Toward better home visits: a mixed-methods study identifying disparities in early childhood program delivery to...

Research and policy developments in the area of early childhood development and health equity have led to an increase in parent support interventions. An extended home visiting program within Child Health Services in collaboration with social services was developed to improve health equity among children in socioeconomically deprived areas as an early, trust-based, and proportionate universalism intervention. To ensure that evidence-based program models are replicated and implemented successfully, it is essential to monitor fidelity to core components during program delivery. This study aims to investigate the delivery of home visits during the scale-up of an early childhood home visiting model in socio-economically disadvantaged areas in Gothenburg, Sweden, with particular focus on health equity.

A convergent mixed-methods approach was applied, using data from fidelity monitoring collected through a questionnaire filled out after each visit by the nurses and social workers who provided the home visits. Initial directed content analysis with pre-determined categories was carried out. The qualitative findings informed a subsequent quantitative analysis, which included non-parametric testing to compare program delivery based on variation in home visit characteristics.

The reported content of home visits was very similar to the original program core components. Professionals indicated high levels of satisfaction with their ability to implement the program model, successfully working in professional teams, and establishing an alliance with families. At the same time, communication and parents' participation were noted as challenging aspects. Disparities in program delivery were found between visits with and without an interpreter present, as well as visits with one or both parents present.

The findings suggest successful replication of the program model during scale-up. However, the disparities observed in staff reports on program delivery represent a threat to the principles of proportionate universalism and could potentially increase inequities in the conditions for optimal child development. It is therefore essential to develop strategies to overcome language barriers, to promote fathers' continued engagement, and to ensure equitable program delivery.

The study was retrospectively registered on 19/09/2024 in the ISRCTN registry (ISRCTN19253469).