Patterns of Visit Attendance in the Nurse–Family Partnership Program

Objectives. We examined visit attendance patterns in the Memphis trial of the Nurse–Family Partnership and associations between these patterns and family characteristics, outcomes, and treatment–control differences in outcomes.Methods. We employed repeated measures latent class analysis to identify attendance patterns among the 228 mothers assigned to receive home nurse visits during pregnancy and until the child was aged 2 years, associated background characteristics, outcomes, and treatment–control differences by visit class. Home visits were conducted from June 1990 to March 1994. We collected outcome data from May 1992 to April 1994 and July 2003 to December 2006.Results. We identified 3 visit attendance patterns. High attenders (48%) had the most visits and good outcomes. Low attenders (33%) had the most education and the best outcomes. Increasing attenders (18%) had the fewest completed visits during pregnancy, the poorest intake characteristics, and the poorest outcomes. Treatment–control group differences varied by class, with high and low attenders having better outcomes on some measures than did their control group counterparts.Conclusions. Three patterns were associated with distinct groups of mothers with different long-term outcomes. Further examination and use of patterns to classify mothers and prioritize resources may improve efficiency in the Nurse–Family Partnership.Low visit attendance is a common problem with preventive interventions1 and occurs across home visitation programs.2–5 Missed visits are concerning because they are missed opportunities for providers to educate and support families. The positive outcomes intended for these programs are diminished with shorter duration of involvement4 and less contact time between the family and the visitor.6 The degree to which low visit attendance is a problem, however, is not easily quantified because there may not be a simple dose–response relationship between visit attendance and outcomes.Missed visits are associated with participant background characteristics and outcomes inconsistently across studies. Some of these inconsistencies may be attributable to differences in goals, target populations, and service providers. Other apparent inconsistencies may result from assumptions of linear or dichotomized relationships,5,7–10 in which there is some evidence of nonlinear associations. For instance, in the Elmira, New York, and Memphis, Tennessee, trials of the Nurse–Family Partnership (NFP), completing more visits was associated with lower maternal psychological resources in a linear relationship with an index based on mother’s intelligence, mental health, mastery (the extent to which the mother believes she can control her own life outcomes), and self-efficacy11 as well as a quadratic function with mothers with high and those with low psychological resources both receiving more visits than mothers with average psychological resources.12Lower visit attendance has been associated with lower income8,10 and education3,8 and worse mother and child health.10 However, stress, substance abuse, and mental health problems are associated with higher visit attendance.7 In one study, more social support was associated with lower visit attendance,7 but in another, being married and living with a partner was associated with higher visit attendance, whereas living alone was associated with lower visit attendance.3 The relationship between psychosocial characteristics and visit attendance is complex.Completed visits require cooperation between the mother and the nurse; the mother must be available at the scheduled time and the nurse must reach out to build trust and must reschedule missed appointments. Differences in visit patterns may reflect differences in families’ needs, mothers’ abilities to participate, and visitors’ interpretations of those needs. Visitors’ responses to these factors may differ depending on service provider characteristics or the personality match between the mother and nurse.13 In one program, sites with visitors who delivered the program with more flexibility had higher retention than did other sites,3 and increasing visitor flexibility increased completed home visits.2Visit attendance can be measured in many ways, including time to attrition, number of visits completed, and total contact time. Examining visit patterns over time instead of these aggregate measures may uncover nonlinear relationships and provide insight into the families’ experiences. Visit patterns can indicate if there are common times when families drop out or frequently miss visits or if there are other common trajectories. Previous work identifying attendance patterns focused on programs with a fixed number of visits,8,14 but home visiting programs often have a variable number, depending on the timing of enrollment.Visit attendance patterns at specific times during an intervention with a variable number of sessions have not been studied, to our knowledge, nor have the relationships between such patterns and outcomes. Identification of distinct visit attendance patterns may help predict which families would benefit from retention efforts and may improve our understanding of complex relationships between dose and outcomes.NFP is an evidence-based home visitation program implemented nationally15 in which fewer than half of recommended visits were completed in the original trials and in the current national replication of the program.2,3 NFP starts during pregnancy and recommends visits until the child’s second birthday.16 Visit frequency varies over time to support relationship development between the nurse and family and to accommodate shifts in maternal and child health and development over this 2.5-year period.17 Nurses promote improvements in the mothers’ health and parenting behaviors, economic self-sufficiency, and supportive relationships and link mothers with health and community services.18Three randomized controlled trials of the NFP model found consistent improvements in a range of outcomes, including children’s home environments, children’s language development, childhood injuries, and the timing of subsequent pregnancies for mothers.11,19–21 The intervention affected some outcomes for the whole sample and others (including child’s academic achievement) only for children of mothers with low psychological resources (40%–50% of the samples).The effects of NFP depend on engagement of the families with the program in accordance with the visit patterns achieved in the original NFP trials. Because of different levels of family need and engagement, we examined 3 questions: (1) Were there discernible variations in completed visit patterns over the course of the program? (2) Were those variations associated with risk and outcomes? (3) Were there intervention–control group differences in outcomes for the subgroups defined by visit patterns?     

