Abstract
Objectives: A formative evaluation of a home-based family intervention, Family Foundations (FF), targeting parent mental health and conflict in the perinatal period was conducted. The aims were to (a) assess parent satisfaction and recommendations for improvement, (b) identify perceived enablers and barriers to engagement, and (c) obtain preliminary outcome data related to parent mental health, conflict, and coparenting. Methods: A mixed-methods evaluation was conducted with 41 families at risk of or experiencing parental conflict. FF was delivered by two organizations in Australia. Qualitative interviews with parents and FF clinicians were conducted, and intervention outcomes were assessed using parent survey. Results: Feasibility of reach and recruitment of the target population was demonstrated. Parents' indicated a high level of satisfaction with all aspects of FF and offered recommendations for improvements to resources and delivery. Service, program, clinician, and family characteristics as enablers and barriers to engagement in FF were identified. Both mothers and partners reported a decrease in their child's exposure to conflict. Mothers also reported a decrease in mental health symptoms and parenting hostility and an increase in positive coparenting behavior. Conclusion: Feasibility and acceptability of home-based FF in the perinatal period had been established, with preliminary evidence of positive outcomes for families. Implications: The current findings generate evidence to inform further development of home-based FF and wider implementation in health and social care services in Australia.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 1036-1057 |
| Number of pages | 22 |
| Journal | Family Relations |
| Volume | 71 |
| Issue number | 3 |
| DOIs | |
| State | Published - Jul 2022 |
All Science Journal Classification (ASJC) codes
- Education
- Developmental and Educational Psychology
- Social Sciences (miscellaneous)
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In: Family Relations, Vol. 71, No. 3, 07.2022, p. 1036-1057.
Research output: Contribution to journal › Article › peer-review
TY - JOUR
T1 - Evaluation of home-based Family Foundations targeting perinatal mental health and couple conflict in Australia
AU - Giallo, Rebecca
AU - Seymour, Monique
AU - Skinner, Lorraine
AU - Fogarty, Alison
AU - Field, Karen
AU - Mead, Jemma
AU - Rimington, Helen
AU - Galea, Kate
AU - Talevski, Tom
AU - Ruthven, Claire
AU - Brown, Stephanie
AU - Feinberg, Mark
N1 - Funding Information: This study was supported by the Victorian Government Department of Health and Human Services Building Evidence Based Programs and Practice in Child, Youth and Family Services funding; the NHMRC Safer Families Centre of Research Excellence; and Victorian Government's Operational Infrastructure Support Program to MCRI. R.G. was supported by a National Health and Medical Research Council (NHMRC) Career Development Fellowship, and S.B. was supported by a NHMRC Research Fellowship. The funding organizations had no involvement in the conduct of the study and the authors are independent of the funding sources. Funding Information: This study was supported by the Victorian Government Department of Health and Human Services Building Evidence Based Programs and Practice in Child, Youth and Family Services funding; the NHMRC Safer Families Centre of Research Excellence; and Victorian Government's Operational Infrastructure Support Program to MCRI. R.G. was supported by a National Health and Medical Research Council (NHMRC) Career Development Fellowship, and S.B. was supported by a NHMRC Research Fellowship. The funding organizations had no involvement in the conduct of the study and the authors are independent of the funding sources. This study is the first to report on the acceptability and preliminary outcomes of home-based FF delivered in real-world service settings in Australia. Importantly, we demonstrated that it was possible to reach and recruit the intended target population. At baseline, approximately half of the families reported partner conflict, and one in three reported parent mental health difficulties. The majority of families (87%) were experiencing two or more risk factors for parental conflict and mental health problems including relationship difficulties, young parental age, low educational attainment, low income, and parenting two or more children. Reaching and offering early interventions such as FF to families experiencing, or at risk of, conflict and mental health difficulties is important not only for parents themselves but also for their children, who are at risk of health, well-being, and developmental difficulties across the life course (Rogers et al., 2020; Schiff et al., 2014). There was high level of satisfaction with all aspects of FF. Specifically, parents appreciated that it was delivered in their own home by two clinicians at a time that suited them. Although this has implications for organizations (i.e., higher level of staff resourcing per family than usual, workforce availability outside of business hours), there are potential benefits for parent engagement. In the interviews, mothers and clinicians agreed that the home visits made FF accessible, overcoming potential common barriers to attendance associated with employment and difficulties finding childcare. The value of home-based models to overcome barriers to help-seeking and service use by those who are less likely to attend health and social services in the community is well documented (McDonald