Can Home Visitation Improve the Health of Women and Children at Environmental Risk?

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Can Home

Visitation

Improve

the Health

of

Women

and Children

at Environmental

Risk?

David

L. Olds,

PhD,

and

Harriet

Kitzman,

PhD

From the University of Rochester, Rochester, New York

ABSTRACT. We reviewed randomized trials of prenatal

and infancy home-visitation programs for socially disad-vantaged women and children. Some home-visitation programs were effective in improving women’s health-related behaviors during pregnancy, the birth weight and length of gestation of babies born to smokers and young adolescents, parents’ interaction with their children, and children’s developmental status; reducing the incidence

of child abuse and neglect, childhood behavioral prob-lems, emergency department visits and hospitalizations for injury, and unintended subsequent pregnancies; and increasing mothers’ participation in the work force. The more effective programs employed nurses who began visiting during pregnancy, who visited frequently and long enough to establish a therapeutic alliance with fam-ilies, and who addressed the systems of behavioral and psychosocial factors that influence maternal and child outcomes. They also targeted families at greater risk for health problems by virtue of the parents’ poverty and lack of personal and social resources. Pediatrics

l990;86:108-116; home visits, maternal-child health, birth

weight, development, abuse.

In recent months, the federal government has expressed increased interest in funding home-vis-itation services for pregnant women and young children.’4 In 1989, for example, Congress modified Title V of the Social Security Act for the first time to authorize explicitly funding of home visitation for pregnant women and infants,5 although they did not appropriate funds for this work. In addition, a number of states have begun supporting maternal and child home-visit services with Medicaid dollars, after years of cutbacks in these services.6 In light of this, it is particularly important to recognize that,

Received for publication Feb 12, 1990; accepted Mar 21, 1990. Reprint requests to (D. L. 0.) Dept of Pediatrics, Box HWH, University of Rochester School of Medicine and Dentistry, 601 Elmwood Aye, Rochester, NY 14642.

although home visitation is a promising strategy, many home-visitation programs simply do not work. Consequently, it is especially important to know what kinds of home-visitation programs work best for pregnant women and young children.

In this paper we examine randomized trials of home-visitation services from the standpoint of three factors that we believe are critical in deter-mining their success: 1) the underlying causal model of influences on maternal and child out-comes; 2) the corresponding content and structure

of the services; and 3) the degree to which the population served is at environmental, behavioral, or psychosocial risk for the particular problem un-der consideration. In examining the research from these perspectives, we have attempted to disentan-gle these issues from the design and methodologic problems that inevitably complicate field experi-ments.7 We have limited the review to randomized trials that tested programs designed either to im-prove the outcomes of pregnancy (in particular, birth weight or length of gestation) or the health or development of socially disadvantaged young chil-dren (less than 3 years of age) and their mothers. Secondary prevention programs delivered to popu-lations already exhibiting problems (such as low birth weight or developmentally delayed babies) are excluded. Most previous reviews of home-visitation programs for socially disadvantaged women and children have produced largely discouraging conclu-sions.’#{176} We have published a book chapter that

provides additional details on the trials discussed in the present review.11

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ARTICLES

109 PRENATAL

PROGRAMS

Four randomized trials have examined the impact of prenatal home visitation on birth weight and length of gestation.’2’5 Only one of these found a discernible impact on these outcomes and the effect of that program was concentrated among women who smoked or who were very young (<17 years) at registration.’5

“Social-Support”

Models

The three studies that did not find positive effects on birth weight or length of gestation employed what the authors referred to as “social-support” interventions. These investigators used rather nar-row definitions of social support, however, in that the home visitors either actively avoided teaching about health-related behaviors, or only provided such information upon request.’2’4 Social support consisted of activities such as serving as a confi-dante (emotional support), providing concrete as-sistance (help with transportation, shopping, child care), facilitating women’s use of community serv-ices, and helping women with their relationships with family members and friends.’2’4 No attempt was made to determine the extent to which program effects in these social-support trials might have been greater among women at behavioral risk.

