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PEDIATRICS Vol. 101 No. 3 March 1998, pp. 486-489
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ABSTRACT |
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Traditional pediatric care is often based on the assumption that parents have the basic knowledge and resources to provide a nurturing, safe environment and to provide for the emotional, physical, developmental, and health care needs of their infants and young children. Unfortunately, many families have insufficient knowledge of parenting skills and an inadequate support system of friends, extended family, or professionals to help with these vital tasks. Home-visitation programs offer an effective mechanism to ensure ongoing parental education, social support, and linkage with public and private community services. This statement reviews the history and current research on home-visitation programs and provides recommendations about the pediatrician's role in supporting and using home visitation.
Home visitation for parents is a widespread
early-intervention strategy in most industrialized nations other than
the United States. In most countries, home health visiting is free,
voluntary, not income-related, and embedded in comprehensive maternal
and child health systems. Although a causative link has not been
demonstrated conclusively, countries with extensive home visitor
programs generally have lower infant mortality than does the United
States. This is despite per capita health spending in the United States
that far exceeds expenditures in other industrialized
countries.1 Denmark established home visiting by law
in 1937 after a pilot program was successful in lowering infant
mortality. France provides free prenatal care and home visits by
midwives or nurses to provide education about smoking, nutrition,
alcohol and other drug use, housing, and other health-related issues.
In England, every prospective mother is visited at home at least once
before birth, with six more visits typically occurring before the child
is 5 years of age.2 In the United States, home-visitation
services have been perceived by many as too costly and unnecessary for
all new families.
Home-visitation programs began in the United States in the late 19th
century. Public health nurses and social workers provided in-home
education and health care to women and children, primarily in poor
urban environments.3,4 At the beginning of the 20th century, the New York City Health Department implemented a home visitor
program, using student nurses to instruct mothers about breastfeeding
and hygiene. This program reduced the high mortality rate of inner-city
infants from summer diarrhea when previous efforts of private agencies
had failed.5 In the late 20th century, as funding for
public health nurses has declined relative to the need, home-visitation
programs have focused on families with special problems such as
premature or low-birth-weight infants, children with developmental
delay, teenage parents, and families at risk for child abuse or
neglect.6
Almost 20 years ago, Dr C Henry Kempe suggested that to ensure
the right of every child to comprehensive care, every pregnant woman be
assigned a home health visitor who would work with the family until the
child began school.7 Insurance companies declined to pay
for this service because of a lack of empirical evidence to support its
effectiveness. Kempe continued to advocate home visiting vigorously,
suggesting that it could play a major role in the prevention of child
abuse. He reiterated these ideas in the 1978 Abraham Jacobi Award
Address.8 In 1980, the American Academy of Pediatrics held
a conference on home visitation. The conferees were unable to find
sufficient research on home visitation to recommend it as national
policy.4
In the 1992 Jacobi Award Address, Sia9 renewed Kempe's
arguments, citing additional information about the effectiveness of
health-related home-visitation programs in Hawaii in improving health
and social outcomes for children. The publication in 1988 of Schorr's
book, Within Our Reach: Breaking the Cycle of
Disadvantage,10 encouraged Sia and other advocates in
Hawaii to move ahead with the first statewide home-visitation program.
