Alan Melnick

Improving the Nurse–Family Partnership in Community Practice

BACKGROUND: Evidence-based preventive interventions are rarely final products. They have reached a stage of development that warrant public investment but require additional research and development to strengthen their effects. The Nurse-Family Partnership (NFP), a program of nurse home visiting, is grounded in findings from replicated randomized controlled trials. OBJECTIVE: Evidence-based programs require replication in accordance with the models tested in the original randomized controlled trials in order to achieve impacts comparable to those found in those trials, and yet they must be changed in order to improve their impacts, given that interventions require continuous improvement. This article provides a framework and illustrations of work our team members have developed to address this tension. METHODS: Because the NFP is delivered in communities outside of research contexts, we used quantitative and qualitative research to identify challenges with the NFP program model and its implementation, as well as promising approaches for addressing them. RESULTS: We describe a framework used to address these issues and illustrate its use in improving nurses’ skills in retaining participants, reducing closely spaced subsequent pregnancies, responding to intimate partner violence, observing and promoting caregivers’ care of their children, addressing parents’ mental health problems, classifying families’ risks and strengths as a guide for program implementation, and collaborating with indigenous health organizations to adapt and evaluate the program for their populations. We identify common challenges encountered in conducting research in practice settings and translating findings from these studies into ongoing program implementation. CONCLUSIONS: The conduct of research focused on quality improvement, model improvement, and implementation in NFP practice settings is challenging, but feasible, and holds promise for improving the impact of the NFP.

The costs of recruitment and retention of women from community-based programs into a randomized controlled contraceptive study.

Study aim. Assessing recruitment and retention activities needed to enroll women identified through community-based programs (such as the Women, Infants, and Children (WIC) program) into a randomized controlled clinical trial on nurse-delivered contraceptives in the home. The majority of women in this study had low socioeconomic status indicators and low levels of education, and the majority were young. Methods. Recruitment sources and number of contact-attempts were collected and analyzed. Full time equivalents needed to undertake these activities were estimated. Results. Two hundred and forty five women were identified in recruiting and enrolling 103 study participants involving 1,232 contact-attempts. Self-referral had the highest ratio of referrals to enrollees (55.6%), while this ratio was the lowest for community outreach (33.3%). Retention activities succeeded in maintaining over 90% of the sample. Ninety-two percent of English-speaking participants completed the study versus 79% of Spanish-speaking participants. The time expenditure per enrollee was 10.4 hours for recruitment and 1.2 hours for retention, with an estimated cost per enrollee of

The influence of nurse home visits, including provision of 3 months of contraceptives and contraceptive counseling, on perceived barriers to contraceptive use and contraceptive use self-efficacy.

324.03 for recruitment and

Public Health Accreditation and Metrics for Ethics: A Case Study on Environmental Health and Community Engagement

39.14 for retention. More retention activities were required to maintain women in the comparison group than in the intervention group.

THE PUBLIC IN PUBLIC HEALTH ETHICS: THE PUBLIC HEALTH SOCIETY RESPONDS

OBJECTIVE To identify the influence of a community health nurse (CHN) home visit on perceived barriers to contraceptive access and contraceptive use self-efficacy. METHODS We enrolled 103 women into two groups in a randomized trial evaluating the influence of contraceptive dispensing and family planning counseling during home visits on perceived barriers to accessing contraceptives and contraceptive use self-efficacy. Both groups received counseling by a CHN about sexually transmitted disease and pregnancy prevention, and a resource card listing phone numbers of family planning clinics. After randomization, the CHN dispensed three months of hormonal contraception to the intensive intervention group and advised the minimal intervention group to schedule an appointment at a family planning clinic. Data collection at baseline and 12 months included demographic, reproductive and other health-related information as well as quantitative assessments of information on perceived barriers to contraceptive access and contraceptive use self-efficacy. RESULTS The mean age of participants was 24.7 years. Three-fourths had household incomes under

Randomized Controlled Trial of Home‐Based Hormonal Contraceptive Dispensing for Women At Risk of Unintended Pregnancy

25,000. We found significant reductions in three perceived barriers to contraceptive access for both groups, as well as significant increases in two measures of contraceptive use self-efficacy at twelve months compared to baseline. CONCLUSION Nurse home visits involving family planning counseling might be effective in reducing perceived barriers to contraceptive access and increasing contraceptive use self-efficacy.

