Measuring success: program fidelity of Queensland’s child health home visiting services. A document analysis
Nicole Latham
A B , Jeanine Young C D * , Josephine Wilson C and Michelle Gray B E
A Digital Health, Sunshine Coast Hospital and Health Service, Birtinya, Qld 4575, Australia.
B School of Health, University of the Sunshine Coast, Sippy Downs, Qld 4556, Australia.
C School of Health, University of the Sunshine Coast, Petrie, Qld 4502, Australia.
D Sunshine Coast Health Institute, Birtinya, Qld 4575, Australia.
E Edith Cowan University, Joondalup, WA 6027, Australia.
Australian Journal of Primary Health - https://doi.org/10.1071/PY23002
Submitted: 7 January 2023 Accepted: 30 June 2023 Published online: 20 July 2023
© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of La Trobe University. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Background: The Family CA.R.E. (Community-based Assistance Resourcing and Education) program was introduced in Queensland two decades ago. It aimed to redress health inequalities for infants from families experiencing specific social stressors. The program has been locally adapted over time and has not been evaluated against the original program. This study assessed the extent to which selected hospital and health services in Queensland, Australia have modified the original Family C.A.R.E. program.
Methods: Altheide’s model was used to facilitate a critical document analysis of policies and guidelines for adapted Family C.A.R.E. home visiting programs in use by hospital and health services (target n = 7).
Results: Five of seven eligible services provided service model documentation. There was low alignment with the original Family C.A.R.E. program across four of the five participating services. While the program delivered within Service 4 was highly aligned to the structure and intent of the original model, variation to the program was still evident. Importantly, four of the five participating programs were not collecting evaluation measures.
Conclusions: Health services have adapted the original Family C.A.R.E program format to ‘fit’ the local service environment but have largely failed to collect data to facilitate evaluation. Inability to evaluate the program leads to uncertainty about program success and benefits as well as any unintended consequences for families engaging in unevaluated home visiting programs. This study highlights the importance of monitoring program fidelity and evaluating success given the potential ramifications for this vulnerable cohort and for health service delivery.
Keywords: care co-ordination, child health services, community health: nursing, document analysis, family C.A.R.E program, family health, maternal-child health, nurse home visiting.
Introduction
Investment in an infant’s first years of life has the greatest potential to affect childhood outcomes such as learning, school success, employment, social capacity, and health (Moore et al. 2015, 2017). However, a widening gap exists between outcomes for infants from high-functioning families compared with those from families experiencing vulnerability1 (Heckman and Mosso 2014; Kimla et al. 2019). Within Australia, publicly funded child and family health services, administered by state government services, aim to provide universal services to the general population. Universal services monitor child development, support families in their parenting role, and promote secure attachment between infants and their primary caregiver. Targeted child and family health services, however, aim to reduce disadvantage by addressing risk factors and providing additional support for families experiencing social vulnerabilities (Australian Health Ministers’ Advisory Council 2011). Families experiencing vulnerabilities are often least likely to receive the services they require. Barriers facing these families may include lacking the resources or confidence to access services; invisibility to, or ineligibility for, services; and reluctance to engage due to negative prior service experience (Butler et al. 2012; McDonald et al. 2012). To help overcome this, targeted services often provide care in the family’s home to facilitate access, assist with building rapport, and provide greater support (Australian Health Ministers’ Advisory Council 2011).
Numerous government programs have been implemented in Australia to address childhood disadvantage, to promote optimal health and development, and to combat potential negative sequelae (McDonald et al. 2012). One such program was the Family C.A.R.E. (Community-based Assistance Resourcing and Education) Program (FCP). The FCP was developed from The Family C.A.R.E. Research Project; a nurse home visiting intervention targeting vulnerable families recruited from a major urban tertiary referral hospital in the late 1990s (Cadzow et al. 1999; Chew 2003). Initial evidence from the project demonstrated positive short-term outcomes, and FCP was subsequently incorporated into a broader early intervention program introduced by the Queensland government (Armstrong et al. 1999, 2000; Huston and Armstrong 1999; Chew 2003).