In avoiding teaching patients about health-re-lated behaviors, these three social-support pro-grams seem to have been based on the assumption that the high rates of preterm delivery and low birth weight among socially disadvantaged women are caused by high rates of psychosocial stress in the absence of social support. The evidence on the relationship between stress and poor pregnancy outcome is inconsistent, however.’6 The better con-trolled studies in this area suggest that the relation-ship between stress and low birth weight is either

confounded

with or mediated by adverse health-related behaviors, such as smoking.’7

Ecological

Model

In the one trial that found positive effects on birth weight and length of gestation (N = 400), nurses in Elmira, NY visited families about once every 2 weeks (for an average of nine prenatal home visits).’5 In contrast to the three social-support

pro-grams listed above, the nurses followed a human-ecology model of influences on maternal and child health and integrated health’8 education with so-cial-support activities.’9 They assumed that provid-ing social support, by itself, could not be counted on to improve the behavioral antecedents of low birth weight, such as substance abuse and

made-quate weight gain. Social support and education to change adverse behaviors would have to be corn-bined in a comprehensive program. The ecological model attempts to explain how factors at different levels of proximity to the mother and child (eg, behavioral, biologic, psychologic, sociologic, and economic) interact to form a system of influences on maternal and child functioning. On a practical level, the ecological model leads the home visitor to examine simultaneously maternal personal re-sources, social support, and stresses in the home, family, and community that can facilitate or inter-fere with optimal health-related behaviors during pregnancy and subsequent care of the child. In keeping with this model, the nurses attempted to create a therapeutic alliance with mother and her family by focusing on maternal and family strengths, and they simultaneously carried out three fundamental activities: 1) They educated women about health-related behaviors, such as smoking, alcohol consumption, nonprescription drug use, and managing the complications of preg-nancy. 2) They attempted to enhance social support for the mother by involving other family members and friends in the program. 3) They helped families find needed health and human services. Treatment differences were produced in health-related behav-iors (smoking and diet), maternal health (fewer kidney infections), informal social support, and women’s use of community services. The positive effects of the program on birth weight and length of gestation, however, were limited to young ado-lescents (<17 years) and smokers, subgroups at higher risk for preterm delivery and low birth weight.’5 The number of young adolescents in this trial was quite small. This report focused on whites

(89% of the total sample).

In spite of our limiting this review to randomized trials, differences in design and implementation of the studies cannot be ruled out as explanations for the pattern of results among these prenatal pro-grams. One might argue that those programs based on narrow definitions of social support (that is to exclude health education) failed to produce positive effects on birth weight and length of gestation because of design and methodologic problems. The Denver trial, for example, was not randomized fully (with 27 of the 89 controls registered after the randomization phase was completed), and it had a sample too small to detect the effects ofthe program on birth weight. The investigators found a 200-g

nonsignificant treatment difference in birth weight and changes in maternal diet, however, that favored the control group.’2’20The other two trials had much larger numbers (1285 in Manchester and 510 in London), but the Manchester trial randomized

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women before they agreed (in principle) to accept a home visitor. The authors correctly included in the analysis of outcomes all those invited to partic-ipate (insofar as data were available), but such an approach became an unusually rigorous test of pro-gram effectiveness in that only 271 of the 655 women assigned to receive home visitors accepted them into their home. All of the other trials ran-domized women after they agreed to be assigned to either a home visitor or a comparison/control

group. In spite of these design and methodologic complications, in balance, results of the Elmira study suggest that the absence of effect on birth weight and length of gestation in these narrowly defined social-support programs can be attributed primarily to their failure to address established behavioral antecedents of poor pregnancy outcomes directly.

Evidence from the Elmira trial also indicates that prenatal home visitation has little enduring effect

on maternal and child health.’5’ 21, 22 This study

included a group of families that were visited during pregnancy but not after the child was born. In spite

of the nurses’ attempts to establish a close working relationship with the family, and their success in improving women’s health-related behaviors, the psychosocial conditions of pregnancy, and the birth weight and length of gestation of babies born to smokers and young adolescents, there were very

few enduring effects of prenatal home visitation on subsequent maternal and child functioning. It is important to note that the program did not affect the lowest ranges of the birth weight and length-of-gestation distributions. Consequently, it is not surprising that improvements in moderate (32 to 36 weeks) preterm delivery or mean birth weight had few discernible long-term effects. At-risk fam-ilies who received both prenatal and postnatal home

visitation, on the other hand, experienced substan-tial improvements in maternal and child health during the first 2 years after 222

Both the Elmira and London studies demonstrate that home visitors can improve the psychosocial context of pregnancy (such as family members’ support of mother, her use of community services, and reductions in depression) when there is an explicit effort to improve these aspects of preg-nancy.’4’ ‘ The absence of effect on birth weight and length of gestation in the London trial shows that improving the psychosocial context of preg-nancy (without an emphasis on improving health-related behaviors) is insufficient to improve preg-nancy outcome. Moreover, the absence of any long-term effect of prenatal intervention (without post-natal follow-up) in the Elmira trial shows that improving mean birth weight, moderate preterm

delivery, and psychosocial conditions in the pen-natal period, by themselves, is not enough to im-prove the long-term functioning of at-risk women and children.

