Implementing mental health interventions within a national nurse home visiting program: A mixed-methods evaluation
Authors: Leeman Jennifer , Ledford Alasia , Sprinkle Sharon , Gasbarro Mariarosa , Knudtson Michael , Bernhardt Elisabeth , Zeanah Paula , McMichael Georgette , Mosqueda Allison , Beeber Linda 
Published: September 2022

Background Up to half of low-income mothers experience symptoms of depression and anxiety that affect their well-being and increase their children's risk for behavioral and emotional problems. To address this problem, an engaged research/practice planning team designed the Mental Health Innovation (MHI), a multicomponent implementation strategy that integrates evidence-based mental health interventions within the national Nurse-Family Partnership (NFP). The MHI includes four implementation strategies: online training modules, clinical resources, team meeting modules, and virtual consultation. Methods A convergent, mixed methods observational design was applied to evaluate implementation outcomes, guided by the RE-AIM framework. We operationalized Reach as the number and demographics of women enrolled in NFP agencies exposed to MHI strategies. Adoption was operationalized as the number and proportion of nurses and supervisors who used MHI implementation strategies. For implementation, we assessed multilevel stakeholders’ perceptions of strategy acceptability and feasibility. Data were pulled from NFP's national data management systems and collected through focus groups and surveys. Quantitative data were analyzed using counts and summary statistics. Qualitative themes were generated through content analysis. Results The MHI reached agencies serving 51,534 low-income mothers (31.2% African American and 30.0% Latina). Adoption rates varied across implementation strategies. Between 60% and 76% of NFP nurses ( N = 2,100) completed each online module. Between 27% and 51% of nurse supervisors ( n = 125) reported using each team meeting module. Of 110 teams invited to participate in virtual consultation, 40.9% ( n = 45) participated. Mothers served by agencies participating in virtual consultation differed significantly from those who did not, with lower percentages of African American and Latina. Qualitative themes suggest that MHI strategies were generally viewed as acceptable; perceptions of feasibility varied across strategies. Conclusions This study identified both strengths and opportunities for improvement. Further evaluation is needed to assess the MHI's effectiveness in improving mothers’ mental health. Plain Language Summary Up to half of low-income mothers experience symptoms of depression and anxiety. To reach these mothers, this study implemented evidence-based mental health interventions in a national nurse home visiting program that provided services to over 51,000 low-income mothers (31.2% African American and 30.0% Latina). The study aimed to build nurse- and agency-level capacity to identify, support, and refer mothers with mental health symptoms. Four strategies were used to implement mental health interventions in the nurse home visiting program: online training modules, team meeting modules, clinical resources, and virtual consultations. This paper reports findings from an evaluation of the reach, adoption, and perceptions of these strategies. Study findings indicate that nurses and their supervisors generally valued the implementation strategies but were more likely to adopt some strategies than others. The majority of nurses adopted online modules, which were perceived as easy to use and were required by the national nurse home visiting program. Less than half of nurse supervisors adopted team meeting modules or virtual consultation. Supervisors noted concerns about the feasibility of using both strategies. Findings from the evaluation were applied to further improve implementation strategies. Future evaluation is needed to determine how well the refined strategies work and whether they impact nurse home visitors’ capacity to address the mental health needs of low-income mothers.