Begun in 1993, this program currently is the subject of two rigorously
designed outcome studies and has stimulated research and development of
similar programs in other states.11
A small but growing body of research has supported the
effectiveness of home-visitation programs. The following benefits have been found as an outcome of some, but not all, home visitor
programs:12
Prenatal Effects
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HISTORY OF HOME-VISITATION PROGRAMS
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POTENTIAL BENEFITS OF HOME-VISITATION PROGRAMS
Postnatal Effects
Long-term Effects
A 15-year follow-up study of families who received a mean of nine home visits by nurses during pregnancy and 23 home visits up to their child's second birthday has demonstrated the following long-term benefits:
The observed effect of home-visitation programs seems to be greatest in high-risk populations, such as mothers who are teenagers, unmarried, poor, or have been abused themselves, and in children who are preterm or low birth weight. 15
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PERTINENT VARIABLES IN HOME-VISITATION PROGRAMS |
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Home visitors may be professionals or paraprofessionals, volunteers or paid workers. The services they provide may be social, health-related, or educational and may be targeted to an individual child or to an entire family.6 They are not intended to replace office-based pediatric care, but rather to supplement and reinforce it. Caution is advised in comparing the outcomes of different home-visitation programs, because they may vary in important ways, including the following:
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ELEMENTS OF SUCCESSFUL HOME-VISITATION PROGRAMS |
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Olds has made a plea that health and human services groups not make recommendations about, design, or implement home-visitation programs without considering the empirical evidence about the types of programs that are more successful.14 Current research indicates that more successful programs contain the following elements:8,14
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COST-EFFECTIVENESS OF HOME VISITATION |
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Are home-visitation programs cost-effective? Olds writes that "a major portion of the cost for home visitation can be offset by avoided foster care placements, hospitalizations, emergency room visits, and child protective service worker time incurred during the same period that the home visitor program is provided. The long-range financial savings to the community are in all likelihood substantially greater, as is the reduction of human suffering."6 Olds reports that current home-visitation programs cost between $300 and $1750 per family per year depending on the level and frequency of services provided. Even the most expensive programs pay for themselves by the time the children are 4 years old. Approximately 80% of the cost savings comes from reduction in welfare payments and food stamps, with one third of the savings coming from reduction in unintended subsequent pregnancies.8,14
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NEED FOR EVALUATION AND SAFETY |
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Many small home-visitation programs are being developed and implemented around the country. In the absence of careful design, attention to empirical findings from previous research on home-visitation programs, and high standards for field experimentation, it will be difficult to determine whether public and private monies are well spent. Public funding measures for home-visitation programs should require both continuous examination of outcome measures and the ability to make midcourse corrections.8,14 Accrediting may be a key component to providing some degree of uniformity, accountability, and quality in home-visitation programs. Home-visitation programs also must ensure the safety of their visitors and protect them from the violence often found in the environment of families with the highest needs.19
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LIAISON WITH PRIMARY PROVIDERS |
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Home visitors can be health care advocates to improve access to
providers of health care. Home visitors can be partners with pediatricians and other clinicians, working in the home setting to
provide essential education and supportive services to at-risk children
and families and to improve adherence to medical prevention and
treatment regimens. Home-visitation programs include a "degree of
social support that is difficult to provide in most clinical settings;
outreach and liaison between the pediatrician, the family, and the
community; involvement with socioeconomic issues that directly affect
the well-being of the child and family; reinforcement and follow-up of
preventive care, peer helper support, as well as encouragement, by the
home health visitor who has the advantage of being with the family in
its own home
a more accepting, less threatening setting for the
family."6
Home-visitation programs should be integrated into a community's existing health care system, expanding the effectiveness of private providers, health maintenance organizations, and public health nurses. Visitation programs can provide or supplement services that are constrained by managed care or budgetary reductions. Aspects of home-visitation services for pregnant women, infants, and preschool children already are provided in many communities through public and home health agencies, parent-child services, hospitals, and private agencies. In some areas, home-visitation programs have linked with Head Start and other community-based family support programs to provide continuous services from conception to the start of school.20
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CONCLUSION |
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Home-visitation programs can be an effective early-intervention strategy to improve the health and well-being of children, particularly if they are embedded in comprehensive community services to families at risk.4 Home-visitation programs are not a panacea, sufficient unto themselves to reverse or prevent the damaging effects on children of poverty and inadequate or inexperienced parenting. Successful home-visitation programs require physician support and participation.
