Moving toward precision in prenatal evidence-based home visiting to achieve good birth outcomes: assessing the alignment of local programs with their national models.

BACKGROUND: Low birthweight and preterm birth rates are higher in the United States than in other developed countries and exhibit pronounced racial inequities. Home visiting is a strategy to promote equity in birth outcomes. Research points to precision home visiting as the path to equity. The purpose of this study is to describe local programs' risk reduction priorities, intended behavioral pathways, and expectations of home visitors; compare these local program features with those of their national model; and assess the strength of implementation systems to support staff in meeting job expectations. METHODS: We surveyed local programs implementing one of four evidence-based home visiting models that aim to promote good birth outcomes: Family Spirit, Healthy Families America, Nurse-Family Partnership, and Parents as Teachers. RESULTS: Representatives from 169 local programs completed the survey. Overall, 59% endorsed all their model's high priority risks, 16% endorsed all its required behavioral pathways, and 11% endorsed all its required techniques. Local programs went beyond their national model's explicit intentions. Overall, 91% of local programs prioritized risks beyond those of their model, 85% endorsed behavioral pathways beyond those of their model, 95% endorsed visitors' use of techniques not explicitly endorsed by their model but compatible with it, and 19% endorsed use of techniques judged incompatible by their model. Implementation system strength was positively associated with local program and model expectations. CONCLUSIONS: Precision home visiting to achieve health equity requires shared learning of what works best for whom. This observational study showed the Precision Paradigm's usefulness for cross-model research to advance precision.

Changing the home visiting research paradigm: models' perspectives on behavioral pathways and intervention techniques to promote good birth outcomes.

BACKGROUND: The US is scaling up evidence-based home visiting to promote health equity in expectant families and families with young children. Persistently small average effects for full models argue for a new research paradigm to understand what interventions within models work best, for which families, in which contexts, why, and how. Historically, the complexity and proprietary nature of most evidence-based models have been barriers to such research. To address this, stakeholders are building the Precision Paradigm, a common framework and language to define and test interventions and their mediators and moderators. This observational study used portions of an early version of the Precision Paradigm to describe models' intended behavioral pathways to good birth outcomes and their stance on home visitors' use of specific intervention technique categories to promote families' progress along intended pathways. METHODS: Five evidence-based home visiting models participated. Model representatives independently completed three structured surveys focused on 41 potential behavioral pathways to good birth outcomes, and 23 behavior change technique categories. Survey data were used to describe and compare models' intended behavioral pathways, explicit endorsement of behavior change technique categories, expectations for home visitors' relative emphasis in using endorsed technique categories, and consistency in endorsing technique categories across intended pathways. RESULTS: Models differed substantially in nearly all respects: their intended pathways to good birth outcomes (range 16-41); the number of technique categories they endorsed in any intended pathway (range 12-23); the mean number of technique categories they endorsed per intended pathway (range 1.5-20.0); and their consistency in endorsing technique categories across intended pathways (22%-100% consistency). Models were similar in rating nearly all behavior change technique categories as at least compatible with their model, even if not explicitly endorsed. CONCLUSIONS: Models successfully used components of the Precision Paradigm to define and differentiate their intended behavioral pathways and their expectations for home visitors' use of specific technique categories to promote family progress on intended pathways. Use of the Precision Paradigm can accelerate innovative cross-model research to describe current models and to learn which interventions within home visiting work best for which families, in which contexts, why and how.

Impact of a Child Abuse Primary Prevention Strategy for New Mothers.

First Steps (FS) is a brief obstetrics-based primary prevention strategy that aims to strengthen protective factors to prevent child maltreatment. This randomized controlled trial assessed how well FS services aligned with family interests and needs, how FS providers used communication strategies to build partnership with mothers, and the impact of FS on mothers' parenting knowledge in core content areas and access to services. Mothers completed a baseline survey and were randomly assigned to FS and control conditions (n = 374 and 375, respectively). The parenting education services provided to mothers were assessed by independent participant report immediately postintervention for the full FS group and by analysis of audio-recordings of the FS encounter for a subsample (n = 150). Outcomes were measured at 4 months via maternal survey. Compared to controls at follow-up, FS mothers had significantly higher knowledge scores in some areas but similar access to needed services. Few mothers lacked access to most services at baseline, and FS content was similar to that provided by other hospital personnel. FS providers' communication style promoted rapport, but providers did not tailor content to mothers' educational and service access needs. Implications of the findings for similar services are discussed.

