Development, Acceptability, and Initial Implementation of an Interactive Text-Messaging Program for Fathers with Low Income.

OBJECTIVES: This study describes the development, acceptability, and implementation of an interactive text messaging program to engage fathers enrolled in home visitation programs. METHODS: We used an iterative development approach that integrated rapid testing of intervention content with acceptability feedback from program participants to examine the processes of implementation. In Study 1, we describe the rapid testing framework and present data from 171 men who provided feedback on Text4Dad content via three online surveys. In Study 2, a case study, we use administrative data from 108 fathers with whom we pilot-tested Text4Dad in three community-based home visiting programs, with the program implemented by fatherhood program community health workers (F-CHWs). Content analysis of exchanges between F-CHWs and fathers describes the specific use of Text4Dad. RESULTS: Across all three online surveys, fathers reported positive reviews of the Text4Dad content. The F-CHWs used Text4Dad mainly to push out information, especially that related to home visit scheduling and local events, instead of engaging in bidirectional interactions with fathers. CONCLUSIONS FOR PRACTICE: We conclude with a set of recommendations for social service and maternal and child health providers regarding the feasibility of implementing text messaging to support home visiting in community-based settings.

"Sustaining NSW Families" as a hybrid face-to-face/virtual program: Experiences of clients and clinicians.

To explore clients' and clinicians' perspectives about the acceptability and perceived outcomes of the Sustaining New South Wales (NSW) Families (SNF) program shifted to a hybrid service delivery model during the COVID-19 pandemic. Mixed methods design comprising cross-sectional online surveys and a focus group. Eighty clients who accessed the SNF service and 12 SNF clinicians. Anonymous client survey comprising questions about perceived benefits and impacts of the hybrid SNF program model, and suggestions for change. Clinician focus group discussion about perceived benefits and challenges of the hybrid SNF model. The hybrid SNF program is a child and family health nursing home visitation program for families with moderate level psychosocial risks. It comprises a mix of face-to-face and virtual telehealth/telephone appointments, delivered during pregnancy and up to 2 years postpartum. Clients reported high levels of satisfaction with the program, and improvements in confidence and decision-making. Clinicians spoke of increased efficiency and flexibility, and capacity for ongoing service provision during the COVID-19 period. Technology access issues were identified as a barrier. Overall, however, both clients and clinicians expressed a preference for face-to-face SNF service provision. While further studies are required to test clinical outcomes, the hybrid SNF model is acceptable to clients and clinicians.

Parents' comprehensive health literacy and child health after attending extended home visiting in Swedish multicultural settings-A case-comparison study.

BACKGROUND: Parents' low health literacy (HL) has negative impacts on child health. Parental interventions may improve parents' HL and thus impact child health positively. OBJECTIVES: This study aimed to gain knowledge about associations between parents' comprehensive HL (CHL) and child health after an extended postnatal home visiting program in Swedish multicultural, disadvantaged settings compared to parents receiving regular child healthcare (CHC). MATERIALS AND METHODS: This quasi-experimental study used a case-control sampling method to recruit first-time parents through two CHC centres in Stockholm (2017-2020). Participants (N = 151) were interviewed twice through structured questionnaires when their child was <2 months and 15-18 months old. HLS-EU-Q16 assessed parents' CHL. Children's medical records (0-18 months) were reviewed regarding breastfeeding, children's exposure to smoking, language development and healthcare utilisation. Data were analysed with regression models and non-parametric tests. RESULTS: No significant association was found between parents' CHL and child health. However, significantly fewer unplanned visits to the CHC centre were observed among children (0-18 months) in the intervention group irrespective of CHL, compared with children to parents with improved CHL in the comparison group (F = 3.856, p = 0.011). CONCLUSIONS: Postnatal home visiting interventions practicing proportional universalism and family-centred care may reduce unplanned visits within CHC in disadvantaged settings despite parents' CHL. Further studies with long-term follow-up are suggested to explore associations between parents' CHL and child health. TRIAL REGISTRATION: As a clinical study (not a clinical trial) with appropriate ethical permission with participants' consents, this study was retrospectively registered (18 February 2020) in the ISRCTN registry (ISRCTN10336603).

