Promoting First Relationships^®: Implementing a Home Visiting Research Program in Two Tribal Communities

Abstract

Background.

Few, if any, home visiting programs for children under the age of three have been culturally adapted for American Indian or “Native” reservation settings. We recently adapted one such program: Promoting First Relationships (PFR).

Objectives.

To culturally adapt PFR while maintaining program fidelity, we used a community-based participatory approach to elicit input from two American Indian partners.

Methods.

University-based researchers, reservation-based Native project staff, and Native tribal liaisons conducted collaborative meetings, conference calls, and focus groups to adapt PFR to reflect local community needs and values.

Lessons Learned.

Working closely with onsite Native project staff, being flexible and open to suggestions, and attending to the logistical needs of the community are imperative to developing and implementing adaptations.

Conclusions.

Several adaptations were made based on the collaboration between researchers and Native project staff. Collaboration is critical for adapting programs so they can be tested in ways that respect both American Indian culture and research needs.

BACKGROUND

In 2010 Congress authorized the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) to provide $1.5 billion for home visiting services across the United States. Congress specifically set aside 3% of that funding to support Tribal¹ Home Visiting Programs. As a result of the MIECHV Program, over 3,100 Native families with children under the age of five have benefited from nearly 55,000 preventive intervention home visits (Novins, Meyer, & Beltangady, 2018). Home visiting, and in particular, nurse home visiting, is considered a key resource for communities in the United States; it is a service delivery system that provides preventive and intervention services needed for families to improve maternal, infant, and child outcomes. Home visiting programs such as Nurse Family Partnership have been extensively studied and proven an effective strategy. However, most randomized control studies of home visiting programs have not occurred in tribal communities.

Many evidence-based programs have been criticized because they were tested solely in general population samples but then implemented in demographically specific settings without replication, adaptation, or appropriate validation (Lee, Aos, & Miller, 2008). Only one out of 18 home visiting programs for tribal communities has been rated by the Home Visiting Evaluation of Effectiveness as “Evidence-Based” within a tribal community (Lyon et al., 2015). To address this limitation, two successive randomized controlled trials (RCTs) of Promoting First Relationships^® (PFR), a home visiting program, were conducted in two rural, reservation-based American Indian communities. The first RCT was a pilot study with a wait-list control group at one site. Results from this study informed the second RCT, which is larger and includes simultaneous intervention and control groups with a different tribe.

Promoting First Relationships^® Home Visiting Program

The aim of this research was to collaborate with American Indian communities to adapt and then assess the effectiveness of the Promoting First Relationships^® (PFR) home visiting program developed by Dr. Jean Kelly at the University of Washington (UW) School of Nursing in the Barnard Center for Infant Mental Health and Development. PFR is a 10-week, manualized strengths-based program (Kelly, Zuckerman, & Rosenblatt, 2008; Kelly, Zuckerman, Sandoval, & Buehlman, 2003) designed for caregivers with children younger than five years. Unlike many home visiting programs, PFR is designed narrowly to support the parent-child relationship rather than to meet tangible needs through case management. PFR is based on attachment theory and empirical research showing that children who have a safe, sensitive, and nurturing relationship with an adult experience better outcomes across multiple domains of functioning, leading to better overall adjustment and mental health (Perry & Conners-Burrow, 2016).

In two prior RCTs conducted in child welfare populations, caregivers who participated in PFR demonstrated an increase both in observed caregiver sensitivity and in their knowledge of child development (Oxford, Spieker, Lohr, & Fleming, 2016; Spieker, Oxford, Kelly, Nelson, & Fleming, 2012). In these child welfare studies, PFR also resulted in improvements in child competence and better permanency outcomes in child welfare (Spieker, Oxford, & Fleming, 2014), as well as a 2.5 times lower likelihood of children’s placement in foster care and a reduction in children’s observed errors in affective communication (Oxford et al., 2016). In these studies, PFR also yielded better stress regulation in children, as measured by cortisol (Nelson & Spieker, 2013) and respiratory sinus arrhythmia (Hastings et al., 2019). It is essential, however, to rigorously evaluate these models and their adaptations in tribal communities, as implementing such research on home visiting services in partnership with tribal communities is an important step toward building an evidence base specific to the needs of American Indian families.