Correction to: Randomized Trial of a Training Program to Improve Home Visitor Communication around Sensitive Topics.

The article "Randomized Trial of a Training Program to Improve Home Visitor Communication around Sensitive Topics", written by Allison West, Laina Gagliardi, Amanda Gatewood, Susan Higman, Jane Daniels, Kay O'Neill and Anne Duggan, was originally published electronically on the publisher's internet portal (currently SpringerLink) on 31 May 2018 without open access.

Randomized Trial of a Training Program to Improve Home Visitor Communication around Sensitive Topics.

INTRODUCTION: Strong communication skills are necessary to engage families, perform accurate assessments, and motivate behavior change around sensitive issues encountered in home visiting. METHODS: A two-arm, cluster-randomized trial evaluated the impact of a trans-model communications training course for home visitors. Fourteen home visiting programs in Maryland were assigned to a training intervention (n = 7 programs; 30 visitors) or wait-list control group (n = 7 programs; 34 visitors). Independent observers assessed training fidelity. Visitor's attitudes, knowledge, and confidence were assessed through surveys. Their skills were assessed through coding of video-recorded visits with standardized mothers. Data were collected at baseline, within 2 weeks post-training, and at 2 months post-training. Regression models accounted for clustering within programs and controlled for characteristics on which study groups differed at baseline. RESULTS: Independent observers rated the training highly on fidelity and acceptability. Home visitors rated it as useful, consistent with their model, and worth the effort. Immediately following the training, the training group scored higher than the control group on a range of indicators in all domains-knowledge, attitudes, confidence, and skills in using motivational communication techniques. At 2 months post-training, impacts on knowledge and attitudes persisted; impacts on confidence and observed skill were attenuated. DISCUSSION: The training course showed favorable immediate impacts on knowledge, attitudes, confidence, and skills, and long-term impacts on home visitor knowledge and attitudes. The findings underscore the need for ongoing reinforcement of skills following training.

Home Visiting: A Service Strategy to Reduce Poverty and Mitigate Its Consequences.

Home visiting programs are increasingly recognized as an important part of the early childhood system of care in the United States. The objectives of this report are to review the rationale for home visiting; characterize the Federal Home Visiting Program; highlight the evidence of home visiting effectiveness, particularly for low income families; identify opportunities to promote coordination between medical homes and home visiting programs; and explain the critical role of research, evaluation, and quality improvement to strengthen home visiting effectiveness. Home visiting programs offer voluntary home-based services and other supports to meet the needs of vulnerable pregnant women and young families. Home visiting intends to address poverty in 2 ways. First, it promotes economic self-sufficiency directly by building parents' knowledge, skills, and motivation related to employment opportunities and by linking families with community services such as adult education and job training. Second, it mitigates the effects of poverty through direct service and community linkages to enhance parents' capacity for positive parenting and for their own health and family functioning. Home visiting has shown effectiveness in multiple domains, including family economic self-sufficiency, birth outcomes, maternal health, child health and development, and positive parenting practices. Authorized as part of the Affordable Care Act in 2010 and reauthorized in 2015, the Federal Home Visiting Program invests an unprecedented $1.9 billion in the form of grants to states to expand home visiting programs and support rigorous research. As part of the early childhood system of services, home visiting programs must coordinate with other community services and supports. Programs will be most effective when resources are used efficiently, duplication of services is avoided, and alignment and reinforcement of other providers' messages are achieved. The Federal Home Visiting Program has established 4 mechanisms of research, evaluation, and quality improvement to enhance home visiting implementation and effectiveness.