Date Published: May 6, 2019
Publisher: Public Library of Science
Author(s): Lynn Kemp, Tracey Bruce, Emma L. Elcombe, Teresa Anderson, Graham Vimpani, Anna Price, Charlene Smith, Sharon Goldfeld, Briony Hill.
Home visiting programs are implemented in high income countries to improve outcomes for families with young children. Significant resources are invested in such programs and high quality evaluations are important. In the context of research trials, implementation quality is often poorly reported and, when reported, is variable. This paper presents the quality of implementation of the right@home program, a sustained nurse home visiting intervention trialled in Australia, and delivered in a ‘real world’ context through usual child and family health services. right@home is structured around the core Maternal Early Childhood Sustained Home-visiting (MECSH) program, which is a salutogenic, child focused prevention model.
At each visit right@home practitioners completed a checklist detailing the client unique identifier, date of contact and activities undertaken. These checklists were collated to provide data on intervention dose, retention to program completion at child age 2 years, and visit content, which were compared with the program schedule. Quality of family-provider relationship was measured using the Session Rating Scale. Exploratory factor analysis was conducted to identify clusters of activities and allow qualitative assessment of concordance between program aims and program delivery.
Of 363 intervention families offered the program, 352 (97·0%) commenced the program and 304 (87·3%) completed the program to child age 2 years. 253 of 352 (71·9%) families who commenced the program received more than 75 percent of scheduled visits including at least one antenatal visit. Families rated the participant-practitioner relationship highly (mean 39.4/40). The factor analysis identified six antenatal and six postnatal components which were concordant with the program aims.
The right@home program was delivered with higher adherence to program dose, schedule and content, and retention than usually reported in other home visiting research. Program compliance may have resulted from program design (visit schedule, dose, content and delivery flexibility) that was consistent with family aims.
The past two decades have seen increasing research evidence that sustained nurse home visiting (SNHV) can improve health and development outcomes for children and families experiencing adversity [1, 2, 3]. As a result, in high income countries like the USA , UK and Australia, home visiting programs are increasingly being implemented for expectant families and those with young children identified with vulnerabilities or risks for poorer outcomes. These programs are supported by policy and funding initiatives such as the US Maternal, Infant, and Early Childhood Home Visiting Program , which require that the implemented programs be evidence-based.
This study explored the implementation fidelity of a SNHV program, known as right@home, for families experiencing adversity. Through systematic monitoring processes, a broad range of fidelity measures were included, covering the amount and duration of service delivery, and the quality of the relationship between the practitioner and parent/s. Unlike other fidelity reporting, extensive recording of activities conducted in the home visits allowed detailed exploration of actual content delivered and concordance with program aims. Program delivery had strong adherence to the dose, retention and scheduled focus module content, and families reported a strong working alliance with their right@home practitioner. Poor adherence to delivery of the SmallTalk program in the second year was the only area of concern.
The right@home program was implemented with fidelity. Families in the right@home trial intervention group were retained in the program for the expected duration, and received the program dose as scheduled in terms of the total number of visits overall and in each program stage. Antenatal and postnatal content actually delivered was consistent with the program aims. The retention of families in the program and the proportion of schedule dose received were much higher than achieved in comparable home visiting programs. The families also rated the relationship with their nurse provider consistently highly. This fidelity was particularly notable as the right@home program was delivered through usual child and family health services, rather than using nurses or systems especially established for the research. The structure and flexibility of the program and alignment with families’ capacity, together with the timeliness and depth of the quality monitoring processes, may have contributed to program fidelity that was superior to most previously evaluated home visiting programs.