Process evaluation Introduction

The process evaluation was designed to explore in more detail the delivery and experience of gFNP. It considered the uptake of gFNP for women who agree to the intervention and the attrition from gFNP provision. It also determined the extent to which the programme was delivered with integrity based on anonymised data from standardised data forms documenting sessions delivered, the content domains covered in sessions, attendance and participants’responses to the content, comparing the information with recommendations for delivery of one-to-one FNP from the US National Office and from the UK FNP NU. It also provided qualitative information to set the results in context by determining the acceptability of the programme for clients and practitioners plus their thoughts on its feasibility in the future, with reference to the findings of the implementation evaluations.57,67,68,121

Background

Model of the Group Family Nurse Partnership programme delivery used for the First Steps study

Delivery of the programme for the trial participants was by two FNs, one of whom had also notified their intention to practise as a midwife. Groups were scheduled to be held fortnightly from mid-pregnancy to the end of the baby’s first year (44 sessions in all), at an accessible community venue. The programme’s content follows the FNP programme in that six content domains are incorporated: maternal personal health, maternal role, life course development, family and friends, environmental health, and referrals to health and human services. Content is delivered through discussion, specially designed group activities and a range of printed material that clients are encouraged to keep in a folder. FNs record attendance for each registered client, rating their attendance and responses to each session attended and also record for each session the proportion of time spent on each of the content domains.

The two FN facilitators delivering group sessions at each site were also experienced in delivering home-based FNP and continued to deliver this while delivering the group sessions, albeit with a reduced caseload. It was intended that each group would ideally comprise between 8 and 12 women whose partners (if they had them) would be encouraged to attend. The criteria for young women recruited to take part in the study were that they were likely to benefit from the support offered by gFNP but were not eligible for FNP, namely expectant mothers aged<20 years with one or more previous live births, or expectant mothers aged 20–24 years with low/no educational qualifications and no previous live births. Additionally, their EDDs were to be within 6 to 8 weeks of each other for each group in each site.

Routine antenatal care was provided during the pregnancy group sessions according to NICE guidelines,62

and at the postnatal sessions infancy checks were carried out according to the HCP.54_{The expectant}

mothers are encouraged to carry out pregnancy checks themselves with guidance from the FNMW, one of the group’s two facilitators. Incorporation of this strategy is based on studies in the USA suggesting that this ‘Centring Pregnancy’approach61,122_{encourages self-efficacy and could promote peer-to-peer learning.}46

In addition, it was anticipated that thegroup contextof gFNP would help young mothers to develop social networks with other young women with babies, reducing social isolation and increasing social capital. Variants of the gFNP model of programme delivery just described had previously been evaluated and modestly adapted during the 3-year period immediately preceding the trial, with the findings summarised in brief below, indicating that the model described above was appropriate for testing the efficacy of gFNP using a RCT approach.

Findings from the feasibility studies

Following development work in 2009, two feasibility studies were commissioned to evaluate the acceptability of gFNP for both clients and practitioners. The models of delivery differed in the nature of the practitioners providing the programme. In Phases I and II57,123_{the programme was provided by two}

fully trained FNs, one of whom had also notified their intention to practise as a midwife and the second a fully trained health visitor. In Phase III67,121_{a modified approach was used, involving only one FN. She was}

present throughout the programme and the second facilitator for the pregnancy sessions was a local community midwife, who was then replaced by a local children’s centre child and family support worker for the infancy component. All the new non-FNP practitioners in Phase III undertook a short training course developed to support them in group facilitation roles and to provide them with some knowledge of the FNP curriculum and its strength-based mode of delivery. In both studies, recruitment was a balance between conforming to the suggested criteria, especially gestational age and the range of gestational ages to include, and identifying sufficient women. Refinement of the educational qualifications of eligible participants was also made. The initial stage of the formative evaluation in two sites124_{concluded that}

the original eligibility criteria, either being younger than 20 years and expecting a second child or aged 20–25 years and expecting a first child, with gestation ideally 12 weeks at referral, led to two challenges: (1) to identify a sufficient number with due dates close together; and (2) to identify women early enough in their pregnancies, most were recruited after 12 weeks’gestation. A second phase of feasibility work at the same two sites,57_{using additional eligibility criteria of low or no educational qualifications and/or}

no employment found again that the average gestational age at referral in both groups was beyond the recommendation of 12 weeks and that to identify sufficient women the range of gestational ages needed to be about 2 months rather than 6–8 weeks. This meant that there was some disruption to the programme around the time that infants were born with some women still focusing on antenatal issues, whereas others had newborns. In further feasibility research in four locations,67_{criteria for participant}

recruitment were the same as those described in Phase II and substantial effort was again required to identify sufficient clients, but it was possible to start all groups with between 8 and 12 clients. The feasibility studies suggested that gFNP was highly acceptable to both service users and to the practitioners delivering the service. Clients liked the idea of meeting other‘mums’like themselves and making new friends, and saw the opportunity to discuss parenting issues with other parents in addition to the professionals as an extra advantage.57,121_{In both studies, many clients also commented that they}

had developed their social networks as a consequence of attending the group.121,123_{A key impact of taking}

part in gFNP was said to be an increase in personal confidence and in their ability to look after their babies; there was also a reported improvement in mental health from being less isolated and receiving more support from health professionals and other members of the group.67

When asked about the gFNP approach, and the materials and resources used in delivering the programme agenda, clients generally said that they preferred more practical activities and especially those that they could do with their babies. The majority considered that the inclusion of routine midwifery care in the group was a bonus when deciding to accept the programme, expecting it would allow more contact with a midwife and health visitor than would be the case if receiving routine services.68_{However, there were}

mixed responses from clients when asked how they felt about carrying out their own health checks. Although the majority of the women interviewed expressed the view that carrying out the checks gave them a sense of independence and control over their own pregnancies, there were some who voiced the opinion that they would prefer a nurse to do the tests for them in case they made mistakes; others were ambivalent about the process.67,68,121

Attendance at the gFNP sessions was greater during the pregnancy phase than in infancy in both feasibility studies. Attendance was also highly variable; although some clients attended almost all sessions, others attended as few as two. When asked about non-attendance, transport problems were an issue for some and after their babies had been born some clients found it too tiring to organise themselves to get to group sessions or had employment or educational opportunities.68

PROCESS EVALUATION

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The gFNP practitioners found the programme acceptable and they enjoyed working in a group context,67,68

but some reservations were expressed regarding programme delivery by non-FNP professionals. Despite the training provided for non-gFNP health professionals, their lesser knowledge of the FNP approach placed a heavier burden on the FN facilitators.68_{Division of responsibilities was most evident during pregnancy,}

community midwives being more confident about and concerned with health checks, while taking a more backseat role for other programme content. They reported less confidence in delivering the gFNP content and in the strength-based style of delivery (motivational interviewing),43_{which is central to FN training.}

In contrast, during the infancy sessions the division between FNP and non-FNP professionals was more balanced with both FNs and Sure Start Family Support workers involved with infant health checks and in delivering gFNP content. However, for the First Steps trial the original staffing model was used; all practitioners were FNP professionals.

Quantitative information about service delivery