Adapting Home Visiting Programs within American Indian Communities

Cultural adaptation is defined as the systematic modification of a treatment or intervention program to increase fit, relevance, and appropriateness of the program to the community in which the service is delivered (Bernal, Jiménez-Chafey, & Domenech Rodríguez, 2009). Resnicow, Baranowski, Ahluwalia, and Braithwaite (1999) refer to two types of adaptations: surface structure and deep structure adaptations. Surface structure adaptations are defined as changes that are made to program materials and messages to better align with “superficial” characteristics of a population in order to improve fit and acceptability within that community; deep structure adaptations are program changes that are made to incorporate historical, social, structural, psychological, or cultural factors relevant to the population.

We frame our adaptations using the approach proposed by Resnicow et al. (1999) and recently applied to evaluations of home visiting programs adapted to tribal settings in the MIECHV program by Hiratsuka et al. (2018). Hiratsuka et al. reviewed four home visiting programs adapted within tribal communities. They identified two surface structure adaptations (use of Native imagery and indigenous language for project name) and five deep structure adaptations: changes to hiring and program relationships; changes to staff training; changes to the curriculum; adding group activities; and adding program services to address structural inequalities (housing, poverty). Referencing Resnicow et al. and Hiratsuka et al., we outline both surface and deep structure adaptations to the PFR program.

We describe the development of our community partnerships and then detail the adaptation and implementation of the PFR model, including both surface and deep adaptations, as well as 1) partnership formation and function; 2) setting, hiring process, and project name/logo; 3) training and adaptations in training; and 4) delivery and content adaptations. All these factors varied between tribes, but for study purposes, they are presented broadly without identifying specific communities. We conclude with lessons learned and wider implications for home visiting programs in rural American Indian communities. Ours is the first home visiting program we are aware of that was designed and tested in general populations, and then adapted to and tested in American Indian communities using rigorous RCT design.

METHODS

Partnership Formation and Function

The partnership that enabled this research began between the two tribes and academic investigators at Washington State University (WSU), in what Weiner and McDonald (2013) describe as a targeted, area-based collaboration between academic researchers and well-established community organizations. Through longstanding collaborative relationships, investigators at WSU became aware that the two tribes were interested in expanding services and research pertinent to very young children in their communities. Through discussion between WSU and tribal leaders and stakeholders, Promoting First Relationships^® was identified as a potential model that would be appropriate for the communities. Faculty leading the Promoting First Relationships^® program at UW were invited to present PFR to tribal members, leaders, and stakeholders at each tribal nation.

Each tribe engaged with the project in a unique manner during the initial presentation, which sought to give the tribes enough information about the PFR program to enable them to assess their interest in participation. After the initial presentation at the first site, the presenters invited a tribal elder who was a locally respected nurse to participate in a PFR workshop so that she could fully understand the program and share this understanding with her community. She became a key advocate for PFR and helped us set up focus groups and identify methods to hire local intervention providers and research staff. At the second site, the PFR model was presented to a group of tribal leaders so they could learn about its underlying philosophy. These leaders then identified key members of the community to begin the process of setting up focus groups. Both tribes had a positive perception of PFR, largely because its focus on relationships and its strengths-based approach align well with expressed cultural values.

Once funded, the appropriate parties signed Memoranda of Understanding detailing the roles and responsibilities of community and university collaborators. Two academic teams were involved in these studies – one at WSU and the other at UW. The WSU team includes a faculty member with decades of experience conducting research with Native communities, and two American Indian researchers who work as tribal liaisons. Both are members of tribes unrelated to our study communities, and both have established community relationships with each site and an understanding of local processes for research approval. The UW team consisted of faculty implementing and evaluating PFR in other contexts and PFR trainers.

