary across populations, program implementers should evaluate population-specific risk-outcome associations in order to select interventions that are most likely to benefit families in target communities. We used data collected in a rural community in upstate New York (i.e., Elmira) and three standard statistical methods (i.e., bivariate, multivariate, and cumulative risk analyses) to assess associations between maternal socio-demographic risk factors and outcomes typically targeted with HV interventions. With the results, we illustrated how program implementers could use population-specific analyses of data collected prior to the implementation of HV interventions to select interventions that may be most likely to benefit families in a target community. For example, our multivariate results suggested that lower socioeconomic families in Elmira were particularly at-risk for child maltreatment, poor family economic self-sufficiency, and poor child academic achievement, indicating that it may be particularly beneficial to implement HV programs that have been shown to affect these outcomes (e.g., Nurse Family Partnership and Parents as Teachers) in Elmira. We encourage program implementers to conduct similar population-specific analyses to help select evidence-based HV interventions for their target communities.

Federal Investments in Evidence‐Based Early Childhood Home Visiting: A Multiple Streams Analysis

AbstractChild poverty, child maltreatment, and child health and development are major public policy issues. By the end of the Great Recession in 2009, as many as one in four children under the age of five were living in poverty and six million children were subject to child maltreatment reports in America. For decades, evidence‐based home visiting (EBHV) programs have provided effective early interventions for preventing child maltreatment and promoting child and family outcomes to pregnant women and families with children age birth to five years old. Despite this, no widespread federal policies or funding supported home visiting before 2010. Through the Patient Protection and Affordable Care Act (ACA), the federal government invested $1.5 billion in home visiting with the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) initiative. While many articles examine the effectiveness of home visiting and call attention to the unprecedented features of MIECHV, this article applies the multiple streams framework to illuminate the unique social and political contexts culminating in the inclusion of MIECHV in ACA. The findings in this article are significant for policy analysts, advocates, and program developers and for establishing policies requiring evidence‐based practices.

Cultural adaptation of an evidence-based home visitation programme: Latino clients’ experiences of service delivery during implementation

Purpose – The purpose of this paper is to examine the experiences of Latino clients following a naturalistic cultural adaptation made to SafeCare, an evidence-based home visiting intervention designed to address specific linguistic and cultural issues affecting the Latino community during implementation in San Diego County, California. Design/methodology/approach – Hierarchical linear models examined whether Latino clients experienced differences in perceptions of SafeCare delivery, working relationship with the home visitor and satisfaction with services when compared with non-Latino clients and whether language of service delivery and provider-client ethnic match were related to Latino clients’ experiences of the intervention. Findings – Overall, across several different dimensions, there was no decrement in experience with SafeCare for Latino clients compared to non-Latino ones, implying that adaptations made locally adequately engaged Latino and Spanish-speaking clients in services without compromising perceived adherence to the programme model. Research limitations/implications – Because this was a non-experimental study, conclusions could not be drawn as to whether the locally adapted SafeCare would fare better in Latino client ratings than SafeCare unadapted. However, the findings are important because they contradict concerns that EBPs may not be relevant to diverse client groups, and support the idea that when adaptations are made, it is possible to maintain adherence at the same level of adherence as when the programme is delivered in its non-adapted form. Originality/value – The study explicitly documents and generates knowledge around an organic adaptation made in a community to an evidence-based intervention for a client group about whom there has been documented concern regarding the relevance of and engagement in services.

Evidence-Based Home Visitation Programs Work to Put Children First

Evidence-Based Home Visitation Programs Work to Put Children First