POSTNATAL

PROGRAMS

The Improvement

of Maternal

Teaching

and

Children’s Cognitive Development

We reviewed 10 trials of home-visitation pro-grams that examined maternal teaching and chil-dren’s cognitive development as outcomes.21’ 2332

Educational Models. Seven of these studies ex-amined narrowly defined educational models.2329 The underlying causal model in these programs is that poor children’s developmental delays are the result of inadequate educational stimulation of the child. The way to remedy the problem, according to this model, is through parent education and the promotion of growth-fostering parent-child inter-action. Five of these programs employed para-professional home visitors and found negligible2628 or modest (4 to 5 points)2325 effects on IQ. Two of these trials studied the Mother-Child Home Program33 in this program, home visitors (usually paraprofessionals) visit families of young children during 2 consecutive years in those months that the public schools are in operation. The visitors teach parents to play intellectually stimulating games with their children. Randomized replications of this model both in New York City and Bermuda26’27 failed to reproduce positive IQ findings derived from an earlier quasi-experimental design,33 al-though both replications did produce minor im-provements in specific maternal and child skills

that were taught in the 27

More recently, a program of prenatal and post-natal home visits by public health nurses was tested in Montreal (N = 47)28 The visited women received

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differ-ARTICLES

III

ences in Bayley mental and motor development (1 and 4 points, respectively) were negligible.

The fourth trial (carried out in Kingston, Ja-maica, N = 58) tested the effects of weekly

visita-tion by community health aides (supervised by nurses) with poor, urban (predominantly black) families.29 The home visitors attempted to improve the quality of maternal-child interaction and parent and child self-esteem. The visited group showed marked differences (about 11 points) in develop-mental quotients, as well as in hearing and speech. The sample used in this study was more deprived economically than its US counterparts.

Ecological Models. Three trials simultaneously emphasized social support and education to im-prove parents’ qualities of care giving. We have classified them as ecological models. Two of these trials (carried out in Elmira, NY, and Seattle, WA) found positive effects of home visitation on chil-dren’s developmental status that were concentrated among the higher risk subgroups in their sam-pies.21’3#{176}The third trial used a sample that was at high sociodemographic risk (poor, unmarried teen-agers).31’32 They all employed nurse home visitors who began visiting during pregnancy.

In the Elmira trial (N = 400), reviewed above for

its impact on pregnancy outcomes, the nurses vis-ited once a week for the first 6 weeks after delivery and then on a schedule of diminishing frequency so that, by the 24th month of the child’s life, they visited once every 6 weeks.2’ The nurses attempted

to improve the children’s developmental accom-plishments by teaching parents about factors that influence infant development and by promoting sensitive and growth-promoting care giving. The

nurses also taught parents about the management

of health and behavioral problems; promoted ma-ternal life-course development (planning for future pregnancies, continuing their educations, finding work and a career, etc); involved other family mem-bers and friends in the pregnancy, birth, and early care of the child; and linked parents with other needed health and human services. Treatment dif-ferences of about 10 points in mental development were found for the children born to poor, unmarried teenagers. Although only marginally significant statistically (P < .10), these 10-point differences in cognitive development at 12 and 24 months of age were moderate to large effects clinically. Moreover, they corresponded to highly significant differences between these two groups in the number of educa-tionally stimulating toys in the homes (P < .01),

the amount of restrictive and punishing behavior on the part of the child’s care givers (P < .05), and other indications of improved maternal and child health outlined below.