et al., 2012). Delivering FF in the home may also aid use and generalization of the skills in the environment in which parents will need to use them. Several features of FF were identified as particularly important for the engagement of fathers. These included (a) the focus on the parenting partnership in raising children; (b) involving fathers in the intake process to convey the importance of their involvement in FF and address any concerns or hesitations about what it would involve; and (c) inclusion of a male clinician to build relationships with fathers, provide opportunities to discuss men's health issues, and challenge attitudinal barriers to help-seeking commonly held by men. These findings are important given research indicating that men's help-seeking behavior and uptake of mental health interventions and support is markedly lower than women's (Thompson et al., 2004) and the need for more father-inclusive practices in child and family services to promote the engagement of fathers (Lee et al., 2018). It was also important to identify the barriers to engagement and intervention completion. Although one in five families dropped out after an average of two sessions, many of these occurred in the early stages of implementation of FF when the inclusion criteria and intake processes were being refined. For at least half of the families that dropped out, substance use or severe relationship conflict were not disclosed at intake. These families found it difficult to engage in FF and were offered different supports to meet their needs. Some parents also found it particularly challenging if their parenting partner was not fully engaged and committed to FF. Taken together, these findings indicate that FF may not be appropriate for some families and highlights the importance of a thorough intake process that engages both parents to assess their readiness and identify potential barriers to engagement and intervention completion of FF. With respect to potential improvements to FF to enhance engagement and completion, a small number of mothers shared that the content was repetitious, and more opportunities to discuss their specific needs and practise skills would be helpful. This can be a common challenge of manualized programs that are carefully designed to provide parents with maximum opportunities to reinforce, practice, and internalize the content and skills learned in the program. Although it is possible to build more flexibility into FF, it would require careful assessment and decision-making by clinicians to determine how they do this and ensure that program fidelity is still maintained. This may require more intensive training and supervision. Greater representation of diverse families in the resources, translated materials, and employment of bicultural staff are key considerations for future program development. This is critical given the challenges migrant, Aboriginal, and LGBTQI families often face in accessing culturally and socially appropriate care and support in the early years of parenting. The final aim of the study was to gather preliminary evidence about the outcomes for families. Decreases in depressive, anxiety, and stress symptoms were reported by mothers. Although improvements in mental health were not specifically noted in the interviews, several mothers spoke about having stronger coping skills and a willingness to reach out for support in the interviews. These are important outcomes because a key focus of FF is to practice emotion regulation and stress management skills, as well as to practice how to ask for help. There were decreases in mothers' and partners' reports of how much they engaged in conflict in front of their children. FF provides psychoeducation about what it can be like for children to see their parents fighting and conveys the importance of using a broad range of positive communication strategies when there are disagreements. In the interviews, mothers and clinicians noted improvements in communication and conflict resolution skills, and several mothers highlighted the usefulness of specific mnemonics to help them use the skills in conflict. This is an important finding given research indicating that observing conflict can (a) be highly distressing for children, (b) threaten their sense of security in their family relationships, and (c) model negative ways of handling conflict in relationships (Davies & Cummings, 1994; Grych & Fincham, 1990). Research also indicates that it can be beneficial for children to see their parents problem-solve conflicts, work together, and support one another (Feinberg, 2002). Mothers in this study reported increases in coparenting support and agreement, and this was also corroborated in the interviews. This was an important outcome as FF focuses on shared values and understanding differences and shared decision-making skills. Mothers and clinicians also noted that FF helped to foster greater empathy and understanding between parents. This may be an important practice underlying the process of strengthening coparenting agreement and support and is worth further exploration. There were also perceived benefits of FF for parenting and parent–child relationships. This was also reflected in decreased hostility by mothers. Although specific content about children's temperament, parenting values, and goals may have been important in facilitating changes in parenting behavior, we also hypothesize that there were indirect effects on parenting behavior via improvements in parent mental health, decreased conflict, improved