An embedded, ecological and evidence- based approach to improving - - PowerPoint PPT Presentation

Centre re for Primary ry Health Care and Equity

An embedded, ecological and evidence- based approach to improving outcomes for families with young children

Lynn Kemp

Associate Professor and Director, Centre for Health Equity Training Research and Evaluation

UNSW Research Centre for Primary Health Care & Equity

UNSW Research Centre for Primary Health Care & Equity

When 12-year-old Jessica Burns was asked what she wanted from her future, she answered: “a good job, like where you get like heaps of

• money. I’d be like a decent mum,

like a husband with no violence and everything, so it could be a happy family, you know, but like that would never happen…”

Targeted service

Income Improving

• pportunities

for health and development

Changing the gradient

Universal HV service Community Societal resources Macroclimate Universal Plus service Universal Partnership Plus service

Targeted services

• Identified referral
• Highly differentiated population
• Specific (often manualised) service delivery
• Quality/fidelity measures
• Usually „out of system‟ (care hands over and discharges

back)

• Population offer
• Undifferentiated population
• Large numbers (whole population)
• Flexible service delivery (in response to need)
• Care within the „system‟

UNSW Research Centre for Primary Health Care & Equity

Universal services

Universal ecological approach

UNSW Research Centre for Primary Health Care & Equity Universal HV service Community Societal resources Macroclimate Targeted service

UNSW Research Centre for Primary Health Care & Equity

What help?

• Comprehensive review of 133 home visiting programs

worldwide to identify effective program components

• Programs for mothers from low socioeconomic groups
• Home visiting by nurses where a broad range of outcomes is

desired

• Highly targeted interventions by psychologists/ counsellors for

mothers with postnatal depression

• Programs commencing antenatally
• Programs including child development, parenting skills, parent-

infant interaction and direct and indirect provision of resources

• Qualitative study with health visitors, other health and social

care providers to develop useful program

• Surveys/focus groups with families

UNSW Research Centre for Primary Health Care & Equity

Conceptual foundations

• Investment in the early years provides the best
• pportunity to improve life-long health and wellbeing
• Working with families in their own communities to

address the social determinants of their health using an ecological approach

• Opportunities for optimal health and development

for all children through universal population approach to support all families including extra support for all those who need it (proportionate universalism)

• Working in partnership with families and promoting

connectedness with the service system

• Strengths-based, flexible and responsive

approaches

• Building sustainable capacity (family, professional,
• rganisational and system)

UNSW Research Centre for Primary Health Care & Equity

Why a universa sal l approach?

Not just first st time mothers rs

Lanier P, Jonson-Reid M (2014) Comparing Primiparous and multiparous mothers in a nurse home visiting prevention program. Birth 41:4;344-352

Why a universa sal l approach?

UNSW Research Centre for Primary Health Care & Equity

“Well if I‟m already asking for help it‟s because I‟m an unfit mum. So she was just sort of reassuring me that that‟s not the case…Yeah, because I think it was more a confirmation that it‟s okay to feel how I feeling and it‟s okay to get help.” (Cathy).

Group activities Other services and supports Home visiting Community visibility

Programme structure

Programme components

• Supporting mother and child

health and wellbeing

• Supporting mothers to be

future oriented and aspirational

• Child development parent

education program

• Supporting family and social

relationships

• Additional support in

response to need

UNSW Research Centre for Primary Health Care & Equity

Home visits

• 25 home visits by an assigned health visitor from pregnancy to child

age 2

• pregnancy home visiting (3 visits)
• infancy home visiting (16 visits)
• toddler home visiting (6 visits)
• Visit content designed to meet agreed goals of family and health

visitor and provide comprehensive support

UNSW Research Centre for Primary Health Care & Equity

• infant, mother and family

health and wellbeing

• preventive health care
• referrals to other providers
• anticipatory guidance
• child development parent

education

• planning and goal setting
• fostering apsirations

Proacti ctive ve, , planned, anticipa ipatory tory

Why antici cipato atory, ry, child-develop velopme ment t focusse ssed d approach?

UNSW Research Centre for Primary Health Care & Equity

“ I didn‟t realise you had to put children on the floor for them to crawl. I, I‟d either leave them in the bed

• r in a bouncer or whatever, but to actually on the

floor to play, and experiment and just little things like that and it‟s made a big a huge difference with [child‟s name] impact on her learning and growing I believe” (Tessa).