Essentials of public health ethics

As public health departments around the country undergo accreditation using the Public Health Accreditation Board standards, the process provides a new opportunity to integrate ethics metrics into day-to-day public health practice. While the accreditation standards do not explicitly address ethics, ethical tools and considerations can enrich the accreditation process by helping health departments and their communities understand what ethical principles underlie the accreditation standards and how to use metrics based on these ethical principles to support decision making in public health practice. We provide a crosswalk between a public health essential service, Public Health Accreditation Board community engagement domain standards, and the relevant ethical principles in the Public Health Code of Ethics (Code). A case study illustrates how the accreditation standards and the ethical principles in the Code together can enhance the practice of engaging the community in decision making in the local health department.

Should Home‐Based Contraceptive Dispensing become a Routine part of Public Health Nurse Practice? Review of Nurse Perceptions

The Public Health Leadership Society (PHLS) would like to thank Lear for his thoughtful comments on the Principles of the Ethical Practice of Public Health (more commonly known as the Public Health Code of Ethics).1 As the organization that led the development of the code, PHLS is pleased to respond to Lear’s comments by clarifying how we arrived at the present version. The code emerged as a result of our profound respect for the rights of individuals in the communities we serve and our enduring commitment to assuring the public’s health. Development of the code was initiated and led by what is now the PHLS Standing Committee on Public Health Ethics, which consists of public health professionals from local, state, and national public health practice organizations and public health academia. These individuals were formally encouraged to develop the code during a town hall meeting attended by representatives from a broad range of stakeholders at the 2000 Annual Meeting of the American Public Health Association (APHA) in Boston, Mass. A draft code was reviewed and critiqued in May 2001 in Kansas City, Mo, by 25 public health professionals and ethicists. A revised version was presented for discussion at another town hall meeting at the 2001 Annual Meeting in Atlanta, Ga. Before the meeting, the code was published on the APHA Web site and an e-mail address was provided for public reactions and feedback. The present code reflects input and discussion from all of these forums, and the development process was described in the Journal2 and on the APHA Web site. While PHLS went to considerable lengths to elicit feedback from a broad range of stakeholders, including the public, during the development process, it was not feasible to involve every individual or organization that might have had meaningful feedback to offer. However, PHLS has a continued commitment to providing opportunities for public comment (see http://www.phls.org/products.htm and http://www.apha.org/codeofethics). Thanks in part to the support of the Centers for Disease Control and Prevention, feedback continues to be collected and catalogued by PHLS, and an updating of the code is anticipated every 2 to 3 years.

Family Partnership in Community Practice - Improving the Nurse

CONTEXT Women frequently experience barriers to obtaining effective contraceptives from clinic-based providers. Allowing nurses to dispense hormonal methods during home visits may be a way to reduce barriers and improve -effective contraceptive use. METHODS Between 2009 and 2013, a sample of 337 low-income, pregnant clients of a nurse home-visit program in Washington State were randomly selected to receive either usual care or enhanced care in which nurses were permitted to provide hormonal contraceptives postpartum. Participants were surveyed at baseline and every three months postpartum for up to two years. Longitudinal Poisson mixed-effects regression analysis was used to examine group differences in gaps in effective contraceptive use, and survival analysis was used to examine time until a subsequent pregnancy. RESULTS Compared with usual care participants, enhanced care participants had an average of 9.6 fewer days not covered by effective contraceptive use during the 90 days following a first birth (52.6 vs. 62.2). By six months postpartum, 50% of usual care participants and 39% of enhanced care participants were using a long-acting reversible contraceptive (LARC). In analyses excluding LARC use, enhanced care participants had an average of 14.2 fewer days not covered by effective contraceptive use 0-3 months postpartum (65.0 vs. 79.2) and 15.7 fewer uncovered days 4-6 months postpartum (39.2 vs. 54.9). CONCLUSION Home dispensing of hormonal contraceptives may improve womens postpartum contraceptive use and should be explored as an intervention in communities where contraceptives are not easily accessible.