#UMNMCH student Cora Vavra (she/her/hers) (MPH 2022) wrote this reflection on how her coursework and applied practice experience have contributed to her career in MCH at the Minnesota Health Department (MDH). In this piece, she describes her experience with family home visiting and working with MDH on a continuous quality improvement project.
When I was in nursing school during my undergraduate degree, I thought I had made a big mistake choosing to become a nurse. I felt I lacked the passion and skills I saw in my fellow peers. Then I discovered public health, specifically family home visiting, and everything changed. I had found my place. I became a public health nurse working in the field of family home visiting, where I have had the opportunity to partner with families to promote maternal and child health. As a home visitor, I was focused on individual and community level factors, but I wanted to deepen my understanding of the systems that impact families. I was also drawn to learning how family home visiting can affect maternal and child outcomes and how we can continually improve home visiting services to be a part of system changes that advance family health and wellbeing. This led me to UMN’s MCH program. As a student, I was able to align my interests with coursework in the MCH program and through my applied practice experience with the Family Home Visiting section of the Minnesota Department of Health (MDH).
What is family home visiting?
Family home visiting programs are public health programs that provide services to families during the prenatal and early childhood period using evidence-based models. MDH’s Family Home Visiting section offers consultation, technical assistance, professional development, data collection and evaluation, continuous quality improvement (CQI), and grant management support for agencies providing these services throughout the state. My work as a student centered around a CQI project to increase depression screening rates by home visiting agencies.
Why depression screening?
Perinatal depression is a public health issue that affects one in eight women (CDC, 2020). Screening for depression is recommended in family home visiting programs to detect and make referrals to mental health services. From 2019 to 2020, there was a significant drop in depression screening rates for families receiving home visiting services across the state. I learned that there were many reasons behind this decrease, such as home visiting staff being re-deployed to COVID-19 duties, barriers to screening in virtual visits, and cultural barriers in how to approach screening with clients of diverse cultures.
As a student working with MDH, I conducted key informant interviews with home visiting agencies. Qualitative findings revealed that many home visitors felt providing depression screenings to families of diverse cultural backgrounds was challenging due to language barriers, the stigmatization of mental health in some cultures, and barriers with interpreter services. Additionally, in a literature review that I conducted, there was a finding that inequities exist for postpartum depression screening in home visiting; Almond and Lathleen (2011) found that inequities exist when not all women, especially women of minority ethnic groups, are screened by the majority white home visitors.
How does MDH use CQI to improve depression screening?
A systems approach to improving the delivery of home visiting includes continuous quality improvement (CQI) projects that are year-long projects focused on measurable and attainable goals. In 2021, the CQI goal for family home visiting was to increase the depression screening rate by 10% during the three-month window either after a primary caregiver enrolls in home visiting services or after the infant’s birth. As a part of the project, I participated in CQI check-in calls with MDH staff and home visiting agencies in which we reviewed data on depression screenings and agencies developed change ideas to test through the Plan Do Study Act (PDSA) model of CQI.
At the end of 2021, effective change ideas were shared in a webinar showcase that I participated in creating with MDH staff and home visiting agencies. Additionally, we developed a second webinar specifically addressing ways to improve the culturally appropriate delivery of depression screenings as a means to increase screening for all families receiving services. A key theme that arose was the importance of home visitors receiving training in cultural humility. Overall, the CQI project led to an 18.6% increase in depression screenings statewide.
From this experience with MDH, as well as coursework in the MCH program, I learned how to apply systems thinking to the public health issue of perinatal depression using CQI tools. In conducting key informant interviews, I also gathered a new understanding of how cultural differences can create barriers to the implementation of home visiting services, yet how these differences can also help guide home visitors and agencies to listen to families’ ideas on how to improve the delivery of home visiting programs. The experience led me to a new position at MDH, where I work now as an Implementation Coach that supports training and technical assistance needs of home visiting agencies across the state.
Cora Vavra graduated with her MPH in MCH in 2022. Her background is in maternal and child family home visiting and public health nursing. Cora received her BS in Nursing from Indiana University. She has worked as a nurse home visitor with Goodwill of Central and Southern Indiana in Indianapolis, Indiana and with the Fond du Lac Band of Lake Superior Chippewa. In February 2022, Cora started in a new position as an Implementation Coach with the Minnesota Department of Health in the Family Home Visiting section. In her spare time, she enjoys getting outside for runs along the lake and hiking where she lives in Duluth, MN.
Almond, P. & Lathlean, J. (2011). Inequity in provision of and access to health visiting
postnatal depression services. Journal of Advanced Nursing, 67(11), 2350-2362.
CDC. (2020). Depression among women. Retrieved April 24, 2022 from
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