Nurse-Moderated Internet-Based Support for New Mothers: Non-Inferiority, Randomized Controlled Trial.

BACKGROUND: Internet-based interventions moderated by community nurses have the potential to improve support offered to new mothers, many of whom now make extensive use of the Internet to obtain information about infant care. However, evidence from population-based randomized controlled trials is lacking. OBJECTIVE: The aim of this study was to test the non-inferiority of outcomes for mothers and infants who received a clinic-based postnatal health check plus nurse-moderated, Internet-based group support when infants were aged 1-7 months as compared with outcomes for those who received standard care consisting of postnatal home-based support provided by a community nurse. METHODS: The design of the study was a pragmatic, preference, non-inferiority randomized control trial. Participants were recruited from mothers contacted for their postnatal health check, which is offered to all mothers in South Australia. Mothers were assigned either (1) on the basis of their preference to clinic+Internet or home-based support groups (n=328), or (2) randomly assigned to clinic+Internet or home-based groups if they declared no strong preference (n=491). The overall response rate was 44.8% (819/1827). The primary outcome was parenting self-competence, as measured by the Parenting Stress Index (PSI) Competence subscale, and the Karitane Parenting Confidence Scale scores. Secondary outcome measures included PSI Isolation, Interpersonal Support Evaluation List-Short Form, Maternal Support Scale, Ages and Stages Questionnaire-Social-Emotional and MacArthur Communicative Development Inventory (MCDI) scores. Assessments were completed offline via self-assessment questionnaires at enrolment (mean child age=4.1 weeks, SD 1.3) and again when infants were aged 9, 15, and 21 months. RESULTS: Generalized estimating equations adjusting for post-randomization baseline imbalances showed that differences in outcomes between mothers in the clinic+Internet and home-based support groups did not exceed the pre-specified margin of inferiority (0.25 of a SD) on any outcome measure at any follow-up assessment, with the exception of MCDI scores assessing children's language development at 21 months for randomized mothers, and PSI Isolation scores at 9 months for preference mothers. CONCLUSION: Maternal and child outcomes from a clinic-based postnatal health check plus nurse-moderated Internet-based support were not inferior to those achieved by a universal home-based postnatal support program. Postnatal maternal and infant support using the Internet is a promising alternative to home-based universal support programs. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry Number (ANZCTR): ACTRN12613000204741; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363712&isReview=true (Archived by WebCite at http://www.webcitation.org/6rZeCJ3k1).

Usage, adherence and attrition: how new mothers engage with a nurse-moderated web-based intervention to support maternal and infant health. A 9-month observational study.

OBJECTIVES: To identify factors predicting use, adherence and attrition with a nurse-moderated web-based group intervention designed to support mothers of infants aged 0-6 months. DESIGN: 9-Month observational study. SETTING: Community maternal and child health service. PARTICIPANTS: 240 mothers attending initial postnatal health checks at community clinics who were randomly assigned to the intervention arm of a pragmatic preference randomised trial (total randomised controlled trial, n=819; response rate=45%). INTERVENTION: In the first week (phase I), mothers were assisted with their first website login by a research assistant. In weeks 2-7 (phase II), mothers participated in the web-based intervention with an expectation of weekly logins. The web-based intervention was comparable to traditional face-to-face new mothers' groups. During weeks 8-26 (phase III), mothers participated in an extended programme at a frequency of their choosing. PRIMARY OUTCOME MEASURES: Number of logins and posted messages. Standard self-report measures assessed maternal demographic and psychosocial characteristics. RESULTS: In phase II, the median number of logins was 9 logins (IQR=1-25), and in phase III, it was 10 logins (IQR=0-39). Incident risk ratios from multivariable analyses indicated that compared to mothers with the lowest third of logins in phase I, those with the highest third had 6.43 times as many logins in phase II and 7.14 times in phase III. Fifty per cent of mothers logged-in at least once every 30 days for 147 days after phase I and 44% logged-in at least once in the last 30 days of the intervention. Frequency of logins during phase I was a stronger predictor of mothers' level of engagement with the intervention than their demographic and psychosocial characteristics. CONCLUSIONS: Mothers' early use of web-based interventions could be employed to customise engagement protocols to the circumstances of individual mothers with the aim of improving adherence and reducing attrition with web-based interventions. TRIAL REGISTRATION NUMBER: ACTRN12613000204741; Results.

Effectiveness of nurse home visiting for families in rural South Australia.

AIM: To evaluate the effectiveness of a 2-year post-natal home-visiting programme delivered by nurses to socially disadvantaged mothers in rural regions of South Australia. METHODS: The intervention group consisted of 225 mothers who lived in rural regions and enrolled in the programme between 2010 and 2012. The comparison group consisted of 239 mothers who lived in rural areas between 2008 and 2009 when the programme was not yet available. All participants were eligible for enrolment in the home-visiting programme. Participants in both groups were assessed at baseline (mean child age = 15.2 weeks, SD = 2.4), prior to programme enrolment, and again when children were aged 9, 18 and 24 months. Outcomes were evaluated using the Parent Stress Index, Kessler Psychological Distress Scale, Ages and Stages Questionnaire, Child Behaviour Checklist, and MacArthur Communicative Developmental Inventory. RESULTS: During the follow-up period, there was little difference in the pattern of scores across the two groups. Mixed models adjusting for baseline differences between the groups did not identify any significant Group × Time interactions. This suggests that the linear trajectories of scores on outcomes did not differ significantly between the two groups. CONCLUSIONS: Findings suggest that the home-visiting programme did not have a measurable effect on maternal or child outcomes. However, the programme was relatively early in its rollout, and the greater challenges of recruitment, training and support, along with rural nurses' broader responsibilities for delivering other maternal and child health services, may explain why effects seen in the metropolitan area were not evident in rural regions.