In the Seattle study (N = 147), two models of

nurse home visitation were compared.3#{176} (Some de-tails of this study can be found in a report that is an analysis of the data outside of the context of the randomized trial.35) The first model (Information/ Resource) consisted of traditional public health nurse home visitation in which the nurses provided information to families about child development and parenting in a didactic way and helped families find needed community resources. In the second model (Mental Health), the nurses explicitly at-tempted to foster a therapeutic relationship with the mother in an attempt to enhance the mother’s social competence. They simultaneously promoted optimal parenting behavior and maternal skills in handling family relationships and problems. (We have categorized the Mental Health model under the section on ecological models, because the nurses taught parents to improve qualities of care giving and simultaneously attempted to address the envi-ronmental determinants of poor parenting out-comes. They simply placed a great deal of emphasis on first establishing a therapeutic alliance with the mother, an essential element of social support. The investigators excluded a no-treatment control group from the design. There were significant dif-ferences in favor of the Mental Health group in assessments of the mothers’ teaching and qualities

of the home environment. The positive effects of the experimental Mental Health model were con-centrated in children born to mothers with low IQ (and other indicators of less competence), and the children born to higher-lQ (and more competent) women tended to perform better in the traditional Information/Resource model. At 2 years of age, the children of low-lQ mothers in the Mental Health model had Bayley motor development scores that were 9 points higher than their counterparts in the Information/Resource model.

The findings of the study must be qualified for several reasons. First, the two treatment conditions also differed in the amount of contact, with the Mental Health group receiving both more visits (19.1 vs 13.7) and greater contact duration (25.3 vs 11.9 hours), so the extent to which treatment dif-ferences can be attributed to the models (as opposed to amount) of intervention is unclear. Second, the nurses following the lnformation/Resource model carried out activities similar to their Mental Health model counterparts; they “provided therapy” (eg, attempted to establish a therapeutic relationship with the mother) for the majority (51%) of their time vs 65% of the time for the Mental Health model, which attenuated the treatment contrast. Finally, high rates of attrition in the Information! Resource group (53%) compared to the Mental

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Health group (20%) further complicates the inter-pretation of any differences. It is reasonable to conclude that these significant differences in attri-tion are the result of women in the Information/ Resource group not getting as much of what they needed from the program as their counterparts in the Mental Health group. Most of the women who dropped out were at greater psychosocial risk.

It is worth noting that the one remaining ecolog-ically based home visitation program (N = 95)

covered in earlier reviews produced gains of about 9 points in developmental quotients. This program consisted of nurse home visitation begun during

pregnancy and intensive pediatric care that both continued through the child’s third birthday.31’32 This program used the health of the mother and child as a point of connection with parents to begin addressing the psychosocial needs of the mother and the behavioral and developmental needs of the child. Its comprehensive nature makes it consistent with the ecological model. The program was pro-vided to low-income unmarried adolescent primi-gravidas, women with sociodemographic character-istics similar to those who benefited the most in the Elmira trial.

Prevention of Maltreatment, Psychosocial, and

Health Problems in Mothers and Children

Three randomized trials have tested home-visit-ation programs as a means of preventing child abuse and neglect,21’36’37 and three additional trials examined health and other types of psychosocial

outcomes’2”0”2

Prevention of Maltreatment. The three trials that looked at child abuse and neglect produced mixed

results. The earliest in this series was carried out in Denver (N = 150).36 (This study is separate from the first Denver study reported above.) They tested the effects of intensive pediatric consultation plus weekly home visitation by public health nurses and paraprofessional home visitors beginning in the newborn period and following up families through the child’s second birthday. The visitors offered anticipatory guidance and crisis support services to women at risk for child abuse and neglect. There was no written protocol to guide the home visitors’ efforts to improve parent-child interaction (Gray J, spoken communication, November 28, 1989). There

were no statistically significant treatment differ-ences in reported and verified cases of child abuse and neglect, indications of abnormal parenting, the number of accidents, immunizations, or scores on the Denver Developmental Screening Test. Visited women nevertheless took their children to the hos-pital less frequently for serious injuries.’6

In a trial carried out in Greensboro, NC (N = 202), paraprofessionals visited poor women and

their children nine times during the first 3 months

of the children’s lives. This intervention was com-pared to two other treatment conditions: early and extended contact (rooming-in) between mothers and newborns and a no-treatment control group.37

No treatment differences were detected in child abuse or neglect, although the early-contact group experienced some modest benefits in mother-child interaction. No effort was made to determine whether treatment effects were present among fam-ilies at higher risk.

