Effects Of Home Visitation Services On Maternal And Child Outcomes: A Randomized Control Trial

• Locate a nursing study that examines the effects of an intervention. Provide a summary of the study, focusing primarily on the intervention. Was the development and implementation of the intervention described in detail? Based on a theoretical framework? Did the design of the study promote investigation of the effects of the study---for example, was there comparison of experimental and control groups? Were there variables that could have impacted the findings that were not part of the intervention? Was there evidence of efforts to monitor the safety of participants? Are there any ways that the study could have been improved?

• Locate a nursing study that utilizes some aspect of the internet (for instance, for recruitment, delivery of an intervention, or completing online assessments. What challenges did the researchers face, and how were these challenges overcome (or not)? How could future research efforts be improved?

Description of the Home Visitation Intervention

A randomized control trial was conducted in order to determine the effects of infancy and prenatal home visitation services on the outcomes related to pregnancy childhood injuries and repeated childbearing in a community. The study was based on findings that home visitation services have proved effective in bringing about an improvement in child and maternal outcomes in different populations (Olds et al., 2014). The randomized control trial was conducted in the public system that focused on obstetric care in Memphis. An average of seven visits was made during pregnancy, followed by 26 visits from birth of the child to the second birthday. The intervention primarily composed of adherence to a detailed visit-by-visit protocol that guided the women in enhancing their health related behavior, steps of taking care of their children and life goals development such as, educational achievement, pregnancy planning, and workforce participation (Kitzman et al., 1997).

The intervention also made the nurses provide assistance to the women to complete a day long diet history on regular basis, followed by plotting the gain of weight on every visit. Smoking cigarettes and use of alcohol or other illegal drugs were also measured by the nurses, followed by a behavioral analysis, which made the women reduced their adherence to substance abuse. The home visit programs also helped in teaching the women the early signs and symptoms, which should be identified in relation to pregnancy complications, and also encouraged them to take necessary steps for informing office staff about the prevailing conditions, thus facilitating their treatment. Following delivery of the child during home visits, the nursing professional also supported the caregivers and mothers to improve the emotional and physical care of the children, followed by teaching the parents the strategies that should be adopted to recognise signs of illness and other disease among the children, recording of temperatures and communicating with office staff about the presenting complaints. Home visits also focused on promotion of child-parent interaction with the use of communication signals, enhancement of interest in children's play and promoting the cognitive and emotional development. The intervention also placed due focus on helping women gain a sound understanding of the objectives and goals, which in turn helped in solving the problems that they had encountered while finding work, planning for education, or family planning. Hence, it can be said that the development and implementation of the program plan that focused on home visits were discussed in details by the researchers (Kitzman et al., 1997).

Details of the Randomized Control Trial Design

While the researchers did not elaborate on presence of one treatment and one control group, they explained in details the four treatment groups to which the women were randomized. Treatment 1 comprised of 166 women who were given free round-trip cab transportation for the prenatal appointments. However, they did not get any postpartum assessment of services. Treatment 2 comprised of 515 women who were given free transportation for prenatal and developmental screening, besides referral services for children during 6, 12 and 24 months. 231 women present in treatment 3 also received the free screening and transportation services like treatment 2, in addition to intensive nurse home visitation programs during pregnancy, postpartum visits in the hospital prior to discharge, and at their homes.  228 women were placed in treatment 4 who received same services as that of treatment 3. However, the nurses continued to visit them in their houses till the second birthday of the child. Thus, it can be stated that the authors took all possible efforts in order to determine the effectiveness of the home visitation program by randomizing the target population into four different groups, each being subjected to a different scenario (Kitzman et al., 1997).

Owing to the fact that the researchers identified and assessed all the dependent variables including substance abuse, cigarette smoking, urinary tract infection, yeast infection, previous abortion, child abuse, mastery, mental health, and maternal psychological state, it can be suggested that they took efforts in monitoring the safety of the women who were given home visitation services. All the dependent variables that might have played an important role in the effects of intervention were taken into account (Kitzman et al., 1997).

The study might have been improved by conducting an assessment of the extent to which postnatal effects were largely dependent on the prenatal initiation of home visitation services. Conducting a careful examination of the same would further help in elaborating on the immediate impacts of home based visitation on the maternal and child outcomes. Furthermore, conducting a randomized control trial with an intervention group and the control group would also have helped in providing more clarity regarding the results (Tappen, 2015). Subjecting the intervention group to home based visitation programs from pregnancy state till a year after childbirth, and the control group to usual doctor appointments and care services might have elaborated more on the mechanism by which the home visits help in enhancing the  quality of life of both women and their children.