An equivalence evaluation of a nurse-moderated group-based internet support program for new mothers versus standard care: a pragmatic preference randomised controlled trial.

BACKGROUND: All mothers in South Australia are offered a clinic or home-visit by a Child and Family Health community nurse in the initial postnatal weeks. Subsequent support is available on request from staff in community clinics and from a telephone helpline. The aim of the present study is to compare equivalence of a single clinic-based appointment plus a nurse-moderated group-based internet intervention when infants were aged 0-6 months versus a single home-visit together with subsequent standard services (the latter support was available to mothers in both study groups). METHODS/DESIGN: The evaluation utilised a pragmatic preference randomised trial comparing the equivalence of outcomes for mothers and infants across the two study groups. Eligible mothers were those whose services were provided by nurses working in one of six community clinics in the metropolitan region of Adelaide. Mothers were excluded if they did not have internet access, required an interpreter, or their nurse clinician recommended that they not participate due to issues such as domestic violence or substance abuse. Randomisation was based on the service identification number sequentially assigned to infants when referred to the Child and Family Health Services from birthing units (this was done by administrative staff who had no involvement in recruiting mothers, delivering the intervention, or analyzing results for the study). Consistent with design and power calculations, 819 mothers were recruited to the trial. The primary outcomes for the trial are parents' sense of competence and self-efficacy measured using standard self-report questionnaires. Secondary outcomes include the quality of mother-infant relationships, maternal social support, role satisfaction and maternal mental health, infant social-emotional and language development, and patterns of service utilisation. Maternal and infant outcomes will be evaluated using age-appropriate questionnaires when infants are aged <2 months (pre-intervention), 9, 15, and 21 months. DISCUSSION: We know of no previous study that has evaluated an intervention that combines the capacity of nurse and internet-based services to improve outcomes for mothers and infants. The knowledge gained from this study will inform the design and conduct of community-based postnatal mother and child support programs. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12613000204741.

Effectiveness of nurse home-visiting for disadvantaged families: results of a natural experiment.

OBJECTIVE: To evaluate the effects of a postnatal home-visiting programme delivered by community health nurses to socially disadvantaged mothers in South Australia. DESIGN: The intervention group of 428 mothers lived in metropolitan Adelaide and the comparison group of 239 mothers lived in regional towns where the programme was not yet available. All participating mothers met health service eligibility criteria for enrolment in the home-visiting programme. Participants in both groups were assessed at baseline (mean child age=14.4 weeks SD=2.3), prior to programme enrolment, and again when the children were aged 9, 18 and 24 months. SETTING: State-wide community child health service. PARTICIPANTS: 667 socially disadvantaged mothers enrolled consecutively. 487 mothers (73%) completed the 24-month assessment. INTERVENTION: Two-year postnatal home-visiting programme based on the Family Partnership Model. PRIMARY OUTCOME MEASURES: Parent Stress Index (PSI), Kessler Psychological Distress Scale and the Ages and Stages Questionnaire. RESULTS: Mixed models adjusting for baseline differences were used to compare outcomes in the two groups. The mothers in the home-visiting group reported greater improvement on the PSI subscales assessing a mother's perceptions on the quality of their relationship with their child (1.10, 95% CI 0.06 to 2.14) and satisfaction with their role as parents (0.46, 95% CI -0.15 to 1.07) than mothers in the comparison group. With the exception of childhood sleeping problems, there were no other significant differences in the outcomes across the two groups. CONCLUSIONS: The findings suggest that home-visiting programmes delivered by community health nurses as part of routine clinical practice have the potential to improve maternal-child relationships and help mothers adjust to their role as parents. CLINICAL TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12608000275369.

Nurse perceptions of family home-visiting programmes in Australia and England.

AIMS: Nurse home-visiting programmes are employed to enhance the functioning of disadvantaged mothers and young children. Despite the key role played by nurses, there is little empirical evidence describing the views and experiences of nurses who deliver home-visiting programmes. This study compared the views and experiences of nurses delivering home-visiting programmes in England and South Australia. METHODS: Participants were 108 nurses delivering the South Australian Family Home Visiting programme (2008-2011), and 44 nurses delivering the Family Nurse Partnership programme in England (2007-2009). Data were collected using a standard questionnaire that was completed by nurses in each country. The questionnaire asked nurses about their level of influence on programme outcomes, approaches they used to retain maternal engagement with the home-visiting programmes, barriers to effective programme delivery and the effectiveness of supervision. RESULTS: Both groups of nurses considered that their greatest influence was improving mothers' confidence with parenting skills and increasing mothers' knowledge about children's development. Each group identified quality of nurse-mother relationships as the factor most relevant to retaining maternal engagement. Other influential factors were flexibility of timing for visits and the capacity of the programmes to meet specific needs of mothers. CONCLUSION: There was consistency in the nurses' views about the home-visiting programmes delivered in England and Australia. Future studies should utilise prospective designs to identify the mechanisms by which factors influence the quality of nurse-mother relationships, approaches used by nurses to solve family problems and elements of mother-nurse relationships that have the strongest influence on programme outcomes.