In a recently released issue of Pediatrics, Dr. Sharon Goldfeld and a team of collaborators from Australia describe a trial of the “right@home” Nurse Home Visiting (NHV) program and measure its impact on parenting and the home environment through age 2 years (10.1542/peds.2018-1206). Mothers who had 2 or more of 10 adverse risk factors were eligible to participate. Women were randomized to receive either “right@home,” consisting of 25 home nurse visits from pregnancy through the child’s second birthday, or usual care, which included 6-9 nurse visits including one in the home over the same time period. Of the 722 enrolled mothers, 596 (82.5%) provided information at 2 years of age on the primary outcomes, which included 13 areas within the 3 domains of (1) child care (sleeping, feeding and safety), (2) parental responsivity including bonding and nurturing parenting, and (3) the home environment with focus on literacy and learning activities.
This ambitious study “paid particular attention to program design, logic and fidelity, often missing from published [Nursing Home Visiting] research.”1 The “right@home” program was piggy-backed onto existing services, used a curriculum approach delivered by a multidisciplinary team including (usually) the same nurse familiar to the family and a social worker, and interestingly, deliberately included increasing spacing of visits over time to build the family’s independence. Since the intervention was multi-faceted and comprehensive, the authors deliberately chose to assess it with multiple outcomes, both to embrace the many possible impacts of the program, and also for purposes of comparison with other trials. They acknowledge the statistical imperfection of this approach! So in addition to the primary outcomes described above, there was another entire tier of secondary outcomes, including a host of variables ranging from breastfeeding to parenting efficacy to maternal mental health and child global health. Initially I felt overwhelmed by the sheer volume of outcomes, but as I re-read sections I realized the beauty of this approach.
Nurse home visiting is intuitively appealing. It makes sense that an empathic and trained health provider visiting multiple times in the home could make a unique difference by “meeting the parent where she/he is” (literally and figuratively). One challenge, however, has been in identifying outcomes that are meaningful, measurable and not susceptible to bias. For example, episodes of non-accidental trauma are a problematic outcome measure since their frequency may depend on reporting bias and ascertainment bias, and can change with active preventive intervention. The work of Goldfeld et al takes a fresh and broad approach to the outcomes challenge, and demonstrates that “right@home” NHV is a potentially promising approach. Anyone interested in public health or in serving the underserved will enjoy this article tremendously.
1. Goldfeld et al Nurse Home Visiting for Families Experiencing Adversity: A Randomized Trial. Pediatr 10.1542/peds.2018-1206.