A comparison of virtual versus in-person delivery of SafeCare on parent and implementation outcomes.

BACKGROUND: Evidence-based prevention services for child abuse and neglect (CAN), typically delivered via home visiting (HV), pivoted to virtual delivery in 2020 to continue family services while adhering to the COVID-19 public health guidelines. OBJECTIVE: The study aims are to compare parent and implementation outcomes for the HV program, SafeCare©, delivered virtually versus in-person, across a 2-year period. METHODS: Three data sources were used to examine parent program engagement and skill mastery, as well as provider fidelity. Sources included: 1) quantitative service data collected as part of routine SafeCare implementation (in-person families, n = 923; virtual families, n = 1978), 2) qualitative survey data collected from SafeCare providers (n = 212) and 3) focus group data with SafeCare Providers (n = 9). RESULTS: Service data were examined using mixed models due to the nesting of the data, with all analyses controlling for time. Qualitative data from the survey and focus groups were analyzed using thematic coding. Data were triangulated from the three sources to answer the primary research question. Findings suggest that virtual delivery of SafeCare holds promise, with parents who participated virtually completing more modules at a faster pace than in-person clients. SafeCare parents demonstrated positive programmatic outcomes regardless of whether they participated in the program virtually or in-person. Provider fidelity remained high in the transition to virtual delivery. However, technology-related logistical issues and provider self-efficacy related to virtual delivery presented challenges to program success. CONCLUSIONS: The study has multiple implications for the HV field about the viability of virtual service delivery. Further research is warranted with data collected directly from parents, and a more critical analysis of what works best for whom and when to further advance the field.

Development of a culturally enhanced caregiver-facilitated language nutrition intervention "+Language is Medicine" to address developmental delay in Diné (Navajo) toddlers.

Introduction: Developmental Delay (DD) is highly common in American Indian and Alaska Native (AI/AN; Indigenous) toddlers and leads to high numbers of AI/AN children who eventually need special education services. AI/AN children are 2.89 times more likely to receive special education compared to other children in the U.S., yet developmental disorders are more frequently under diagnosed and untreated in AI/AN infants and toddlers. DD, which can be identified as early as toddlerhood, can lead to negative impacts on developmental trajectories, school readiness, and long-term health. Signs of DD can be identified early with proper developmental screening and remediated with high quality early intervention that includes effective parent training. There are many evidence-based language facilitation interventions often used in Early Intervention programs. However, in communities in rural parts of the Navajo Nation where there are limited services and resources, infants and toddlers with early signs of DD are often missed and do not get the culturally responsive support and evidence-based intervention they deserve. Methods: The community-based +Language is Medicine (+LiM) study team partnered with tribal home visitors, community members, and a Diné linguist/elder using a collaborative virtual workgroup approach in 2021 and 2022 to present the +LiM pilot study aims and to discuss strategies for enhancing a language intervention for toddlers experiencing DD in their tribal community. This paper will detail the stages of community engagement, intervention enhancement and preparation for field testing of the +LiM intervention to address elevated rates of DD in toddlers in the Northern Agency of the Navajo Nation. Results: Two major outcomes from this collaborative workgroup included: (1) a team-initiated redefining of language nutrition to align with Indigenous values that center cultural connectedness and native language use and (2) a five-lesson caregiver-facilitated curriculum titled +Language is Medicine which includes caregiver lessons on language nutrition, language facilitation, shared book reading, pretend play, and incorporation of native language into home routines. These two workgroup outcomes were leveraged to develop a pilot pre-/post-intervention study to test the effectiveness of the +LiM intervention with caregiver-toddler dyads living on the Navajo Nation. Discussion: Delivering tailored child interventions through tribal home visiting are cost-effective and innovative methods for reaching reservation-based families who benefit from culturally responsive parent coaching and instruction. The +LiM team has applied a precision tribal home visiting approach to enhance methods of early intervention for children with DD. Our enhancement process was grounded in Indigenous community-based participatory research that centered culture and language.

