Changing the Home Visiting Research Paradigm: Models’ Perspectives on Behavioral Pathways and Intervention Techniques to Promote Good Birth Outcomes

Abstract

Background: The US is scaling up evidence-based home visiting to promote health equity in expectant families and families with young children. Persistently small average effects for full models argue for a shift in the research paradigm to understand what interventions within full models work best, for which families, in which contexts, why, and how. Historically, the complexity and proprietary nature of most evidence-based models have been barriers to such research. To address this, stakeholders are building the Precision Paradigm, a common framework and language to define and test interventions and their mediators and moderators. This observational study applied portions of the Paradigm to describe models' intended behavioral pathways to good birth outcomes and their stance on home visitors' use of specific intervention techniques to promote families' progress along intended pathways.Methods: Five of the six eligible evidence-based models participated. Model representatives independently completed three structured surveys focused on 41 intended behavioral pathways and 23 behavior change technique categories. Survey data were used to describe: the number and nature of models' intended behavioral pathways to good birth outcomes; the behavior change techniques they required or recommended home visitors to use; the relative emphasis given to required/recommended techniques; the compatibility of other techniques with their model; and the consistency of their stance on techniques across intended pathways.Results: Models defined 31.6 intended pathways on average but varied in their number of intended pathways (range 16-41) and the nature of such pathways. They varied in the number of technique categories they required (mean 3.2, range 0-8.9) or recommended (mean 10.6, range 1.5-20.0) that home visitors use. That said, all models rated nearly all technique categories as at least compatible with their model, even if not explicitly required or recommended. Within intended pathways, models varied in the relative emphasis to give to specific techniques. Models varied in the consistency of their requirements and recommendations for using specific techniques across intended pathways.Conclusions: The Precision Paradigm is a promising resource to accelerate innovative cross-model research to clarify which interventions within home visiting work best for which families, in which contexts, why and how.

Home visitor perspectives on implementing a precision approach to home visiting in communities serving Native American families

“…This framework considers context to consist of participants (e.g., providers, clients), organizations, and community characteristics through which home visiting operates. Context influences participant reach and engagement, and the pathway from interventions (e.g., motivational interviewing, behavioral change techniques) to knowledge, attitudes, and skills among home visitors (e.g., how lessons are delivered) to target behaviors (e.g., engage in stress reduction activities), which lead to intended outcomes (e.g., healthy birthweight) (Duggan et al, 2021). The Precision Paradigm framework is grounded in theory, empirical evidence, and home visiting stakeholders' experience (Duggan et al, 2021).…”

“…Context influences participant reach and engagement, and the pathway from interventions (e.g., motivational interviewing, behavioral change techniques) to knowledge, attitudes, and skills among home visitors (e.g., how lessons are delivered) to target behaviors (e.g., engage in stress reduction activities), which lead to intended outcomes (e.g., healthy birthweight) (Duggan et al, 2021). The Precision Paradigm framework is grounded in theory, empirical evidence, and home visiting stakeholders' experience (Duggan et al, 2021). The intention is to shift away from the full evidence-based home visiting model and towards specific interventions within the model that works best for clients, with consideration for contextual factors and asking why and how such interventions meet program goals (Duggan et al, 2021).…”

“…The Precision Paradigm framework is grounded in theory, empirical evidence, and home visiting stakeholders' experience (Duggan et al, 2021). The intention is to shift away from the full evidence-based home visiting model and towards specific interventions within the model that works best for clients, with consideration for contextual factors and asking why and how such interventions meet program goals (Duggan et al, 2021).…”

Who enrolls in home visiting prenatally and how does this impact child and family outcomes in the first year of life?

“…To address this complicated system of risks and intervention, some researchers in home visiting have adopted a Precision Paradigm to help identify and respond to these risk factors (Duggan, 2021). This study uses the Precision Paradigm to specifically explore the potential moderating effects of context on child and family outcomes as shown in the model of the Precision Paradigm.…”

“…This approach is particularly well-tailored to answer policy and programmatic questions surrounding what works for whom in prevention and intervention programs in determining programmatic aims (Supplee et al, 2012). Using this paradigm, we can identify 1) the intervention, including the techniques and methods of delivery, 2) mediators, or mechanisms of action and target behaviors, and 3) moderators, or usage and context of the intervention (Duggan, 2021).…”