Children benefit up to the age of 12 years old from prenatal and infancy home visiting by nurses; with reduced substance use, improved academic performance and reduced mental health problems
- Correspondence to Kathleen F Norr
845 South Damen Avenue, Chicago, IL 60612-7350, USA;
Research supporting nurse–family partnership
This report of positive impacts on mental health and academic achievement of children at age 12 is the most recent publication from a highly significant programme of maternal-child health research. The intervention focused on improving pregnancy outcomes, child health and development and economic self-reliance through semistructured nurse home visits to socioeconomically disadvantaged first-time mothers from mid-pregnancy through 2 years after birth. Randomised trials in three US cities had similar positive short- and long-term impacts for mothers and children, with stronger positive impacts for the most disadvantaged group. Based on ecological theory, attachment theory and self-efficacy, these positive results strongly support these enduring conceptual frameworks as guides for intervention. Despite minor methodological issues expected in any extended longitudinal study, in my judgement these issues do not detract from the consistent and strong findings. This is one of only a handful of community maternal-child evidence-based interventions in the USA that have moved into an implementation phase. The Nurse-Family Partnership now has programmes in 31 states and lobbied for the recently passed Home Visitation Grant Program for States (for details and links to all publications, see: www.nursefamilypartners.org).
New directions for research
Another related study has identified a vigorous agenda for future research to establish a stronger evidence base for this and other home visiting programmes, including process evaluation, tailoring home visits to different contexts, more exploration of costs and cost-effectiveness and trials of scaling-up strategies.1 I especially endorse their emphasis on identifying the intervention's ‘active ingredients’ to facilitate replication. The study suggests that efficacy relates to the visit process, especially mother's engagement in visits and high acceptance of nurses as advisors, not the ‘dose’ measured as number of visits. Home visits include multiple learning strategies to build self-efficacy,2 for example role modeling by the nurse and some skill-building and rehearsal for some specific parenting skills. Future research should explore the relative contributions of the different learning strategies in home visits to intervention effectiveness. Another important question is whether the stronger effects identified for the most disadvantaged families is a sufficiently robust finding to justify targeting only those groups. I will not comment further on their much-needed future research suggestions but instead suggest additional new directions for research.
Since these trials began, a large body of evidence has identified group interventions as powerful ways to change behaviour. Group healthcare models in the USA have had positive impacts, such as the Centering Pregnancy group prenatal care model which reduced preterm births by one-third in a recent clinical trial (for descriptions and links to studies, see www.CenteringHealthcare.com). Also, peer group interventions using Bandura's2 social-cognitive model to build self-efficacy have been effective for HIV prevention.3 Linking this individual-level home visit programme with group intervention has the potential to increase effectiveness or provide equivalent effectiveness at lower cost.
Another important challenge is linking this intervention with the World Health Organization's primary health care model (PHC) and Millennium Goals for global health and development (www.un.org). PHC is a proven strategy to ensure that all people have essential healthcare that is scientifically sound, culturally acceptable, accessible, affordable, participatory and promotes self-determination and self-reliance. Although not specifically linked to PHC, the programme is congruent with PHC in many ways, including a broad conceptualisation of health and economic development, an early prevention focus and health-worker community partnership. However, it does not incorporate community participation and would need considerable modification for resource-poor settings. Using nurse home visitors, based on their finding in the Denver trial that paraprofessionals were less effective than nurses, is especially challenging for global replication in the context of the global nurse shortage. Despite these considerable challenges, it is important to bring this strong evidence-based intervention to resource-poor countries where child health and development improvements are urgently needed.
Public policy research in the USA and globally is needed to help governments and health providers realise the human and monetary advantages of evidence-based early intervention for young families. For example, the cost of programmes like the Nurse–Family Partnership is borne by the healthcare system, while long term benefits and financial savings also affect education, social welfare services, criminal justice and the economy. Policy research should address this barrier to wider implementation, especially in the USA where a national healthcare system is lacking.