Whose is SUS? About the social representation of the users of the Family Health Program

The present study analyzes the representation of the users of SUS and PSF, presenting data obtained by semi-structured interviews, using the theoretical referential of the qualitative research. The results show a social representation marked by a focused vision and assistance, pointing to the concentration of public resources in poor segments of the society and centered in the biomedical model of attention. It stands out that PSF did not reach their objectives to provide changes in the praxis in health. In relation to the social control, it is observed that only 5.9% of the interviewees know the CMS. The presented data show a great ignorance by the studied population on the sanitary system and conquered social laws, and many people still see SUS as a "health plan for the poor". Due to the lived reality, the need of the implementation of strategies is emphasized for the reach of larger powerment/liberation of the population, seeking to build effective possibilities so that their actors will be active participant of the process of construction of a common project, actually based on the democratic ideals of SUS, being PSF strategically important in the accomplishment of these actions.     

Evaluation of the quality of Family Healthcare Program in municipalities of Ceará: a multidimensional approach

We evaluated the quality of the Family Healthcare Program of Ceará (Brazil) by adopting a multidimensional model based on the theoretical assumptions of two important scholars, both well-known at an international level, namely Avedis Donadedian and John ?vretveit. We adopted the well-known approaches to the quality of healthcare of the first author: structure, process and outcome. Of the latter, we adopted the three dimensions of quality: quality perceived by patients, by professionals and by managers. The research was conductedten municipalities of the State of Ceará. Even though different nuances and emphases were used, the informants (physicians, nurses, coordinators of family healthcare teams, municipal secretaries of health and users) some aspects responsible for the improvement of the quality of Family Healthcare were identified. As a final result the study highlight a range of dimensions and quality indicators according to the perspective of the different actors involved in the study.     

Inclusion of oral health services in the Family Health Program in the State of Paraná, Brazil

The aim of this study was to analyze the implementation of dental care in the Family Health Program (FHP) in the State of Paraná, Brazil, one year after Ministry of Health (MoH) Ruling 1,444 went into effect. A qualitative and quantitative study was designed, focusing on the 136 municipalities which had included oral health services in the program by early 2002. The dental care teams received previously tested questionnaires on administrative and operational issues. The mean population covered by each team is close to the minimum stipulated by the MoH in 2000. However, some teams experienced difficulties in developing all the activities under their responsibility. Referral of more complex cases was also reported as a critical point. Favorable reception by the population and participation by dentists in the training courses were identified as positive points. Finally, a large proportion of dentists were under temporary work contracts (37.7%); there were also reports of the need to train general dental practitioners with an adequate profile for the FHP.     

