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Adapting Current Strategies to Implement Evidence-Based Prevention Programs for Paraprofessional Home Visiting

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Abstract

This paper describes a strategy for using evidence-based interventions (EBI) that does not require replication and fidelity. Eight parents, identified as positive role models, conducted home visits for 101 low-income Latina and Korean pregnant women. The home visitors, called mentor mothers (MM), were trained in 10 of the practice elements common to 80% of child-focused EBI and how to apply these skills to support mothers in obesity prevention, to increase the duration of breastfeeding, and to reduce depression. MM reported the content and skills utilized on each home visit on mobile phones. Each MM made an average of 153 home visits (SD = 173.3), with 28 of these visits being phone contacts. Body mass index (BMI) at 6 months was significantly associated with the frequency of MM focused on coping with depression (r = .24), but was not related to practice elements used by MM. The duration of breastfeeding was significantly related to the frequency with which MM focused on the topic of breastfeeding (r = .28) and parenting (r = .3), and MM use of attending (r = .24) and relaxation (r = .27). Depression was significantly correlated with the frequency of addressing depression (r = .27), but not to practice elements. MM did use different strategies in the first 150 visits compared to their last 150 visits, reflecting data-informed supervision. Evidence synthesized from EBI was used as a novel training method, with real-time monitoring and data-informed supervision providing evidence of iterative quality improvements in MM behaviors over time, as well as a way for linking implementation processes to outcomes.

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Summary

We provide an example of how researchers and providers could begin to experiment with introducing flexibility into the delivery of EBI. Especially with the relatively small sample in this study, we need much more experimentation as to whether and how this model might work. There needs to be a robust strategy, or strategies, in order to broadly implement our existing portfolios of EBI in every family in every community.

There have been a series of implementation studies demonstrating why EBI need to be adapted for populations, delivery contexts, intervention strategies, and organizational settings (Cohen et al., 2008; Kendall & Beidas, 2007). Focusing on maintaining fidelity often reduces the consumers’ engagement with the change agent (Sandler, Schoenfelder, Wolchik, & MacKinnon, 2011), and engagement in EBI is often low. Almost no programs anticipate how to deal with daily crises (le Roux et al., 2013), and research is emerging that this failure negatively impacts outcomes (Leslie et al., 2015). Concerns about how broad diffusion can be feasibly implemented has led to calls for flexibility in standards, novel models of synthesizing evidence, and iterative quality improvement in the DNA of each behavioral EBI (Aarons et al., 2012; Kazdin & Blase, 2011; Rotheram-Borus, Swendeman, & Chorpita, 2012).

This study provides one example of how to experiment with existing standards, but utilize knowledge from existing EBI. The model is not inexpensive, however. In contrast to the typical 1-week training for paraprofessional home visitors (Witkin, 2013), we conducted a month of training. Data-informed supervision requires monitoring MM home visits weekly. In the field, half of the MM did not demonstrate improvement over time and the workload of these MM was reduced. While the paraprofessionals are much less expensive than nurses, multiple strategies were implemented to ensure quality: rigorous selection criteria and eliminating MM who did not engage mothers well and those who did not improve over time.

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Authors and Affiliations

  1. Mary Lou Fulton Teachers College, Arizona State University, PO Box 871811, Tempe, AZ, 85287, USA

    Erin Rotheram-Fuller

  2. University of California at Los Angeles, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA, 90024, USA

    Dallas Swendeman, Maryann Koussa Youssef & Mary Jane Rotheram-Borus

  3. University of Maryland School of Medicine, 737 W. Lombard Street, Baltimore, MD, 21201, USA

    Kim Becker

  4. PracticeWise, LLC, 340 Lee Ave, Satellite Beach, FL, 32937, USA

    Eric Daleiden

  5. University of California at Los Angeles, 3227 Franz Hall, Los Angeles, CA, 90095, USA

    Bruce Chorpita

Authors
  1. Erin Rotheram-Fuller
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  2. Dallas Swendeman
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  3. Kim Becker
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  4. Eric Daleiden
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  5. Bruce Chorpita
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  6. Maryann Koussa Youssef
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  7. Mary Jane Rotheram-Borus
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Corresponding author

Correspondence to Mary Jane Rotheram-Borus.

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Funding

This study was funded by Kellogg Foundation Grant # P3018725 and supported by grants from the National Institutes of Health MH58107, 5P30AI028697, and UL1TR000124. Clinical trial registration: NCT01687634

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

The institutional review boards of the University of California Los Angeles (UCLA), Stellenbosch University, and Emory University approved the study. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

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Rotheram-Fuller, E., Swendeman, D., Becker, K. et al. Adapting Current Strategies to Implement Evidence-Based Prevention Programs for Paraprofessional Home Visiting. Prev Sci 18, 590–599 (2017). https://doi.org/10.1007/s11121-017-0787-z

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