Health visitors

Targeted home visits by trained professionals to parents with children aged two and under.
First published
Effect scale Quality of evidence
Effect Impact on crime Mechanism How it works Moderator Where it works Implementation How to do it Economic cost What it costs
Overall reduction

Moderate

Low

Moderate

Low

Low

Focus of the intervention

Home visits in early childhood involve trained personnel – known as health visitors in the UK – visiting the home of parents with children within the first two years of the child’s life.

Visits can begin during pregnancy or after the birth. Visitors provide information about child care, children’s health and development, and parental training.

The visitors offer support to the parents and often deliver a combination of services. While home visits are universal in the UK, they are not in the USA. In the USA they are often targeted at specific population groups, such as parents on low incomes, ethnic minorities, young and first-time mothers, and those with lower educational achievements. Homes where mothers and children are believed to be at risk of abuse are also specifically targeted.

This narrative summary is based on two systematic reviews – Review one covering 26 studies and Review two covering six studies. The narrative is primarily based on Review one, with Review two contributing additional evidence to the effect and mechanism sections. The majority of the individual studies included in the reviews were based on evidence from the USA, with additional studies from the Netherlands (two) and Australia (two).

The focus of this narrative is on the effect of home visiting on child abuse and neglect, violence by children in later life and domestic violence between parents. 

Effect – how effective is it?

Overall, the evidence suggests that home visits in early childhood have reduced crime.

The specific outcomes covered by the reviews are:

  • child abuse and neglect
  • violence by children in later life
  • domestic violence between parents

The meta-analysis in Review one covered 20 studies. Its findings suggested that on average, rates of abuse and neglect were 39% lower for those children whose families received early childhood home visits compared to those families who did not.

Review one found two individual studies where children in families who received home visits in early childhood reported significantly lower levels of convictions, self-reported arrests and numbers of individuals processed through the probation system in later life, when compared to children whose families did not have home visits. A further two studies found evidence of no effect of early childhood home visits for children’s violence in later life.

One study in Review one and three studies in Review two found that early childhood home visits reduced domestic violence and abuse between parents, when compared to parents in families who did not receive home visits. A further three studies in Review two found no evidence of effect of home visiting on domestic violence and abuse between parents. 

After analysing the effect sizes of studies measuring child abuse and neglect, the authors of Review one found that studies of higher methodological quality had significantly smaller effect sizes than lower quality studies. Higher quality study designs (studies with random allocation of participants to groups) saw an average reduction of 27.5%. Those of lesser quality (without randomised allocations) saw a much higher average reduction of 68.3%. 

How strong is the evidence?

Although Review one was systematic, some forms of bias that could influence the study conclusions remain.

Review one had a well-designed search strategy and statistically analysed differences in the effect size between different study designs. However, the review did not take into account potential issues with publication bias, statistical dependency or weighting by size of the study sample.

Although Review two was systematic, many forms of bias that could influence the study conclusions remain.

Review two undertook an assessment of the risk of bias in the primary studies and considered the validity of the outcome constructs. However, due to the variation in the outcome measures a meta-analysis was not carried out. 

Mechanism – how does it work?

Reviews one and two suggested a number of ways in which home visits in early childhood may reduce crime.

Review one suggested that human ecology theory (which stresses the importance of the home environment of a child for their development) and attachment theory (which stresses the importance of the child-parent bond) could explain how home visits may reduce child neglect and parental violence.

By increasing parents’ self-confidence, knowledge and skills, early childhood home visits are believed to improve the environment in which children are raised and improve positive attachment to the parents.

Giving parents knowledge and resources is believed to help improve child development, skills, health and wellbeing, leading to less violence being perpetrated by or against members of the household.

Review two suggested that early childhood home visits create opportunities to reach women experiencing domestic violence and abuse. Home visits targeted at such mothers are presumed to support positive parental relationships and help children to cope with the negative effects of witnessing domestic violence and abuse between their parents.

However, neither Review analysed or tested these assumptions.  

Moderators – in which contexts does it work best?

Review one presented and tested a number of contextual factors that might have influenced the effect of early childhood home visits.

Home visits in early childhood appeared to be more successful for households with low socio-economic status.