The third trial in this series was the Elmira study outlined above21’22 which tested the effects of pre-natal and infancy nurse home visitation (through the child’s second year of life). The incidence of verified cases of child abuse and neglect during the first 2 years of the child’s life was reduced by 50%

for the sample as a whole (from 10% in the control group to 5% among the nurse-visited families), but this difference was not statistically significant. As sociodemographic risk increased (that is, as pov-erty, teenage parenthood, and single-parent status were combined), the incidence of maltreatment in-creased in the comparison group but not in the nurse-visited group. Among families at greatest so-ciodemographic risk, the incidence of maltreatment increased to 19% in the control group, but remained relatively low (4%) among those who were nurse-visited (P = .07). This finding was corroborated by

systematic, blinded observations of the treatment and comparison-group women in their homes and analyses of their children’s emergency department records. The nurse-visited high-risk mothers were observed to restrict and punish their children less frequently. They also took their children to the emergency department fewer times during the first 2 years of life.2’ Moreover, treatment differences in

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ARTICLES

I 13

and employees may tax parents’ capacity to cope,

but participating in the work force may also in-crease parents’ income, social integration, and awareness of societal sanctions against maltreat-ment.

The numbers of cases in the treatment and con-tro! groups in the Denver and Greensboro trials are not large, limiting the statistical power ofthe design

to detect program effects on infrequently outcomes like child abuse. The incidence of reported ma!-treatment in each of these studies was (nonsignifi-cantly) higher among the home-visited families, however. This may be a reflection of the higher rates of surveillance among the visited families. Thus, the absence of effect in these trials is prob-ably not due to small sample size.

Prevention of Health and Psychosocial Problems.

Two additional trials looked at health and psycho-social outcomes other than child abuse and neglect. Paraprofessional home visitors in the Denver pro-gram (described in the discussions of both prenatal programs and programs to improve cognitive de-ve!opment) provided “social support” to high-risk families during pregnancy and the first 14 months of the child’s life.’2’20 No efforts were made to teach methods of interacting with the child or promoting cognitive or socioemotional development system-atically, although the home visitors interacted spontaneously and naturally with the infants

(Daw-son P, written communication, January 1990). Visited families made more trips to the physi-cian’s office for sick visits than did families in the control group.’2 At 4 months postpartum, the home-visited mothers showed more warmth and encour-agement of their infants’ learning efforts than did controls. Several program effects were conditioned by the mothers’ age and ethnicity. In observations of the mothers’ teaching of the child, for example, teenage and Hispanic mothers who were visited showed greater sensitivity toward their infants and their infants showed greater reciprocity than did their counterparts in the control group. At 12 months of age, visited mothers held less authoritar-ian attitudes toward child rearing than did controls. (Dawson P, January 1990, unpublished data). There were no treatment differences in infant at-tachment classifications.20 A!! of these assessments were carried out by individuals who knew the moth-ers’ treatment assignment.2#{176}

The models of nursing study in Seattle (also reviewed above) examined the impact of the differ-ent programs on maternal social skills and a variety

of other maternal and child psychosocial out-comes.’#{176}”5Although there were no treatment dif-ferences in maternal social skills or infant attach-ment at 1 and 2 years of age, women assigned to

the Mental Health model had a more positive view

of themselves, had less depression, and perceived greater social support than did women in the Infor-mation/Resource group.’#{176}Most importantly from the standpoint of this review, maternal risk factors interacted with treatment conditions. The effects of the Mental Health program were greater for those at greater risk for care-giving dysfunction. For example, children of mothers with lower lQ (<90) had more secure attachments to their moth-ers in the Mental Health group (48%) than did those in the Information/Resource group (33%). It is important to note that women with high IQ fared

better in the Information/Resource group. Their children were most securely attached to their moth-ers at 1 year of age, and their attachments showed the greatest stability from 1 to 2 years of age. This same pattern of results held for each risk factor studied: IQ, depression, education level, and social skills. The less competent women fared better in

the Mental Health group, while the more competent women fared better in the Information/Resource group.3#{176}These findings must be interpreted in the context of those caveats outlined in the discussion

of this study concerning programs to improve chil-dren’s developmental status.

Finally, it is important to note that the study of pregnancy and infancy nurse home visitation and intensive pediatric care carried out in Washington, DC (discussed in previous reviews and in this article31”2) also produced significant changes in ma-ternal and child behavior. Nurse-visited children displayed better diets, greater self-confidence, and fewer behavioral problems (such as toilet training and extreme shyness) as preschoolers. Their moth-ers were involved in more educationally stimulating activities with their children, used more appropriate methods of handling behavioral problems, and were more likely to continue their own educations.

