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Childhood Injury Prevention Interventions
Home Visitors
Background
Increased social support to high risk families to prevent child abuse can take
the form of information, emotional support, provision of material needs, or
instrumental help such as procuring day care. The most promising interventions
appear to be those that offer more than one type of social support service,
thereby affecting a number of risk factors for child abuse.
There has been a long history in the US and in other counties of health nurses
visiting new mothers and their children in their homes. In the US, this practice
has been largely discontinued on a routine basis, while it has been continued
in the UK and in Scandinavia. Reviewed below are randomized controlled trials
of home visiting and their effect on abuse and injury. This was recently reviewed
by Ian Roberts and colleagues7
in the BMJ and has been incorporated in to the Cochrane library.
Review of home visitor programs:
Author | Maracenko et al., 1994 |
Study design and target population | RCT
USA; high risk women: 110 intervention group, 77 controls
|
Intervention | Prenatal and postnatal; home visits
for parent/health education; professional and peer support |
Outcomes | Out of home placement |
Results | 31.8% intervention group and 19.5%
controls were placed out of home
OR 1.93 (0.97-3.85)
|
Study quality and conclusions | Follow-up was 10 months. Increased
risk of out of home placement in intervention group |
Author | Johnson et al., 1993 |
Study design and target population | RCT
Ireland; disadvantaged first time mothers: 127 in intervention group,
105 in control group
|
Intervention | Postnatal home visiting plus support
and encouragement in child rearing using child development program |
Outcomes | Abuse |
Results | None of the intervention group
and 2.9% of the control group were abused
OR=0.11 (0.01-2.25)
|
Study quality and conclusions | Follow-up for one year. Non-statistically
significant decrease in risk of abuse in intervention group. |
Author | Barth, 1991 |
Study design and target population | RCT
USA; High risk parents: 97 in intervention group and 94 in control
group
|
Intervention | Prenatal and postnatal non-professional
home visits |
Outcomes | Reported abuse |
Results | 66% in intervention group and
57% in control group had reports of abuse
OR=1.44 (0.80-2.58)
|
Study quality and conclusions | Follow-up was 3 years. Non statistically
significant increase in risk of reported abuse. |
Author | Hardy et al., 1989 |
Study design and target population | RCT
USA; Poor inner city mothers: 131 in intervention group and 132
in control group
|
Intervention | Postnatal home visits by non-professionals
giving parenting and childcare education |
Outcomes | Suspected abuse |
Results | 1.5% in intervention group and
9.8% in the control group
OR=0.14 (0.03-0.64)
|
Study quality and conclusions | Follow up for 1.9 years. Significantly
decreased risk of abuse in the intervention group. |
Author | Dawson et al., 1989 |
Study design and target population | RCT
USA; Pregnant women receiving pre-natal care, not selected for
high risk: 67 in intervention group; 44 in control group
|
Intervention | Prenatal and postnatal home visiting
by non-professionals providing emotional support and help in getting concrete
services |
Outcomes | Reported abuse |
Results | 7.5% in intervention group and
2.3% in control group
OR=3.47 (0.39-30.74)
|
Study quality and conclusions | 1 year follow-up. Increased risk
of reported abuse in intervention group, although non-significant and very
wide confidence limits |
Author | Olds et al., 1986 |
Study design and target population | RCT
USA; High risk primiparous mothers who were teen, low income
and/or unmarried: 400 participants
|
Intervention | Prenatal and postnatal home visiting
by nurse; focus on parenting, health education, child development, strengthening
social network, linking family to community services |
Outcomes | Abuse confirmed by CPS |
Results | 5% abused in intervention group
and 10% in control group at 2 years; 8% in intervention group and 5% in
control group at 2-4 years. |
Study quality and conclusions | Follow-up to 4 years. Intervention
appeared to decrease risk of abuse during the first 2 years while the visits
were occurring but no difference during ages 2-4 after the visits stopped. |
Author | Lealman et al., 1983 |
Study design and target population | RCT
UK; high risk families: 103 in intervention group and 209 in
control group
|
Intervention | Postnatal visits by social worker |
Outcomes | Abuse |
Results | .9% in intervention group and
1.4% in control group. OR=0.67 (0.07-6.55) |
Study quality and conclusions | Follow up for 1.5 years. Non significant
decrease in risk of abuse. |
Author | Siegel et al., 1980 |
Study design and target population | RCT
USA; low income mothers: 159 in intervention group and 162 in
control group
|
Intervention | Postnatal home visits by non-professionals
to support mother |
Outcomes | Reported abuse |
Results | 8.8% in intervention group and
5.5% in control group. OR=1.64 (0.69-3.91) |
Study quality and conclusions | Follow-up for 1 year. Non significant
increase in risk of abuse in intervention group |
Author | Gray et al., 1979 |
Study design and target population | RCT
USA; high risk families: 50 intervention and 50 control
|
Intervention | Postnatal home visits |
Outcomes | Suspected abuse |
Results | None of the intervention group
and 10% in the control group. OR=0.08 (0.00-1.52) |
Study quality and conclusions | Follow-up 1.4 years. Large decrease
in risk of suspected abuse, but non-significant with wide confidence limits. |
Author | Huxley and Warner, 1993 |
Study design and target population | Controlled trial
USA; 20 high risk families who received services matched
to 20 high risk families who did not receive services
|
Intervention | Prenatal and postnatal home visits
by nurses |
Outcomes | Confirmed child abuse |
Results | 1 of 20 in the intervention group
and 4 of 20 in the control group |
Study quality and conclusions | Follow-up for 13 months in intervention
group and 16 months in control group. Nonsignificant decrease in risk of
abuse. |
Summary of home visitor programs
Of the nine studies,the frequency of abuse was lower in 4 and
higher in 5. However, there is a serious potential to bias in these studies
in that the home visited families would have come under greater scrutiny, which
could have resulted in increased reporting of abuse. This would have increased
the likelihood of reported abuse in the intervention group. This would seriously
underestimate the effect of home visiting on abuse.
In addition, there was substantial variation in the types of individuals doing
the home visits. Some were professionals such as nurses, others were non-professionals.
The study by Olds and colleagues13
is one of the best known and one of the clearest for its effects. It used professional
nurses.
Finally, the Olds study also indicates that the effect does
not persist after the home visits cease. Continued visits may be needed while
the child is at high risk.
Recommendations on home visitor programs
The data are promising and suggest that home visits are a potentially
useful strategy to decrease child abuse. While the data are not yet definitive,
the US Advisory Committee on Child Abuse and Neglect recommends universal home
visiting for all new mothers. If it is done, high risk families may need to
be followed long-term. In addition, professional visitors appear to be more
effective than non-professionals.
Recommendations for future research
Currently, Olds and colleagues are conducting at least one other
RCT of home visiting to assess its effects. The children in the existing studies
should be followed longer than the 1-2 years in many of these studies to identify
longer-term impacts of the intervention.
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