Between 2000 and 2004, the FCP was trialled in selected Queensland hospital and health services (HHSs). State government funding was provided across 4 years in HHSs with low socio-economic status, high birth rates, and high rates of reported domestic and family violence, child abuse, and neglect among the population they serviced (Chew 2003). The FCP targeted families experiencing low maternal mood, financial stress, and domestic and family violence (Chew 2003). It was designed as a structured home visiting program to be delivered over a 12 month period to maximise protective factors during pregnancy and the first year of an infant’s life (Queensland Health 2000). The intervention focused on developing trusting relationships with families; providing anticipatory infant care, and promoting healthy growth and development; supporting families to make decisions in the best interests of themselves and their children; and facilitating access to community resources and celebrating successes in caring for their child (Huston and Armstrong 1999; Queensland Health 2000). Home visiting staff collected client-related data at specific program intervals for monitoring purposes. The FCP also aimed to enhance early identification and management of ‘at risk’ families and increase child health nurse (CHN) awareness and skills in supporting maternal and infant health and wellbeing. Specific objectives included to:
improve maternal and infant health, parent–infant attachment and self-efficacy in parenting,
support infant cognitive and physical development,
decrease maternal depression, anxiety, and distress,
reduce the risk of infant abuse and neglect, vaccine preventable morbidity or mortality, and Sudden Infant Death Syndrome (SIDS) (Queensland Health 2000).
Having a state-wide approach to home visiting programs facilitates the delivery of co-ordinated and consistent services. However, since its commencement two decades ago, the FCP has been adapted by each HHS into which it was introduced (Latham et al. 2020), although it is not clear how these contemporary programs vary from the original FCP. Furthermore, it is not known how intended outcomes are measured in these adapted programs, if at all. Adaptations from the original FCP have not been evaluated or reviewed.
Reviews prepared for the Australian Research Alliance for Children and Youth (ARACY) Sustained Nurse Home Visiting Project detailed factors making programs effective and identified successful methods of engaging with vulnerable families (Huston and Armstrong 1999; McDonald et al. 2012). A recent scoping review by Latham and colleagues also identified specific elements of effective Australian-based home visiting programs, drawing particular attention to the importance of maintaining program content and intervention fidelity to achieve intended outcomes (Latham et al. 2020). Box 1 provides a summary of the common elements identified across programs. This scoping review aligned with the findings of the review prepared for ARACY by McDonald and colleagues (2012) (herein referred to as the ARACY review), highlighting that program content should focus on the risk factors the program was designed to prevent. If programs are adapted, they must be monitored to ensure the desired behavioural change and health outcomes for vulnerable families continue to be achieved (Duggan et al. 2022; McDonald et al. 2012; Latham et al. 2020).
| Box 1. Common elements identified within contemporary child health home visiting programs in Australia. |
| Most common elements |
| Positive nurse relationship |
| Professional community nurse |
| Antenatal visits |
| Duration over 2 years |
| Program fidelity |
| Program flexibility |
| Family partnership |
| Information tailored to family needs |
| Less common elements |
| Continuity of carer |
| Programs targeted to families most likely to benefit |
| N.B. Summary of key findings from scoping review conducted by Latham et al. (2020). |
Without a strong evidence base demonstrating that interventions are achieving their intended effects, it is difficult to assess where public funding is best allocated. There is also increasing acknowledgement of the potential risk of harm or unintended outcomes of untested programs (Norton and Chambers 2020). There is a clear need to identify the extent of variation in Queensland’s home visiting programs and their adherence to best practice principles. The aim of this study was therefore two-fold:
To compare contemporary programs against the original FCP to determine variations in components and/or evaluation measures.
To compare contemporary programs against the best-practice program elements identified by the ARACY review (Moore et al. 2012) and the scoping review (Latham et al. 2020) to determine opportunities for service improvement.
Methods
This descriptive study used Altheide’s five stage framework (Altheide and Schneider 2012) to analyse documents relating to contemporary home visiting programs in Queensland. This approach was chosen as Altheide’s framework has been used widely in the published literature and allowed for a critique and comparison of the selected programs’ process, practice elements, impacts, and evaluation measures against the original FCP.
Stage 1: Sampling selection
Queensland public HHSs were the target population from which the sample of programs was drawn. Services were eligible for inclusion if they a) had a current community child health service using the FCP (or adapted derivative) to deliver services to vulnerable families; or b) had been part of the original FCP trial between 2000 and 2004 (Chew 2003).
Seven eligible HHSs were identified across metropolitan, regional, and remote areas of Queensland through clinical networks for child and youth health. These HHSs serviced populations with considerable proportions of families experiencing socioeconomic challenges and vulnerabilities, including Aboriginal and Torres Strait Islander families and those living in regional communities (Queensland Health 2000; Moore et al. 2012).
Stage 2: Data collection
Service managers of eligible HHSs were contacted directly via email to request policy or procedural documentation regarding the service’s home visiting program. Five of the seven HHSs supplied documentation. One HHS declined to participate as a review of the service’s program was being undertaken at the time of the study. The remaining HHS did not engage with the request.