Implementation of the Family Health Program and socio-spatial exclusion in the city of São Paulo, Brazil

The present article analyzes the implementation of the Family Health Program (FHP) in S?o Paulo, Brazil, taking as its reference the occupation of the city's space, characterized by strong socio-spatial segregation. The population coverage and consolidation achieved by the FHP and the partner institutions' legal and institutional formats were identified in 96 Administrative Districts (AD). The study then proceeded to stratify these ADs beginning with their position in a ranked social exclusion map. ADs were classified in five groups. Based on these results, a typology was produced in the FHP implementation in this capital city of the State of S?o Paulo. Clearly distinct patterns were identified when the ADs were ranked for exclusion/inclusion. FHP implementation was effective within the peripheral ADs, especially those in Group 1, indicating pressure for the Municipal Health Secretariat to comply with its discourse, which had assumed the FHP as a health care model to be implemented throughout the city, at least reaching the entire low-income population.     

The domestic violence against the elderly within the Family Health Program of Niterói (RJ, Brazil)

This article investigates the magnitude and characteristics of violence against the elderly by trusted people at Ilha da Concei??o, Niterói--RJ registered at the Family Health Program. A domestic survey interviewed 343 individuals with 60 years or more, selected by a simple random sample. To identify the violence it was used the Conflict Tactics Scales. Information about identification, demographics and socio-economics characteristics were obtained using the National Health Interview Survey. The Mini-Mental State Examination was used to evaluate mental health. In order to evaluate the functional capacity, the Health Assessment Questionnaire was used. In cases of alcohol suspicion among men, it was used the instrument CAGE. To female elder or caregivers, the TWEAK instrument was used. 43% reported at least one episode of psychological violence. Physical violence was reported by 9.6% of the interviewed, 6.1% reported serious physical violence in this period. The prevalence of different modalities of violence was higher among the youngest individuals, with higher scholarity, among those who have one of the pathologies that characterize the elderly as having a vulnerability (depression and/or urinary incontinence/fecal and/or diabetes and/or rheumatism) and those living with the greatest number of individuals.     

Evaluation of oral health actions in the Family Health Program in the Mosqueiro district, Pará State, Brazil

The extension of Brazil's Family Health Program Teams through the introduction of Oral Health Teams (OHT) as required by Decree N degrees 1,444 dated December 28, 2000, was an important step in the restructuring of the Oral Healthcare System, ensuring easier access to good quality dental care and treatment for less privileged segments of the population. In the Mosqueiro district of Pará State, an Oral Health Team was added to the Family Health Program in 2002, working closely with the local community through home calls and school visits, as well as at the Family Health Unit. In order to assess these Oral Health activities, 103 users of the Family Health Program Unit responded to a questionnaire with closed and semi-open questions in July 2004. The resulting data were tabulated, showing that most of these users were young adult women with high school diplomas but lacking access to higher education. This public felt that Oral Health quality had improved considerably, being satisfied with the performance of the current team.     

Education in reproductive health: proposal or reality in the Family Health Program?

As supervisors of primary health care units in the State of Ceará, Brazil, we have observed a low supply of health education services. As part of the activities under the Family Health Program (FHP), we attempted to investigate the causes of this short supply and identify flaws in the development of such activities. Interviews and participatory observation were adopted as the research method. The following causes were defined in the lack of health education practices: disorganization of demand, insufficient coverage of the population by FHP teams, resistance by both health professionals and the population to educational activities, absence of adequate floor space for conducting such activities, and lack of support materials. The following flaws were identified in the implementation of activities: limited exchange of experiences among participants; limited focus on the group's needs; frequent use of scientific language; transfer of outdated information; and inadequate utilization of teaching materials. The conclusion is that there is a need to retrain health professionals and to improve the availability of physical resources and teaching materials in order for education in reproductive health to become a reality in the FHP.     