Monitoring the Safety of Participants

Internet based interventions that are conducted by nurses working in the community have been found to have the potential to provide assistance and supports to mothers who seek help from the internet on different aspects of child care. The randomized control trial was based on findings that elaborated on the effectiveness of internet based interventions and tried to assess the non-inferiority of outcome for infants and mothers, who were subjected to a postnatal health check that was moderated by nurses and conducted in a clinic (Aardoom et al., 2016). The researchers compared this internet based support group at a time when the infants were 1-7 months of age, with a control group, where the infants had received usual care services that comprised of postnatal home support delivered by community nurse. The recruitment of the participants was entirely based on the use of internet. Most participants for new mothers who had been referred by the burning hospitals present in CaFHS community located in Adelaide, South Australia for the postnatal health checkup. The new mothers with telephoned from March still December 2013 by the administrative officers, in order to arrange for their health checkup,  following which their verbal consent was obtained for consultation with the research team. The research team members telephoned all the mothers in order to obtain their informed consent, after providing them elaborate details on the objective and probable benefits of the study. This was followed by arranging visit to the mothers in their homes at different locations by research assistant, which was concomitant with the delivery of an in-depth description, prior to obtaining consent and conducting pre-intervention assessment.

This was followed by informing the women about the primary goal of their study to ascertain whether new internet+clinic based support programs were helpful to infants and their mothers. Mothers who expressed a strong desire for this program or usual home based support were allocated to the intervention group. Nonetheless, mothers who did not have any strong preference were randomly allocated to the two groups, which followed serial assignment based on service identification number (even vs. odd).  819 women of the total 1827 mothers who were contacted agreed to participate in the study. The researchers also excluded women from the study if they did not have any access to internet, needed an interpreter or suffered from different problems such as, domestic violence, ill health of the infants, or substance abuse (Sawyer et al., 2017).

Possible Improvements to the Study

The major challenges faced by the researchers were that all mothers who participated in the study belonged to socially advantage group. Hence, it was not possible for them to recruit women belonging to different social economic background in their study, in order to determine the effectiveness of internet based interventions. The authors also failed to analyze the cost effectiveness of internet based interventions in the study. Hence, future research is needed in order to overcome these challenges. However, some of the potential benefits that the internet based intervention offered to the authors were related to improving and maintaining the reach of the population, thereby ensuring quality control of all the information that was provided, and facilitating access to all kinds of referral services, during the first year of the infant. Other potential benefits that were elucidated by the researchers were related to the fact that the internet provided them the opportunity to track the engagement level of the mothers to the support program. Use of different feedback and online quizzes helped in assessing their knowledge acquisition. However, the researchers also stated that the necessity of replacing fixed review with other approaches that are more sensitive towards the development and modifications of children posed great challenges for research (Sawyer et al., 2017).

Future research must take into account persuasive designs that will improve retention of the mothers by incorporating larger control and sample group, with the aim of conclusively determining feasibility of internet based interventions. Additionally, in order to appropriately comment on effectiveness of such intervention, future studies should report the incidence data of different health related complications, with the use of standardized interview (Tappen, 2015). Efforts must also be taken by public health policies in order to promote research for reducing associated healthcare costs in the long run. Healthcare providers should also try to implement effective and existing interventions into routine care practices, in order to enhance the health and well-being of the target population.

Figure 1- Pie chart showing population estimates

References

Aardoom, J. J., Dingemans, A. E., van Ginkel, J. R., Spinhoven, P., Van Furth, E. F., & Van den Akker?van Marle, M. E. (2016). Cost?utility of an internet?based intervention with or without therapist support in comparison with a waiting list for individuals with eating disorder symptoms: a randomized controlled trial. International Journal of Eating Disorders, 49(12), 1068-1076.

Kitzman, H., Olds, D. L., Henderson, C. R., Hanks, C., Cole, R., Tatelbaum, R., ... & Engelhardt, K. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing: a randomized controlled trial. Jama, 278(8), 644-652.

Olds, D. L., Kitzman, H., Knudtson, M. D., Anson, E., Smith, J. A., & Cole, R. (2014). Effect of home visiting by nurses on maternal and child mortality: results of a 2-decade follow-up of a randomized clinical trial. JAMA pediatrics, 168(9), 800-806.

Sawyer, M. G., Reece, C. E., Bowering, K., Jeffs, D., Sawyer, A. C., Mittinty, M., & Lynch, J. W. (2017). Nurse-Moderated Internet-Based Support for New Mothers: Non-Inferiority, Randomized Controlled Trial. Journal of medical Internet research, 19(7).

Tappen, R. M. (2015). Advanced nursing research. Jones & Bartlett Publishers.