conflict resolution skills, and increased coparenting. Parent mental health difficulties and conflict are established risk factors for harsh parenting behaviors, and they can make it difficult for parents to engage in sensitive and responsive interactions with their children (Krishnakumar & Buehler, 2000; Shelton & Harold, 2008). Although the short- and longer-term effects of group-based FF on parenting and children's emotional-behavioural functioning has been established (Feinberg et al., 2014), exploring the short-term impacts of home-based FF and mechanisms underlying long-term benefits for children is an important area for rigorous evaluation research in the future. Finally, the lack of significant findings for partner mental health, coparenting, and parenting behavior is due further consideration. Although it is likely that the sample size for partners (n = 19) was too small and underpowered to detect small effects, it is possible that partners needed more time to implement the FF strategies and perceive change in their mental health and relationships. It is also worth noting that on average, partners' baseline scores for mental health symptoms were relatively low, and their scores for coparenting behavior were relatively high. For example, mothers' pretest scores for depressive symptoms was about.6 standard deviation units higher than partners' pretest scores. Thus, floor and ceiling effects may have limited the potential for improvement. Further, these partner baseline scores may also have influenced their perceived need for FF and their level of engagement. Future research with larger samples and a more robust evaluation design is required before drawing firm conclusions about whether FF works as well for partners as it did for mothers. There are several limitations to note. This real-world evaluation was embedded within a newly funded initiative that supported establishment and implementation of home-based FF within two services in Australia. There were several challenges in implementation setup including establishing referral pathways, intake, and assessment procedures. This initial preparatory work took time, and recruitment was initially slow. The sample size was small, limiting statistical power to detect small to moderate intervention effects. Further, the sample was not representative of families from non-English-speaking and indigenous backgrounds, same-sex parents, or families with more complex family structures (i.e., stepfamilies, kinship and extended family carers). The evaluation did not include a control or a comparison group, and the outcomes were assessed immediately after the intervention. It is possible that parents needed more time to implement the intervention strategies before changes in some outcomes became noticeable. A longer term follow-up is required to assess change and maintenance in parent and family functioning over time. The organizations were responsible for collecting assessment data from parents, and they had limited resourcing to follow-up parents who had not returned their final assessment measures. Finally, only parents who completed FF were informed about the interviews, and it is likely that parents who were engaged and had more a positive experience of FF opted to participate in the interviews. Notwithstanding these limitations, this pilot study demonstrates the feasibility of implementing home-based FF with families in Australia. The mixed-methods approach was a particular strength. The rich interview data offered insight into the acceptability, enablers and barriers, and benefits of the intervention from the perspectives of both parents and clinicians, providing an opportunity to triangulate findings and add meaning to the self-report survey data. The pilot results are encouraging and a necessary first step in gathering evidence to inform further development of home-based FF and wider implementation in health and social care services in Australia. This study was supported by the Victorian Government Department of Health and Human Services Building Evidence Based Programs and Practice in Child, Youth and Family Services funding; the NHMRC Safer Families Centre of Research Excellence; and Victorian Government's Operational Infrastructure Support Program to MCRI. R.G. was supported by a National Health and Medical Research Council (NHMRC) Career Development Fellowship, and S.B. was supported by a NHMRC Research Fellowship. The funding organizations had no involvement in the conduct of the study and the authors are independent of the funding sources. Two community organizations were funded by the Victorian Government Department of Health and Human Services (Australia) to pilot the home-based model from January to November 2018. A mixed-methods evaluation was conducted. Qualitative interviews were undertaken with parents who had received FF and clinicians who delivered it. Parents were asked about their satisfaction with FF and how it could be improved, and both parents and clinicians were asked about (a) enablers and barriers to engagement in FF and (b) perceived outcomes for families. Outcomes for families were also investigated using data collected by the organizations as part of their routine clinical and quality assurance purposes. Ethics approval for the qualitative study was obtained from the Royal Children's Hospital Human Research Ethics Committee, and the collection and use of routinely collected assessment data by the organizations was governed by Australian health and privacy legislation. Participant consent was