Both studies followed a similar process with two phases. Phase 1 included implementing two focus groups and training tribal members to deliver the home visiting program and to conduct the research visits. Adaptations were identified in Phase 1 from the focus groups and training process and are the topic of this paper. Phase 2 entailed recruiting parents and their children under the age of three into the study and randomly assigning them to a treatment condition; Phase 2 is not addressed in this work (see Booth-LaForce, et al., 2020). The first RCT study relied on a wait-list (WL) design; we will refer to this site/study as the WL site. Phase 1 began in fall 2013 and Phase 2 began in the fall of 2014. The second study was an RCT with random assignment of participants to either the active intervention (PFR) or simultaneous control arm that we will refer to as the SC site. Phase 1 began in the summer of 2014 and Phase 2 began in the summer of 2015. The two tribes were in different states and were unlikely to interact with each other. In both cases, however, WSU and UW benefited from the support of members of both tribes in obtaining approval for the proposed research through tribal council resolutions and the relevant tribal and university institutional review boards.

Study Settings, Hiring, and Naming

Both sites were located on rural reservations. At the WL site, the study was located at the local Tribal Health Clinic; at the SC site, the study was located in a health promotion center. Each site had unique geographical and contextual characteristics that required attention. It immediately became clear in both settings that caseload expectations would have to be adjusted to accommodate the expanse of the reservation geography and that funding would need to increase to accommodate fuel costs. The study also purchased road safety kits for staff; in some cases, staff had to travel up to one hour in one direction to meet with eligible families.

Similarly, during the winter, it became impossible to reach some families, and the program service delivery was delayed, while in the summer, pow wow season led to a slow down because staff or families receiving the program were attending local, regional, or national pow wows. Accordingly, adjusting program expectations due to local geographical and cultural characteristics was essential for success.

At each site, two groups of staff were hired -- one to conduct research activities and the other to implement PFR home visiting services. All staff members were American Indian tribal members, a deep structure adaptation (Hiratsuka et al., 2018). At each site, university research staff and tribal members collaborated to create job postings for local positions and to determine where and how to advertise for applicants. We selected a broad range of advertising venues fitting to each site and location, both on and off each reservation, including health clinics, public bulletin boards, online university job postings, tribal radio announcements, and job service websites. Applicants were chosen for interviews based on education, work experience, and community involvement. Interviews were conducted in person or by videoconference. However, because few applicants from the reservations had home visiting experience or relevant educational or work histories, we expanded the nature and duration of PFR training, as discussed below under Deep Structure Adaptations.

Introducing PFR to the community and building community-based relationships in the two successive studies followed a standard scenario. First, during the months-long period that PFR providers were trained, we convened two focus groups at each site, with two meetings per group. Focus group participants included tribal elders, tribal staff who worked with children and families, and women with children. At the WL site, participants were identified by local tribal members who supported the program; at the SC site, they were identified by local staff hired by the program. The WL site had 11 focus group participants; the SC site had 13 focus group participants. Groups were held around lunchtime and food was provided. During the first round of meetings, the WSU tribal liaison introduced the overall project and the UW PFR trainer described the home visiting service in detail, requesting feedback about the fit of PFR with tribal values and needs.

Adaptations to the PFR program arose from two distinct pathways. The first pathway was from feedback during the focus group sessions, in which participants recommended specific adaptations to enhance cultural relevance and acceptability. These adaptations were made and presented back to the focus group for review and approval before participant recruitment. The second pathway was from the research visitors’ and PFR providers’ training process; both groups provided valuable feedback during their training that led to deep structure adaptations (described later). Adaptations that were made in response to concerns or suggestions of the research visitors and PFR providers occurred during weekly staff meetings with both tribal providers and tribal research visitors; this close weekly communication added depth to the university partners’ contextual understanding. Recommendations from weekly staff meetings were brought to the senior leadership meetings. After discussion, recommendations were shared with other senior leaders and tribal liaisons, and decisions were made regarding recommendations. During this process, the academic researchers tried to be responsive to the desires of each community while maintaining program integrity—a topic of recent debate in the literature (Castro & Yasui, 2017; Mejia, Leijten, Lachman, & Parra-Cardona, 2017). Specifically, we adapted only those aspects of PFR that could increase cultural relevance while maintaining the program’s core characteristics.

