• By Dartington SRU
  • Posted on Tuesday 01st May, 2007

New study brings home the value of the health visitor

A new survey of the effectiveness of home visiting highlights the value of combining a proven clinical strategy with a mastery of practicalities. A sound, logical approach to choosing recipients, supervising well-trained staff and rigorously monitoring performance has been shown to increase the prospect of good results. Deborah Daro’s work for the Ounce of Prevention Fund and Chapin Hall Center for Children at the University of Chicago also exposes the difficulty policy makers encounter when they know the value of a service model but struggle to keep the expertise of those who provide it up-to-date, or to integrate their role into the evolving pattern of services.Home visits prior to a baby’s birth and during the first year of life are routine in many European countries. In the US they are considered more of a novelty, having grown out of programs designed, implemented and evaluated in the 1960s and 1970s.In England every newborn child gets some support from a health visitor to detect developmental delays. Health visitors also offer some family support and are involved in protecting children against maltreatment. The service is universal but for most families it amounts to no more than a few visits.Daro estimates that in the US, where there are roughly four million new births a year, somewhere between 400,000 and 500,000 children receive intensive home visitation. There the service is enduring and generally well evaluated, and the recipients are mainly poor. Some rigorous evaluations are under way, but they concentrate on intensive variations intended for poor children who are at risk of maltreatment or a significant developmental delay.So what is the best way forward for the policy maker? To seek to replicate one of the six proven models Daro lists in her overview? Or to continue to improve the quality of programs generally and get them integrated into current support systems?She leans towards the latter strategy — and also argues strongly for modest expectations. While it is true that home visiting in the first years of life is associated with a series of improvements to child development, it is not a panacea.In the US, in addition to the evaluation of individual programs, there are many meta-analyses looking at results in combination, which point toward the benefits to the parents and to the child. Parents have a better birth, know more about how to interact with their child and make better use of available services. The programs propel them into more involvement in their child's learning. For the children the pay-off is in terms of both cognitive and non-cognitive skills. They become more competent socially, their pre-school skills are enhanced and they behave better.But In all cases, the impact of home visits on child development, though important, are modest. Good outcomes are more likely if the work starts in the months between conception and birth.Less well reported are the efforts to ensure quality of implementation. Daro describes the six US inititiatives where the aim has been to get the best from site selection, management information, performance standards and self-assessment, and she draws out messages that will help policy makers in Europe as well as the U.S. Sound logic models, well trained and competent staff, high quality supervision, strong organisational capacity and consistent implementation of programs are the main messages Critically, home visits make a difference not only because they make available direct support, but also because they connect the parent to other community resources and supports.Daro has been instrumental in establishing the Home Visit Forum in the US to promote these good practice messages and learn more about what works in program implementation. But, despite the progress, the challenges on both sides of the Atlantic are immense. In the US 37 states have services based in some way on proven models, but program fidelity can be suspect. In England, there has been prevention programs have proliferated but with little attention to basic issues such as staff training, salary and supervision. And our knowledge about impact on outcomes remains pitifully poor.• The idea of a nurse undertaking developmental checks on a child in the first weeks of life is well established in several EU states. Generally speaking, the service is universal and linked to pre-natal care for the mother, and to midwifery provision. In England, all parents have contact with a health visitor who measures the child and undertakes a series of other developmental checks. In the United States, where there is no universal provision, most families with insurance get support from a pediatrician.

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