A Qualitative Inquiry into Nurse-Family Partnership Black Client Perspectives.

Nurse-Family Partnership (NFP) is a home visiting program designed to improve pregnancy outcomes, child health and development, and life course outcomes for families facing socioeconomic inequalities through support and education provided by nurses to first-time mothers during pregnancy and up to 2 years postpartum. Studies show that home visiting programs like NFP have positive outcomes, but attrition remains a concern which may impact the desired health equity goals. Black mothers are more likely to withdraw from the NFP program, and research is lacking regarding their experiences in home visiting programs despite facing maternal health inequities rooted in racism. The present study aimed to understand factors that influenced program continuation and provide insights for program improvement. Semi-structured qualitative interviews were conducted with 21 Black NFP clients from multiple sites. Key findings include the importance of the nurse-client relationship, access to reliable health information, and racial concordance in the nurse-client pairing. Clients valued supportive, nonjudgmental nurses who provided dependable support and education. Racially concordant partnerships were perceived as more comfortable and understanding, fostering trust and open communication. Clients also suggested that invasion of privacy during home visits and a lack of connection with their nurse could contribute to program discontinuation. Efforts to increase program retention of Black clients should focus on fostering a strong nurse-client alliance. Recommendations include increasing racial diversity in the nurse workforce, implementing a nurse-client matching system, and allowing clients to request a new nurse if needed.

Home Visiting and Child Welfare Involvement: A Matched Comparison Group Study.

The present study is one of the largest quasi-experimental studies to date on the effects of home visiting on documented child maltreatment during a child's first two years of life. In this matched comparison group study, we compare 8796 families that participated in a home visiting program (HV families) to 8796 similar non-participating families (non-HV families) selected from birth records using Coarsened Exact Matching. Using sequential logistic regression, we identify that HV families have significantly higher odds of experiencing a child maltreatment investigation by their child's second birthday compared to non-HV families; however, among those that were investigated, HV families have significantly lower odds of having their first investigation substantiated for maltreatment. Overall, HV families do not differ significantly from non-HV families in the odds of experiencing a substantiated investigation over 2 years. We share implications for considering surveillance bias, and we highlight the importance of including both substantiated and unsubstantiated investigations when studying the effects of home visiting on documented child maltreatment.

Early Parental Knowledge and Parent-Child Conversations Promote Preschool Language Skills: A Randomized Controlled Trial.

OBJECTIVE: This randomized controlled trial examined the long-term impact of the 3Ts-HV intervention on preschool-aged children's language skills through promoting parental knowledge and parent-child conversational turns during toddlerhood among families from low-socioeconomic status backgrounds, controlling for parental education level, parental language skills, and child's age. METHODS: Ninety two parent-toddler dyads of low socioeconomic status were randomized to receive either the 3Ts-HV intervention (n = 46) or Healthy Lifestyle control (n = 46) curriculum from 14 to 20 months. Parental language skills were assessed at 14 months; parental knowledge was assessed at 14 and 26 months; parent-child conversational turn count was assessed at 14 and 38 months; children's language skills were assessed at 50 months. RESULTS: A significant serial mediation effect (ß = 0.05, 95% CI [0.002; 0.13]) revealed that the 3Ts-HV intervention increased parental knowledge at 26 months, contributed to more frequent parent-child conversational turns at 38 months, and in turn promoted children's language skills at 50 months. CONCLUSIONS: The present study provides empirical evidence illustrating the underlying longitudinal processes from increasing parental knowledge and enriching parent-child linguistic interactions during toddlerhood, to promoting children's language development at preschool age. These findings point to a significant path to supporting families who face socioeconomic challenges early in life to promote equity in children's early language experiences and narrow disparities in children's developmental outcomes.