Group activities

• Reducing isolation for mothers is important for mental

health and reducing postnatal depression

• Families benefit from connecting with other families with

young children

• source of support
• other advice and ideas for good parenting
• delivery of therapeutic programs in groups

UNSW Research Centre for Primary Health Care & Equity

Community visibility

• Connecting families and

services within the community

• Whole community

commitment to improving

• utcomes for families with

young children

UNSW Research Centre for Primary Health Care & Equity

Other supports

• Coordinated multidisciplinary approach
• support from other health and social services
• connecting families with primary health care
• connecting families with education services
• secondary and tertiary care for identified needs for

parents and children

UNSW Research Centre for Primary Health Care & Equity

Embedded and ongoing

• Build practitioner and service capacity to identify and

respond to remediable risk in the population – where and when needed

• Ecological and multidisciplinary approach to support

family, practitioner and service capacity building and access to resources

• Proportionate universal approach with service

targeted to vulnerable families embedded within the broader universal service system

• Evidence based approach to achieve outcomes for

families

Strengths of approach

UNSW Research Centre for Primary Health Care & Equity

Evid idence ence base

• Randomised controlled trial (NSW)
• Individual randomisation
• Reported 2011
• USA Department of Health and Human Services HomVEE approval as

an effective evidence-based program

• Quasi-experimental trial (NSW)
• Whole population intervention compared with historic control
• Due to report end 2015
• Randomised controlled trial (Victoria/Tasmania)
• Independent research
• Individual randomisation
• Due to report end 2016
• Quasi-experimental study (Somerset)
• Commencing this year

UNSW Research Centre for Primary Health Care & Equity

Monitorin itoring g quality lity

20 40 60 80 100 Q2 Q3 Q4 % MECSH uptake Uptake benchmark 10 20 30 40 50 60 70 80 90 100 Q2 Q3 Q4 % Antenatal uptake as proportion of all uptake antenatal commencement benchmark 20 40 60 80 100 Q2 Q3 Q4 % Proportion recommended number of scheduled visits Visit frequency as recommended Visit frequency at least minimum benchmark 5 10 15 20 25 30 Q2 Q3 Q4 mean Impact measures PSQ and PEI PSQ mean PEI mean PSQ benchmark PEI benchmark

Benchmarking chmarking

Programme outcomes

Kemp L, Harris E, McMahon C, Matthey S, Vimpani G, Anderson T, Schmied V, Aslam H, Zapart S. (2011) Child and family outcomes of a long-term nurse home visitation program: a randomised controlled trial. Archives of Disease in Childhood 96:533-540

• Children

– More engaged – Improved development

• Mothers

– Less birthing intervention – Improved health – Longer time breastfeeding – Improved confidence – Improved use of services

• Families

– Improved home environment

• Community

– Fewer vulnerable children at school entry

Licenced programme:

Australia

• 11 sites in New South Wales, Victoria and Tasmania

United Kingdom and Jersey

• 9 sites

Republic of Korea

• 8 sites

USA

• 1 site

Programme implementation

UNSW Research Centre for Primary Health Care & Equity

Essex (5 sites), Plymouth, Jersey, Somerset, Lewisham

• Training programme
• Supervision programme
• Data system
• Interdisciplinary, interagency

partnerships

• Sustainable caseload build

UNSW Research Centre for Primary Health Care & Equity

UNSW Research Centre for Primary Health Care & Equity

MECSH research and implementation teams Supporting services Project funders Participating families

Further information l.kemp@unsw.edu.au http://www.earlychildhoodconnect.edu.au/

Thank you

UNSW Research Centre for Primary Health Care & Equity

Further information and references

Aslam H, Kemp L. Home Visiting in South Western Sydney: An Integrative Literature Review, Description and Development of a Generic Model. Centre for Health Equity Training Research and Evaluation, Liverpool, NSW, 2005. http://cphce.unsw.edu.au/sites/default/files/publication_related_files/Home_visiting_SWS.pdf Kardamanidis K, Kemp L, Schmied V. (2009) Uncovering psychosocial needs: Perspectives of Australian Child and Family Health Nurses in a sustained home visiting trial. Contemporary Nurse 33(1):50-58. Kemp L, Anderson T, Harris E, Travaglia J (2005) Sustained nurse home visiting in early childhood: exploring Australian nursing competencies. Public Health Nursing.22;3:254-259. Kemp L, Eisbacher L, McIntyre L, O’Sullivan K, Taylor J, Clark T, Harris E. (2006-7) Working in partnership in the antenatal period: What do child and family health nurses do? Contemporary Nurse. 23(2):312- 320. Kemp L, Harris E. (2012) The challenges of establishing and researching a sustained nurse home visiting programme within the universal child and family health service system. Journal of Research in Nursing 17:139-141. Kemp L, Harris E, McMahon C, Matthey S, Vimpani G, Anderson T, Schmied V, Aslam H. (2013) Benefits of psychosocial intervention and continuity of care by child and family health nurses in the pre and postnatal period: Process evaluation. Journal of Advanced Nursing 69(8), 1850-1861 Kemp L, Harris E, McMahon C, Matthey S, Vimpani G, Anderson T, Schmied V, Aslam H, Zapart S. (2011) Child and family outcomes of a long-term nurse home visitation program: a randomised controlled

• trial. Archives of Disease in Childhood 96:533-540.

Kemp L, Harris E, McMahon C, Matthey S, Vimpani G, Anderson T, Schmied V. (2008) Miller Early Childhood Sustained Home-visiting (MECSH) trial: design, method and sample description. BMC Public Health. 8:424. Lanier P, Jonson-Reid M (2014) Comparing Primiparous and multiparous mothers in a nurse home visiting prevention program. Birth 41:4;344-352