An embedded, ecological and evidence- based approach to improving outcomes for families with young children Centre re for Primary ry Health Care and Equity Lynn Kemp Associate Professor and Director, Centre for Health Equity Training Research and Evaluation
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…” UNSW Research Centre for Primary Health Care & Equity
Changing the gradient Macroclimate Societal resources Community Universal HV service Universal Plus service Improving Universal Partnership Plus service opportunities for health Targeted service and development Income
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) Universal services • 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 ecological approach Macroclimate Societal resources Community Targeted service Universal HV service UNSW Research Centre for Primary Health Care & Equity
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 opportunity 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, organisational 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? “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). UNSW Research Centre for Primary Health Care & Equity
Programme structure Home visiting Community visibility Group activities Other services and supports
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 - infant, mother and family - child development parent health and wellbeing education - preventive health care - planning and goal setting - referrals to other providers - fostering apsirations - anticipatory guidance UNSW Research Centre for Primary Health Care & Equity
Proacti ctive ve, , planned, anticipa ipatory tory
Why antici cipato atory, ry, child-develop velopme ment t focusse ssed d approach? “ 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 or 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). UNSW Research Centre for Primary Health Care & Equity
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 outcomes 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
Strengths of approach • 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 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 100 90 100 80 70 80 60 60 50 % % 40 40 30 20 20 10 0 Q2 Q3 Q4 0 Q2 Q3 Q4 MECSH uptake Antenatal uptake as proportion of all uptake Uptake benchmark antenatal commencement benchmark 100 30 80 25 60 % 20 40 mean 15 20 10 0 Q2 Q3 Q4 5 Proportion recommended number of scheduled visits 0 Q2 Q3 Q4 Visit frequency as recommended Impact measures PSQ and PEI Visit frequency at least minimum PSQ mean PEI mean PSQ benchmark PEI benchmark benchmark
Benchmarking chmarking
Programme outcomes • 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 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
Programme implementation 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 • 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
Thank you MECSH research and implementation teams Supporting services Project funders Participating families Further information l.kemp@unsw.edu.au http://www.earlychildhoodconnect.edu.au/ UNSW Research Centre for Primary Health Care & Equity
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