Australian Context

Australian literature concerning the role and impact of community and child health nurses is limited, and is focused on the changing structure of services amidst government policy and skilling requirements (Barnes, MacPherson & Senior, 2006). Whilst it would appear that child community nursing in Australia is moving towards a psychosocial support model (Briggs, 2006), there is little evidence that training and service structure is reflecting this (Kruske, Barclay, & Schmied, 2006). Specialist training of community and child health nurses varies markedly across the country, and provides inadequate preparation of some of the core skills required in the workforce (Kruske & Grant, 2012). Research has identified issues regarding nursing application of the principles of family partnership, continuity of care, provision of resources to provide sustained nurse home visiting and conflicting demands on the nursing role (Kruske, et al., 2006). These issues are likely to impact on parental engagement in services; however there is currently no literature to support a possible link between these closely interdependent aspects of home visiting.

No studies could be found that investigated the phenomenon of maternal involvement in Australian nurse home visiting programs, and many evaluations fail to report the characteristics of those who were unable to complete the intended number of visits. The 1996 audit of Australian Home Visitor Programs (Vimpani, Frederico, & Barclay, 1996) did not identify maternal involvement as a contributor to the success or failure of a program. It was identified in the context of problems associated with evaluating the effectiveness of home

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visiting programs as a preventive strategy for child abuse and how home visitors know a program is not working (Vimpani, et al., 1996). By not including involvement as a priority in the subsequent framework or in the audit’s recommendations, the report effectively placed this issue as a low priority when implementing or evaluating home visiting programs in Australia. A recent overview of Australian universal maternal and child health services suggested that improved collaboration, and ongoing support for nurses, in the form of increased supervision and ongoing education, is essential to improving the engagement of vulnerable families in services (Schmied, et al., 2008).

The higher program retention rate reported in Australian trials (Armstrong, et al., 1999; Armstrong, et al., 2000; Fraser, et al., 2000; Kemp, et al., 2008), could explain the lack of interest in local research into intensity or duration of maternal involvement compared to that observed in the international literature. At 6-week follow-up of the Family Care RCT in Queensland, the retention rate was 96% (Armstrong, et al., 1999), with 76% retention at 12- months (Fraser, et al., 2000). Participants in the intervention group who did not complete the program were more likely to be young, to move house frequently, to have poor parental attachment to the infant and a low maternal sense of competence (Fraser, et al., 2000). These results are in conflict with data from the MESCH trial in New South Wales.

Late presentation for antenatal care and an income deriving from part-time employment, pension or benefits were significantly associated with loss to follow-up in the MESCH program (Kemp, et al., 2008). Women who identified themselves as being abused as a child were significantly less likely to be lost to follow-up at 18-months (Kemp, et al., 2008). Whilst rates of retention for the trial compare favourably with other studies into maternal involvement, the authors reported being disappointed with retention rates of 86% at 12- months, 74% at 24-months and 62.5% at 30-months (Kemp, et al., 2008). These high rates of retention should be interpreted with caution, as they represent participants retained in the randomised controlled trial only. Information regarding participant retention, and intensity of maternal involvement in the actual home visitation program was unable to be obtained.

In spite of this recognition of the importance of retention and acknowledgement of the need to understand any fundamental differences between those who complete the program and those who do not, there is no suggestion for further research into maternal involvement in Australia, highlighting the lack of acknowledgement of its importance. Furthermore, perhaps

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due to complications when conducting research with participants for whom English is not a first language, there is little data regarding the relationship between ethnicity and attitudes and access to home visiting in mothers from non-English speaking backgrounds. Additionally, Riggs and others (2012) have documented the challenges in accessing refugee families, both for a universal home visit and further child health clinic care. Little is known about factors affecting access to home visiting in Australia in general. One retrospective study found that culturally and linguistically diverse populations were less likely to receive a single, universal home visit by a nurse or volunteer (L. M. Wen, et al., 2007), and when they were visited, were more likely to find the visit “uncomfortable” or “very uncomfortable”. Other factors associated with poor acceptance of home visits were households that were not smoke-free, younger mothers, and fathers with lower education. Qualitative evaluations found Indigenous families strongly supported an intensive nurse home visiting program in South Australia, however these results may be positively skewed as only long-term participants were interviewed (Sivak, et al., 2008). These findings have important implications for Australian program development, accessibility to programs and meeting the needs of minority populations.