Development of an outcome indicator framework for a universal health visiting programme using routinely collected data.

BACKGROUND: Universal health visiting has been a cornerstone of preventative healthcare for children in the United Kingdom (UK) for over 100 years. In 2016, Scotland introduced a new Universal Health Visiting Pathway (UHVP), involving a greater number of contacts with a particular emphasis on the first year, visits within the home setting, and rigorous developmental assessment conducted by a qualified Health Visitor. To evaluate the UHVP, an outcome indicator framework was developed using routine administrative data. This paper sets out the development of these indicators. METHODS: A logic model was produced with stakeholders to define the group of outcomes, before further refining and aligning of the measures through discussions with stakeholders and inspection of data. Power calculations were carried out and initial data described for the chosen indicators. RESULTS: Eighteen indicators were selected across eight outcome areas: parental smoking, breastfeeding, immunisations, dental health, developmental concerns, obesity, accidents and injuries, and child protection interventions. Data quality was mixed. Coverage of reviews was high; over 90% of children received key reviews. Individual item completion was more variable: 92.2% had breastfeeding data at 6-8 weeks, whilst 63.2% had BMI recorded at 27-30 months. Prevalence also varied greatly, from 1.3% of children's names being on the Child Protection register for over six months by age three, to 93.6% having received all immunisations by age two. CONCLUSIONS: Home visiting services play a key role in ensuring children and families have the right support to enable the best start in life. As these programmes evolve, it is crucial to understand whether changes lead to improvements in child outcomes. This paper describes a set of indicators using routinely-collected data, lessening additional burden on participants, and reducing response bias which may be apparent in other forms of evaluation. Further research is needed to explore the transferability of this indicator framework to other settings.

Educating Families on Urgent Maternal Warning Signs: Learning From a Pilot to Improve Training and Tools for Maternal and Child Home Visiting Programs.

Early recognition of the warning signs of pregnancy-related complications and provision of timely, quality care could prevent many maternal deaths. We piloted a maternal warning signs education intervention with five Maryland-based maternal, infant, and early childhood home visiting programs serving populations disproportionately affected by adverse maternal outcomes. The intervention included a 1.5-hr online training for home visitors, monthly collaborative calls with program managers, and a client education toolkit with a 3-min video, illustrated handout of 15 urgent maternal warning signs, magnet with the same, and discussion guide for home visitor-client interactions. A mixed-methods formative evaluation assessed the acceptability, feasibility, and utilization of different components of the intervention. Home visiting program staff reported that the materials were highly acceptable and easily understood by diverse client populations. They valued the illustrations, simple language, and translation of materials in multiple languages. Program managers found implementation a relatively simple process, feasible for in-person and remote visits. Despite positive reception, not all components of the toolkit were used consistently. Program managers and staff also identified the need for more guidance and tools to help clients communicate with health care providers and advocate for their health care needs. Feedback from pilot sites was used to adapt the training and tools, including adding content on patient self-advocacy. Home visiting programs have a unique ability to engage families during pregnancy and the postpartum period. This pilot offers lessons learned on strategies and tools that home visiting programs can use to improve early recognition and care-seeking for urgent maternal warning signs.

Health Professionals' Experiences with Health-Promoting Dialogues for Older Home-Dwellers-A Qualitative Study.