The type of person who visited the home to provide help and information to parents was also found to have an impact upon the effectiveness of the intervention.

Programmes that used nurses and mental health workers saw significantly larger decreases in crime (47.8% and 44.5% respectively) than those that use paraprofessionals (17.7%), who are trained to assist professionals but do not hold professional licences. This was true across all crime outcomes, including child abuse, neglect and domestic abuse between parents.

It was also found that programmes of a longer duration (of two years or more) showed significantly larger decreases in crime than shorter programmes.

Multi-component programmes that involved both pre-natal and post-natal visits showed significantly higher decreases in crime (74.3% reductions) than those which were post-natal only (20.9% reductions).

Implementation – what can be said about implementing this initiative?

Review one noted that early childhood home visits are universally offered in the UK but in the USA – where the studies from the review were conducted – visits are targeted towards at-risk groups.

Targeted populations included teenage parents, single mothers, families of low socio-economic status, families with very low birthweight infants, parents previously investigated for child maltreatment, and parents with alcohol, drug, or mental health problems.

In the USA, programme components may include one or more of the following:

  • training of parents in prenatal and infant care
  • training in parenting to prevent child abuse and neglect
  • developmental interaction with infants and toddlers
  • family planning assistance
  • development of problem-solving and life skills
  • educational and work opportunities
  • linkage with community services

Home visit programmes may be accompanied by the provision of day care, parent group meetings for support and instruction, and advocacy.

Review one noted that barriers to successful implementation of programmes include the recruitment, training and retention of health visitors due to low pay and difficult working conditions. Paraprofessional visitors may also require more training and supervision than professionals.

Economic considerations – how much might it cost?

Where information about the cost of the intervention was reported in the primary studies, this was highlighted within Review one. No cost-benefit analysis was conducted as the relevant information was not available.

For one study, the direct costs of nurse visits for two years was $6,286 per family in 1997. Another study from the same year reported average programme costs of $958 per family.

The review mentioned one cost-benefit study that found a benefit of $350.61 per low income family.

However, for the whole sample, which also included families of medium and high income, they found a cost of $3,081 per family rather than an overall benefit.

General considerations

  • The majority of individual studies included in the reviews were conducted in the USA. Early childhood home visits may be more targeted and comprehensive than the universally available but more basic support offered in the UK. This needs to be kept in mind when interpreting the results. 
  • It is unknown whether home visits can provide a sustaining effect in reducing domestic violence between partners as the longest follow-up was 24 months.

Summary

Overall, the evidence suggested that home visits in early childhood have reduced child abuse and neglect, violence by children in later life, and domestic violence between parents.

The reviews suggested that the use of home visits encourages self-confidence, knowledge, skill, and a positive personal relationship between parents, thus providing a stable home environment for children.

Home visits in early childhood appeared to be more successful for households with low socio-economic status.

Programmes that used nurses and mental health workers were found to be more effective than programmes that used paraprofessionals.

Further, programmes that included pre-natal and post-natal visits were more effective than those that only include post-natal visits. 

It was also noted that early childhood home visits are universally offered in the UK but in the USA – where the studies from the review were conducted – visits are targeted towards at-risk groups.

Barriers to successful implementation of programmes include the recruitment, training and retention of visitors due to low pay and difficult working conditions.

Reviews

Review one

Quality of evidence
Mechanism How it works Moderator Where it works Implementation How to do it Economic cost What it costs

No information

Moderate

Low

Low

Reference

Review two

Quality of evidence
Mechanism How it works Moderator Where it works Implementation How to do it Economic cost What it costs

Low

No information

No information

No information

Reference

Prosman, GJ., Lo Fo Wong, S.H., Van Der Wouden, J.C., Lagro-Janssen, A.L.M. (2016) 'Effectiveness of home visiting in reducing partner violence for families experiencing abuse: a systematic review', Family Practice, 32(3), pp. 247-256.

Summary prepared by

This narrative was prepared by UCL Jill Dando Institute and was co-funded by the College of Policing and the Economic and Social Research Council (ESRC). ESRC grant title: 'University Consortium for Evidence-Based Crime Reduction'. Grant reference: ES/L007223/1.

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