During Phase 2, tribal research staff attended weekly videoconferences with university research coordinators and senior university leadership. Tribal PFR providers also met weekly with a PFR master trainer who trained them and provided reflective consultation. All day-to-day aspects of the program, from research methods to service delivery, were managed during these two sets of meetings. Issues not resolved in these meetings were elevated to senior leadership at the tribal or university level and tribal liaisons for ad hoc meetings. Senior university leadership also met monthly to review progress.

PFR Non-adapted Training Process

The PFR program is disseminated by Parent-Child Relationship Programs at the UW’s Barnard Center for Infant Mental Health and Development (www.pcrprograms.org). The first author was also the director of the PFR program, enabling a seamless integration of the adaptations made for the present project. PFR uses a range of modalities to deliver training, including in-person classroom training, in-person workshops, and web-based distance learning. The latter approach is ideal for serving rural American Indian communities. Two intervention providers were hired at each site. Their training began with a three-day, in-person workshop conducted in Seattle by the first author. The workshop introduced PFR concepts and intervention strategies, as well as content on early child development, social and emotional growth, and parenting behaviors that support children’s needs. Then, over the next three weeks, trainees watched 11 hour-long training videos and met as a group twice weekly by videoconference with their PFR trainer to discuss the video content. Next, each trainee recruited from their community three “practice families” who were willing to receive the PFR program from a trainee. In preparation for each home visit, the trainee received a videoconference mentoring session with a PFR trainer, during which they discussed the parent’s and child’s unique needs and how to implement PFR.

Surface Structure Adaptations

Surface structure adaptions that were made included: 1) using tribal preferred advertising methods to advertise for positions; 2) enlisting Native artists and community members to design the study logos; and 3) having community members and staff select project names and aligning those names with each tribe’s culture and language.

Deep Structure Adaptations

Deep Structure Training Adaptations

During the initial WL study, we augmented the training process to expose trainees to content on home visiting and child development, given the trainees’ lack of prior experience in this area. The same augmentations in training continued for the full SC site. These revisions increased the amount of time that trainees spent with PFR staff by one to two hours per week during their work with practice families. The extra time enabled the following expansions in training:

• Extra readings and weekly discussions on child development, children’s and caregivers’ social and emotional needs, professional boundaries, and safety during home visits.

• Additional opportunities to view video recordings of families to practice PFR methods.

• Additional training on using handouts with families, including concepts associated with each handout and techniques for delivering its content; for this expansion, trainers and trainees role-played the administration of handouts.

• Additional training and support at one site regarding trauma, interpersonal violence, substance use, and encountering sex offenders. Although our capacity to meet this need was limited by the site’s remote location, in some instances, we were able to introduce appropriate online training or secure local experts to provide in-service training. We also increased the number of reflective consultation meetings, which occurred monthly with a university psychologist and focused on how PFR providers manage their experiences with families.

• Individualized rather than group mentoring to allow enough time to optimize learning for each trainee on a personal level. Individualized mentoring, and specifically privacy, became very important in the context of providing support for trainees in close-knit community settings typical of rural reservations. Individualized mentoring allowed us to maintain the privacy and confidentiality of trainees and practice families, and to enhance the feelings of security and trust.

The process of making these adaptations was informative for the developers of PFR. Indeed, some adaptations have been included in the implementation of PFR projects in non-tribal settings. This outcome reflects the bidirectional learning atmosphere of PFR projects as well as the benefits of testing the model in diverse settings.