DISCUSSION

The evidence reviewed here suggests that home-visit programs with the greatest chances of success have the following three characteristics: 1) They are based either explicitly or implicitly on ecological models. That is, influences on maternal and child health are viewed in terms of systems of material, social, behavioral, and psychological factors rather than single influences. 2) They are designed to address the ecology of the family during pregnancy and the early childbearing years with nurse home visitors who establish a therapeutic alliance with the families and who visit frequently and long enough to address the systems of factors that influ-ence maternal and child outcomes. 3) They are

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targeted on families at greater risk for maternal and child health problems by virtue of their poverty and lack of personal and social resources. The pro-grams with the greatest success (Elmira, Seattle, and Washington, DC) included each of these three characteristics.”2”22”#{176}32

Efforts to isolate the most important ingredients

of these successful programs are misdirected, as each appears to play a synergistic role in strength-ening the entire program. This principle is sup-ported by the following findings from

home-visita-tion programs that did not include all of these features and that failed to produce positive findings:

. Social support during pregnancy (without the

alteration of adverse behaviors) is not enough to improve birth weight and length of gestation.’2’14

C Prenatal home visitation, even if successful in

improving the outcomes of pregnancy, is not enough to promote long-term maternal and child functioning if it is not followed by comprehensive postnatal home visitation.21’22

. Frequent visitation over a long period, by itself,

is not enough to affect maternal and child health.’2’26’27

. Employing nurses as home visitors, by itself, is

insufficient.28

. Focusing on high-risk families, by itself, is not

enough.26’28

We infer from this pattern of successful program features that the ecological model’8 holds the

great-est promise for understanding the interrelated health and developmental problems of women and

children from disadvantaged families. These prob-lems are connected to one another by the women’s own psychological resources, the stressful life cir-cumstances that they often endure, and the fre-quent absence of appropriate social support. To be optimally effective, programs must address simul-taneously the psychological needs of the parents (especially their sense of mastery and competence); the parental behaviors that influence maternal, fe-tal, and infant development; and the situational stresses and social supports that can either interfere with or promote their adaptation to pregnancy,

birth, and early care of the child.’9

How might home-visitation programs affect gen-eral pediatric care? As the “new morbidity” de-mands an increasing portion of pediatricians’ time, they find it increasingly necessary to address psy-chosocial, behavioral, and environmental influ-ences on child well being. Home-visitation

pro-grams, if properly designed and executed, hold con-siderable promise as a means of augmenting office-based and clinic-based efforts to address the needs

of families at environmental risk.38’39

In England and many other European countries, home visitation is provided to all families,

irrespec-tive of their risk status.’ This raises the question as to whether such service should be made

univer-sally available to a!! families in the United States. The evidence reviewed here suggests that such an approach may not be a cost-effective allocation of limited resources. By increasing the availability of the service to everyone, the intensity of the service would have to be diminished to those who would benefit the most. This does not mean, however, that we know enough to target precisely the families most likely to benefit from this kind of service. It does suggest that such services are likely to produce greater benefit if they are focused on communities

with high rates of poverty and single and adolescent parenthood. By focusing on high-risk communities, such services can be focused where they are most likely to help, without singling out and possibly stigmatizing certain individuals as being in need of special services.

Both the Elmira and Seattle trials found that the impact of their experimental services were greater

for families at greater risk for the particular prob-lems under consideration. Moreover, one of the more successful programs consisted of prenatal and infancy nurse home visitation (plus intensive pe-diatric care) focused on poor, unmarried adoles-cents, and women at high risk for a variety of maternal and child health problems.”32 The Seattle trial suggested, nevertheless, that lower-risk women benefitted more from a more traditional model of visitation based on the provision of information and linkage with community resources. This sug-gests that the effect of such services also depends upon the match between the program model and the needs of the families, a topic that should be explored in future research. Finally, the risk char-acteristics of families who benefit the most from these services have yet to be delineated fully. It is conceivable, for instance, that drug abuse and Se-vere emotional impairment may be a significant barrier to program effectiveness. The studies ex-amined in this review, however, did not have suffi-ciently large samples of such high-risk groups to determine whether these conditions are intractable.