“Home Practice Is the Program”: Parents’ Practice of Program Skills as Predictors of Outcomes in the New Beginnings Program Effectiveness Trial

An examination of the content and processes of evidence-based programs is critical for empirically evaluating theories about how programs work, the “action theory” of the program (West et al. in American Journal of Community Psychology, 21, 571–605, 1993). The New Beginnings Program (NBP; Wolchik et al., 2007), a parenting-after-divorce preventive intervention, theorizes that program-induced improvements in parenting across three domains: positive relationship quality, effective discipline, and protecting children from interparental conflict, will reduce the negative outcomes that are common among children from divorced families. The process theory is that home practice of program skills related to these parenting domains is the primary mechanism leading to positive change in parenting. This theory was tested using multi-rater data from 477 parents in the intervention condition of an effectiveness trial of the NBP (Sandler et al. 2016a, 2016b). Four research questions were addressed: Does home practice of skills predict change in the associated parenting outcomes targeted by the program? Is the effect above and beyond the influence of attendance at program sessions? What indicators of home practice (i.e., attempts, fidelity, efficacy, and competence) are most predictive of improvements in parenting? Do these indicators predict parenting improvements in underserved subpopulations (i.e., fathers and Latinos)? Structural Equation Modeling analyses indicated that parent-reported efficacy and provider-rated parent competence of home practice predicted improvements in the targeted parenting domains according to both parent and child reports. Moreover, indicators of home practice predicted improvements in parenting for fathers and Latinos, although patterns of effects varied by parenting outcome.     

The Development and Dissemination of the Triple P—Positive Parenting Program: A Multilevel,Evidence-Based System of Parenting and Family Support

This paper describes the theoretical and empirical basis of a unique multilevel system of parenting and family support known as the Triple P—Positive Parenting Program. The program incorporates five levels of intervention on a tiered continuum of increasing strength and narrowing population reach. The self-regulation framework of the program is discussed and an ecological or systems-contextual approach to dissemination of the program to service providers is highlighted. Implementation issues to consider in effective program dissemination are discussed including managing the politics of family support, strategies for coping with changes in government, maintaining quality, balancing cost and sustainability, and remaining data responsive. Future research directions are identified.     

The Impact of Lifelong Family Care on Family Caregivers’ Perceptions of the Sexuality of Young Adults with Intellectual Disabilities in the Western Cape of South Africa

Sexuality and Disability - This paper presents findings of a constructivist grounded theory study conducted within the Western Cape Province of South Africa. The study explored how family...     

Observance of the Laws of Family Purity in Modern–Orthodox Judaism

This research is a follow-up to a previous study measuring the observance of the ritually unclean period (Niddah) among Modern–Orthodox Jews. A total of 267 participants completed an online questionnaire comprised of a list of 16 “strict” and “lenient” forbidden behaviors. Participants reported whether they had engaged in these behaviors during Week 1 (the actual menstrual period) and during Week 2 (the “clean days” following the cessation of bleeding). Results showed that laws were being violated, with more transgressions during the second week than the first week. Additionally, more “lenient” laws were being broken than “strict” ones. Level of religious observance was significantly negatively correlated to the number of transgressions. However, there was no significant correlation between the number of transgressions and the age at marriage, sex, or how long one had been married.     

Family health program: a space for the reconstruction of social representations of the health-disease process?

A qualitative study that investigated the social representations of health-disease process of families accompanied by Family Health Program (FHP) in the rural zone in the municipal of Lafaiete Coutinho, Bahia, Brazil, aiming at analyzing the social representations of families about the health-disease process. Data were colected through a semi-structured interview with 23 members of several families. Content analysis was used do understand sense nucleous. The results showed that the FHP interferes in the reconstruction of social representations of health-disease process, through the organization of health services and of social production of health. It was concluded the FHP has contributed for the democratization of knowbdge of health-disease process, however it is necessary to dimystify cultural values reinforced by a model of attention that emphasized the recovery of diseases.