obtained for their deidentified data to be provided to the researchers. Two community organizations were funded by the Victorian Government Department of Health and Human Services (Australia) to pilot the home-based model from January to November 2018. A mixed-methods evaluation was conducted. Qualitative interviews were undertaken with parents who had received FF and clinicians who delivered it. Parents were asked about their satisfaction with FF and how it could be improved, and both parents and clinicians were asked about (a) enablers and barriers to engagement in FF and (b) perceived outcomes for families. Outcomes for families were also investigated using data collected by the organizations as part of their routine clinical and quality assurance purposes. Ethics approval for the qualitative study was obtained from the Royal Children's Hospital Human Research Ethics Committee, and the collection and use of routinely collected assessment data by the organizations was governed by Australian health and privacy legislation. Participant consent was obtained for their deidentified data to be provided to the researchers. The target population were parents from families expecting a baby or in the first postnatal year, reporting at least one risk factor for high partner conflict, including (a) self-reported parent mental health difficulties, (b) young parental age (<24 years); (c) low educational attainment (high school or below), (d) low employment (not in paid employment, part-time or casual), (e) self-reported relationship difficulties, or (f) parenting two or more children. Both parents in each family had to consent to participate in FF and complete the assessment measures. Parents were not eligible if they had a family violence intervention order, pending court case for family violence, or child protection involvement. Approximately 133 families contacted the intake team expressing interest in FF, and of these, 52 (39.1%) enrolled. Common reasons for not enrolling included family did not meet the inclusion criteria, family no longer interested, and partner not wanting to take up the program. Of the 52 enrolled, 11 did not commence FF or give consent to complete the assessments. A total of 41 families enrolled and commenced FF and gave consent to complete the assessments. Their demographic characteristics are presented in Table 1. The majority were couples in a heterosexual relationship with a second or subsequent child. All Parent 1s were mothers, and the majority were born in Australia and English-speaking, with a post–high school qualification. Parent 1s are consistently referred to as mothers henceforth. The majority of Parent 2s were fathers, with the exception of two mothers in a same-sex relationship. Parent 2s are referred to as parenting partners or partners henceforth. The majority of partners were born in Australia, English-speaking, and in paid employment. Verbal conflict was reported by approximately half of the families, and two thirds reported parent mental health difficulties. With respect to the inclusion criteria above, 87% reported two or more risk factors, and a third reported four or more risk factors. Eight parents consented to participate in the qualitative interviews. All were mothers, were from different families, and had completed all FF sessions. Seven clinicians (three males, four females) participated in the qualitative interviews. The sample had an average of 14 years' experience working with families, and the majority had a social work qualification (n = 4). Information about FF was distributed to maternal and child health services, community child and family health services, general practices, and local hospitals in northern and western metropolitan Melbourne. The intake team engaged with both parents/caregivers within the family by telephone to assess suitability for the program. They were asked questions reflecting the inclusion (e.g., currently experiencing mental health or relationship difficulties) and exclusion criteria (e.g., currently experiencing family violence or if the child protection service was involved with their family). Both parents within each family who enrolled were asked to complete surveys approximately 1 to 2 weeks before the intervention and approximately 2 weeks after the final session. The 10 sessions were delivered to both parents in the family in their home by the same male and female clinicians with counseling, parent education, or allied health (psychology, social work) qualifications. A pool of approximately 20 clinicians (five male, 15 females) were available, and several were from diverse LGBTQI and cultural backgrounds (e.g., Eritrean, Samoan, Sudanese). Clinicians received 3-day training involving (a) presentations on the theoretical and evidence-base for FF; (b) demonstrations modelling session delivery; and (c) opportunities for discussion, experiential learning, and skills practice. Ongoing supervision was provided by experienced managers within the services. Each family was provided with workbooks and all resources required for the exercises. Sessions were offered during and outside of business hours, with an average duration of 60 minutes. Clinicians completed a session fidelity checklist after every session, indicating whether they delivered the key content, if any departures from content occurred, and the reasons for these. Approximately 95% of the session content was delivered as intended, with the lowest fidelity for Sessions 9 and 10 (~90%). Common reasons for not delivering the session as intended