Stage 3: Data organisation
All relevant documents received were included in the document analysis, with key program elements identified and tabulated for comparison with those of the original FCP. The key elements of the original FCP are documented in Table 1.
Stage 4: Data analysis
Data variables (program aim, target group, eligibility, theoretical/conceptual frameworks, and evaluation measures) were extracted by the principal author (NL) and confirmed by research team members (see Table 2). Adapted programs were compared against the original FCP and each other, to identify similarities and differences across program elements. A scoring system was developed for this study to rate the alignment of the adapted programs to the original FCP. The researcher rated the alignment of each element of the adapted programs on a 3 point scale (0 = nil similarity, 1 = some similarity, 2 = same). Each program was then given an overall alignment rating (low = 0–4, moderate = 5–8, high = 9–12).
Stage 5: Report findings
Results of this analysis, including the strengths and limitations of contemporary programs and their alignment with the original FCP, are discussed in the context of findings from the ARACY reviews (Armstrong et al. 1999, 2000; Huston and Armstrong 1999; Chew 2003; McDonald et al. 2012; Moore et al. 2012) and the scoping review (Latham et al. 2020).
Results
Home visiting programs for five of the seven eligible HHSs were available for review. These services covered parts of the state in metropolitan (Service 2), regional (Services 3, 4, and 5), and remote (Services 1 and 5) areas (Queensland Health 2018). Home visiting programs in all participating services were provided by experienced registered nurses with additional qualifications in child and family health.
Table 2 illustrates the characteristics of adapted programs currently used in participating HHSs.
Program aims
There was considerable variation in the stated aims of the programs reviewed, with limited evidence that program content was focused on addressing specific risk factors. The original FCP aimed to build parenting skills, reduce risk factors, and improve infant outcomes, specifically among families likely to experience health inequality. The program aims of Services 2 and 3 were most consistent with this. Service 1 was more focused on conducting needs assessments in a collaborative environment, while Service 4 was the only service to specifically aim to redress health inequalities. No specific program aims were articulated by Service 5.
Target group
Whereas the original FCP was specifically targeted towards families experiencing poor maternal mood, financial stress, and violence, Service 4 was the only service to have retained this original target group. Most services’ target groups were significantly expanded from the original FCP. Aboriginal and Torres Strait Islander families and families from culturally and linguistically diverse backgrounds were included within the target groups for Services 1, 2, and 3.
Eligibility criteria
Contemporary programs retained some consistency with respect to the assessment tools used to determine eligibility. However, criteria for inclusion were substantially expanded across most programs compared with the original FCP. Services using a Care Coordination model (Services 1, 2, and 3) had much broader eligibility criteria.
Theoretical and conceptual frameworks
Care Coordination was used in Services 1, 2, and 3,2 while Services 4 and 5 both used an adapted version of the FCP. Care Coordination is a form of case management, helping a broad range of families navigate existing health services. This contrasts with the FCP’s narrower scope and focus on addressing factors associated with abuse and neglect. A common element through each of the programs was the use of the Family Partnership Model, incorporating goal setting and the development of a partnership between the CHN and the family. Another common element was supervision meetings, conducted regularly between CHNs and early intervention parenting specialists (social workers or psychologists with experience in attachment and parenting). Case conference meetings (which may include a paediatrician or child protection liaison officer3) were used to discuss families’ progress, difficulties, and complex needs and formulate a management strategy plan. Services 2 and 3 highlighted continuity of care as a priority (noting this was not always possible), a factor not mentioned in other programs’ documentation.
Program duration and evaluation measures
There was considerable variation in program duration and not all programs provided antenatal visits. Service 1 provided postnatal unstructured visiting tailored to the family’s identified needs, usually across a 6-month period. Service 2 provided a highly structured program with oversight from child health managers; families were reviewed every 3 months and discharged when all goals were met. Service 3 accepted referrals at any age, broadening the scope of services referring families (i.e. paediatric and child development services). It had a flexible visiting structure with a common duration of 2 years. Service 4 followed the original FCP visiting structure and duration (15 visits over 12 months), which would allow evaluation against the original program, should relevant measures be collected. Service 5’s program had a duration of 3–6 months and was the only service to specify evaluation measures.