Home-dwelling older people without healthcare services might develop vulnerability and health-related issues that should be detected proactively by service providers. Health-promoting measures directed towards the target group could facilitate living longer and better at home, as well as delay the need for healthcare services. One approach is through health-promoting dialogues between the municipality and healthcare professionals. This study aims to explore the experiences of healthcare professionals involved in health-promoting dialogues with home-dwellers aged over 75 years without health service decisions in Norway. Data were collected through three focus groups. Thematic analysis was applied to the data resulting in the emergence of one major theme, "challenging dialogues", comprising three sub-themes: "promote the individual's perspectives", "uncovering vulnerability", and "ambiguity of the dialogues". The health-promoting dialogue uses a resource perspective for the elderly to remain independent in old age and can reveal vulnerability and underlying needs. The purpose of the dialogue appears ambiguous for the target group, which leads to unclear service expectations and frequent rejections of the offer. Nevertheless, this health-promoting service has a clear purpose of identifying and meeting the needs of the target group in a broader sense during the ageing process.

Home-visiting Parenting Programs to Improve Mother-Infant Interactions at Early Ages: A Systematic Review.

Objective: To systematically review studies examining the effects of home-visiting preventive parenting programs (HV-PPs) on improving the quality of mother-child interactions in early childhood. Method: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, we identified 3,586 studies published between 2018 and 2022 by searching the following databases: PubMed, Web of Science, BVS/LILACS, SciELO, and PsycNET/PsycINFO. After applying the eligibility criteria, 17 articles were selected for review. Results: Most studies were conducted in high-income countries (53%) and the remainder were conducted in upper-middle-income countries, predominantly using a randomized controlled trial design and with strong methodological quality. The 17 studies applied 13 different HV-PPs, predominantly using video feedback, based on various dosages and schedules. Most studies (77%) showed significant positive effects on mother-child interactions by improving mainly positive maternal behaviors (e.g., sensitivity and responsiveness). Positive effects occurred independent of the study design, sample characteristics, measures, and constructs assessed. However, the findings suggest that the combination of fewer than six sessions, durations shorter than three months, and a very early start did not impact mother-child interactions, as expected. Few studies have explored negative maternal behaviors, children's behaviors, and dyadic interactions such as mutuality and synchrony. Conclusions: HV-PPs positively impacted mother-child interactions in early childhood despite the large heterogeneity across program designs, outcome measures, and overlapping constructs. Based on the results, we discuss the practical and economic implications of using parenting programs as a preventive approach.

A Qualitative Analysis of the Effects of COVID-19 on Home Visiting Service Provision.

Home visiting programs have been found to improve parenting practices and to reduce negative child outcomes. The 2019 coronavirus disease (COVID-19) resulted in an abrupt transition to telehealth services for many home visiting services. Limited research has examined the impacts of delivering home visiting services via telehealth, and the effects of this abrupt transition during COVID-19 is understudied as well. This study examined the impact of the abrupt transition to telehealth as a result of COVID-19 on home visiting service provision in one mid-sized midwestern community from the perspective of clients and providers. We conducted semi-structured interviews with both home visiting clients and providers (N = 26) in prevention-focused home visiting services. Although some benefits to telehealth were reported, providers discussed challenges with regard to engaging clients in services and difficulties in completing important home visiting tasks (i.e., assessment of child development, teaching parent-child interaction). Providers and clients also noted that they missed face-to-face interactions. Effective use of telehealth in home visiting requires provision of devices that allow for video-chatting as well as development of effective methods to engage in observation and teaching tasks.

Home visitors' needs and perceptions of the benefits of a home visiting program for childcare support in Japan: A qualitative study of home visitors.

BACKGROUND: The Home Visiting Program for Childcare Support (HV-CCS; "Yoiku Shien Homon Jigyo" in Japanese) has targeted families in need of parenting support and those at risk of child maltreatment in Japan. OBJECTIVE: The aim of this study was to explore the needs and perceptions of benefits of home visitors in HV-CCS. PARTICIPANTS AND SETTING: Sixteen home visitors agreed to participate in the interview. METHODS: This study conducted 1-hour semi-structured interviews with 16 home visitors and analyzed approximately 18 h of interview data using thematic analysis. RESULTS: The findings suggested that home visitors required training to enhance individual skills and knowledge about mental health of caregivers or children. Additionally, they required environmental support, particularly for transportation expenses and parking places. Multidisciplinary communicative support is also necessary, as well as system to improve the process of support. Home visitor perceived the HV-CCS as beneficial in preventing child maltreatment by improving parenting skills and home environment, providing psychological support for mothers, and entering families' intimate spaces. CONCLUSIONS: To ensure the continuity and improvement of home visits for parents and children in Japan, it is essential to address the identified needs of home visitors.