included interruptions due to children being present; parent tiredness, parents harder to engage due to recent conflict, parents raising issues that needed to be contained, poor time management (i.e., activities running over time, clinicians overexplaining concepts), and perceived content overlap in the final sessions by clinicians. Both parents from each family who completed FF were informed about the qualitative interviews in their final FF session, and clinicians were invited to participate by their manager. Consent was obtained by the research team, emphasizing that nonparticipation or withdrawal would not affect access to services (for parents) and employment (for clinicians). Semistructured interviews were conducted over the phone or face-to-face by a researcher with postgraduate training in psychology. Interviews ranged from 40 to 60 minutes, and the audio recordings were transcribed verbatim. Parents from each family were compensated for their time with a $50 grocery store voucher. The Depression Anxiety Stress Scale-21 (DASS-21; Lovibond & Lovibond, 1995) consists of 21 items assessing symptoms of depression, anxiety and stress in the previous week. Response options ranged from Does not apply to me at all (0) to Does apply to me very much or most of the time (3). It has excellent reliability and validity, with clinical cut points and normative data available for Australian samples (Crawford et al., 2011). Cronbach's alpha for all subscales at pre- and post-intervention for mothers and partners were acceptable, ranging from.70 to.95. The Interparental Conflict subscale from the Quality of Co-parental Interaction Scale (Australian Institute of Family Studies, 2005) comprises of five items assessing verbal conflict (disagreements, arguments, anger, hostility) and one item assessing physical conflict (arguments with pushing, hitting, kicking or shoving). Response options ranged from never (1) to always (5). Cronbach's α for mothers at pre- and post-intervention was.77 and.81, respectively, and.85 and.79 for partners at pre- and post-intervention. Child Exposure to Conflict subscale from the Coparenting Relationship Scale (Feinberg et al., 2012) assessed parents' perceptions of the degree to which their child is exposed to conflict (e.g., How often do you yell at each other within earshot of the child?). Response options ranged from never (0) to very often (6). Cronbach's α for mothers at pre- and post-intervention was.79 and.88, respectively, and.91 and.93 for partners at pre- and post-intervention. The Coparenting Relationship Scale (Feinberg et al., 2012) assesses (a) coparenting support (e.g., My parenting partner appreciates how hard I work at being a good parent), (b) endorsement of partner parenting (e.g., My parenting partner pays a great deal of attention to my/our child), and (c) coparenting agreement (e.g., My parenting partner and I have the same goals for my/our child) were used. The 17 items were rated from Not true of us (0) to Very true of us (7). Cronbach's alpha for all subscales at pre- and post-intervention for mothers and partners were acceptable, ranging from.70 to.90. Parenting warmth was measured using a modified five-item subscale from the Child Rearing Questionnaire (Sanson, 1995). Parents indicated how often they feel close to and express affection toward their child (e.g., Hug or hold this child for no particular reason). Response options ranged from Never/almost never (1) to Always/almost always (5). Cronbach's alpha for mothers at pre- and post-intervention was.91 and.85, respectively, and.84 and.88 for partners at pre- and post-intervention, respectively. Parenting hostility was assessed using adapted items from the Early Childhood Longitudinal Study of Children (National Center for Education Statistics, 2000). Parents rated how often they engage in hostile behaviors during interactions with their child (e.g., I have raised my voice with or shouted at this child). Response options ranged from Not at all (0) to All of the time (10). Cronbach's α for mothers at pre- and post-intervention was.90 and 81, and.82 and.83 for partners at pre- and post-intervention. Using the FF Satisfaction Survey, parents rated their satisfaction with FF including the aims, content, workbook, video, home visits, and the number and duration of sessions. Thematic analysis of interview data was conducted by two researchers using the process recommended by Braun and Clarke (2006), which involves (a) familiarization with the data, (b) generation of initial codes, (c) identify themes across codes, (d) review themes, and (e) define themes. Throughout the process, meetings were held to discuss the analysis and reach consensus on codes and themes. The interviews and thematic analysis were conducted simultaneously to engage with the emerging themes and for the point of adequate data saturation (no new themes emerging) to be identified. All pre–post comparisons of survey data were analyzed using dependent-measures t tests for (a) participants who had complete data and (b) those with missing data due to intervention dropout or loss to follow-up (intention to treat [ITT]). Multiple imputation was conducted, whereby 40 complete datasets were imputed using chained equation modeling, and the pooled estimates were averaged using Rubin's rules. Cohen's d was reported as the measure of effect size for the complete case analyses, with.20,.50, and.80 representing small, moderate, and large effect sizes, respectively. Publisher Copyright: © 2022 National Council on Family Relations.