Although there is no direct evidence on the rela-tive effectiveness of programs focused on primi-paras vs multiparas, those with the clearest positive effects registered women bearing first chil-dren.’5’21’22’31”2 Moreover, from the standpoint of a public health primary-prevention strategy, it makes sense to focus limited nurse home-visitation

serv-ices on women bearing first children. Their im-proved health-related behaviors, care giving, and conditions in the home may carry over to later-born children; and, as in the Elmira study, there may be fewer subsequent unintended pregnancies.

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ARTICLES 115 planners to date is whether to employ nurses, other

professionals, or lay workers as home visitors. A!-though not a single study addressed this issue sys-tematically, it is revealing that (with the possible exception of the Jamaica trial’8) the studies with the most dramatic and broad-based effects were those that employed nurses.’5’21’22’30’2 Because

pro-grams that used paraprofessional home visitors also employed more narrowly focused interventions (either “social support” during pregnancy or

edu-cation after the baby was born), it is difficult to sort out the effects of the intervention model from the background of the visitors.

It is not surprising, given the outcomes examined in this review, that the programs that produced the most positive effects were those that employed nurses who began visiting during pregnancy.

Preg-nant women are concerned about the anatomic and physiologic changes of pregnancy. By virtue of their role, nurses are likely to be viewed by family mem-hers as professionals who have important

know!-edge that will help women with the challenges of pregnancy, labor, and delivery. Nurses meet impor-tant needs of women at this stage in the life cycle, and thus increase their value to the visited families. It is our observation that once the baby is born, parents are more concerned about the physical health of their infants than they are about their infants’ cognitive or socioemotional development. While their preoccupation with the child’s physical well-being usually shifts as the child matures, it is our impression that parents are most likely to we!-come the insights and observations of nurses early in infancy because of the nurses’ training and knowledge. Their role enhances their ability to communicate about issues of importance to parents and adds credibility to their efforts to support other aspects of care giving and to help families meet their needs.

In evaluating the findings of this review, it is important to remember that few of the conclusions drawn here were based on the systematic compari-son of program features in the context of a single research design. Because many of the conclusions are based on the results of a mere handful of exper-iments, they should be tested more systematically in the next wave of research on home-visit pro-grams for at-risk women and children. It is

partic-ularly important to determine the relative effec-tiveness of non-nurse visitors because of the limited number of nurses currently available to carry out such activities, and the rapid proliferation of para-professional home-visitation programs. Moreover, studies of program costs and economic benefits are sorely needed to find out whether home-visit pro-grams (as many have suggested) pay for themselves in averted expenditures for future problems.

Finally, we must emphasize that the more effec-tive programs reviewed here demonstrate what it is possible to do with well-designed and well-imple-mented home-visitation programs. It is essential that we preserve both the form and spirit of those programs as they are disseminated. Experience sug-gests that programs replicated in the real world

may not resemble their experimental models.40 Con-sequently, it will be important to test the effective-ness of such programs as they are transported into health-care institutions and to examine the re-sources necessary to support them, such as the educational preparation of home visitors, on-going training, and other support services.

ACKNOWLEDGMENTS

This research was supported by a grant from the Bureau of Maternal and Child Health and Resource Development (Grant Number MCR-78--43) via a grant from the National Center for Nursing Research (ROl-NR-01691) and a William T. Grant Faculty Scholars Award to the first author (Grant Number 861-080-86).

Aversion of this paper was prepared by the first author for the Cornell University Medical College Fifth Confer-ence on Health Policy, “Improving the Life Chances of Children at Risk,” February 15 to 16, 1990, New York, NY.

We thank Peter Dawson, MD, Gilbert Forbes, MD, Howard Foye, MD, Jane Gray, MD, Carole Hanks, DrPH, Elizabeth McAnarney, MD, and Joan Pinhas, PhD for their comments.

REFERENCES

1. National Commission to Prevent Infant Mortality. Home

Visiting: Opening Doors for America ‘s Pregnant Women and

Children. Washington, DC, 1989

2. National Commission to Prevent Infant Mortality. Death

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AAP

ANNUAL

OR SPRING

MEETING?

The guest paid his bill at the resort hotel, and as he departed he noticed a sign saying, “Have You Left Anything?”

The man went back and spoke to the desk clerk: “That sign is wrong,” he said. “It should read, “Have You Anything Left?”

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1990;86;108

Pediatrics

David L. Olds and Harriet Kitzman

Risk?