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RECOMMENDATIONS |
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The American Academy of Pediatrics encourages pediatricians to:
COUNCIL ON CHILD AND ADOLESCENT HEALTH,
1997 TO 1998
S. Kenneth Schonberg, MD, Chairperson
Steven J. Anderson, MD, Chairperson
Committee on Sports Medicine
and Fitness
Judith Ann Bays, MD, Chairperson
Committee on Child Abuse and
Neglect
Paula Duncan, MD, Chairperson
Committee on School Health
Marianne E. Felice, MD, Chairperson
Committee on Adolescence
Joel E. Frader, MD, Chairperson
Committee on Bioethics
Richard B. Heyman, MD, Chairperson
Committee on Substance Abuse
Murray L. Katcher, MD, PhD, Chairperson
Committee on Injury and
Poison Prevention
Peter Michael Miller, MD, MPH, Chairperson
Committee on Early
Childhood, Adoption, and Dependent Care
Mark L. Wolraich, MD, Chairperson
Committee on Psychosocial
Aspects of Child and Family Health
Philip R. Ziring, MD, Chairperson
Committee on Children With
Disabilities
LIAISON REPRESENTATIVES
Emmett Francoeur, MD, FRCPC
Canadian Paediatric Society
Audrey H. Nora, MD, MPH
Maternal and Child Health Bureau
Lucille Perez, MD
National Medical Association
CONSULTANT
Mark D. Widome, MD
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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REFERENCES |
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home visitations.
NRCCSA News.
1996;
5:1-8 This article has been cited by other articles:
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E. F. Donovan, R. T. Ammerman, J. Besl, H. Atherton, J. C. Khoury, M. Altaye, F. W. Putnam, and J. B. Van Ginkel Intensive Home Visiting Is Associated With Decreased Risk of Infant Death Pediatrics, June 1, 2007; 119(6): 1145 - 1151. [Abstract] [Full Text] [PDF] |
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B. Barnet, J. Liu, M. DeVoe, K. Alperovitz-Bichell, and A. K. Duggan Home Visiting for Adolescent Mothers: Effects on Parenting, Maternal Life Course, and Primary Care Linkage Ann. Fam. Med, May 1, 2007; 5(3): 224 - 232. [Abstract] [Full Text] [PDF] |
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D. Tandon, K. Parillo, C. Jenkins, J. Jenkins, and A. Duggan Promotion of Service Integration Among Home Visiting Programs and Community Coalitions Working With Low-Income, Pregnant, and Parenting Women Health Promot Pract, January 1, 2007; 8(1): 79 - 87. [Abstract] [PDF] |
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V. B Sheppard, R. E Zambrana, and A. S O'Malley Providing health care to low-income women: a matter of trust Fam. Pract., October 1, 2004; 21(5): 484 - 491. [Abstract] [Full Text] [PDF] |
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I. M. Paul, T. A. Phillips, M. D. Widome, and C. S. Hollenbeak Cost-Effectiveness of Postnatal Home Nursing Visits for Prevention of Hospital Care for Jaundice and Dehydration Pediatrics, October 1, 2004; 114(4): 1015 - 1022. [Abstract] [Full Text] [PDF] |
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S. S. El-Kamary, S. M. Higman, L. Fuddy, E. McFarlane, C. Sia, and A. K. Duggan Hawaii's Healthy Start Home Visiting Program: Determinants and Impact of Rapid Repeat Birth Pediatrics, September 1, 2004; 114(3): e317 - e326. [Abstract] [Full Text] [PDF] |
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A. Duggan, L. Fuddy, E. McFarlane, L. Burrell, A. Windham, S. Higman, and C. Sia Evaluating a Statewide Home Visiting Program to Prevent Child Abuse in at-Risk Families of Newborns: Fathers' Participation and Outcomes Child Maltreat, February 1, 2004; 9(1): 3 - 17. [Abstract] [PDF] |
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D. Wertlieb Converging Trends in Family Research and Pediatrics: Recent Findings for the American Academy of Pediatrics Task Force on the Family Pediatrics, June 1, 2003; 111(6): 1572 - 1587. [Full Text] [PDF] |
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D. L. Olds, J. Robinson, R. O'Brien, D. W. Luckey, L. M. Pettitt, C. R. Henderson Jr, R. K. Ng, K. L. Sheff, J. Korfmacher, S. Hiatt, et al. Home Visiting by Paraprofessionals and by Nurses: A Randomized, Controlled Trial Pediatrics, September 1, 2002; 110(3): 486 - 496. [Abstract] [Full Text] [PDF] |
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G. Watt Policies to tackle social exclusion BMJ, July 28, 2001; 323(7306): 175 - 176. [Full Text] [PDF] |
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