PY - 2022/7
Y1 - 2022/7
N2 - Objectives: A formative evaluation of a home-based family intervention, Family Foundations (FF), targeting parent mental health and conflict in the perinatal period was conducted. The aims were to (a) assess parent satisfaction and recommendations for improvement, (b) identify perceived enablers and barriers to engagement, and (c) obtain preliminary outcome data related to parent mental health, conflict, and coparenting. Methods: A mixed-methods evaluation was conducted with 41 families at risk of or experiencing parental conflict. FF was delivered by two organizations in Australia. Qualitative interviews with parents and FF clinicians were conducted, and intervention outcomes were assessed using parent survey. Results: Feasibility of reach and recruitment of the target population was demonstrated. Parents' indicated a high level of satisfaction with all aspects of FF and offered recommendations for improvements to resources and delivery. Service, program, clinician, and family characteristics as enablers and barriers to engagement in FF were identified. Both mothers and partners reported a decrease in their child's exposure to conflict. Mothers also reported a decrease in mental health symptoms and parenting hostility and an increase in positive coparenting behavior. Conclusion: Feasibility and acceptability of home-based FF in the perinatal period had been established, with preliminary evidence of positive outcomes for families. Implications: The current findings generate evidence to inform further development of home-based FF and wider implementation in health and social care services in Australia.
AB - Objectives: A formative evaluation of a home-based family intervention, Family Foundations (FF), targeting parent mental health and conflict in the perinatal period was conducted. The aims were to (a) assess parent satisfaction and recommendations for improvement, (b) identify perceived enablers and barriers to engagement, and (c) obtain preliminary outcome data related to parent mental health, conflict, and coparenting. Methods: A mixed-methods evaluation was conducted with 41 families at risk of or experiencing parental conflict. FF was delivered by two organizations in Australia. Qualitative interviews with parents and FF clinicians were conducted, and intervention outcomes were assessed using parent survey. Results: Feasibility of reach and recruitment of the target population was demonstrated. Parents' indicated a high level of satisfaction with all aspects of FF and offered recommendations for improvements to resources and delivery. Service, program, clinician, and family characteristics as enablers and barriers to engagement in FF were identified. Both mothers and partners reported a decrease in their child's exposure to conflict. Mothers also reported a decrease in mental health symptoms and parenting hostility and an increase in positive coparenting behavior. Conclusion: Feasibility and acceptability of home-based FF in the perinatal period had been established, with preliminary evidence of positive outcomes for families. Implications: The current findings generate evidence to inform further development of home-based FF and wider implementation in health and social care services in Australia.
UR - http://www.scopus.com/inward/record.url?scp=85123260683&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85123260683&partnerID=8YFLogxK
U2 - 10.1111/fare.12647
DO - 10.1111/fare.12647
M3 - Article
AN - SCOPUS:85123260683
SN - 0197-6664
VL - 71
SP - 1036
EP - 1057
JO - Family Relations
JF - Family Relations
IS - 3
ER -