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Breaking the poverty & poor health cycle

A highly successful home-visit program pioneered in the US is making headway in indigenous communities here, writes Linda Belardi

Aver the past 30 years, a nurse-led home visiting program implemented in the US has seen dramatic changes in infant mortality, school attendance and youth incarceration.

Rates of child abuse and neglect in targeted communities have dropped by 50 per cent and by age 19, criminal arrests fell by more than 40 per cent.

But even more significant than the sheer scale of the long-term effects on communities is the fact that these results can be replicated.

Three large randomised clinical trials of the nursing intervention conducted over 30 years have demonstrated a pattern of “sizeable and sustained effects” on child and maternal outcomes, meaning policymakers can be confident of repeating these results.

Diverse communities of young first-time mothers usually unmarried and often living in poverty were targeted in Memphis, Denver and Elmira in New York State and the scientific trials produced remarkably similar results. Babies were born healthier, their school readiness improved, and over time families reduced their reliance on welfare.

The Coalition for Evidence-Based policy, a not-for-profit American organisation, said there are probably only about 10 programs across all areas of social policy in the US that currently meet this top tier standard in evidence-based policy.

Professor David Olds from the Prevention Research Centre for Family and Child Health at the University of Colorado is the architect of this “science” of social change and the founder of the Nurse-Family Partnership program (NFP).

The NFP is an intensive home visitation program that links vulnerable mothers with registered nurses, starting during pregnancy and continuing up until the child is two years of age. The structured and sustained nurse visits provide intensive education and support to women to promote healthy behaviours during pregnancy and to support a child’s early learning and development.

Due to its record of success, the NFP has been introduced into 40 states in America and now six countries worldwide, including Australia in 2009.

A trial of the US model, known locally as the Australian-Nurse Family Partnership Program (ANFPP), is currently underway at three sites; Cairns, Wellington in central NSW and Alice Springs. The program is delivered by primary healthcare services with experience in providing indigenous maternal and child services.

The NFP was introduced to the Northern Territory in 2009 after nearly a decade of lobbying by the Central Australian Aboriginal Congress (CAAC).

The “Olds model” was identified as a suitable program for local adaptation because it was achieving results in areas of major concern in Alice Springs, including high rates of infant mortality, youth drug and alcohol abuse, high levels of incarceration and poor school attendance.

Annie Power, acting nurse supervisor with CAAC in the Northern Territory, works with a team of seven registered nurses and three Aboriginal community workers to deliver the program, which has just had its first cohort of 12 women graduate in March.

She says the model demonstrates the power of early intervention, especially during pregnancy, to fundamentally alter the life outcomes of a child. Under the requirements of the program the first home visit with the pregnant mother must occur prior to 28 weeks gestation.

The program also tackles the social determinants of health by addressing the environment in which Aboriginal babies are born.

“Professor David Olds first identified in the mid-1970s that young women and first-time mums in particular, really need some support and education around what it is to be a parent and he saw that developing a program in early pregnancy where women are quite open to new ideas might be the place to start,” Power tells Nursing Review.

Ninety-two women are currently enrolled in the program in Alice Springs, including nine women in outlying indigenous communities within a 100 kilometre radius. Power says self-referrals are also increasing. “That’s the gold standard when women are saying they want to be part of this program.”
While the ANFPP is still in its early phase, initial results are promising.

Since its introduction in 2009, smoking rates during pregnancy have dropped and women have felt empowered to make new life choices, says Power. “We’ve noticed women wanting to return to work or to school and making positive life choices around their own personal safety and the safety of their kids.”

She recounts the case of an indigenous mother who left the program within the first year of signing up. Disappointed with the early departure, the team followed up the young mother to investigate her reason for leaving.

The team later discovered that the early exit was instigated by a decision to move interstate to protect herself from an abusive relationship. “She told us that talking to the nurse home visitor got her thinking about what she wanted from her life and as a result she made the decision to move away from Alice Springs. That’s pretty powerful.”

On a daily basis the nurse home visitors also report subtle but important changes in the attitudes of the women to their mothering role.

Elise is a nurse home visitor in Alice Springs. She says the women have developed a deeper appreciation of their responsibilities as a parent and the importance of the mother’s role as teacher.

“Working from a strengths-based perspective means we are always looking to encourage women. When you sit with a mother and tell her that her baby will learn more in the first two years of life from her and her family than for the rest of her baby’s life, you can see the pride and esteem rise up within her,” says Elise.

The nurses also spend a lot of time teaching mothers about identifying baby cues and assisting mothers to bond with their child.

