The Linkages for Prevention project

About the program

The Linkages for Prevention project is a community-wide intervention, with a specific emphasis on health outcomes for low-income mothers and infants. The program aims to improve the way preventive health care services are organised and delivered by adopting a three-tiered approach: community-, practice- and family-level.

The primary objective of the project is to achieve process change that would lead to clinically relevant changes in client outcomes. It seeks to improve health outcomes by addressing specific care delivery processes at the level of clinical interaction between care providers and patients.

The community-level intervention aims to build lasting change in the organisation of health care in the community. It seeks to achieve policy level changes, engage multiple practice organisations, and enhance communication between public and private practice organisations to improve coordination and avoid duplication of services.

The objective of the practice-level interventions is to overcome specific barriers in the process of care delivery so that preventive services could be effectively delivered.

The family-level intervention seeks to address risk factors for adverse health outcomes via home visiting.

Who does it work for?

The project is for parents with children under the age of 2 and is particularly designed for low-income families.

The project has only been evaluated in the USA (Margolis et al. 2001).

A quasi-experimental design study was conducted with 208 people (103 people were in the intervention group and 105 people were in the control group). On average, mothers were 23 years old. The majority of participants were African American and at, or below, the poverty level.

The program has not been tested in Australia or with Aboriginal Australians.       

What outcomes does it contribute to?

Positive outcomes:

• Child hospitalisations (injuries/ingestions): there are fewer hospitalisations for injuries or ingestions in families who received the Linkages for Prevention project.
• Child’s medical care: parents are more likely to have made well-child healthcare visits (checkups etc) when receiving the Linkages for Prevention project.
• General parenting behaviours: homes are more likely to have environmental safety features, such as a poison control centre number when families received the program.
• Parent’s substance use: fewer mothers report smoking tobacco after receiving the program than mothers who didn’t receive the program.

No effects:

• Child abuse reports (substantiated): the program has no significant effect on the number of substantiated neglect cases recorded by social services.
• Parenting attitude: the program has no significant effect on parenting satisfaction.
• Parenting knowledge: the program has no significant effect on parents’ knowledge of child development.
• Parent’s mental health: the program has no significant effect on maternal depression rates.
• Parent’s social support: the program has no significant effect on social support for parents.

Negative outcomes:

• Parent’s use of services: mothers report using social services less after the birth of their child when receiving the program.

How effective is it?

Overall, the Linkages for Prevention project has a mixed effect on client outcomes.

How strong is the evidence?

Mixed research evidence (with adverse effects):

• At least one high-quality randomised controlled trial (RCT) or quasi-experimental design (QED) study reports statistically significant positive effects for at least one outcome, AND
• An equal number or more RCT or QED studies of similar size and quality show no observed effects than show statistically significant positive effects, AND
• No RCT or QED studies show statistically significant adverse effects.

How is it implemented?

The Linkages for Prevention project had 3 intervention levels: community, practice and family.

The community-level intervention included:

• An advisory board with representatives from community agencies, primary care practices, and county government. The advisory board provided advice on how the project could fit in among existing community health improvement projects.
• Seeking leadership from state health policy makers to develop needed resources and achieve cooperation between the health and mental health departments necessary to implement the home visiting program.
• Practice meetings so physicians and staff could share new approaches to organising preventive care.
• A task force of all the groups to identify and close gaps in immunisation outreach activities.
• Link practice and family interventions by encouraging home visitors to identify a nurse in each practice they could communicate about the families they worked with.

The practice-level intervention included:

• Hiring and training staff and providing ongoing staff supervision
• Providing structured protocols for care delivery
• Providing regular feedback and data about the implementation of the program
• Implementing office-based quality improvement systems (see Bordley et al. (2001) for more information).

The family-level intervention included intensive home-visiting to pregnant women and their infants. Home visiting began when the mother presented for prenatal care. It involved 2 to 4 visits per month through the infant’s first year of life. Home visiting provided mothers with:

• parental education on fetal and infant health and development
• training in injury prevention and discipline
• informal support systems
• links to needed health and human services.

Home visits were conducted by a public health nurse and an early childhood educator. The early childhood educator was added to the nurse visitor to enhance the emphasis on early childhood development.

How much does it cost?

Not reported

Where does the evidence come from?

One QED conducted in the USA, with 208 participants (Margolis et al. 2001).

Further resources

Bordley, WC, Margolis, PA, Stuart, J, Lannon, C, Keyes, L, (2001), ‘Improving preventive service delivery through office systems’, Pediatrics, vol. 108, no. 3, pp.

Margolis et al. (2001), From concept to application: The impact of a community-wide intervention to improve the delivery of preventive services to children. Pediatrics, Vol. 108, No. 3, pp. (e)42.