Study protocol for a randomized controlled trial of the Parent-Child Assistance Program: a case management and home visiting program for people using substances during pregnancy.

BACKGROUND: Perinatal substance use can have significant adverse effects on maternal and child health and family stability. Few interventions are specifically designed to address this significant public health problem. The Parent-Child Assistance Program (PCAP) is a 3-year case management and home-visiting intervention that seeks to help birthing persons with at-risk substance use during pregnancy to achieve and maintain substance use disorder recovery and avoid exposing future children to substances prenatally. At-risk refers to a level of substance use that creates problems in the individuals' lives or puts them or their children at risk of harm either prenatally or postnatally. Although the program has consistently shown substantial pre- to post-intervention improvements in its participants, PCAP remains to be tested with a rigorous randomized controlled trial (RCT). This study protocol describes a randomized controlled trial that aims to examine the effectiveness of the intervention compared to services as usual in affecting primary outcomes related to substance use and family planning. Secondary outcomes will concern connection to recovery support services and family preservation. METHODS: Using an intent-to-treat design, the study will recruit from two metro areas in Oklahoma and enroll 200 birthing individuals who are pregnant or up to 24 months postpartum with at-risk substance use during their current or most recent pregnancy. Participants will be randomly assigned, stratified by location, to receive either PCAP or services as usual for 3 years. Participants in the PCAP condition will meet with their case manager approximately biweekly over the course of the intervention period, in their local communities or in their own homes whenever possible. Case managers will assist with goal setting and provide practical assistance in support of participants' goals. Primary and secondary outcomes will be assessed at baseline and 12, 24, and 36 months post-baseline using the Addiction Severity Index interview and a self-administered survey. DISCUSSION: Results from this trial will help to gauge the effectiveness of PCAP in improving parent and child well-being. Results will be reviewed by federal clearinghouses on home-visiting and foster care prevention to determine the strength of evidence of effectiveness with implications for federal financing of this program model at the state level. TRIAL REGISTRATION: ClinicalTrials.gov NCT05534568. Registered on 6/8/2022.

Unique Profiles of Postpartum Family Needs and Evidence of Racial and Ethnic Disparities: Insights from Community Implementation of Family Connects.

OBJECTIVES: To delineate specific family needs during the postpartum period using data from Family Connects (FC), a universal home-visiting initiative, and to scrutinize potential racial and ethnic disparities in these needs. METHOD: FC implementation data spanned from July 1, 2009, to August 31, 2021, in seven counties across the USA. Data encompassed nurse-led in-home assessments for 34,119 families. Nurses evaluated needs across four domains (healthcare, parenting/childcare, safe home, and parent support) comprising 12 risk factors. FINDINGS: Overall, families reported high levels of need, and community connections were facilitated for 57% of visited families. Significant differences in need profiles between whites and minority groups were revealed, reflecting both disparity and uniqueness. Employing the Oaxaca decomposition approach, we found that racial/ethnic disparities in socioeconomic attributes were associated with racial/ethnic gaps in the need profiles. CONCLUSIONS: The event of giving birth is both high risk and high opportunity for preventive intervention. Home-visiting programs, as an evidence-based approach, must address the diverse spectrum of familial needs comprehensively.

Maintaining Family Engagement During Home Visitor Turnover: a Mixed Methods Study of Best Practices.