Power says the nurses take on the role of educator, listener and mentor and provide an important anchor in the women’s lives.

Through goal setting and motivational interviewing, the mothers are supported to provide more skilled parenting and to concentrate on their strengths, environment and personal health. “The response from women has been incredible. Women love getting this information; it’s like a sponge effect,” says Power.

“Women are really in some tough situations but what these women share with their nurses is just incredible. We’re really privileged to be able to share this model with women and for women to share their experience and learning with us.”

Beyond a clinical role for nurses

Home visitation has a long tradition in healthcare but rarely does it involve such a sustained period of relationship-building across two and a half years.

Similar programs commonly provide only a single visit to a newborn, often by a volunteer rather than a trained health professional within the first few weeks of birth.

As part of the ANFPP, mothers are visited on average every two weeks throughout the entire program. However, the frequency of the visits increases to a weekly basis during peak periods of the process, such as upon entering the program and immediately post pregnancy.

Power says the program also challenges the traditional clinical role of the nurse. “We don’t weigh babies or conduct physical assessment. It is all about education and support, which can provide an initial challenge for nurses coming into the program.”

The intensive program also requires a huge level of commitment from both the mothers involved and the nurse home visitors working in Central Australia.

While there is an attrition rate Power says it is small and reflective of the Northern Territory’s transient population.

Nurses as agents of change

Above all, the program demonstrates the power of professional nursing.
In the early 1990s, alternate models of the NFP emerged which substituted registered nurses with a lower qualified professional. Paraprofessionals used in these trials produced small effects that rarely achieved statistical or clinical significance.

Professor Olds says the skills and public trust in nurses increases their persuasive power with mothers and families and is believed to be what makes the difference. Nurses were also able to identify emerging complications earlier and were more successful at encouraging mothers to stop or reduce smoking.

Australian adaptation

Locally, the home visiting program is delivered by Aboriginal community-controlled health services and funded by the federal government. However, the program maintains close contact with NFP headquarters at the University of Colorado Health Sciences Centre.

Quarterly teleconferences are held with Olds or senior clinicians from the US sites to discuss the model’s adaptation in Australia and what can be learnt from 30 years of development.

Australian nurses in the ANFPP have also undertaken private visits to Germany and the UK to observe the global replication of the model. “There is a real sense of being part of something bigger,” says Power. “We are welcomed all over the world and it’s important to get a sense of how it is working in different countries.”

Nurse supervisors at the three Australian sites also collaborate frequently via teleconference to share successes and lessons learnt as the model is trialled and adapted to the Australian indigenous context.

“We throw ideas on the table all the time about what works for us here and the nursing teams based in Cairns and Wellington will try it in their sites,” says Power.

While the US program has been conducted with mainly young unmarried women living in poverty from a range of cultures and demographics, the Australian trial targets women (indigenous or non-indigenous) who are having an indigenous baby. The low indigenous uptake of primary health services coupled with concerning health statistics make this group a priority area for targeted funding by the federal government.

Aboriginal and Torres Strait Islander mothers are more likely to smoke during pregnancy and have five times the maternal death rate. Twenty per cent of indigenous mothers are also teenage mothers compared with approximately 4 per cent of non-indigenous mothers.

While faithful to its key principles, the program in Australia differs to the original US model in some distinctive ways; it accepts second-time mums as well as new mums and has introduced the support role of the Aboriginal community worker (ACW) or family partnership worker.

One of the primary roles of the ACW is to act as a link between the program and the community.

They help to engage with indigenous women, provide language support to the nurses and to ensure the cultural appropriateness of the resources used.

“The nurse’s role in the program has been well defined – it emanates from the US, but one of the challenges for Australia is to develop the ACW role to ensure that they are well-supported and trained to do their role,” says Power.

National rollout postponed

In this year’s May budget, progress on a national rollout of the program received a significant blow when the federal government announced a withdrawal of funding for the ANFPP, saving $23.2 million over four years.

A spokeswoman for the Department of Health and Ageing said it would not expand the trial to the originally planned seven sites because appropriate service providers could not be recruited to deliver the program.

“Although funding was initially provided for seven sites, after three selection rounds to seek suitable organisations to implement the program, only the existing four sites were identified,” she told NR.

She said funding to existing service organisations would not be reduced. However, the Victorian Aboriginal Health Service (VAHS) has chosen to withdraw from the ANFPP reducing the existing trial sites to three.

An evaluation report of the program is currently being finalised by the department.

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