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.