Alignment with original FCP
Results indicate some consistency between contemporary programs, but considerable variation from the original FCP, as shown in Table 3. Low alignment was identified across four of the five participating HHSs.
| Comparator | Characteristics of original FCP | Services 1, 2 and 3 | Service 4 | Service 5 | |||
|---|---|---|---|---|---|---|---|
| Care Coordination | ASA | Family C.A.R.E | AS | Family C.A.R.E. | AS | ||
Eligibility criteria | EPDS score 16 or above | Not stated | 0 | EPDS score 12 or above | 1 | EPDS score 14 or above | 1 |
Affirmative response to domestic violence initiative questions | Domestic or family violence | 1 | Affirmative response to domestic violence initiative questions | 2 | Domestic violence with another criteria | 1 | |
Affirmative response to financial stress question | Financial hardship or poverty | 1 | Affirmative response to financial stress question | 2 | Financial stress with other psychosocial criteria | 1 | |
Evaluation measures | Multidisciplinary meeting review | 0 | Not stated | 0 | 1 | ||
Duration of program | 12 months | 3 months−2 years | 1 | 12 months | 2 | 3–6 months | 0 |
Target group | Families with issues related to mood, financial stress, and abuse in the home | 1 | Families with issues related to mood, financial stress, and abuse in the home | 2 | Families in the antenatal and immediate postnatal period | 0 | |
Total alignment ScoreB | Low alignment | 4 | High alignment | 9 | Low alignment | 4 | |
AAlignment score (AS): 0 = nil similarity, 1 = some similarity, 2 = same compared with original FCP.
BTotal alignment Score: low = 0–4, moderate = 5–8, high = 9–12.
Discussion
This document analysis compared the home visiting programs of five Queensland HHSs to identify how each had been modified from, and their level of alignment with, the original FCP. Service 4 was the only participating HHS to demonstrate high alignment with the original FCP. Nonetheless, program variation was still evident, including a changed eligibility criterion for maternal mood (reduced Edinburgh Postnatal Depression Scale (EPDS) score from 16 to 12) and a lack of evaluation measures.4 This highlights that changes to the original FCP have not been made in a systematic way, with the potential for program elements to be altered in response to the local service context.
The evaluation methods used in the original FCP were due to the reporting requirements of a trial program.5 For most of the programs (other than Service 5) to have no defined evaluation measures at all, other than review at interdisciplinary and multidisciplinary team meetings, is concerning. This is, however, consistent with the findings of the scoping review (Latham et al. 2020) and other research (Watson et al. 2005), which has indicated home visiting programs are often unable to demonstrate effectiveness due to a lack of meaningful evaluation of data collected. The current study highlights that, while these programs may have successfully improved outcomes for families, this is difficult to demonstrate due to the absence of evaluation. There is a concerning lack of evidence to support the efficacy of current Queensland programs that have been adapted from the original FCP.
In their report of effective strategies for home visiting programs, ARACY stated that how programs are provided is equally as important as what programs provide to families in terms of achieving their objectives (Moore et al. 2012). While the original FCP did not specify a theoretical or conceptual framework, the contemporary programs analysed all had some consistency with the Family Partnership Model. The Family Partnership Model is an evidence-based framework for goal-orientated, partnership practice and is used in home visiting programs and universal child health services (Davis and Day 2010). Originating in the UK, it has been implemented into policy for practitioners working with children and families in Australia, New Zealand, and more broadly across Europe (Day 2013).
Three of the five services reviewed used the Care Coordination model, which broadened eligibility criteria to include target groups outside those of the original FCP (i.e. families experiencing poor maternal mood, financial stress, and domestic and family violence). Interestingly, these programs had a shortened overall program duration of 3 months, unless review of the family’s ongoing needs supported further intervention. In practice, families were often referred to universal child health service programs to meet their ongoing needs (Service 4, personal communication, 31 August 2017).
The ARACY review recommended that sustained home visiting programs be evaluated on their ability to achieve outcomes against stated intentions (McDonald et al. 2012). The original FCP’s aims were to improve the target population’s maternal and infant health, parent–infant attachment and self-efficacy in parenting; support the infant’s cognitive and physical development; decrease maternal depression, anxiety, and distress; reduce risk of infant abuse and neglect; and reduce risk of vaccine preventable morbidity or mortality and SIDS. Having such clear objectives enabled evaluation measures to be defined and collected. This has not been replicated in the adapted versions and makes measuring outcomes for vulnerable families engaged with programs almost impossible.
The key elements of effective programs, identified by both ARACY and the scoping review, that are evident in the adapted models were a professional workforce of registered nurses skilled in child and family health, and provision of relationship-based care (Armstrong et al. 1999, 2000; Huston and Armstrong 1999; Chew 2003; McDonald et al. 2012; Moore et al. 2012). By using the Family Partnership Model, all of the programs were able to meet ARACY recommendations that they be relationship-based, utilise partnerships between families and CHNs, and enable parents to set goal directions (Moore et al. 2012). The EPDS screening for maternal mood distress was utilised in all programs in the antenatal period and was not limited to primiparous mothers.