Deep Structure Delivery and Content Adaptations

Our adaptations of the PFR intervention also involved changes in content and administration. These changes responded to unique community factors, including small populations, rural location, tightly knit family relationships, widespread economic hardship, high prevalence of trauma and violence, and issues of cultural relevance.

Changes in Delivery Logistics.

The following changes involved study delivery logistics:

• At one site, in response to suggestions from focus groups and PFR staff, we added a small gift for the provider to present to the child during research visits. The gift was viewed as a culturally appropriate gesture in line with traditional practices.

• During all interactions, and especially during home visits, we allowed additional time for the PFR provider to “check in” with participants on a personal level, consistent with local cultural norms for interpersonal relations. In both communities, initiating official business at the outset of a meeting would be considered rude.

• At one site, we designated an American Indian member of the research staff as a trusted source of onsite support for PFR providers.

• At one site, we encountered a larger logistical issue stemming from the housing circumstances of participating families. Some caregiver/child dyads resided in multi-family housing, were homeless, or were unable to meet at home because of safety concerns, including domestic violence or substance abuse by household members. Accordingly, the local PFR team designated offsite locations where PFR providers could deliver the program as needed. However, transportation issues made it problematic for some families to meet outside their homes. Sometimes a family unexpectedly obtained access to transportation and called to schedule an appointment the same day. In such cases, PFR providers had to be extremely flexible. We recognize that issues of transportation and appropriate spaces for intervention activities will continue to constrain home visiting programs such as PFR in remote rural settings.

Changes in PFR Curriculum Content.

To support caregivers in building safe emotional spaces with their children, and to respond to issues identified either in focus groups or by local PFR providers, we made the following changes in intervention content:

• Based on feedback from the WL focus group, we developed an additional handout on caregiver/child transitions and separations. This innovation was implemented for the SC site and is now also used in the main PFR program.

• Based on feedback from the SC site, we added the viewing of a publicly available YouTube video to a session on the caregiver’s role as a secure base for the child.

• Based on feedback from the SC site, we redesigned a weekly session that originally asked caregivers about any memory of a first emotion to ask instead about a time when they felt cared for by an adult. This revision was motivated by the amount of childhood trauma reported by caregivers at one site and the desire of the local PFR providers to focus on less traumatizing experiences. This is now an option for all PFR providers, depending on the needs and experiences of the provider and caregiver.

• Based on feedback from the SC providers, we added images to a very wordy handout. The newly designed handout is now part of the main PFR program.

• Based on feedback from both sites, we altered a “Safe and Scary” discussion that focused on caregivers’ internal states relative to safety and replaced it with a “Stressor” discussion that focused on times when caregivers were upset by stressful interactions with children.

• Based on feedback from the WL site, we appointed onsite clinical supervisors to provide local support and manage crises; this innovation was then implemented at the SC site.

Our changes in logistics and PFR content for these tribal communities were iterative during the training phase of the PFR program; this practice implementing PFR allowed ample time to make adaptations and integrate them into the program. These adaptations resulted from close, ongoing communication between university researchers and local staff: a mutual willingness to identify problems and commitment to finding solutions enhanced this process of adaptation. The WSU tribal liaisons were also instrumental in the outcome. Although this process was not always smooth and communication was sometimes challenging, a deep desire for positive results and a commitment to the PFR program on the part of the tribes and the research staff enabled us to implement key adaptations successfully.

LESSONS LEARNED

Overall, our tailoring of PFR to fit the needs of our community collaborators significantly enhanced learning for community members and researchers alike. The resulting blend of tribal, academic, rural, urban, and site-specific cultures has enriched our scientific framework and challenged us to continually modify our processes. We were able to conduct a particularly in-depth exploration of our efforts to balance community needs with scientific rigor. Our work resembles what Hiratsuka et al. (2018) found in their review of adaptations made to four home visiting models within tribal communities. In both cases, our work and Hiratsuka et al., deep structural adaptations included community engagement and hiring of community members to deliver the program as well as the development of new handouts, content or activities and changes to delivery and training.