Evidence-based home visiting services (EBHV) are available in states and localities nationwide through the federally-funded Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. Nevertheless, the anticipated benefits of EBHV, such as improved child developmental outcomes and increased positive parenting practices, may be undermined by the fact that most families withdraw from services earlier than the model developers planned. Prior studies have linked family attrition with staff turnover. The current study used a mixed methods design to investigate the conditions under which families remained active in the home visiting program after their assigned home visitor resigned. Coincidence Analysis revealed that giving families advance notice (at least 1 month) prior to the home visitors' upcoming resignation or developing a strong positive working alliance with the inheriting home visitor appears to independently make a difference for ongoing family engagement at 3 and 6 months following a staff transition. These findings suggest that emphasizing how staff turnover is managed may mitigate the risk of family withdrawal during these transitions.

Structural and relational factors for successful cross-sector collaboration in home visiting: a multiple case study.

BACKGROUND: Aligning delivery and financing systems across sectors to create broader systems of care can improve the health and well-being of families experiencing adversities. We aimed to identify structural and relational factors for best practices to achieve successful cross-sector collaboration among home visiting programs in the United States. MATERIALS AND METHODS: We used a multiple case study approach to identify best practices for successful cross-sector collaboration between home visitors and other community service providers. We selected five diverse exemplary cases with cross-sector collaboration with variation in implementing agency type and geographic location. Cases were selected using a positive deviance approach based on strong coordination and integration with different community service provider types identified from previous survey data. We conducted in-depth qualitative interviews with home visiting staff, community providers, and clients with a total of 76 interviews conducted from 2021 to 2022. We wrote memos to synthesize themes within each case through data triangulation using interview data, documents, and site visit observations. We compared themes across the five cases to create a cross-case synthesis of best practices for successful cross-sector collaboration. RESULTS: Across the five cases, relational factors including leadership from all levels, champions across sectors, and shared goals between community providers were key factors for successful collaboration. Interpersonal relationships, coupled with the desire and capacity to engage, facilitated effective coordination to address families' needs. At the structural level, shared data systems, written agreements, and co-location enabled care coordination activities. Community Advisory Boards provided a venue for developing partnerships, relationship-building, resource-sharing, and increasing awareness of home visiting. CONCLUSIONS: We identified key elements of successful cross-sector collaboration across five case studies where home visitors coordinate care frequently and/or are structurally integrated with a range of providers. These learnings will inform future interventions to improve home visiting collaboration with other community providers to create a system of care to enhance family well-being.

The effects of a large-scale home visiting programme for child development on use of health services in Brazil.

Partnership between early childhood development interventions and primary health care services can help catalyse health care uptake by socially vulnerable families. This study aimed to assess the real-life effects of a large-scale home visiting programme [Primeira Infância Melhor (PIM)] in Brazil on the use of preventive (prenatal visits, well child visits, dentist visits and vaccination) and recovery (emergency room visits and hospitalization) health services. A quasi-experiment nested in a population-based birth cohort study was conducted. The intervention group was firstly defined as all children enrolled in PIM up to age 6 months, and afterwards stratified between those enrolled during pregnancy or after birth up to 6 months. Children receiving PIM were matched with controls on propensity scores based on 27 confounders to estimate effects on health service use from prenatal to age 2 years. Double adjustment was applied in outcome Quasi-Poisson regressions. No evidence was found for effects of PIM starting anytime up to 6 months (262 pairs), or for the children enrolled only after birth (133 pairs), on outcomes occurring after age 6 months. When the programme started during pregnancy (129 pairs), there was a 13% higher prevalence of adequate prenatal visits (prevalence ratio = 1.13; 95% confidence interval 1.01-1.27), but no effect on use of any other health service. Sensitivity analyses suggested longer participation in the programme with reduced visitor turnover might improve its impact on prenatal visits. Integration between PIM and primary health care was not adequate to affect overall patterns of contacts with health services. Nevertheless, prenatal home visits showed potential to increase health service contact during a sensitive period of development, indicating the need to start such programmes before birth, when there is more time for maternal care, and family engagement in a network of services is facilitated.