The elements of effective programs were, however, lacking in several respects. Broad program aims, target groups, and eligibility criteria made it difficult to determine whether programs were reaching families most likely to benefit from intervention or were focused on addressing identified risk factors. Additional focus on cultural sensitivity and non-stigmatising practice is required, given Aboriginal and Torres Strait Islander families and those from culturally and linguistically diverse backgrounds were target groups of several programs. No information was provided about program fidelity or flexibility, and the shortened duration of some programs appeared to be driven by staffing and workload issues rather than client need.
Study limitations
The scope of this study was limited to how, rather than why, home nurse visiting programs differed in Queensland despite being derived from the original FCP. This study was further limited by its reliance on the documentation provided by HHSs. It is possible that the programs reviewed do include elements this study identifies as missing, but this was not substantiated by the documents provided. Consultation with key stakeholders would provide further context and is an area identified for further investigation. Furthermore, only five of the seven eligible HHSs participated in the current study, meaning a comprehensive analysis of home visiting programs state-wide was unable to be conducted.
Conclusion
This study compared nurse home visiting programs in selected Queensland HHSs with the original FCP. There was considerable variation between the programs in use across HHSs, and from the original FCP. The findings demonstrate that home visiting programs in Queensland have been poorly evaluated to date, with only one incorporating evaluation measures. It is understandable that programs may change over time due to a variety of factors. However, limited evaluation may have potentially contributed to model stagnation, with models adapted to meet service needs rather than outcomes for families, further contributing to the paucity of evidence to support home visiting programs. The Home Visiting Applied Research Collaborative (HARC) in the United States has developed a common research framework to help determine which interventions work best for families in different contexts, thereby advancing precision in the delivery of home visiting models (Duggan et al. 2022). Opportunities to address the gaps identified in this study may arise through investigating the evidence base of scalable models of care. For example, the Thriving Queensland Kids Partnership plans to deliver an evidence-based roadmap for family support services aimed at improving child wellbeing during the first 2000 days of life (Australian Research Alliance for Children and Youth 2022).
Continuing to use unevaluated programs raises several concerns. Without rigorous evaluation, it is unclear whether programs are delivering positive benefits for vulnerable families, effecting no change, or potentially resulting in unintended consequences. In a resource limited health environment, there is also a need to ensure public funding is directed towards programs with proven benefits. Best practice principles stipulate that if adapted programs continue to be used, appropriate data must be captured to enable evaluation of their ability to improve outcomes for families. Further research, including collaboration with HHSs, is essential to develop and collect relevant measures and implement evaluation processes. Robust evaluation will ensure that these investments in an infant’s first years of life reach their potential to positively impact childhood outcomes.
Data availability
The data that support this study were obtained from participating HHSs by permission. Data may be shared upon reasonable request to the corresponding author with permission from the relevant HHS.
Conflicts of interest
The principal author (NL) is a former employee of Service 4 but worked outside of the service during data collection and analysis. The remaining authors have no conflicts of interest to declare.
Author contributions
NL and JY conceptualised and designed the study; NL completed the data collection and initial analysis. All authors contributed to the interpretation of data. NL drafted the initial manuscript and JY, JW, and MG substantively revised it. NL, JY, JW, and MG all approved the submitted version of the manuscript. NL, JY, JW, and MG have agreed to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.
Acknowledgements
The authors thank and acknowledge the services for their valuable contribution and willingness to participate in this study. This research did not receive any specific funding.
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Footnotes
1 A ‘compounding effect’ occurs when families experience multiple types of social disadvantage, such as unemployment, low education, poor physical/mental health, alcohol/substance use, physical/sexual violence, or child abuse and neglect (Butler et al. 2012). Families experiencing multiple disadvantages can be considered ‘vulnerable’ or at high risk of experiencing adverse health and wellbeing outcomes.
3 Child protection liaison officers within Queensland hospitals provide advice to staff of the agency responsible for child protection and facilitate referral processes (Department of Children Youth Justice and Multicultural Affairs 2019).
4 This criterion may have been modified based on conflicting evidence about the score required to identify maternal distress, although current research recommends an EPDS score of 13 and above has sufficient sensitivity and specificity to detect major depression in both the antenatal and postnatal periods (Austin et al. 2017).
