摘要：Objectives. We evaluated whether a brief, universal, postnatal nurse home-visiting intervention can be implemented with high penetration and fidelity, prevent emergency health care services, and promote positive parenting by infant age 6 months. Methods. Durham Connects is a manualized 4- to 7-session program to assess family needs and connect parents with community resources to improve infant health and well-being. All 4777 resident births in Durham, North Carolina, between July 1, 2009, and December 31, 2010, were randomly assigned to intervention and control conditions. A random, representative subset of 549 families received blinded interviews for impact evaluation. Results. Of all families, 80% initiated participation; adherence was 84%. Hospital records indicated that Durham Connects infants had 59% fewer infant emergency medical care episodes than did control infants. Durham Connects mothers reported fewer infant emergency care episodes and more community connections, more positive parenting behaviors, participation in higher quality out-of-home child care, and lower rates of anxiety than control mothers. Blinded observers reported higher quality home environments for Durham Connects than for control families. Conclusions. A brief universal home-visiting program implemented with high penetration and fidelity can lower costly emergency medical care and improve family outcomes. The Maternal, Infant, and Early Childhood Home Visiting Program of the federal Patient Protection and Affordable Care Act of 2010 provides $1.5 billion for postnatal home-visiting programs to improve outcomes in the “reduction of emergency department visits.” 1 (p218) Because it is intended as an evidence-based public health policy, most of the funds support programs for demographically high-risk subgroups that have demonstrated efficacy in small randomized controlled trials. 2–4 A meta-analysis 5 of impact studies revealed empirical support for home visiting as a vehicle to reach proximal goals of providing emotional support for parents after birth, improving parenting behavior, and connecting families with individualized community resources to achieve distal impact on reducing emergency medical care. Although these programs are promising, no home-visiting program has ever scaled up successfully to demonstrate population impact on public health, despite the Institute of Medicine mandate to move from basic science to efficacy trials to effectiveness trials to population dissemination. 6 To our knowledge, we describe the first-ever randomized controlled trial of a brief, postpartum universal nurse home-visiting program at the population level. Scaling up for population impact encounters at least 4 challenges. First, home-visiting programs are rarely designed or evaluated for universal reach during a randomized controlled trial (e.g., Nurse-Family Parnership 2 limits itself to demographically high-risk, primiparous mothers who voluntarily enroll in the 2nd trimester, a group that accounts for less than half of all maltreatment cases). Second, as programs scale up, penetration and retention often decline (e.g., 40% of targeted groups never enroll, 7 and participant dropout after enrollment is 50%–67% 8 ). Third, when a program is scaled up, 9 quality and fidelity typically degrade as much as 50%. Finally, programs presume sufficient community capacity to meet families’ needs during a scaled-up dissemination. Impact depends on the home visitor’s ability to find community resources for a family. 10 If a program is implemented during a small randomized controlled trial, the family gains a competitive advantage over nontreated families in accessing fixed-sum resources, but when brought to scale, families’ needs might exceed community capacity to provide services, lowering net impact on child outcomes. The Maternal, Infant, and Early Childhood Home Visiting Program legislation recognizes the importance of community capacity by requiring that programs address “improvements in the coordination of referrals for, and the provision of, other community resources and supports for eligible families.”1(p219) These referrals should be based on an individualized assessment of the family. To our knowledge, no program has systematically attempted to improve community capacity. We report the development, implementation, and impact evaluation of a brief postnatal nurse home-visiting program called Durham Connects that was delivered universally in a mid-sized community with a high rate of poverty. We hypothesized that Durham Connects would achieve its aims to (1) reach most birthing families in the population, with high fidelity of implementation at reasonable cost; (2) improve the family’s connections to individually matched ongoing community resources based on assessed risk and need; (3) improve parenting and family functioning; and (4) improve infant public health outcomes cost beneficially. We report evaluation of aims 1 and 2 through implementation findings and cost analyses and evaluation of aims 3 and 4 through random assignment of all births over an 18-month enrollment period and in-home interviews with a random, representative subsample of families with infants aged 6 months.