Our primary lesson learned was the need for academic staff to engage with logistical challenges in rural settings and to listen to feedback from intervention providers and tribal research staff about these challenges. Weekly staff meetings between academic and tribal staff were an essential component of the adaption process. Without close relationships and bidirectional communication, barriers may not have been identified in a timely manner. For example, home visiting was originally designed for families’ convenience, but our experience suggests that providing alternative sites for program delivery and offering transportation to those sites would extend the reach of home visiting in rural areas. It may also be necessary for home visiting programs to add more time to complete the PFR program, given contextual challenges faced by American Indian families. In the present project, we allowed for more work time and smaller caseloads, as appropriate. Additional training needs were identified early in the process by tribal staff and PFR trainers, and our response to these needs enhanced the project’s effectiveness.

Another key lesson was the degree to which tribal PFR providers and research staff experienced vicarious trauma while working with reservation families. In many tribal communities, families experience difficulties because of ongoing as well as historical trauma. The latter form of trauma resulted from European colonization and led to intergenerational grief, loss of land and culture, and disruption of familial and tribal relationships. Historical trauma has shaped the context for home visiting programs in tribal communities by exacerbating the prevalence of personal experience of trauma, including disproportionately high rates of suicide, homicide, alcoholism, domestic violence, and child maltreatment (Heart & DeBruyn, 1998). PFR providers must navigate all these challenging realities, underscoring the need to demonstrate that a home visiting service can be effective in Native communities.

Also challenging were our efforts to ensure that our research aims and processes were carried out with sufficient fidelity to meet the scrutiny of the research community and result in a rigorous test of the effectiveness of PFR. Similarly, our navigation of the divergent cultural norms and customary practices of university researchers and rural tribal members was significantly facilitated by the work of our tribal liaisons. Critical to our overall success was education for university staff on tribal cultural norms and practices, along with education for tribal staff on the rationale behind research policies and the critical difference between service delivery and academic research. Education for both groups was delivered by the tribal liaisons and by the community and academic personnel. Our success in surmounting these challenges demonstrates the importance of engaging the project team in ongoing consultation and dialogue regarding the purpose of RCTs.

CONCLUSIONS

We identified three factors that we believe were instrumental to the successful implementation of our program and are relevant to any ongoing nursing or social service practice in rural tribal communities: 1) development of strong relationships; 2) engagement in bidirectional communication; and 3) identification of programs that are embraced by the community. First, the WSU faculty member had a longstanding relationship with each tribal community prior to the selection of PFR as a program of interest. Once UW and PFR were included in the partnership, the inclusion of American Indian tribal liaisons from WSU was essential. Second, weekly meetings facilitated bidirectional communication to ensure the best possible process for both tribal and academic partners. Third, the success of the implementation process was largely due to the desire of tribal leadership and members to bring the PFR program to their communities. After they received their initial training in PFR, tribal personnel expressed even greater enthusiasm because of the program’s emphasis on relationships and strengths. Staff engaged in both components of our program – research and service provision – also recognized the importance of evaluating PFR with Native families and were therefore committed to designing the best possible intervention.

Our implementation of RCTs to test PFR in two American Indian communities engaged onsite tribal staff, community members, and university staff in a constructive process that led to important program adaptations. The majority of adaptations were deep structural adaptations that were responsive to the needs of each unique community. Both the PFR program and the cultural values of the two intervention studies align with a strengths-based model in which service provision centers on the caregiver-child relationship. We believe that PFR resonated well with participating families and other community members. Feedback from Native staff and community focus groups revealed their appreciation for PFR and its positive emphasis on resilience. The philosophy underlying PFR appears to be a good fit for both study communities, even though they are geographically and culturally distinct. Thus far, this research confirms the effectiveness and acceptability of PFR in tribal communities and is suitable for broad dissemination within tribal communities.